Djerriwarrh Health Services Quality of Care Report 2013/2014€¦ · incidents are recognised, reported and analysed, and this information is used to improve safety systems. This

Djerriwarrh Health ServicesQuality of Care Report2013/2014

2 Djerriwarrh Health Services Quality of Care Report 2013-2014

Mission Statement Helping people of our community to better health and well-being

Vision Statement Providing quality integrated health services within available resources

to the people of our community and encouraging personal responsibility for health care

Values Djerriwarrh Health Services is committed to the following values which

underpin the basis of our principle key objectives:

Integrity and professionalism

Team work

Effi cient and cost effective services

Maximized patient/client satisfaction

A commitment to quality outcomes

Respect for all staff

Management by fact

Performance accountability

Our report for you

3Djerriwarrh Health Services Quality of Care Report 2013-2014

Our report for you • Welcome to our Quality of Care report

• Accreditation

• Your Health Service

• Our Health Service

National Safety & Quality Health StandardsConnecting to our community – Cultural Diversity • Aboriginal Health

• Strengthening Multicultural Communities

• Our patient story

• Our Diverse Community

Measuring the care we provide to you • Breakdown of complaints

• Victorian Patient Satisfaction Monitor

• Executive summary

Public Sector Residential Aged Care Services (PSRACS) Quality Indicators • Quality indicators

Our amazing VolunteersRecognition of Achievements • Health Literacy

• Advance Care Planning

• Productive Ward

• Dental

Have your SayFeedback

Welcome to our Quality of Care report

In preparing this ‘Quality of Care Report’, we have relied upon the feedback and

participation of our community. This is your hospital and feedback is what impacts

and drives the improvements we make. At Djerriwarrh Health Services (DjHS) we are fortunate to have community members

actively involved in our committees and working groups, including the Board,

Community Advisory Committee, Consumer Representatives (focus groups) and

Redevelopment User Groups.

By involving our consumers it enables the community to express ways in which

we can improve our services. We are continuously recruiting patients, carers and family members to our Consumer Representatives register, which affords

even more opportunities for consumers to provide feedback and play an active role

in producing changes and improvement across DjHS.

Our staff play an integral role in providing expertise and feedback for our health

service through committees, such as our Patient Client Care Committee, Health and Safety Committee, Risk Review Committee,

Clinical Risk Management Committee and Infection Control Committee. All

of the information obtained from these Committees is channelled back to our senior

staff and community members to ensure appropriate actions are undertaken to make

improvements or changes as required.

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AccreditationDjHS strives to provide the best possible quality of care to our patients, residents and clients. We take considerable pride in knowing that we meet the very high quality standards as set out by the accrediting body Australian Council of Healthcare Standards (ACHS), along with other accrediting agencies. The Health Service is an industry leader in a number of quality standards that cover a wide variety of issues including actual clinical care, how the organisation is managed, infection control, risk management and emergency procedure planning. DjHS is currently accredited through the Australian Council of Healthcare Standards (ACHS) as well as the Aged Care Standards Agency.

We continue to work tirelessly on developing the 10 National Safety and Quality Health Service Standards, these now outline the mandatory component of our future accreditation process. We have established a number of programs to assist us to meet these standards this includes; tools to monitor compliance of care improved identifi cation and escalation of care for deteriorating patients. Staff have been provided with excellent on line education resources to help identify risk, safety and quality responsibilities.

Your Health Service Djerriwarrh Health Services (DjHS) serves the rapidly expanding population of the City of Melton and Moorabool Shire. This is one of the largest growth areas in Australia. A continuing challenge for our organisation is being able to provide the health services that the community needs within our available resources – in particular the Bacchus Marsh and Melton Regional Hospital has little capacity to expand its services within the confi nes of the present building.

We are excited by the news of a new Melton Community Health Centre. The Minister of Health Hon. David Davis MP announced as part of the 2014/15 State Budget an allocation of $14m for a new Melton Community Health Centre (including $5m funded through the Growth Areas Infrastructure Contribution).

This announcement is the result of Djerriwarrh Health Services working in partnership with the City of Melton and other service providers in the area, over a long period of time. The new Melton Community Health Centre will enable the existing Community Health staff to be relocated into modern facilities, and also provide an excellent opportunity to extend the health service delivery in partnership with other healthcare providers.


Melton Health

Djerriwarrh Health Services will continue to provide updates on the progress of the new Community Health Centre though the Clinician’s Update and other media sources as the project unfolds.

Our Health Service has fi ve campuses:Bacchus Marsh and Melton Regional Hospital: providing 42 acute hospital beds (including 11 maternity), a wide range of theatre procedures (including ENT, general surgery, obstetrics, orthopaedics, dental), 30 residential care beds (Grant Lodge), outpatient care (radiography, physiotherapy) and community health (with a wide range of allied health and counselling services).

Melton Health: providing ambulatory care to the core programs of Day Medical (Urgent Care, Renal Dialysis and Oncology), Adult Health (Chronic Disease Management, Orthopaedic and Neurological Rehabilitation as well as a number of specialist medical clinics), Women and Children’s Health (Childbirth Education, Obstetric Care, Day Stay Program and Paediatric Assessment Clinics) and Dental Services.

Bacchus Marsh Community Health Centre: providing allied health, counselling, community nursing and palliative care.

Melton Community Health Centre: providing allied health and counselling services.

Caroline Springs Community Health Centre: providing general community health programs


Standard 1: Governance for Safety and Quality in Health Service OrganisationsDjHS has always ensured that we have an integrated system of governance that actively manages patient safety and quality risks. With the standards, we have a more succinct way of ensuring we reach our goals.

Standard 1 requires that:

• The governance system sets out safety and quality policy, procedures and/or protocols and assigns roles, responsibilities and accountabilities for patient safety and quality.

• The clinical workforce is guided by current best practice and uses clinical guidelines that are supported by the best available evidence.

• Managers and the clinical workforce have the qualifi cations, skills and approach to provide safe, high-quality health care.

• Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.

This will be evidenced in the following standards.

Standard 2: Partnering with ConsumersStandard 2, aims to ensure that our health service is responsive to patient, carer and consumer input and needs. It is extremely important that Djerriwarrh Health Services has structures in place to form these partnerships with consumers and carers. We have been actively encouraging consumers and carers to participate in the improvement of the patient experience and patient health outcomes, by providing feedback and being involved on our various committees.

Consumers and carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.

Recent accomplishments in partnering with consumers include the development of the ‘Consumer Representatives’ brochure. Valuable feedback regarding the brochure was provided by the Community Advisory Committee and our new Consumer Representative focus group. A newly developed consumer representative focus group has been formed to review over 150 of our existing brochures provided to our clients across DjHS. We are hoping to develop more focus groups in the near future to review more of our health literature right across the network of our other sites.

