QUALITY OF CARE REPORT 2012 - Parliament of Victoria · 2013. 6. 12. · Models of care provided are GP led care and public antenatal care. ... QUALITY OF CARE REPORT 2012 . THE KILMORE

THE KILMORE & DISTRICT HOSPITAL

QUALITY OF CARE REPORT 2012


The Kilmore & District Hospital is a Publicly Funded Community Hospital and is

Fully Accredited with the ACHS and ACSAA Care

ACUTE WARD • 30 bed inpatient ward – medical, surgical, maternity and palliative care.

Referral via local GP

MATERNITY SERVICES • Comprehensive Maternity Services provided.

• Models of care provided are GP led care and public antenatal care. Referral through GP or self referral possible

OPERATING THEATRE • Types of surgery include Ear, Nose & Throat, Orthopaedic, Gynaecology, Urology and General surgery.

Referral through local GP to visiting specialists.

24-HOUR URGENT CARE CENTRE • Our Urgent Care Centre is open 24 hours per day and staffed with experienced Nurses who are able to provide first

line care.

• Local General Practitioners support the department on an on call basis.

DISTRICT NURSING SERVICES

• Home nursing care provided including personal care, specialist wound care, administration of intravenous medication, post surgical follow up care. Referral through GP, Hospital or self referral.

DIAGNOSTIC SERVICES • Healthscope Pathology undertake blood tests and Electrocardiograph testing on site.

• Capital Health Radiology provide X-ray, CT scanning and Ultrasonography. Referral via local GP

RESIDENTIAL AGED CARE • 30 bed Caladenia Nursing Home and 30 bed Dianella Hostel (Respite Available)

• Providing residential aged care for elderly people with high nursing care needs and also those who require assistance with their activities of daily living.

• Applications can be made directly to Dianella Hostel and Caladenia Nursing Home once the Aged Care Assessment Team has undertaken the required assessments.

CONSULTANT SPECIALISTS

• Gynaecology, General Surgery, Cardiology, Cancer, Urology Referral via local GP

For further information, please telephone 5734 2000

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Contents

Introduction ................................................................................................................................................... 2

Community .................................................................................................................................................... 2

Consumer, Carer and Community Participation ................................................................................... 3

Improving Care for Aboriginal and Torres Strait Islander Patients ................................................... 4

Staff Health and Well Being ........................................................................................................................ 7

Volunteers ...................................................................................................................................................... 8

Compliments and Complaints.................................................................................................................. 10

Urgent Care Centre (UCC) ..................................................................................................................... 12

Operating Theatre Services ..................................................................................................................... 13

Radiology ...................................................................................................................................................... 13

Aged Care .................................................................................................................................................... 14

Risk Management ........................................................................................................................................ 17

Infection Control ........................................................................................................................................ 19

Transfer of Care Project 2012 ................................................................................................................ 22

Day Oncology Unit .................................................................................................................................... 23

Maternity Services ...................................................................................................................................... 24

Acute Ward ................................................................................................................................................. 25


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Introduction It is with pleasure that I introduce the 2011/12 Quality of Care Report. The purpose of this report is to inform our community and other interested parties about the services we provide and highlight how we are improving the quality of those services.

We are proud of the services we provide, within the context of a small rural health service. We recognise that we are not the provider of all services. Our vision however is to be your “preferred provider and facilitator for whole-of-life health related services”. If we do not provide the service, we will help you navigate the health system to attain the services you need.

We continue to strive to improve the range of services available for our community. In May 2011, we were approved for a $20 million redevelopment which will see our hospital grow from 30 to 60 acute beds. We will also build an outpatient facility which will accommodate a range of community services to improve the continuum of care. We are currently in the design phase of this project with construction expected to be completed by November 2014.

To enable wider access to this report you may obtain a copy though your local doctor’s surgery, pharmacies, post offices, Mitchell Community Health Service, Kilmore Library or a local real estate agency. The report may also be found on our internet site: www.kilmoredistricthospital.org.au.

Bart Ruyter, Chief Executive Officer

Community The Kilmore & District Hospital and Nursing Home provides comprehensive acute and aged care services to our rapidly increasing catchment population of 25,000 that extends to Broadford and Pyalong in the North, Wallan and Craigieburn in the South and Lancefield and Romsey to the West of Kilmore, Victoria, Australia.

The area is Taungurung country and was developed as a rural farming area by early Irish and Scottish settlers with sheep and cattle as primary industry. Today, Kilmore's strengths are in automotive, education, health, manufacturing, transport, horse racing, commerce, farming and tourism. (Kilmore Mechanics website, accessed 2012).

Kilmore is becoming a metro/rural ‘fringe’ town as we are an easy commute to the Northern suburbs and Melbourne. It is estimated several hundred people travel to Melbourne to work each day, an hour's drive or train ride from neighbouring Kilmore East. As such there is a growing commuter population entering the area. Population predictions project significant growth in the future.

PLEASE GIVE US YOUR FEEDBACK ON THIS REPORT Email: [email protected] Phone: 5734 2000 Letter: The Kilmore & District Hospital, Reply Paid 185, Kilmore 3764 Website: www.kilmoredistricthospital.org.au

mailto:[email protected]

http://www.kilmoredistricthospital.org.au/

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Consumer, Carer and Community Participation The Victorian Government’s Doing it with us not for us is a policy aimed at involving people in decision making about health care. The policy’s Strategic Direction 2010–13 includes five new standards for consumer, carer and community participation in Victorian public health services. The following table outlines our progress to date in meeting the participation indicators.

