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April 2009 • Policy Patter • As I see it • On the ground • Pharmacy Focus Private Mental Health: Solving the Puzzle for Patients PLUS... • Safety & Quality Initiatives and Priorities • Outcomes of Labour in Private and Public Hospitals • Meet one of the animators from MARY and MAX Adam Gault/Digital Vision/Getty Images 2 Private Hospital - April 2009 1 Private Hospital - April 2009 Australian Private Hospitals Association DIAMOND SPONSOR APHA Major Sponsors Chief Executive Officer: Michael Roff Director Policy and Research: Barbara Carney Public Affairs Manager and Editor: Lisa Ramshaw Member Services Manager: Angela Hook APHA NATIONAL COUNCIL John Amery .. Mater Misericordiae Hospital T’ville Steve Atkins ............................. Healthe Care Australia Dr Leon Clark .................. Sydney Adventist Hospital Philip Currie .................... Sydney Adventist Hospital Peter Freeleagus ... Cura Day Hospitals Group Pty Ltd Christine Gee ................... Toowong Private Hospital Leanne Kemp .. Manningham Day Procedure Centre Alan Kinkade ............................... Epworth HealthCare Moira Munro .................................................. Perth Clinic Craig McNally .............................. Ramsay Health Care Dr Lisa O’Brien ................ Skin & Cancer Foundation Amanda Quealy ........................................ Hobart Clinic Chris Rex ........................................ Ramsay Health Care Richard Royle ................................ UnitingCare Health Grant Rudman .............................................. Nephrocare Daniel Sims ................................... Ramsay Health Care Dr Mark Stephens ........... Chesterville Day Hospital Ben Thynne .............................. Healthe Care Australia George Toemoe ....................................... St Luke’s Care Stephen Walker .......................... St Andrews Hospital PLATINUM ASSOCIATE MEMBERS Health Super Pty Ltd HPS Pharmacies NAB Health GOLD ASSOCIATE MEMBERS 3M Healthcare Active Partners in Health Solutions Anaesthesia Systems B. Braun Australia Pty Ltd Blake Dawson Cardinal Health Charity Life Clear Outcomes Pty Ltd Communio Pty Ltd Commercial Flooring Australia Coregas Daydots DLA Phillips Fox Fresenius Medical Care South East Asia Pty Ltd GE Healthcare Global-Mark Health Industry Plan Healthsolve Pty Ltd HWL Ebsworth Lawyers Intrinsix Pty Ltd Johnson & Johnson Medical Pty Ltd Knight Frank Valuations Medtronic Australasia Pty Ltd Menette Pty Ltd Olympus Realise Performance Regal Health Services Schiavello Hospital Solutions Pty Ltd Stargate Consulting Group Terumo Corporation The College of Nursing The PayOffice Group Thinc Projects Unique Care Pty Ltd ASSOCIATE MEMBERS Private Hospital is published five times a year (April, June, August, October and December) as a joint undertaking between the Australian Private Hospitals Association Ltd (ACN 008 623 809) and the Australian Publishing Resource Service Pty Ltd (ACN 082 824 397). APHA Office: Level 3, 11 National Circuit, Barton ACT 2600. Postal Address: PO Box 7426, Canberra BC ACT 2610, Australia. Phone: (02) 6273 9000. Fax: (02) 6273 7000. E-mail: [email protected] Website: www.apha.org.au Adesse Australian Health Services Alliance Boyd Health Management Department of Veteran’s Affairs Global Health H Polesy & Co. Healthcare Management Advisors Pty Ltd Herring Health & Management Services Pty Ltd Home Nurses iSoft John Randall & Associates Medicraft Hill-Rom Australia Pty Ltd Meditech Pty Ltd Merrill Lynch Noarlunga Health Services Novartis Consumer Health Australasia Origin Healthcare Queensland X-Ray Thiess Health Transport Accident Commission APRS Pty Ltd: Level 6, 38 Currie Street, Adelaide SA 5001. Postal Address: GPO Box 1746, Adelaide SA 5001, Australia. Phone: (08) 8113 9200. Fax: (08) 8113 9201. E-mail: [email protected] Website: www.aprs.com.au APHA and accompanied by a stamped self-addressed envelope, otherwise received electronically at [email protected] Material in Private Hospital is protected under the Commonwealth Copyright Act 1968. No material may be reproduced in part or in whole without the written consent from the copyright holders (APHA). Private Hospital welcomes submissions and a diversity of opinion on hospital-related issues and will publish views that are not necessarily the policy of the APHA. All material must be relevant, cogent, submitted to the Electronic images must be to print standard - 300 dpi or higher. Please retain duplicates of all hard copy text and illustrative materials. The APHA does not accept responsibility for damage to, or loss of, material submitted. Neither the APHA, APRS or their servants and agents accept liability, including liability for negligence, arising from the information contained in Private Hospital. 