Standard 3: Preventing and controlling health care associated infectionsAntimicrobial Stewardship at Djerriwarrh Health Service – A Quality Improvement

Prevention and control of healthcare associated infection is an essential element of patient safety and a priority area for DjHS. Improving the safe and appropriate use of antibiotics within the health service is an important component of preventing healthcare associated infections and this has been identifi ed as a key quality improvement activity.

The emergence of antibiotic resistant bacteria is closely linked with inappropriate antibiotic use. Studies show that up to 50% of antimicrobial (antibiotic) regimens prescribed for patients in hospitals are considered inappropriate. When comparing Australian data with northern European hospitals, Australian hospitals have a higher overall rate of inpatient antimicrobial use.

An effective approach to improving antimicrobial use in hospitals is an organised antimicrobial management program; this is known as antimicrobial stewardship (AMS). Antimicrobial stewardship involves a systematic approach to optimising the use of antibiotics. This approach is used to reduce inappropriate antimicrobial use and improve patient care.

National Safety and Quality Health StandardsDjerriwarrh Health Services has formed working groups that are responsible for implementing the actions and criteria defi ned in the National and Safety and Quality Standards. These working groups are led by clinicians who focus on areas that are essential to improving patient safety and quality of care. Information and updates are regularly displayed throughout the organisation.


At DjHS, along with other infection control strategies such as hand hygiene and surveillance of healthcare associated infections, the development of an effective antimicrobial stewardship program is considered a key strategy to prevent the emergence of antimicrobial resistance and decrease preventable healthcare associated infections.The Infection Control Team in collaboration with our Pharmacy Department at DjHS has established an antimicrobial stewardship working party to improve the use of antibiotics within the health service and thus improve patient outcomes.Since its inception in 2013, the working party has held regular meetings to develop an action plan, audit tools, and reporting schedules for audit results.The fi rst major priority for the working party was the development of an action plan to guide the activities of the antimicrobial stewardship program. The action plan is an enduring work in progress with the actions including the following:

• To oversee and audit the use of antimicrobials at DjHS to ensure the appropriate and safe use of antibiotics. This has involved the development of an audit tool with a reporting schedule that includes reporting to Senior and Executive Management Committees. The audits have been used as a means of monitoring the clinical workforce who prescribe antimicrobials, for monitoring antimicrobial usage and the adherence to policies and procedures. This allows us to highlight areas

where we can make quality improvements by changes in practice.

• Reports, results and feedback are presented to the antimicrobial stewardship working party,the Infection Control, Patient Client Care and Clinical Risk Management Committees. Recommendations are made from the audit results, ratifi ed with support from senior management and subsequently actioned.

• The development of an antibiotic protocol policy: This policy has been based on the Australian Therapeutic Guidelines – Antibiotics (Version 14). The protocol is reviewed regularly to maintain currency and aims to promote best practice guidelines for the appropriate prescribing at DjHS – the protocol has been peer reviewed and approved by the Best Practice and the Clinical Risk Committees.

• The protocol has been Ratifi ed by the Medical Advisory Group, the Obstetric Group and the Anaesthetic Group. The protocol is now available via the health services intranet for all clinicians and prescribers.

• The development of a formulary: A formulary is a list of antimicrobial agents that have been approved as suitable for use at DjHS. This list includes restricted antimicrobials and the rules for governing their use. The formulary is updated periodically and compliance with it is audited. This improvement serves as a best practice guideline for prescribers.

• The establishment of links with an Infectious Diseases Physician. Our Infectious Disease Physician adds legitimacy to our AMS program by collaborating with our medical staff to ensure the goals of the AMS are understood and met. Prescribers are able to seek expert advice from the Infectious Diseases Physician when prescribing becomes complex.

• Development of a liaison relationship with a Clinical Microbiologist. Liaison arrangements have been formalised with our contracted pathology service. Antibiotic prescribing can often be dependent on microbiology testing and discussion with a Clinical Microbiologist can provide information that interprets isolate signifi cance and antimicrobial susceptibility.

Continuation of the actions of the working party and the AMS program will assist in improving the effectiveness of antimicrobial prescribing at DjHS and optimise the best care for our patients.


Standard 4: Medication ManagementLike all health services, DjHS is now required to meet the requirements of the National Safety and Quality Health Service (NSQHS) Medication Safety Standard.

The Medication Safety Standard requires health service organisations to implement systems that reduce the occurrence of medication incidents and improve the safety and quality of medicines use.

The intention of this standard is to ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and carers.

Medication Incidents are monitored at DjHS with a quality improvement focus to determine appropriate changes in practice or procedures to prevent future incidents.

In 2013/2014, a total of 172 medication incidents were reported. This is an increase from 52 incidents in 2012/2013.

One of the quality improvement activities undertaken as part of the Medication Safety Standard that has contributed to the increased reporting of prescribing incidents is the introduction of a Medication History and Reconciliation Form that is completed on admission for patients at Bacchus Marsh and Melton Regional Hospital.

Medication reconciliation involves documenting an accurate patient medication history and in the context of the plan for care, comparing it to admission, transfer or discharge medication orders. It helps to ensure that patients receive all intended medicines to avoid medication errors of transcription, omission, duplication of therapy and drug interactions.

This process is particularly important for high risk patients which are defi ned at DjHS as:

• Patients over 65 years of age

• Patients taking multiple medications (>5 regular medicines)

• Patients who have had changes to their medicines during admission

• Patients suspected of non- adherence or taking high risk medicines

• Patients whose length of stay is >3 days

Results of an audit conducted in April 2014 to assess our compliance with documentation of patient medication history and medication reconciliation showed that 97% of patients had a medication history documented and 93% of patients audited had evidence of medication reconciliation.

A medication Incident Scoring Tool is used to assess the risk severity of the medication incident.

The Incident Severity Rating (ISR) is defi ned as:

• ISR 1 – Severe (including death)

• ISR 2 – Moderate

• ISR 3 – Mild

• ISR 4 – No harm (near miss)

The Health Service investigated each incident and undertook quality improvement activities to help reduce them in the future.

A review of High Risk Medicine procedures was undertaken to assess whether additional medication safety initiatives could be used to prevent potential medication errors.

High Risk Medicines.High Risk Medicines are medications which have a heightened risk of causing signifi cant harm when used in error and include:

• Medications with a low therapeutic index

• Medications that present high risk

when administered via the wrong route or when other system errors occur.

Examples of these medicines are the ‘PINCH’ Drugs:

• Potassium

• Insulin

• Narcotics

• Chemotherapy

• Heparin and other anticoagulants

Alert stickers on these medicines were implemented to identify these medicines as ‘high risk’ and increase awareness amongst clinical staff.

High Risk medicines also featured in Medication Safety presentations to nursing staff and Medication Safety newsletters and notice boards throughout the year.

Venous Thromboembolism (VTE).Another quality improvement activity undertaken as part of the Medication Safety Standard during the year was implementation of Venous Thromboembolism (VTE) Risk Assessments and the development of VTE Prophylaxis Guidelines.