Table 1: Reporting against targets for “Doing it with us not for us”

Indicator % compliance achieved

Standard 1: The organisation demonstrated a commitment to consumer, carer and community participation appropriate to its diverse communities. 37%

Standard 2: Consumers, and, where appropriate, carers are involved in informed decision-making about their treatment, care and wellbeing at all stages and with appropriate support.

75%

Standard 3: Consumers, and, where appropriate, carers are provided with evidence-based, accessible information to support key decision-making along with continuum of care.

40%

Standard 4: Consumers, carers and community members are active participants in the planning, improvement, and evaluation of services and programs on an ongoing basis. 66%

Standard 5: The organisation actively contributes to building the capacity of consumers, carers and community members to participate fully and effectively.

Descriptive reporting – target

not applicable

COMMUNITY ENGAGEMENT GROUP In August we held our inaugural Community Engagement Group Meeting The Kilmore & District Hospital acknowledges the diverse attributes and skills of members of the community and the valuable contribution they make to enhance the environment for patients, residents, staff and visitors. The group will: • Advise us on strategies to enhance and promote consumer and community participation at all levels within

the Kilmore & District Hospital;

• Identify and advise on priority areas and issues requiring consumer and community participation and advocate on behalf of the community in regard to these issues;

• Assist the Executive in communication with The Kilmore & District Hospital consumers and community • Advise on major strategic issues and initiatives; • Assist in the development, ongoing monitoring and reporting of established key performance indicators; • Undertake projects and activities as agreed.


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Improving Care for Aboriginal and Torres Strait Islander Patients

The Kilmore & District Hospital is working to meet the goals and key result areas of the Improving Care for Aboriginal and Torres Strait Islander Patients (ICAP) program as outlined in the table below.

Table 2: Report on progress against key result areas of Improving Care for Aboriginal and Torres Strait Islanders.

Key Result Area Progress

Key Result Area 1 Establish and maintain relationships with Aboriginal communities and services

• Participating in Lower Hume Cultural Diversity Group which includes representatives from Aboriginal communities and services.

• Met with local elders at local health service planning meetings and groups

• During NAIDOC week, a presentation was made to the Dianella residents including Aboriginal bush culture, artefacts and history.

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

• Regional cross cultural training offered to staff • Attendance of staff at a number of cross cultural

workshops • Planned cross cultural in-service for staff

Key Result Area 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

• Equity of Access action planning underway to identify and implement improvements in this area.

• Transfer of care project working to develop consistency and cultural sensitivity in discharge planning and referrals.

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

• Access of equity working to address this. • Transfer of Care and supportive care project also

working to develop referral systems to meet these needs

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CULTURAL DIVERSITY Table 3: Report on progress of standards for cultural diversity planning

Goal Progress

Standard 1 A whole of organisation approach to cultural diversity is demonstrated

The Equity of Access working party comprises members from each part of the organisation and extensive representation for the community and culturally diverse groups. This group will work on the Action Plan to ensure that there is a consistent approach to cultural diversity issues. An Aboriginal staff member is a representative on this committee.

Standard 2 Leadership for cultural diversity is demonstrated

Both the Chief Executive Officer and Director of Nursing are members of the Equity of Access working party and there is executive representation on the Mitchell Cultural Diversity Committee.

Standard 3 Accredited interpreters are provided to everyone who needs one

Each patient admitted to Hospital is screened to determine the need for an interpreter. Interpreters are booked to be on site during days of surgical procedures in advance and the telephone interpreting service is utilised for unplanned attendances.

Standard 4 Inclusive practice in care planning is demonstrated, including but not limited to dietary, spiritual, family, attitudinal, and other cultural practices

Care planning for residents and patients identifies cultural needs and are addressed individually through assessment and discussion with the patient or resident. Identified needs are accommodated individually due to the nature of our small rural community approach.

Standard 5 CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis

Engaging with culturally diverse members of the community in the planning and review of programs occurs wherever possible, but can be challenging due to the low numbers of such people in our community. Demographic projections however indicate that this will change significantly in the future and it is the aim of the organisation to continue to improve and review these programs. Current volunteers come from diverse backgrounds and are able to provide both specific and general cultural input into lifestyle and wellbeing programs within Aged Care.

Standard 6 Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness

Staff are afforded time and resources to attend professional development opportunities and such education is encouraged. Staff at both Dianella and Caladenia have accessed training opportunities to support culturally sensitive practices and activities. Whilst the general uptake is currently low, it is anticipated this will increase as the numbers of culturally diverse members in the community grow.


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ACCREDITATION Table 4: Organisation accreditation status

Area Type of Accreditation Accreditation Period

Next Survey Due

Acute Hospital areas & DNS

Equip National 4 years March, 2013

Aged Care Aged Care Standards and Accreditation Agency (ACSAA)

3 years 2015 Assessment visits annually.

CARE COORDINATION The role of the Care Coordination Committee is to promote continuity of care throughout the whole episode of care and after discharge. This year we decided to merge a number of committees to promote an effective, safe and standardised approach to screening and care planning for residents, patients and consumers This committee merges, Surgical Processes, Transition of Care, Transfusion Safety and Quality, Supportive Care, Deteriorating Patient, and Clinical Handover. Focus is currently on Deteriorating Patient Management. This committee involves clinical leaders from all departments in the organisation.

The Aim is to ensure a patient’s deterioration is recognised in a timely fashion and appropriate action taken. A new simplified process with clear parameters for all age groups (neonates, paediatrics, adults) outlining when escalation of care should be triggered is being developed. Observation charts are being reviewed to increase our ability to review and monitor management of the deteriorating patient with incident forms completed for all urgent patient reviews. This ensures a proactive, transparent and timely review of all appropriate cases.