4 Private Hospital - April 2009 5 Contents Regulars 08 Chris Rex - Presidents Report 12 Michael Roff - As I see it Features 16 Perinatal Depression Support at SAH 18 APHA Member Mental Health Facilities 23 Mental Health Nurse Incentive Program Pilot 30 Private Mental Health Alliance Improving Mental Health Services for Australians 32 The Work of PMHA’s Centralised Data Management Service 49 Safety and Quality – Initiatives and Priorities for 2009 69 Adverse Outcomes of Labour in Public and Private Hospitals in Australia Health Reform Proposals - So Far, So Good 46 Christine Gee - Quality in Focus National Hand Hygiene Initiative 58 Barbara Carney - Policy Patter Policy Development: Never One Right Way 64 Michael Ryan - Pharmacy Focus A Pharmacist’s Role in Mental Health Care 76 Since the last issue... 79 Angela Hook - Member Benefits 84 Alison Choy Flannigan - Legal Matters 87 On the ground with Jason Lynch 21 16 7 Editor’s Letter Private Mental Health: Essential Services for the Nation Welcome to the first edition of Private Hospital Magazine for 2009. As you will see as you read through the magazine, this edition is dedicated to the private Mental Health sector. This is the first time APHA has dedicated an issue to mental health and the response to my call for submissions was overwhelming. Obviously, there is a lot of good work being performed across the country and our member facilities want everyone to know about it. The private mental health sector consists of 27 stand–alone specialist private mental health facilities with approximately 1,440 beds. A further 22 wards/units are located in general medical/surgical hospitals. The latest data from the Australian Institute of Health and Welfare indicates that these facilities treated more than 123,500 patients in 2006-07 which represented 42% of all hospital-based mental health treatment. Private mental health facilities provide 70% of all sameday mental health treatment and play a vital role in the provision of services to people with mental illness. The interests of private mental health facilities are represented and advanced by the APHA Psychiatry Committee. The Committee members are elected by private mental health facilities in each State and the Committee is chaired by former APHA President Christine Gee. The Committee membership also includes the Chair of the Private Mental Health Consumer Carer Network (Australia) as a permanent observer. Stop Press The 29th Annual APHA National Congress will be held 11-13 October 2009 at the Grand Hyatt Hotel in Melbourne. For more information see: www.apha.consec.com.au The APHA Psychiatry Committee meets quarterly to review the private mental health landscape, identify issues of importance and to canvass and progress activities to support the interests of private mental health facilities. Working with the Private Mental Health Alliance (PMHA), the Committee ensures that the perspectives of private mental health facilities, their staff and patients inform the development of mental health plans, policies and legislation. This magazine may just surprise you as it showcases the variety of mental health facilities and specialties within our member hospitals and the broad spectrum of activities they undertake. From Post Traumatic Stress Disorders to Acute services to Community Private Hospital - April 2009 Outreach teams, our members help in a wide variety of ways. We also look at the Outcomes of Care by private hospitals with psychiatric beds and a program at the Sydney Adventist Hospital specifically for perinatal depression. Regular readers of this magazine will notice two new faces amongst our regular columnists. APHA’s long serving Director of Policy and Research, Paul Mackey left the organisation in January. I would like to personally thank Paul for all of his dedication to Policy Patter and the other numerous articles and contributions he made to the magazine during his seven years at APHA. Our new Director of Policy and Research, Dr Barbara Carney, introduces herself in this edition’s Policy Patter and is already proving to be an excellent member of the APHA team. We also have a new Members Services Manager, Angela Hook. Angela is busy working on the next APHA Annual Congress which will be held 11-13 October 2009 in Melbourne and many other initiatives for members. Please contact Angela if you have any membership enquiries. She looks forward to meeting as many of you as possible in the coming months. And finally, the June edition of Private Hospital will have an environmental and sustainability focus. If your hospital has a great story to share with others on this topic, please contact me at [email protected]. I look forward to hearing from you. Lisa Ramshaw Editor, Private Hospital 8 president’s report... with Chris Rex Award Modernisation One of the Federal Labor Government’s election promises was to simplify the industrial relations system in Australia in a process that is known as Award Modernisation. Many of you would be aware that this process is currently being undertaken by the Australian Industrial Relations Commission (AIRC) and involves the replacement