The prevention of VTE in acute care hospitals has been recognised nationally and internationally as a priority patient safety issue because of the strong evidence base for preventative measures and high potential for improvements in patient outcomes

This involved the establishment of a VTE working Group at DjHS to address the following key areas:

• Develop a VTE Risk Assessment form for all admitted adult surgical and medical patients.

• Develop VTE Prophylaxis Guidelines for pharmacological and mechanical prophylaxis (such as compression stockings).

• Implement the new version


of the adult National Inpatient Medication Chart (NIMC) which includes a VTE prophylaxis section to facilitate documentation of:

• VTE Risk Assessment completion

• Pharmacological prophylaxis

• Mechanical prophylaxis

An audit of compliance with completion of VTE Risk Assessment Forms and prophylaxis prescribing was conducted in June 2014.

Results of the audit showed that 88% of high VTE risk surgical patients (Total Hip and Total Knee Replacements) and 95% of medical patients had a completed VTE Risk Assessment Form in their medical record.

Medication Safety Self Assessments and Audits.During the year DjHS completed the Medication Safety Self-Assessment for Australian Hospitals (MSSA) and the Medication Safety Self -Assessment for Oncology.

Both of these assessments identifi ed areas in which improvements to medication safety and management could be made in the organisation.

This included the implementation in the Oncology Unit of a “Time Out” checklist for oncology nursing staff to be used in the administration of chemotherapy to patients in Melton Health Day Medical Unit.A number of other audits in relation to Medication Safety were also completed throughout the year.

These included audits in relation to compliance with:

• National Inpatient Medication Chart (NIMC) documentation

• Labelling of Injectable Medicines, Fluids and Lines

• Antibiotic Usage and compliance with prescribing protocols

• High Risk Medicines

• Drug Distribution, Storage and Expiry Date management

• Medicine References availability

Results of Medication Safety Audits were reported to Pharmacy Advisory Group, Clinical Risk or Patient Client Care Committees with recommendations for improvement activities outlined in the reports.Error Types

80

60

40

20

0Missed Dose

Prescribing

S8 RecordStorage

Wrong PatientOther

ADR

Wrong Drug

Wrong Dose

Known Allergy

2012/20132013/2014

Administration

140

130

120

110

100

90

80

70

60

50

40

30

20

10

0 ISR1 ISR2 ISR3 ISR4 2012/2013 2013/2014

Severity Risk Score

170160150140130120110100

908070605040302010

0

= 2012 / 2013= 2013 / 2014

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Total

Graph 1: Medication Incident Totals


Standard 5Patient Identifi cation and procedure MatchingStandard 5 requires at least 3 approved identifi ers must be used each time identifi cation occurs. For example, at admission or registration, when care, therapy, services, or advice/information is provided and when transferring responsibility for care.

The approved identifi ers accepted for use in patient identifi cation, include:• patient name (family & given names) • date of birth• unit record number. Other identifi ers that may be used include full address, medicare card number, pension card number, photograph or photo ID.

The method used to identify patients varies in each area and depends on the activity being performed. For example patient identifi cation bands are to be worn by all inpatients and must display the three core items: patient full name, date of birth and unit record number. Whereas photo id is used for residents in aged care.

Verbal confi rmation of a patient identifi cation must occur prior to the commencement of any activity. Staff must ask the patient to state their details.

Standard 6 Clinical Handover. Clinical handover is extremely important to ensure patient information is handed over accurately and in a timely manner. DjHS uses the ISBAR format for handovers, to ensure all relevant information is communicated.

Handover audits for "discharge planning" and "shift to shift" handovers are being conducted to ensure our standardised handover practices are being adhered to.

Standard 7 Blood and Blood Products Standard 7 is dedicated to blood and blood products and we have been working towards achieving this with new policies, forms and brochures.

While transfusion is a lifesaving procedure it carries risk that needs to be managed safely.

Red cell transfusions are carried out at DjHS to treat emergency bleeding after childbirth or surgery, to correct anaemia and for those who have haematological conditions and cannot produce their own red cells. Of the 264 transfusions carried out in 2013/2014 60% were for haematology, 8% for obstetrics, 1% surgical and 17% for medical reasons.

In the ‘blood product’ category we administer Immunoglobulins. 107 Immunoglobulin infusions were given in 2013/2014 for immunodefi ciency and neurological conditions to a core group of 10 patients.

Standard 8Preventing and Managing Pressure InjuriesStandard 8 requires that DjHS has governance structures and systems in place to prevent and manage pressure injuries. The Standard 8 working committee has introduced the Braden Risk Assessment tool and is currently developing a Pressure Injury Care Pathway for patients at risk of or who have existing Pressure Injuries. The working Committees of Standard 8 and Standard 10, (Preventing Falls and Harm from Falls), have worked in conjunction to ensure the Pressure Injury Care pathway is suitable for both medical and surgical patients.

Transfusions DjHS Jan – Dec 2013

279 episodes of red cell transfusion

Surgical 1%

Obstetric 8%

Autologous 6% Oncology

6% Palliative

3%

Haematology59%

Medical17%


Standard 9Recognizing and Responding to Clinical Deterioration Has four essential elements. These include:

1. Measurement and documentation of observation.

2. Escalation of Care

3. Rapid Response Systems

4. Clinical Communication

The Djerriwarrh Health Services ‘Deteriorating Patients Workgroup’ was established in 2011, and includes representatives from Medical, Nursing and support staff. The group have investigated methods of documentation, implemented a Clinical Escalation and MET call response, and updated the Code Blue Procedure.

The ‘Between the Flags’ Adult Observation Chart, as used by NSW Health, has been implemented in the Medical/Surgical Unit. This is a track and trigger type of chart, with embedded coloured areas to signify when escalation is required.

A trial of the Theatre Services ‘track and trigger tool' is currently being conducted. A draft Maternity Services tool is also being developed. Audits of charts and responses to clinical deterioration are conducted on a regular basis and any issues are communicated to staff.

Standard 10Preventing Falls and Harm from FallsStandard 10 requires DjHS have governance structures and systems in place to reduce falls and minimise harm from falls. Patients on presentation, during admission and when clinically indicated, are screened for risk of a fall and the potential to be harmed from falls. Prevention strategies are in place for patients at risk of falling. Patients and carers are informed of the identifi ed risks from falls and are engaged in the development of a falls prevention plan.

We have introduced new screening and assessment tools into the organisation over the last few months to help identify if a patient is at risk of falls and harm from falls. Environmental audits have been undertaken to help to ensure the surrounds are safe and comfortable. Staff have received education to help use these tools and how to make referrals to physiotherapist and occupational therapist or home assessment to assist patients. Equipment and aides are also available.

Patients are seen by the Discharge Planner during their stay and plans, such as home help, meals on wheels, home assessments, are put into place to assist once they are discharged home.