As of January 2013 all health organisations will be assessed for compliance against the National Safety and Quality Health Standards. Standard 9 relates to Recognising and Responding to Clinical Deterioration in Acute Health Care.

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PATIENT SATISFACTION The Kilmore & District Hospital participates in the Victorian Patient Satisfaction Monitor and each 6 months a sample of patients are sent questionnaires regarding their experience here. We receive a biannual report outlining responses received and our results show that patients are generally satisfied with the care and information we provide. However, in saying this, we recognise there is room for improvement The areas we have identified as opportunities for improvement this year are:

• Hand Hygiene – patient awareness of staff practices; • Information provided to patients regarding rights and responsibilities; • Information regarding how to make a complaint; • Information provided before admission.

The graph below illustrates our results in the past two reports – we will now implement strategies to improve in these areas.

Staff Health and Well Being The Kilmore & District Hospital takes the health and well being of our staff seriously. Numerous activities are conducted throughout the year to meet these needs. These include discounted fitness club memberships and health screening programs. All staff are encouraged to participate.

EAP Employee Assistance Program We have an Employee Assistance Provider and which offers confidential, professional support, advice and counselling to all of our employees.

• An Employee Assistance Program (EAP) is a work-based intervention program designed to enhance the emotional, mental and general psychological wellbeing of all employees.

• The aim is to provide preventive and proactive interventions for the early detection, identification and/or resolution of both work and personal problems that may adversely affect performance and wellbeing.

• These problems and issues may include, but are not limited to, relationships, health, trauma, substance abuse, gambling and other addictions, financial problems, depression, anxiety disorders, psychiatric disorders, communication problems, legal and coping with change.


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Volunteers Our hospital and aged care facilities continue to benefit from the ongoing support of our valued volunteers.

Money raised through the work of the Hospital Auxiliary enables the purchase of equipment for the direct benefit of residents and patients. This has included the purchase of a resuscitation trolley and a specialised wheelchair with an attached IV pole for the hospital. The acquisition of stools at Caladenia supports good back care for staff and volunteers during mealtimes. Enabling staff and volunteers to sit at equal levels with residents has increased the capacity for positive social interactions and conversations.

Volunteers dedicate many hours to running the Op Shop, which is open three days per week and raises much needed funds for the hospital. The Op Shop’s constantly updated supply of donated items has earned it a reputation as a ‘must go’ spot for seasoned op shoppers from Kilmore and further afield and is a valued community service.

Each week our fondly named 'flower ladies' arrange freshly cut flowers throughout the hospital, and in Caladenia and Dianella. As of June 2012 the volunteer support to residents living at Caladenia and Dianella has grown to approximately 170 hours per week. This support includes assistance during mealtimes, running planned activities such as daily Bingo, gentle hand massage and manicures, regular conversations, knitting for charity, personal shopping, special dining, community access, community radio, footy tipping, quizzes, entertainment and cooking. Students from both the Kilmore International School and Assumption College attend regularly during school terms to assist at mealtimes and for early evening conversations and activities with residents.

A key goal of our volunteer program is to increasingly support resident’s individual wishes and interests and to ensure that everyone enjoys opportunities to participate and engage with others either individually or in groups. A key component of this is increased involvement and access within our local community. This year a $2 500 donation from Mitchell Masonic Lodge and a $1500 donation from the Kilmore Lions Club supported community access for Caladenia and Dianella residents respectively.

A major goal for the coming year is to expand our volunteer program into the hospital setting, providing practical support to staff and patients.

We thank all our volunteers for their valued contributions which add that extra personal touch that is always difficult to manage within budgetary constraints. As one staff members commented to a volunteer during Volunteer Week in May, “You do what we would love to do if only we had the time.”

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LIFE BOOKS

Entering aged care is a significant life event. During the settling-in period staff undertake to support the new resident and the new family emotionally in various ways. The lifestyle staff at Dianella Hostel approached the staff and students at Assumption College seeking their assistance in developing Life Books for residents. Due to the large number of students wanting to be involved, the activity was expanded to also include residents at Caladenia.

Visiting schedules were established and students commenced visiting their chosen residents on Thursday 26 April 2012. Residents were asked to bring their memories, their knowledge, photos and other memorabilia to the meetings. Families were also invited to be involved in the process and before long staff found themselves needing to make appointments with residents around their “Life Book days” to deliver care.

Over the period of the activity, touching friendships blossomed and the programme culminated in a celebratory morning tea, DVD presentation and presentation of the completed books at Caladenia, complete with media coverage, on Thursday August 2.

Thirteen days after the presentation one of the residents involved passed away. She had been a resident at both Dianella and at Caladenia, so was well known to staff throughout the organisation. A fitting epilogue to her story was the acknowledgement of “her” students and the display of her Life Book at her funeral service.

DIANELLA ACTIVITIES

A number of visits and activities are organised throughout the year for our residents. Our community bus goes on outings for lunch and local shopping and visits were also made to other local venues including trackside for the Morning Melodies concert, the Children’s First Foundation and Broadford Secondary College. We have also received visits from local craft groups, displaying their dedicated craft and quilting which were very popular with residents.

A number of local performers visit throughout the year including line dancers, cloggers, folk, country and western singers, ballroom dancers and rock’n’roll dancers.

Other special services include Remembrance Day (with assistance from members of the Puckapunyal army barracks of the Australian Defence Force and the local Anglican Parish Priest from Kilmore); the Easter Egg hunt with families invited to help find the eggs and of course Christmas. Dianella invite families and friends to come together for the annual Christmas Party where it has become known that Santa will arrive on a Harley Davidson. We have many choirs visiting and we also hold our own Carols by Candlelight service.