of approximately 4,000 state and federal awards with 130 national modern awards. Representatives from the health industry were invited to submit their preferred awards and comments regarding the process for review by the AIRC. In addition to forwarding written submissions, a number of face-to-face consultations and hearings have also been taking place between the parties over the last six months. The APHA has been actively involved in representing the private hospital industry in this process and through Lucy Fisher (PHAQ), lodged a Private Hospital Industry Award in October 2008 together with a detailed submission, for consideration by the Commission. Submissions were made by both employer and employee representatives from all sectors of the health and aged care industry. A number of clauses proposed by some groups, if adopted, would have had the impact of increasing costs to the private hospital industry by around $400m per annum as well as severely restricting existing employment flexibilities. At subsequent consultations with the AIRC, private hospital industry representatives highlighted how these suggested clauses would impact on our industry and we believe these explanations were taken into consideration when the draft awards were being prepared. In January, the AIRC published four draft awards for industry consultation being: • Nurses Occupational Industry Award 2010 •H ealth Professionals & Support Service Industry and Occupational Award 2010 •M edical Practitioners Occupational Award 2010 •A ged Care Industry Award 2010 Once finalised, these awards will establish the minimum employment conditions for employees earning less than $100k per annum working in the health industry. Thanks to our representations, many of the issues of concern have not been included in the exposure drafts. However, there are still a number of clauses that if placed in the final awards to be released on 3rd April we believe will increase costs to the industry in the order of $142m per annum. In addition, they will have the effect of reducing a number of flexibilities which employers and employees currently enjoy. Industry concerns have been relayed to the offices of the Federal Minister for Employment and Industrial Relations and the Federal Minister for Health and we will keep making representations on behalf of the industry in relation to this matter. There will be a transition period and we expect the transitional clause to be released mid year. This clause will explain how we move from where we are now under our existing awards to the conditions contained in the new, modern awards which take affect from 1/1/2010. We understand there will be a five year transition period but exactly how this will be implemented is as yet unknown. APHA, through Lucy Fisher and Lynda Hepworth, has done an excellent job on behalf of its members in representing the industry throughout this process. We will keep you informed of the outcome in coming months through the APHA news bulletins. Private Health Insurance Premium Increases The recent announcement by Nicola Roxon to allow increases to private health insurance premiums up to 6.02% recognises the increasing costs of healthcare and the economic climate that insurers currently find themselves in. Whilst this could lead to increases in private medical insurance of approximately $150 per annum for families, it is important to keep in perspective that private health insurance in Australia is still relatively affordable compared to other parts of the world. And, the private health care industry offers consumers an excellent product that is delivered cost effectively. Current government incentives keep private health insurance affordable for many and, with an ageing population and an increasing demand for health care, it will be important that the government maintains these incentives to ensure that the excellent balanced health care system we have in Australia is maintained. To this end, it was pleasing to see the last PHIAC report showing that the percentage of Australians insured rose in the last quarter despite the proposed change to the Medicare Levy Surcharge (coming into effect in April) and the current economic crisis. Private Hospital - April 2009 NHHRC Report APHA was invited to the release of the National Health & Hospitals Reform Commission (NHHRC) Interim Report recently. The key message of relevance to the private hospital industry was the Commission’s stated view that the current balance of funding between taxpayers, private health insurance and individual payments was right and it should remain at the current balance for the long term. This was a very positive message for the private health sector as it locks in the balanced health care system in which we play such an important part. Some other areas of interest in the report for private hospitals included a recommendation for public reporting on access, efficiency and quality for both public and private hospitals; improved clinical