Chris Braden, Manager of Infection Control / Clinical Risk


Connecting to our community – Cultural DiversityIn the past 12 months DjHS has continued to implement more programs and build on the work of our Cultural Diversity Plan. We have organised a range of positive activities and introduced new tools to ensure our patients receive a high level of quality health care. By providing culturally safe care we ensure that individuals have the right to have their beliefs and value systems responded to in a respectful and sensitive manner. All patients have the right of respect for their religion, food, prayer, dress, privacy and customs. All of these aspects of care are highlighted in our diversity plan.DjHS offers many groups to cater for clients of all ages; these are some of the services we provide: • Aboriginal men’s group • Aboriginal parents group • Burmese playgroup • Community Health Activity Supported Exercise (CHASE) • Cooking classes – Spice of life cooking group • MARLA Aboriginal Women’s Group • Spice of life – Interactive migrant nutrition program • Sudanese women’s and children’s group

Aboriginal HealthThe Department of Health aims to make a major and measurable impact on improving the length and quality of life for the Aboriginal community.

The government's objectives are to:

• close the gap in life expectancy for Aboriginal people living in Victoria

• reduce the differences in infant mortality rates, morbidity and low birth weights between the general population and Aboriginal people

• improve access to services and outcomes for Aboriginal people

Key prioritiesThe six key priorities of Koolin Balit: Strategic Directions for Aboriginal Health 2012-2022 are:

1. a healthy start to life

2. a healthy childhood

3. a healthy transition to adulthood

4. caring for older people

5. addressing risk factors

6. managing illness better with effective health services

A number of issues contribute to the diffi culty with interfacing with the Aboriginal community in the DjHS catchment area namely:

• The community is fragmented and no central community hub exists. Therefore there is no high profi le location to meet and interact with the community

• The community itself is unaware of the location and number of Aboriginal people residing within DjHS catchment area and therefore contacting one community member does not mean contacting the whole community

• The nature of the poverty cycle and how it affects individuals, family and community infl uences issues such as regularity of attendance and interest with initiatives

All patients havethe right of respect for their religion, food, prayer,dress,

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privacy and customsg


Community groups, activities & initiativesBoth the Aboriginal Men’s and Parent groups completed a 12 month strategic plan. The plan has three main objectives: (i) Community engagement (ii) Identifying Community issues and (iii) Developing responses to Aboriginal Health Promotion and Chronic Care (AHPACC). Once each group has been consolidated, the intention is to form an Aboriginal Youth Group.

With respect to Community engagement, each group is responsible for organising four community BBQs for the year and developing four cultural activities. The aim of which is to keep each group engaged and through the community groups, develop broader community engagement activities. To date three communities BBQs have been organised. On average between 35-45 community members have attended.

Concerning cultural activities, the Men’s group is responsible for developing the following activities:

- Cultural healing retreat

- Cultural art & craft

- Cultural Site mapping

- Native plant mapping

The parents' group is responsible for the following cultural activities:

- Traditional games

- Region cultural history

- Cultural economy

- Cultural visits

- Healing day

In addition to the community BBQ’s and cultural activities, both the Men’s and Parents group will organise a ‘Healing Day’. On the Healing Day, a community nurse will be available to screen community members, and promote community engagement activities and health services.

Partnerships Aboriginal Literacy Foundation

- A Homework group for Bacchus Marsh will be in operation in Term 4.

- DjHS is facilitating establishing a Homework group in Melton potentially with the Melton Primary School.

Moorobool Shire Council

- DjHS Aboriginal Parent Group sat on Moorobool Shire Council National Aboriginal and Islander Day Observance Committee (NAIDOC) and attended the Council’s NAIDOC event, including conducting health checks on the day.

Melton City Council

- Developing ongoing relationship with Melton Council, including utilising the Men’s Shed and working on developing an exercise program for the DjHS Men’s group in conjunction with Melton Wave Pool.

MatchWorks

- Developing ongoing working relationship with MatchWorks. DjHS is establishing itself as Match Works preferred health service for Aboriginal clients in the region.

MacKillop Family Services

- Working with MacKillop Family Services on developing a Parenting program for the Aboriginal community.

Key Achievement in 2014Koolin Balit small grant obtained to support the implementation of community driven strategies to promote a healthy transition to adulthood. This project will be undertaken by working closely with our local Aboriginal Community and key local service providers.

Addressing the challengeFormation of the Aboriginal Parents Group, Aboriginal Men’s Group, Aboriginal Women’s Group and eventually the Aboriginal Youth groups, are the central planks in the strategy to engage with the Aboriginal community.

The groups meet weekly, and act as a ‘virtual hub’ providing a forum to inform on health related services, community feedback on the development of appropriate service delivery and to develop community initiatives for the purpose of attracting interest and support from the Aboriginal community.

Both the Aboriginal Men’s and Parents Group have developed and endorsed a terms of reference, code of conduct and 12 month strategic plan.


Introducing “Can Te”Ni Can Van Uk, otherwise known as “Can Te”, came to Australia in 2007 as a Chin refugee from Myanmar (Burma). Can Te was born in the Matupi township in the Chin State. She sought safety from the persecution occurring to the Chin people. Her long journey to safety, predominantly on foot, led her through Thailand, Singapore and Malaysia.

Can Te eventually reached Melbourne with the support of the United Nations High Commissioner for Refugees (UNHCR). She was pregnant with her fi rst child and arrived without her husband, Muang. He had travelled with her in a small group from Myanmar but after being pushed into separate cars, they had lost each other. Their group had walked through pitch black jungles at night, holding on to the person walking in front of them so as to not get lost.

They travelled by car, boat and eventually plane to reach asylum in Australia. Can Te explains her experiences of being lost, scared, hiding in the jungle, jumping out of leaky boats to swim to safety, being fed once a day and some days not being fed at all. When she arrived in Australia she says she “(had) no worries and I didn’t think (about) nothing. I just hoped my husband would come.” All she could do was protect her new baby “like an egg.” Muang was reunited with his wife and his 7 month daughter, Grace, 1 year later. By the

time Grace was 2 years old, Can Te was ready to join the work force. And so began her determined journey to reaching her dream.

Before coming to Australia, Can Te had moved around to different areas with her family. Her parents encouraged her to learn the local dialects and thus her multilingual skills fl ourished. Can Te can speak the national language, Burmese, and many Chin dialects including Haka, Senthang, Zotung, Matu, Zophei and Falam, not to mention English and a few Chinese and Filipino phrases! Initially the hardship of moving often and learning new languages was a burden. However her language skills have proven to be a unique characteristic in defi ning her role as a well respected and sought after interpreter in Melbourne. Her work has provided a means to support her family of four, engage with her community, local organisations, strengthen leadership skills and be a role model to others. Her dream is to support the Chin people to take initiative, volunteer, learn and develop skills and knowledge to sustain a happy and healthy life in Australia.