In April 2012 we started listening to the “Memory Lane” program with Community Radio OKR 98.3 FM where residents phone in requests for their favourite songs. The program has become quite popular with many residents participating.


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Compliments and Complaints

COMPLAINTS

Complaints received from 1 January 2011 to 31 December 2011

2011 2010 2009 2008 2007 2006

Total Complaints 45 30 24 20 16 23 % complaints actioned within 14 days

98.8% 100% 100% 100% 100% 60%

Average days taken to close 8.4 9 4 5.2 3.81 11

The number of complaints increased again this year. Slight increases were noted in all areas. This may be as a result of staff becoming more comfortable and knowledge-able about registering the feedback via the Victorian Health Incident Management System (VHIMS). We continue to encourage staff to register feedback on the system even if they have resolved it at the time to help us to identify trends.

All complaints except one were actioned within 14 days and took an average of 8.4 days to close. The range of time to complete was from a low of one day to ongoing. Delays of longer periods of time reflect the number of people involved or the complexity of the solution. Type of complaint 2011 2010 2009 2008 2007 2006 % % % % % %

Lack of information 2 0 0 U 6 31

Communication 26 20 22 U 31 30

Concerns about care 26 30 16 U 37 13

Other 31 26 16 U 31 19

Environment 11 23 46

*U=Unavailable

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COMPLAINTS (Cont’d)

This year there was a noticeable increase in the number of complaints about service provision. There were six complaints registered about no doctor on call for the Urgent Care Centre and one complaint about the lack of radiology services available on the weekend. There was also a noticeable decrease in the number of complaints about the environment of the Hospital and Aged Care Services. This could be due to the painting last year and improved outlook. As a proportion of care episodes delivered over the course of a year this remains a very small number. Most complaints were resolved through discussion or with a phone call and letter. Feedback from patients and residents has led to a number of reviews and improvements including:

• Improved dialogue between the Food Services Department and the Residents of our Aged Care Services. These direct conversations are leading to improved satisfaction with the food provided to residents.

• Identification of a number of gaps in our procedures with the resultant development of procedures to guide practice.

• Identification of education and support needed for staff to develop better communication approaches with each other and patients/residents.

• Inclusion of consumer feedback in the development of our Access and Equity Plan

• Review of HR management and introduction of contact officers as first line response to bullying and harassment complaints

COMPLIMENTS

There are 38 compliments on file for 2011. The number is again down this year. Unfortunately, we continue to have difficulty embedding the practice of entering these onto the VHIMS system. It seems that Managers understand the importance of complaints to improve services and care, but see compliments as less of a priority. Compliments are displayed for staff at the unit level which at least gives them some positive feedback. Compliments were spread fairly evenly throughout the organisation with the exception of Acute which received the highest number of compliments. Compliments and complaints are an important mechanism for improving the quality of care provided. Many issues are resolved at the point of care. Formal feedback and outcomes are communicated directly to staff in the area where the feedback arises at staff meetings, may be communicated in the newsletter, and can be discussed at Quality and Risk Committee meetings. Feedback data and information is communicated to the community via this Report.


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Urgent Care Centre (UCC)

UCC PATIENT ATTENDANCE BY TRIAGE CATEGORY

NEW ELECTRIC BED FOR UCC

In June this year the Urgent Care Centre purchased their first electric bed. This Howard Wright Electric Bed was purchased with funds raised by the Garden Party. It is a requirement of the new Occupational Health and Safety Regulations that all new beds purchased are electric. Jeremy from Howard Wright and Cathy from UCC are pictured with the new arrival. EXTENDED SCOPE OF PRACTICE PROJECT

In April of 2012, the Urgent Care Centre successfully submitted a proposal to the Commonwealth Government to obtain a grant to extend the scope of practice of nursing staff in the Urgent Care Centre.

The extended scope of practice project will run for a period of 12 months beginning in September 2012. This ‘upskilling’ project is a pilot programme that if shown to be successful will be available to other rural hospitals throughout Australia to try to support medical staff workforce issues.

This, in effect, should improve productivity by improving patient flow, decrease waiting times for patients in UCC/ED and meeting Key Performance Indicators for triage times.

This project will give the Registered Nurses involved the scope to assess, order diagnostics, treat and discharge patients which will be of great benefit to the local community.

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Operating Theatre Services The operating theatre performed operations on 1185 patients in the last year. The introduction of a theatre 'on call' service enabled out of hours theatre availability for Caesarean births, both during the week and on the weekend. This has reduced the need to transfer unplanned Caesarean births to larger hospitals.

This year the hospital has continued to purchase equipment for the operating theatre, to ensure we meet standards and provide a high standard of care.

We are scheduled to install a new steriliser in September 2012. This is a major piece of work and required significant contingency planning to ensure the hospital maintains services. A new patient information booklet has been developed and provided to all surgeons to give to patients when booking in for surgery. This booklet informs the patient about their admission requirements, their pre-anaesthetic assessment and their fasting requirements. It assists patients to be informed and better prepared for their surgical stay at Kilmore & District Hospital.

A new surgical safety checklist and Team Time Out process have been introduced to improve communication and safety. The Team Time Out process is where the theatre team, consisting of Surgeon, Anaesthetist, Scrub Nurse, Scout Nurse and Anaesthetic nurse, formally confirm identification with the patient before any procedure is undertaken. This practice ensures the correct procedure is being performed, the consent form is correct, any allergies are noted, and that the fasting period has been observed.