training infrastructure and recognition that improvements in aged care and sub acute services could improve bed blocks in the hospital system. NSW Blood Tax The APHA is still actively working on this issue which could see all of our hospitals in NSW charged for blood. The threat of the blood tax being introduced in NSW in the near future has not gone away, but at this stage, we remain unclear as to how the government proposes to implement the charge. The APHA has made representations to the Federal Department of Health & Ageing as well as the Federal Minister for Health on the legalities of this issue. Both are very concerned over the NSW Governments actions and the negative effects it could have on the nature of blood donating and distribution not only in NSW but across the country. The APHA thanks those NSW private hospitals that participated in the public campaign which included getting almost 7000 names on petitions in a very short period of time. We do propose to persist with our active stance against this proposal and will inform NSW members of our next steps in this campaign as soon as possible. Mental Health Care This issue of Private Hospital magazine focuses on mental health care in the private hospital sector. The private hospital industry has an excellent reputation in the provision of comprehensive and innovative mental health care and it is very worthwhile to highlight our achievements in this area. Thanks to all the contributors on this topic. 9 Private Hospital - April 2009 10 Private Hospital - April 2009 11 Private Hospital - April 2009 12 as I see it... with Michael Roff Health Reform Proposals – So Far, So Good? On 16 February, the National Health & Hospitals Reform Commission (NHHRC) released its interim report, entitled; “A Healthier Future for all Australians.” This 356 page report contains 116 separate “reform directions” across 15 chapters, each dealing with different aspects of the health system. In examining this report it is important to remember three points. Firstly, the NHHRC is focussing on long-term reform. Indeed, its terms of reference state that by June 2009: “the Commission will report on a long-term health reform plan to provide sustainable improvements in the performance of the health system.” related to the proposed “Denticare” scheme, This point is also emphasised in the introduction to the report which states; report. “One of the biggest challenges in our work has been to take a truly long-term view and not to get consumed by issues and solutions that are only about the here and now. It is easy to see a problem and tailor a solution to fix it – a point solution – rather than thinking about how patterns of problems could be resolved by system solutions, which is our task.” interested in reform and are involved in policy The second point to remember is that this is an interim report. The NHHRC has already sought feedback on their proposed reform directions through submissions and roundtable discussions. The final report to Government will consider this feedback to finalise reform proposals, examine financial implications and formulate a road map for reform implementation. Thirdly, regardless of the reform proposals contained in the final report, the key determinant of any reforms will be the Government’s response. This will be interesting to watch as long-term reform ideals may run into short-term political expediency as we hit the back end of the federal electoral cycle. Indeed, the Health Minister has already described some of the proposals as “radical” and “ambitious”, while with others (such as an electronic health record) she has said “I do think it’s time that more action is taken.” I am sure you don’t need me to decode these statements for you. Much of the public comment and media coverage following the release of the report which would provide universal access to dental care, funded by an increase in the Medicare levy. While this is certainly a “big-bang” reform idea (and you would be excused if, relying solely on media coverage, you believed this was the central reform idea in the report) it was part of just one of the 15 chapters of the I have always been of the view that if you are advocacy, then patience is definitely a virtue. Therefore, it is gratifying to see that the report picks up on many elements of APHA’s advocacy over a long period. For example, it proposes an Aboriginal and Torres Strait Islander Health Authority to purchase services for indigenous Australians in a similar way that DVA does for the veteran community. This idea was first proposed by APHA in 2003. It also proposes a patient travel and assistance scheme for Australians in remote and rural communities. APHA has advocated such a scheme for many years to improve the value proposition of health insurance for those Australians without easy geographical access to private hospitals. In addition we have long advocated the need for private hospitals to have a seat at the table and a voice in policy