Can Te began volunteering as a community helper interpreting documents and bills for the Chin people. She speaks of the “Aussie accent” being diffi cult to understand at fi rst. But saw the value of volunteering as it was a “good way to get experience”, especially for future interviews and work opportunities. Can Te worked for Brimbank City Council, Maribyrnong City Council, MacKillop Family Services, Legal Aid, Oncall Interpreting Services, VICSEG and Foundation House. In 2012, she met with Natasha Wilton, a Dietitian at Djerriwarrh Health Services (DjHS). She provided interpretation for a new Chin Nutrition Program. Natasha introduced Can Te to the Refugee Health Nurse, Nicola Harman, who supported newly arrived refugees in the City of Melton. They developed the Chin Women’s and Children’s Playgroup and Can Te’s previous experience and strong rapport building skills began making an impact on the Melton Chin Community. The Chin Community now see Can Te as their advocate, leader and reliable friend. Can Te explains she is “proud to help my community and thankful for Djerriwarrh’s support.”

Strengthening Multicultural Communities

“Not just one day, but for every day”

The journey of a multilingual interpreter who became an inspiring community leader.


The Strengthening Multicultural Communities (SMC) Project aims to promote mental health and wellbeing by creating socially inclusive and connected communities with the City of Melton and Moorabool Shire by 2017.

Over the last 12 months, the Melton Chin Community has participated in a Needs Assessment, Assets Building workshops and community meetings to develop a clear plan of what they hope to achieve.

Their participation in group consultations, event planning meetings and successful events has increased their leadership and organisational skills. Their input at every step of the way has resulted in project ownership and a sense of community pride.

Natasha Wilton has been working at Djerriwarrh Health Services for 6 years as

an Accredited Practising Dietitian and Health Promotion Offi cer. The multifaceted nature of nutrition and dietetics has meant

she is involved in disease prevention work, clinical and community dietetics.

She works with patients in the community health centres, Melton Health’s satellite

haemodialysis unit and various group programs in the City of Melton and

Moorabool Shire. Natasha is also funded to manage a health promotion project. In 2013, she initiated the development

and facilitation of the “Strengthening Multicultural Communities Project” which

is part of DjHS Integrated Health Promotion Plan. This role has facilitated the formation

of strong linkages with newly arrived refugees, migrants and key stakeholders

in the western suburbs. She has a keen interest in working with culturally and

linguistically diverse communities towards better health and wellbeing, through

community initiatives which empower people to implement sustainable solutions.

Chin Community Playgroup


Robyn visits Melton Health, Day Medical Unit every three weeks.Robyn has started coming to Melton Health for her regular infusions of Intragam. She had previously been receiving the blood product at Western Hospital but found the travelling too much for her and wanted to be treated close to home. Robyn has a neurological condition called Chronic Infl ammatory Demyelinating Polyneuropathy (CIDP). This condition results in slowly progressive weakness and loss of feeling in the legs and arms. It is caused by the body’s immune system inappropriately reacting against and damaging myelin. Myelin surrounds the peripheral nerves and acts like an insulator so the nerves can conduct impulses properly. CIDP can occur at any age and is more common in men than women. Symptoms include tingling, numbness or altered feeling which often begins in the feet and hands, weakness of the arms and legs and fatigue and aching pain in the muscles.

Robyn fi rst noticed symptoms in 2009 of tingling and weakness in her legs and was unable to walk unaided. After being diagnosed with CIDP she started on Intragam infusions once per month and a rehab program and her symptoms improved but never went away completely. The infusions are now every 3 weeks as the response to treatment doesn’t last as long. Once a very active person Robyn is determined not let her condition hold her back but has found she cannot be as active or independent as she was. Having her treatment at Melton Health is much easier for Robyn and her family as she is unable to drive anymore.

Intragam is an infusion of immunoglobulin’s obtained from plasma. The Red Cross blood service uses the red cells from donations for transfusions and use the straw coloured plasma to make other blood products. It takes 24 blood donors to make the 36g dose that Robyn receives each month. Immunoglobulin infusions are given intravenously to stop the immune system from attacking itself. Without this essential treatment Robyn would end up in a wheelchair and unable to care for herself so she is very grateful to the generous blood donors who provide this freely.

Djerriwarrh Health Services (DjHS) recognises the diversity of the community in which it works. This year, the DjHS Diversity Action Plan has been further developed to specifi cally identify and streamline the work that we are doing across our services in order to support access and inclusion for people from a diverse background. We have two diversity action plans, one for our Grampians region and one for North West Metro. Both Diversity Action Plans encompass people:

• with disabilities

• from culturally and linguistically diverse (CALD) backgrounds

• from Aboriginal and Torres Strait Islander backgrounds

• with Dementia

• experiencing fi nancial disadvantage (including people who experience or are at risk of homelessness)

• living in rural and remote areas

The DjHS Diversity Action Plan goals are to ensure there is a respectful and responsive approach to planning services that acknowledges all people in our community. We aim to provide equitable access to services for all those eligible, regardless of their diversity or disadvantage. In undertaking the actions of these plans, the Health Service has also included the Key Result Areas required under the ‘Improving Care for Aboriginal and Torres Strait Island Patients (ICAP)’ program outlined by the Department of Health.

Our diverse community

Our patient story


These Key result areas are:

• Key Result 1: Establish and maintain relationships with Aboriginal communities and services

• Key Result 2: Provide or coordinate cross- cultural training for hospital staff

• Key Result 3: Set up and maintain service planning and evaluation processes that ensure the cultural needs of Aboriginal people are addressed when referrals and service needs are being considered, particularly in regard to discharge planning

• Key Result 4: Establish referral arrangements to support all hospital staff to make effective primary care referrals and seek the involvement of Aboriginal workers and agencies

DjHS has a working party made up of executive support, managers and staff that work across the health service working closely with the Community Advisory Committee to ensure compliance and commitment to the Diversity Action Plans. DjHS continues its commitment to supporting people from a CALD background and ensuring we are responsive to cultural needs through the Diversity Action Plans and by meeting the following standards outlined by the Department of Health: (www.health.vic.gov.au/cald).

Standard 1: A whole of organisation approach to cultural responsiveness is demonstrated.The DjHS Diversity Action Plan incorporates the six standards of the cultural responsiveness framework and works to meet these standards through a whole organisation approach. The DjHS Diversity Working party supports the Action Plan and includes representatives from all sites and services. The Consumer Advisory Committee also provides feedback and works to support access for clients from a diverse background. The DjHS Language Services policy (reviewed and updated in July 2014) ensures that we meet standards set out in the Department of Human Services Language Services Policy.