Radiology Radiology has recently taken possession of a new L8-18i (Hockey Stick) transducer probe for its GE Logiq E9 Ultrasound Machine. This $20,000 device significantly improves detail when imaging small body parts such as fingers and joints. In addition, its highly compact size allows for improved accuracy when performing Ultrasound Guided Injections into joints such as shoulders.


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Aged Care Kilmore & District Hospital is very proud of its aged care facilities - Caladenia Nursing Home and Dianella Hostel.

ACCREDITATION — KEEPING UP THE STANDARDS

Our accreditation process assures the community we are providing a high standard of care. As well as actual clinical care, the process examines how the organisation is managed, how we minimise the risk of infection, how we are proactive in managing risk and how we are prepared to deal with emergency situations.

The Aged Care Standards and Accreditation Agency conducted our latest accreditation in July 2012. Once again we are proud to report that both the Nursing Home and the Hostel met the criteria for all 44 outcomes of the standards for the maximum period of three years.

Assessors commended all areas of the organisation on the standard of services provided, the cleanliness of the facilities and our focus on meeting our residents’ needs. It was very gratifying to hear one of the assessors, who was conducting her second audit at Kilmore, comment, “There is an air of excitement and camaraderie that can be felt in the air … it’s infectious!”

RESIDENT/RELATIVE SATISFACTION SURVEY — ARE WE GETTING IT RIGHT?

Accreditation results reflected the feedback we received from our annual Resident/Relative Satisfaction Survey.

In the interest of impartiality, it is our practice to have some of our volunteers assist residents with completing the annual Satisfaction Survey. This exercise in itself proved to be worthwhile in that the residents and relatives suggested the survey questions needed to be reviewed!

The survey aims to address all aspects of care and includes questions on personal care services, resident lifestyle and support services. Overall results were again very positive. Suggestions received have been formulated into action plans at both residences. Staff will be working towards implementing goals from the action plans in the near future.

AGED CARE QUALITY INDICATORS — SETTING TARGETS

We also monitor our performance in residential care via mandatory, quarterly submissions of Aged Care Quality Indicators to the Department of Health. These indicators include the prevalence of pressure ulcers, the number of falls and fall related fractures, unexplained weight loss, the incidence of restraint and the use of nine or more medications. They are measured per thousand occupied bed days and are benchmarked against all other public sector residential services in the State. Our figures are consistently under the state-wide figures in all areas except medication management which fluctuates across the reporting period.

Astrid (volunteer), Debbie Tremlett (NUM), Carmel Robinson (Aged Care Supervisor), Barbara Cummins

& Jenny Unsworth (Caladenia staff members) (Photo courtesy of the Free Press)

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MEDICATION MANAGEMENT

One of the most important services we provide to residential clients is to correctly manage their medications. Many of our clients have multiple health problems that require a combination use of multiple medications. Medicines are prescribed to improve the quality of life for the client, but need to be carefully monitored to ensure detrimental side effects are avoided. The range of medications prescribed and the frequency of their administration, challenges us to ensure there are systems in place to protect the health and wellbeing of our residents. On a day to day basis, staff monitor the administration, appropriateness and effectiveness of each resident’s medications. Medication incidents are reported via our Incident Reporting System and are reviewed through the Medication Management Committee. Medication management is assessed through the Accreditation system. Through the Aged Care Quality Indicator reporting system we monitor and report to the Department of Health, the number of residents who are receiving nine or more medications. The intention of this Indicator is to identify the potential risk of polypharmacy and flag the need for review of medications, rather than to scrutinise the day to day administration of medications. In addition, a “Residential Medications Management Review “(RMMR) is undertaken by an external Pharmacist on a regular basis. This comprehensive review is resident-focused, but involves collaboration between the medical practitioner, pharmacist, nursing staff, other health professionals and the resident. Findings are fed back to all relevant parties and recommendations for change are considered. The review determines whether:

• there is a clear indication for continuing therapy with each medicine;

• the dose and frequency appear to be appropriate for that indication;

• the dose form is appropriate for that consumer;

• there are contraindications (due to previous allergies/adverse medicine events or clinical conditions);

• the consumer has been taking the medicine as prescribed or directed;

• the medicine has been achieving the goals of therapy;

• there are any medicines that have been inadvertently omitted;

• there has been appropriate monitoring of the medicine (e.g. serum levels/biochemistry, intolerable side effects);

• there are detrimental interactions with other medicines or food. Reviews undertaken at Kilmore over the last two years have identified the need for minor changes only. Although our data indicates we are using more medications than other similar facilities, feedback from our most recent Medication Review indicates our medication management is appropriate given that we care for residents in the terminal stages of life in our Hostel and Nursing Home, rather than admit to acute care and that our residents have complex medical conditions requiring complex medication management.

http://www.agedcareaustralia.gov.au/internet/agedcare/publishing.nsf/Content/Leaving+Aged+Care+Website?OpenDocument&to=http://www.health.gov.au/internet/main/publishing.nsf/Content/medication_management_reviews.htm


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The following tables show the comparison between the Statewide average incidence of medications compared with of the Hospital’s Aged Care Facilities.

Dianella Hostel Caladenia Nursing Home

MEDICATION MANAGEMENT COMMITTEE

The purpose of our Medication Management Committee is to ensure we comply with legislative requirements as outlined in the Drugs, Poisons, and Controlled Substances Regulations and meet Standard 4 of the National Safety and Quality Health Service Standards. The overarching aim is the safe prescription, dispensing and administration of appropriate medicines to patients and ensuring residents/carers are informed regarding the treatment provided. With this in mind we have been working on two major projects over the last 12–18 months: (1) Antibiotics — Appropriate Use Antibiotic resistance is a hot topic of conversation. The over prescription/overuse of antibiotics over many years has resulted in them not always being effective in treating infections.