development and planning processes. This is especially the case when you consider that private hospitals comprise 34% more beds than the NSW public hospital system, and more beds than public hospitals in Queensland, West Australia, South Australia, Tasmania, the ACT and Northern Territory combined – however, despite this contribution, even the Northern Territory has a greater voice than the private hospitals sector although its total health budget is around 1/7th of expenditure on private hospitals. Private Hospital - April 2009 The report recognises this when it states; “We also want to indicate strongly that national leadership must involve the effective participation of the whole health sector; public and private health services and public and private funders of health care.” And; “We need one health system, not a public health system and a private health system, where ‘ne’re the twain shall meet’. “ There is also discussion of a national framework for clinical training with a dedicated funding stream where funding follows the trainee (another APHA mantra) , optimising the use of existing public and private infrastructure, a national approach to private hospital regulation and a consistent national approach to collection and reporting of safety and quality indicators. Space prevents me from listing all the reform directions of relevance to private hospitals or from discussing the three options for reforming governance of the health system (especially the one described as “radical” by the Health Minister). However, APHA is comfortable with the broad thrust of the Commission’s report. It specifically affirms Australia’s mixed public/private system and maintaining the balance of spending through taxation, private health insurance and out-of-pocket contributions. We believe the reform directions potentially provide new opportunities for private hospitals. APHA has provided the Commission with comments on the report, through submissions, industry consultations and direct meetings. Now we will have to see what is in the final report and, perhaps more importantly, the Government’s response. Watch this space. 13 14 Mental Health New SANE Research: a Life of Loneliness the Harsh Reality for Many People with Mental Illness A new study by SANE Australia reveals people affected by mental illness pay a high price when it comes to relationships and social contact, with the study showing half have no close relationship with another person. The research, conducted September to December 2008, focused on the emotional and physical relationships of people living with a mental illness, the consequences of this for their lives and what can be done about it. The most disturbing result was the impact of mental illness on personal relationships, with almost half having no friends, wanting to, yet struggling to connect with others. Physical intimacy, which includes hugging and touching others, was rare for many. In fact – astonishingly – almost one in six had not touched or been touched by another person for more than 12 months. The study found the numbers of respondents who had: • No close relationship 49% • General community with no close relationship 15% • Not touched or been touched by another person for 12 months 13% • No sexual contact in last 12 months 35% SANE Australia Executive Director Barbara Hocking says extreme social isolation is known to damage mental health, yet it’s something many people with mental illness have to endure. ‘Not only are many people with mental illness dealing with their symptoms and associated problems such as poverty, they are leading isolated lives and often have no partner or even friends to share their lives,’ Ms Hocking said. This impedes their recovery. ‘While governments are promoting social inclusion, these findings highlight the very real need for immediate, specific action to ensure such basic human needs for social contact are not being ignored.’ Sexual health and intimacy also emerged as areas of concern for respondents: •H ad not discussed the issue with their doctor or health worker 50% • Did not know enough about sexual health 65% •N ot receiving routine health checks (e.g. pap tests, prostate checks) 46% SANE has called on government agencies at all levels to improve opportunities for those affected to close relationships with others and improve their capacity for recovery. Recommendations: • Promotion of social inclusion: recoveryfocused rehabilitation programs, to improve confidence, communication and social skills • Support to develop relationships: education and training in how to discuss mental illness and its effect on emotional, physical and sexual intimacy • I mproved sex education: mental illness often starts in late teens, disrupting learning of life skills and education. More practical education about sexuality and related issues needed • S exual health checks: health professionals need incentives to provide regular breast screening, pap smears, STD testing, prostate checks and routine