Standard 2: Leadership for cultural responsiveness is demonstrated by the health service.An Executive Director is responsible for ensuring work within the Diversity Action Plan is completed and reported to the Chief Executive. A new staff member has been appointed to the position of Manager of Organisational Development and completed a vocational graduate certifi cate in consumer engagement. This position encompasses the work that is outlined in the Diversity Actions Plans and supporting all staff across the health service. Managers continue to undertake training in cultural responsiveness, and this process has been formalised through the Diversity Action Plan.


Standard 3: Accredited interpreters are provided to patients who require one.The DjHS Language Services Policy in combination with staff education ensures staff are able to identify when an interpreter is required and to ensure that this occurs. Victorian Interpreting and Translating Service (VITS) accredited interpreters are utilised across DjHS. Reception areas across the health service, now have interpreter service symbols on display for all of our consumers. DjHS will be conducting audits of patient records to determine if there are any consistent circumstances which have led to an interpreter not being provided.

Standard 4: Inclusive practice in care planning is demonstrated, including but not limited to dietary; spiritual; family; attitudinal and other cultural practices.Care plans are utilised across DjHS and aim to ensure any aspects of care needs relating to diversity are identifi ed and understood. Care plans are under review to ensure they are consistent with set criteria to ensure we have a consistent approach. Staff education will help to support staff when engaging with clients from diverse backgrounds, to ensure they are comprehensive in their approach to meeting clients’ needs. Feedback from CALD clients on the provision of care and treatment will be used to inform the review of care planning.

Standard 5: CALD consumers, carers and community members are involved in the planning, improvement and review of programs and services on an on-going basis.DjHS already has strong links with community groups

representing clients from diverse backgrounds. There has been considerable work undertaken within the Diversity Action Plan, to better understand the diversity represented within our community and to seek feedback regarding any barriers to accessing our services. We work closely with other agencies to ensure we serve all people in our community. From our Community Health Service we offer many services engaging our diverse communities the list of these services can be found in our new ‘Community Health’ brochure.

Standard 6: Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness.Cultural education sessions have been conducted across the health network for all staff to attend. All staff undertake training regarding working with clients from a CALD background as part of their orientation to DjHS. Education sessions such as Health Literacy, Health Promotion for Aboriginal and Torres Strait Islander, Melton Burmese and Chin community and Strengthening Multicultural Communities are some of the education sessions that have been provided. As part of our Diversity Action Plans, a future goal for DjHS is that in partnership with the Department of Health, we can develop an online training module for Cultural diversity for all of our staff.

Our diverse community continued


Breakdown of complaints All complaints are received by the Chief Executive and investigated by an Executive member. Complaints allow us the opportunity to identify when improvements in our health care can be made.

The majority of the complaints were varied, however the most commonly received were around:

• Waiting times

• Costs of ambulance transfers

• Perceived rudeness, unprofessional behaviour of staff

• Alleged breach of confi dentiality

Complaints 2012/2013 2013/2014Bacchus Marsh and Melton Regional Hospital (BMMRH) - Emergency Service 17 18

Melton Health – Women’s and Children’s Program 8 12

Melton Health - Urgent Care 8 10Melton Health – Dental Services 9 4Community Health 6 4BMMRH – Theatre Services 2 3Melton Health – Reception / Intake 5 11Maternity 2 4BMMRH - Medical Surgical 4 5Melton Health – Adult Health Program 2 0BMMRH - Medical Specialist 1 5Residential Care 2 2Volunteers 4 0Support Services 5 0Total 75 79

Measuring the care we provide to you.


The Victorian Patient Satisfaction MonitorThe Victorian Patient Satisfaction Monitors is a tool by which we can assess the level of adult patient satisfaction with the care provided by the State’s public hospitals. Consumers are sent surveys following discharge from hospital.

SummaryPatients were generally satisfi ed with most aspects of their stay at Djerriwarrh Health Services. The hospital is typically performing on par with the average.

The majority of patients reported that they were helped a great deal by their stay in hospital and felt that the length of time spent in hospital was about right. Extremely high performance scores were obtained for the items ‘Being treated with respect’, ‘How well cultural/religious needs were met’, ‘Courtesy of nurses’, ‘Personal safety’ and ‘Help received for pain’. The score for the item ‘Courtesy of nurses’ was highly correlated with overall satisfaction, making it a key driver of satisfaction. Consistent with the key drivers of satisfaction, qualitative analysis revealed that 33% of the sample made positive comments about the ‘Staff’ in response to the question ‘What were the best things about your stay in hospital?’. Taken with those items with high performance scores, this underlies the importance of maintaining a courteous, respectful and helpful staff, in a safe hospital environment.

The lowest scoring items which are strongly related to overall satisfaction are:

- ‘Restfulness of hospital’;

- ‘Amount of time given to plan going home’; and

- ‘Clarity of information’.

Targeting quality improvement efforts toward these areas are likely to have the greatest impact on overall satisfaction. Consistent with the lower scoring items, qualitative analysis revealed that 9% of the sample made suggestions to ‘Improve rooms and facilities’ in response to the question ‘What could the hospital do to improve the care and services it provides to better meet the needs of patients?’.

Victorian Patient Satisfaction Monitor – Wave 24: January 2013 to June 2013

Consumer Participation

Discharge and Follow-up

Physical Environment

Complaints Management

Treatment and Related Information

General Patient Information

Access and Admission

Overall Care

All Hospitals Category C Hospitals Djerriwarrh Health Services

60 65 70 75 80 85 90

Overall Care Access & Admission

GeneralPatient

Information

Treatment & Related

Information

ComplaintsManagement

Physical Environment

Discharge & Follow-up

ConsumerParticipation

808485

788282

848888

818485

828587

778381

788284

828586

All HospitalsCategory C HospitalsDjerriwarrh Health Services

Benchmark data comparing Djerriwarrh Health Service with Category C (same hospital category) and/or to Statewide hospital benchmarks


Grant Lodge is one of nearly 200 aged care facilities operating within the Victorian State Health system, we are continually looking at ways to improve services. The Quality Indicators project requires each home to collect certain information about the health of its residents and regularly report this to the government. This information does not include the name or any personal details of individual residents.

Grant Lodge collects and reports information related to the following fi ve areas:

1. Pressure ulcers, also known as pressure sores or bed sores

2. Falls by residents, and broken bones arising from falls

3. Physical restraint of residents

4. The number of medicines residents use

5. Unplanned loss of weight by residents

Quality Indicators are tools or guides that support quality systems and can be used to improve practice at an individual level or at a systems or organisational level. Grant Lodge compares this information with other periods of time and with data from other similar services. Such comparisons are used to monitor and assess performance, identify examples of good practice and identify areas for further investigation.

1. Pressure UlcersDuring 2013-2014 Grant Lodge have remained consistently below the State wide high care rates. Our interventions include regular repositioning using correct manual handling techniques to minimise friction, pressure reducing equipment such as air mattresses and pressure reducing cushions. Nutritional supplements are also provided to residents who are at high risk of developing pressure injuries.