Antimicrobial Stewardship (AMS) refers to the appropriate use of antibiotics. AMS is an effective way for healthcare services to improve their antibiotic prescribing habits and outcomes for patients.

Kilmore & District Hospital has established an AMS working party to review our prescription and use of antibiotics. Staff receive regular feedback and education on the appropriate use of antibiotics. The aim is to make a difference at a local level and provide optimal outcomes for our patients and the broader community.

(2) Labelling of Injectable Medicines This project involves the standardisation of labelling for injectable medicines, fluids and lines. The purpose of this procedure is to promote safer use of medicines and assist health care professionals to identify the correct medicine and correct route of administration at all times.

As part of our Medication Management and Safety Program we regularly monitor and review Medication incidents. We encourage reporting to allow us to identify and monitor trends, with the aim of implementing strategies to reduce the occurrence of incidents. We have a consistent number of medication incidents reported which are predominantly minor. For example, most of our incidents are medication omissions or illegible medication orders.

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Risk Management Falls and compromised skin integrity are two major areas that impact on the quality of life for older people. Over the last 12 months we have begun to see the positive results of measures put into place 18 months ago by the Falls and Skin Integrity Committee.

Measures to minimising skin tears and pressure injuries include:

• All residents and patients have a full assessment on entry to allow staff to identify potential for the development of pressure injuries;

• All mattresses have pressure sensitive foam;

• All residents and patients are repositioned every 2 hours whether they are bed bound or are sitting out in a chair, to relieve pressure on risk areas;

• Staff monitor each resident’s skin integrity during the delivery of daily care;

• The residents and patients nutritional status is regularly assessed to ensure they have a well-balanced fluid and dietary intake;

• Reporting of pressure injuries and skin tears through the Victorian Health Information Service is compulsory;

• Regular auditing of pressure injuries and skin tears is continued through the regular meetings of the Care Coordination Committee.

Our staff recognise falls as a significant risk to our residents and patients. Most falls are due to a combination of factors rather than one isolated cause. The vast majority of residents and patients do not sustain serious injuries, but even a seemingly minor fall can significantly decrease a resident for patient's confidence and make them less inclined to keep active and independent, thereby decreasing their quality of life. Our target is zero harm from falls. Our efforts to attaining this goal have included: • Implementation of Care Coordination Committee; • Regular auditing and reporting of findings to the above

Committee; • Clinical review of situations where residents sustain

fractures; • Promotion of Falls Awareness Week throughout the

hospital; • Initial and ongoing assessment of residents and patients

potential to fall; • The use of height adjustable beds and sensor mats; • Hip protectors for all residents and patients identified as

being at risk of falling; • Regular review of medications which may contribute to the

chances of a fall; • Introduction of regular balance and exercise sessions with

a particular view to having residents and patients involved in taking some responsibility for minimising the risk of falls.


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0%

20%

40%

60%

80%

100%

Year 2005 Year 2007 Year 2011

SAFE USE OF BLOOD PRODUCTS

To ensure we are compliant with best practice guidelines Kilmore Hospital participates in the Blood Matters Victoria Auditing Program. The aim of the Blood Matters Program is to ensure that blood components are administered to patients appropriately and safely, consent policies are available for staff and that they are understood and practiced. Any allergic responses experienced by patients to blood products are reported to the Blood Bank and Blood Matters Program STIR Program – The STIR program is the Serious Transfusion Incident Reporting Program. Fortunately to date, we have not had any incidents to report. Since being involved in the Blood Matters Program, our compliance with Best Practice recommendations has improved each audit, with the final outcome in 2011 being 100%’

The graph demonstrates the improvement in our compliance over the last 6 years. The three areas we have improved in are: There is a written policy on the labelling of blood samples for grouping and cross matching Hospital policy now includes statements on labelling of blood samples for group and cross matching and includes a statement on positively confirming the patient's identity at the point of collection and labelling. The minimum requirements are surname, given name, hospital unit record number or date of birth, date and time of collection plus signature or initials of the collector.

There a written policy on which staff can take samples for blood grouping and cross matching Hospital policy now includes a statement on which staff are accredited to take samples for blood grouping and cross matching. There a written policy on what training should be given to staff who can take samples for blood grouping and cross matching Hospital policy includes statements on training and competencies for staff taking samples for grouping and cross matching. The results of all audits both internal and external are reported to the Care Coordination Committee for monitoring and identification of opportunity of improvement. At Kilmore & District Hospital we review our procedures every two years and staff working in Acute areas complete Mandatory Competencies 2–3 yearly to ensure our practices are current and safe.

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Infection Control It is widely recognised that prevention and control of infections is a key aim of all in healthcare and is vital for positive outcomes and experiences for patients.

Raising the profile of infection control is an important aspect of patient care. This is done in a variety of ways including raising patient awareness and involving patients in their care. The use of infection control displays and handouts together with information on the infection control noticeboards assists in educating and raising awareness.

Staff provide the infection control nurse with information related to infection control issues for patients and whenever possible the infection control nurse will spend time with patients discussing queries and concerns and providing information to them. When required, infection control provides follow up telephone support to patients.

HAND HYGIENE

Hand hygiene is an important component in the prevention of health care infection. Hand hygiene refers to healthcare workers cleaning their hands at the correct time (using the 5 moments for hand hygiene), using correct product and correct techniques.

The 5 moments for hand hygiene refer to the critical times when healthcare workers need to clean their hands. These are:

1. Before touching a patient; 2. Before a procedure; 3. After a procedure or body fluid exposure risk; 4. After touching a patient; 5. After touching a patient’s surroundings.