2. Falls and broken bonesNo resident has sustained any broken bones from falls during 2013-2014. Interventions in place include full assessment by a physiotherapist on admission with 3 monthly reviews. Staff ensure rooms and corridors are free from obstacles and clutter, that residents use appropriate mobility aids and are supervised as required. The use of fl oor line beds, bed alarms, crash mats and hip protectors also reduce the possibility of broken bones or other injury from falls.

The actual number of falls has reduced over this period as a result of our fall prevention strategies. We have a falls prevention champion and a program which includes:

• Assessment and care planning,

• Identifying appropriate fall prevention strategies

• Communication between shifts with handover, communication book, care plans

• Data collection and analysis on falls.

Public Sector Residential Aged Care Services (PSRACS)

Quality Indicators

Indicator 1: Prevalence of Pressure Ulcers (per 1000 occupied bed days)

No. of Stage 4 Pressure UlcersOur Rate 0.00Overall State-wide Rates 0.03State-wide Low Care Service 0.04State-wide High Care Rates 0.04

Indicator 2: Prevalence of Falls and Fall-related Fractures (per 1000 occupied bed days)

Falls RateOur Rate 3.36Overall State-wide Rates 6.83State-wide Low Care Service 5.57State-wide High Care Rates 7.26Fall related Fracture RatesOur Rate 0.00Overall State-wide Rates 0.18State-wide Low Care Rates 0.21State-wide High Care Rates 0.18


Indicator 3: Incident of Physical Restraint (per 1000 occupied bed days)

No of intent to RestrainOur Rate 0.00Overall State-wide Rates 0.51State-wide Low Care Service 0.10State-wide High Care Rates 0.69No of Physical Restraint DevicesOur Rate 0.00Overall State-wide Rates 0.39State-wide Low Care Rates 0.11State-wide High Care Rates 0.58

Indicator 4: Incidence of Residents Prescribed Nine or More Medicines (per 1000 occupied bed days)

Our Rate 2.52Overall State-wide Rates 4.32State-wide Low Care Service 4.42State-wide High Care Rates 4.47

Indicator 5: Incidence of Unplanned Weight Loss (per 1000 occupied bed days)

Rates of residents with Weight Loss >3kgOur Rate 0.84Overall State-wide Rates 0.66State-wide Low Care Service 0.49State-wide High Care Rates 0.76Rates of Residents with Weight Loss each monthOur Rate 0.84Overall State-wide Rates 0.59State-wide Low Care Rates 0.47State-wide High Care Rates 0.64

3. Physical restraints of residentsPhysical restraints can include bed rails, seat belts and chairs with locked tables. Grant Lodge fi gures remain below the State wide high care rates as we promote an environment that minimises the use of restraint.

4. The number of medicines residents useDuring 2013-2014 there has been a downturn in the number of medicines used by residents. In analysing the data it was noted that residents prescribed more than 9 medications are those with multiple illnesses. Medication reviews are periodically conducted by the pharmacy and recommendations made to doctors. The nurse in charge also reviews medications with doctors to determine the necessity and effectiveness of the prescribed medication.

5. Unplanned loss of weight by residentsSignifi cant weight loss is defi ned as weight loss equal to or greater than 3 kilograms over a three month period. To identify residents who are losing weight, each resident is weighed at least monthly. Those who are at high risk of losing weight are weighed weekly or fortnightly and referred to the dietician and/or speech pathologist if required. Nutritional supplements are provided for those residents who are no longer eating well. During the 2nd quarter of 2013-2014 Grant Lodge data was well above the State wide high care rates.


Margaret Herring RN at Grant Lodge

Two buses are owned by Grant Lodge.

These buses are used to transport residents

to outings at no cost to the resident.

Residents enjoy a variety of activities which include day

trips, parks, picinics, luncheons and

many other activities throughout the year


The Consumer VoiceDjHS is keen to recruit Consumer Representatives to be involved in our health service. What are the benefi ts of being a Consumer Representative?

Consumer Representatives will:

• have the opportunity to provide valuable feedback

• be provided with opportunities to be involved with Djerriwarrh Health Services committees and focus groups

• have the chance to raise any concerns and suggestions

This year Ken Polmear retired

(aged 84) after 21 years of volunteering with

Consumer Transport.

We would like to thank Ken and all volunteers for their hard work and

acknowledge their contribution to the

community.

One of the most valuable assets our organization has, is the volunteer. DjHS is fortunate enough to have over 250 volunteers.

Whether fundraising like the Ladies Auxiliary and Kiosk Volunteers or providing a service to the public through Meals, Transport and Visiting, or bringing comfort to the ill and bereaved. Helping people negotiate their way through modern technology, concierges at Melton Health (directing patients who are unsure where to go) or providing long term, post crisis support to women survivors of family violence, Djerriwarrh Health Services is proud and privileged to have such a dedicated and caring team of volunteers.

Our amazing Volunteers

• be proactive representatives for other community members

• have opportunities to be involved with hospital redevelopment committees

For more information or to express your interest, please contact the Chief Executive, on 5367 2000, or pick up a brochure.

Ken Polmear and his wife Dorothy with Chris Frost Volunteer Co-ordinator

One of our great volunteers Mrs. Jeanette Thomas


Health LiteracyIn 2013 DjHS received a grant from Medicare Locals to action work in the area of organisational Health Literacy. Health Literacy can be defi ned as ‘a person or community's ability to obtain, process and understand basic health information and services to make appropriate health decisions’. DjHS recognises that services need to be accessible, easy to navigate through, and that we need to provide information in a manner that is easy to understand to individuals and community members. The grant allowed for a 6 month, 2 day a week, Project Offi cer to action work in this area. Work that has been completed during this period includes an organisation wide Health Literacy Policy, a Document Design Guide which clinicians can utilise when developing written materials, organisational wide templates for the development of brochures, fact sheets and handouts. In addition an organisational online survey was created to determine staff understanding and areas for training opportunities was undertaken.We would like to thank Kerryn Jorgensen and Shannyn McDevitt for all their work and education sessions they provided.

Advanced Care PlanningDjerriwarrh Health Services has recently introduced an Advance Care Planning (ACP) procedure utilising the Respecting Patient Choices planning model. Advanced Care Planning is a process whereby a person, in consultation with their health care provider, family members and important others, make decisions about their future health care, should they become incapable of participating in any medical treatment decisions. Advanced Care Planning support is now available to all adult Djerriwarrh Health Services patients admitted to inpatient clinical areas including Renal Dialysis, Palliative Care, Grant Lodge and Community, Home and Community Care (HACC)clients.

Recognition of Achievements

Shannyn McDevitt


Productive WardProductive Ward- releasing Time to Care is a quality improvement system that provides staff with the skills to examine their own practices and provide the solutions that work the best for them in the ward. It focuses on improving ward processes to release more time for nurses to provide direct patient care. This time allows nursing staff to improve the quality, safety and experience of care provided to patients.