Correct products include soap and water or alcohol based hand rub (ABHR). ABHRs are effective against the majority of bacteria and viruses, take less time to use and can be made more accessible to staff thereby increasing compliance. At the Kilmore & District Hospital, ABHR is available for use at the end of each bed and at the entrance to each room. Posters displayed educate staff, patients and visitors on correct techniques required for soap and water and ABHR.

Staff perform annual competencies for hand hygiene and receive periodic education re hand hygiene issues. In order to monitor staff adherence to the 5 moments, audits are conducted, results submitted and data available on the Australian Government “My hospital” website.


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HAND HYGIENE (Cont’d)

This graph represents results from the last five audits conducted, including the national average for Audit period 2, 2012. These results are a reflection of the commitment by all staff to assist in prevention of transmission of infection.

Staff are encouraged to perform hand hygiene techniques in front of patients whenever possible. This is to ensure patients are aware of and confident their healthcare workers clean their hands prior to and following patient care. Patients are encouraged to discuss hand hygiene practises with staff. The Victorian Patient Satisfaction Survey includes questions regarding hand hygiene practises of staff during their hospital stay and we review this data with the aim of implementing strategies to improve awareness.

CLEANING AUDITS – 2011-2012

The Kilmore & District Hospital has a team of 18 cleaners servicing four sites. This year DHS reported that the Agency received the highest score for External Cleaning Audits in the State, being 97%. (A score of 85% and above is required.) The Kilmore & District Hospital conduct both internal and external audits. Internally we have two accredited auditors who schedule and conduct audits according to requirements. External audits are conducted annually by a nominated external auditor.

Hand Hygiene Auditing Compliance Kilmore & District Hospital

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Audit period 1 2011

Audit period 2 2011

Audit period 3 2011

Audit period 1 2012

Audit period 2 2012

National average Audit 2 2012

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INFLUENZA VACCINATIONS

The Kilmore and District Hospital supports the Department of Health’s recommendation that all health care workers are protected against vaccine preventable diseases. All staff that have direct patient contact should be vaccinated with an annual influenza vaccination due to high risk of exposure and transmission of influenza. Staff are encouraged to attend influenza vaccination clinics set by the infection control nurse, or to attend their GP for vaccination to ensure they receive the benefits of protection of the vaccine. This year staff vaccination uptake has been very successful with the highest influenza vaccine uptake yet!

Our aged care residents are at risk of serious complications from influenza and are subsequently offered and strongly encouraged to have their annual influenza vaccination. Resident uptake of vaccination is excellent with only one resident declining vaccination this year. People who decline vaccination are at greater risk of developing influenza, however there are steps which can be taken to assist in protecting unvaccinated residents. These include keeping well and sick residents separated, encouraging unwell staff to remain at home whilst they are unwell and asking sick visitors not to visit. All who enter hospital and aged care facilities must be encouraged to clean their hands with soap and water or hand gel prior to and following visiting patients and residents.

GASTROINTESTINAL ILLNESS

Outbreaks of gastrointestinal illness tend to peak during the winter months and can have a significant impact on residents, patients and staff. One of our aged care facilities experienced an outbreak of gastroenteritis in June this year. The outbreak was well managed by staff, who promptly put in place our gastro management policy. The outbreak lasted for 9 days with a total of 12 residents and 10 staff affected, which was a significant improvement on a previous outbreak in 2011.

Following resolution of the outbreak, the Infection Control Nurse facilitated meetings with core groups to review management of the outbreak to identify what worked well and how we could improve management of subsequent outbreaks.

INFECTION CONTROL AUDIT RESULTS

Another way we monitor our infection control performance is by conducting infection control audits and benchmarking with other facilities within the Hume region and throughout Victoria.

Infection control compliance audit:

• The aim of this audit is to evaluate the facility’s infection control compliance against the Australian guidelines for infection control.

• The Kilmore and District Hospital overall compliance rate was 96.7% compliance with the Hume region aggregate at 93.9%.

• Areas identified as not/partially compliant are added to the infection control quality plan for improvement.


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Transfer of Care Project 2012

PRIMARY CARE PARTNERSHIP PROJECT — E REFERRAL & CARE PLANNING IMPROVEMENTS

The Transfer of Care Project was a collaborative project undertaken with the Lower Hume Primary Care Partnership in 2012 and supported by the Department of Health. The state-wide project aimed to improve overall communication and care planning, in particular working closely with general practice along with aspects of service coordination and integrated chronic disease management. At Kilmore District Hospital the purpose was to improve the Acute Service and Urgent Care Centre referrals to Kilmore District Nursing Service. Overall the aim was to ensure the referral and care planning process was linked for continuity of client care across the organisation and out into the community. Our approach was twofold. Firstly the process and systems for referrals needed improvement to embrace electronic referral practice in connecting care. Secondly the District Nursing Service care plan was redesigned to reflect identified care planning elements from the clinical indicator auditing. In 2011 when referral audits commenced, care planning clinical indicators were conducted and the district nursing care plan was redesigned.

The Transfer of Care Project activities included:

• Revising the e-referral process and care plan process; • Securing patient referral pathways system (link to supportive care project); • Ensuring ongoing review and development of policy, procedures and guidelines; • Providing education, training, coaching and mentoring for staff development; • Providing leadership & management through effective business planning with links to staff feedback and

performance review; • Developing auditing and feedback systems along with a performance monitoring and evaluation framework; • Building governance structures for Transfer of Care through the Quality Committee. As a result the e-referral process is now working well with e-referrals being sent to and from the organisation. This is a more effective and efficient use of telecommunication resources with less paper based referrals and waste. In addition, the results of the care plan indicator data demonstrates that the District Nursing Care Plan meets 100% of care plan elements and the review and evaluation process has improved.

The performance monitoring evaluation framework supports the reporting and ongoing review of e-referral and care planning activities. The newly developed performance measures and key performance indicators (KPI’s) ensure the changes are embedded into clinical practice and organisational culture supports best practice principles. At the completion of the project we have identified incremental change towards improvements in e-referral and care planning process across the organisation. Overall access to community health care services will improve through the patient referral pathways mapping system and the efficiencies of implementing e-referrals along with the new e-journals.

THE KILMORE & DISTRICT

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Day Oncology Unit

SUPPORTIVE CARE SCREENING

There have been several quality activities that have direct benefit to patient care this year, including the introduction of Supportive Care Screening. A key target of Victoria’s Cancer Action Plan 2008-2011 is to document supportive care screening for 50% of newly diagnosed cancer patients by 2012.

There was previously no formal supportive care screening process at Kilmore & District Hospital for cancer patients.

Supportive Care Screening involves screening people with the Peter Mac Screening Tool for their:

• Physical needs (e.g. pain, fatigue, nausea); • Psychological needs (e.g. anxiety, distress); • Social needs (e.g. practical supports, carer needs); • Information needs (e.g. relating to diagnosis,

prognosis, treatments); • Spiritual needs (e.g. addressing hopelessness, despair).

WHY SCREEN FOR SUPPORTIVE CARE NEEDS?

The National Breast Cancer Centre and National Cancer Control Initiative, 2003 stated, “Evidence shows that cancer patients who have had their supportive care needs addressed have lower rates of anxiety, mood disorders, nausea, vomiting and pain, and significantly greater knowledge about the disease and treatment.”

This project aimed to achieve the VCAP 2012 target of at least 50% of newly diagnosed cancer patients screened for their supportive care needs, using a validated screening tool.

A working group was formed and this consisted of a consumer representative as well as health professionals. Resources were developed that have since been shared with another health service. Newly-diagnosed cancer patients are now assessed for their supportive care needs at the hospital.

THE KILMORE & DISTRICT HOSPITAL DAY ONCOLOGY UNIT REVIEW

Hume Regional Integrated Cancer Service have funded a review (clinical and non clinical) of the Day Oncology Unit. The review aims to improve the current services offered to cancer patients at the hospital. Health professionals and consumers have been interviewed by a cancer specialist consultant to assess the environment, policies, procedures, work flow and support for cancer patients. The final report is due to be released in August 2012 and an action plan will be developed from the findings.


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Maternity Services The Board of Kilmore & District Hospital has reviewed the expenditure and sustainability of the current two maternity models. After careful consideration the Board decided to cease the Know Your Midwife (KYM) model of care. This has resulted in the development of a new model of care by the Maternity Services Team which consists of both midwives and obstetricians who are represented on a committee. The new maternity model aims to support all women attending the hospital – antenatally, intrapartum, postnatally and at home – following the birth of their baby. This model will ensure that there is equality and accessibility for all women. Kilmore & District Hospital has continued to invest in developing the workforce for our local community. Tania Nicholson was awarded this year’s annual Midwifery Scholarship. Last year’s recipient Karen Gates recently graduated from LaTrobe University Bendigo with top honours.

Karen was awarded the ‘St John of God Midwifery Award’, which is presented to an outstanding graduating student in the Postgraduate Diploma of Midwifery course.

Above, one of our fantastic Midwifes, Steph, is pictured with one of our newest additions, Sonny.

Director of Finance and Administration, Colin Clark and Director of Nursing, Jenny Salkeld, congratulate Karen Gates on her achievement.

(Photo courtesy of the Free Press)

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Acute Ward The Acute Ward provides care for not just local people, but people who have been on waiting lists for surgery from other areas. This table shows the top 20 towns where our patients reside:

Township No of Patients

Kilmore 610

Wallan 474

Broadford 374

Craigieburn 87

Heathcote Junction 75

Pyalong 64

Romsey 58

Lancefield 51

Sunbury 46

Whittlesea 44

Epping 26

Doreen 23

Seymour 22

Mill Park 21

Preston 20

South Morang 19

Reservoir 18

Bundoora 18

King Lake 16

Lalor 12

The Acute Ward also cares for patients whose age ranges from 0-100. The following table shows the age range of patients for 2011/12 (excluding newborns).

Age Range No of Patients

1-17 220

18-39 585

40-59 506

60-79 570

80-99 228

100 + 4 This has meant that the quality improvement has covered all age ranges and disciplines. Some of the smaller quality improvement projects have included:

• Improving the environment, painting and the purchase of new TV sets; and

• Reviewing care pathways to ensure that they are up to date and meet patients needs.

The Acute Ward also provides palliative care for local patients. There have been opportunities for ward staff to be part of the Program of Experience in the Palliative Approach (PEPA) Program. This program aims to improve the quality, availability and access to palliative care for people who are dying, and their families, by improving the skills and expertise of health practitioners and enhancing collaboration between service providers.

THE KILMORE & DISTRICT HOSPITAL Rutledge Street, Kilmore, Victoria

PO Box 185, Kilmore 3764 Phone: (03) 5734 2000

Fax: (03) 5782 2019 Email: [email protected]

Documents

QUALITY OF CARE REPORT 2012 - Parliament of Victoria · 2013. 6. 12. · Models of care provided are GP led care and public antenatal care. ... QUALITY OF CARE REPORT 2012 . THE KILMORE