Training was provided for 6 staff in August 2013. Five staff from the Medical/Surgical Unit were selected to roll out the Productive Ward. The Nurse Unit Manager of the Medical/Surgical Ward and the Director of Nursing were also part of the team.

The Productive Ward training included modules which are designed for self-directed learning at ward level.

The team started by submitting a proposal and ward vision to the Executive management team to commence the journey. The Vision Statement and Aims were chosen by the ward staff and are proudly displayed in the centre of the ward for patients, visitors and staff to see.

To create a solid foundation the ward team decided to commence Knowing How You Are Doing (KHWD) and Well

Organised Ward (WOW). ‘KHWD’ took six

months to complete. It has required the greatest culture change and has been the most challenging so far. Ward staff seemed to embrace ‘WOW’ as it was quicker to implement and involved some quick wins for the ward.

The ‘KHWD’ was aimed at developing ward based measures to help the team make informed decisions. The measures chosen by the Medical / Surgical ward team are, falls, pressure injuries, nursing medication errors, deteriorating patient chart audit, hand hygiene audit, staff satisfaction survey, nurses sick leave and direct care time. The ward measures are displayed monthly on a central board in the ward and team meetings are held around the board monthly to discuss and plan last months results and develop actions. The ‘KHWD’ board operates as a ‘score board’ for the unit, to know how they are tracking and to use facts and data to decide where they should focus their improvement efforts.

The aim of Well Organised Ward (WOW) was to make improvements to the ward areas, for example de cluttering and colour coding the store room. This enabled the staff to fi nd things in the store room quicker and with fewer interruptions. ‘WOW’ also had a cost saving benefi t -the reduction of hoarding excess and unused stock.

Patient Status At A Glance (PSAG), is the fi nal foundation module and is currently in its trial phase.

‘PSAG’ is the use of visual management to show important patient information so it can be updated regularly, seen at a glance and used effectively. The team is currently holding regular meetings and gathering staff feedback in order to fi nd out staff needs and expectations.

So far ‘PSAG’ has been very engaging.

The Productive Ward has been both challenging and rewarding.

The team was very proud to receive the ‘Qualitis Productive Ward’ award for 2014.

The team will continue working through the self-directed modules, to achieve signifi cant and sustainable changes and have fun along the way.

Melissa Shand, Louise Ford. Absent: Julia Meek, Darlene Fernandez, Theresa Wren, Paul Hilder


DentalDjerriwarrh Health Services was honoured this year to receive a “People in Health” award, which was a fi rst time honour to recognise those who had demonstrated exceptional commitment, dedication and passion in their work across clinical education, training and workforce development. The Minister for Health award recognised Djerriwarrh Health Services for its partnership with La Trobe University in training fourth and fi fth year dental students.

Djerriwarrh Health Services continues to run twelve public dental chairs located at Melton Health which offer general, denture and emergency treatment to eligible patients.

Two dental chairs are assigned to a qualifi ed dentist or dental therapist and assisted by a qualifi ed dental nurse. Ten dental chairs are allocated to La Trobe University students; a total of 7,337 individuals were treated in 2013-2014.

This year our Dental Service was able to recruit additional dentists to open evening sessions fi ve nights per week. Under the National Partnership agreement for decreasing public dental waiting lists we worked to provide additional dental services to eligible adults in our community. As a result of this initiative, the wait for dental services was signifi cantly decreased and many adult patients benefi ted by receiving dental care sooner than expected. The waiting time for general dental care for adults reduced to 6.5 months, for denture care to 3.5 months and high priority denture care to 1.5 months.

Latrobe University Dental Students at work


Feedback from consumers and their families provides an opportunity for the hospital to identify issues where improvements are required to make positive changes to improve our health servicesDjerriwarrh Health Services has: Opportunity for improvement, Complaints and Compliments forms.

We encourage our patients and their family members to provide us with feedback via email, telephone, in person or via one of our forms as above. Djerriwarrh Health Services has implemented new mailboxes in key reception areas around our hospital, so patients, family members or members of the general public can provide us with feedback. This feedback is collected each week and sent directly to our Chief Executive.

Our Chief Executive views and follows up every Compliment, Complaint, and Opportunity for Improvement that our Health Service receive. Ideally most complaints are dealt with as they occur. DjHS has strict policies and procedures in place to deal with complaints as quickly as possible. Internally we monitor our complaints on a monthly basis, a complaints register is maintained and the progress of complaint resolution is closely monitored. The Board receive a monthly report of all complaints received by DjHS. We endeavour to provide all patients with a ‘Rights and Responsibilities’, brochure and they are also located at reception areas and wards.

Have your say

Angela Mayhew, Manager of Health Information


We appreciate your feedbackPlease provide us with feedback on the form attached, regarding our Quality of Care Report. Our Community Advisory Committee also provided feedback on the report through their meetings.

Distribution of this reportThe 2013-2014 Quality of Care Report will be distributed to health care partners, GP clinics and community leaders. Copies will be available in Djerriwarrh Health Services foyers and on our website: www.djhs.com.au

What do you think of the Quality of Care Report?Please complete this survey and return to:

Chief Executive, P.O. Box 330 Bacchus Marsh Victoria 3340

Did you fi nd this report easy to understand? (please circle) Yes No

What did you like most about this report?

What information would you like to see in this report?

Do you have any suggestions or feedback on other services Djerriwarrh Health Services could offer the community?

Thank you for your comments

Feedback



The 2013-2014 Quality of Care Report is distributed to the Community via

our website, various distribution points in the hospital and was sent to out to community group leaders and GPs.

We trust you will enjoy reading the report and we are looking forward to many

more improvements in our service for you in the coming year.


Bacchus Marsh & Melton Regional Hospital:

Grant Street, PO Box 330Bacchus Marsh VIC 3340

Ph: +61 3 5367 2000Fax: +61 3 5367 4537

Melton Health:

195-209 Barries RoadMelton West VIC 3337

Ph: +61 3 9747 7600Fax: +61 3 8746 2072

Grant LodgeResidential Aged Care:

6 Clarinda Street, PO Box 330Bacchus Marsh VIC 3340

Ph: +61 3 5367 9627Fax: +61 3 5367 8023

Bacchus Marsh Community Health Centre:

Turner Street, PO Box 330Bacchus Marsh VIC 3340

Ph: +61 3 5367 9674Fax: +61 3 5367 4274

Caroline SpringsCommunity Health Centre:

Level 1, 13-15 Lake Street Caroline Springs VIC 3023

Ph: +61 3 9361 9300Fax: +61 3 9361 9399

Melton Community Health Centre:

Cnr. High & Yuille Street,PO Box 3, Melton VIC 3337

Ph: +61 3 8746 1100Fax: +61 3 9743 8640

Documents

Djerriwarrh Health Services Quality of Care Report 2013/2014€¦ · incidents are recognised, reported and analysed, and this information is used to improve safety systems. This