tests. The complete study, Research Bulletin 8: Mental Illness and Intimacy, can be downloaded from the Research area of the SANE website or http://www.sane.org/information/information/ research.html Professor Harvey Whiteford - Kratzmann Professor of Psychiatry and Population Health, The University of Queensland – Awarded AM. On Australia Day 2009, Professor Harvey Whiteford was awarded with a Member of the Order of Australia (AM) with the citation “For service to medicine as a leader in mental health reform, the development of national standards of clinical care, professional competence and economic policy “ In 1999 the Toowong Private Hospital approached The University of Queensland with funding to establish a Professorial Chair. This collaboration was realized in February 2000 with the inaugural appointment of Dr Harvey Whiteford to the Kratzmann Professor in Psychiatry. Named Private Hospital - April 2009 in honor of the family who built, own and operate the Toowong Private Hospital, the Kratzmann Chair was initially established for a five year term. Toowong Private Hospital reaffirmed its commitment to mental health research by providing funding for the Chair for a second five year period in 2005 and was delighted with the re-appointment of Professor Whiteford. Professor Whiteford trained in medicine, psychiatry and health policy in Queensland and at Stanford University, California. He has twenty five years experience as a clinical psychiatrist in public and private practice and has held 15 Mental Health Mental Health Services for Victorians affected by Bushfires In response to the tragic and devastating Victorian bushfires, the Australian Government is providing $7.5 million for the provision of mental health support to affected individuals and communities. This builds on the social workers, psychologists and case managers currently providing counselling and support through Centrelink on the ground in fire affected areas. The package focuses on providing primary mental health care services to people most impacted by the tragedy, and support to professionals providing services to them. It also provides additional telephone based counselling services to respond to broader levels of distress within the Victorian community, and support through community organisations to assist affected communities to reconnect and psychologically recover from the impact of the trauma over the longer term. An initial allocation of $4.5 million is being directed to immediately commencing these activities. Additional funding has been provided to Divisions of General Practice to offer increased mental health care services for people in impacted areas. This will build upon the Access to Allied Psychological Services (ATAPS) Program. Helpline to address the broader emotional response of the community and to provide specialised phone support to children and families who need someone to talk to. While over time many people affected by the bushfires will recover through natural healing processes, some people may require ongoing specialised psychological support. In addition, some health professionals involved in providing support to survivors of the tragedy may need psychological support and follow up over the longer term. In order to provide this longer term support, funding of $3 million has been allocated for 2009-10 to enable: • further support under ATAPS to Divisions of General Practice in affected communities to enable the ongoing provision of specialised services to people with persisting symptoms; Funding is also being provided to telephone counselling services including Lifeline and Kids • ongoing support and training for the broad range of health professionals providing senior clinical and administrative positions including those of Director of Mental Health in the Queensland and Federal governments in Australia and at the World Bank in Washington DC, USA. He has been a visiting Professor at Harvard University and the Institute of Psychiatry in London. In his previous position as the Commonwealth Director of Mental Health he was responsible for the Federal governments’ initiatives in mental health including Australia's National Mental Health Strategy and Suicide Prevention Strategy. His current work involves clinical responsibilities in adult psychiatry at Toowong Private Hospital in Brisbane. He teaches undergraduate and postgraduate university students and his research interests include mental health policy and service development. He has published over one hundred papers in peer reviewed academic journals. He is the Principal Mental Health Advisor to the Commonwealth Department of Health and Ageing. As Director of Mental Health in Queensland, he was responsible for state-wide mental health policy and planning and the administration of the Queensland Mental Health Act and Regulations. Private Hospital - April 2009 psychological services to affected individuals; • specialised telephone services to provide follow up calls and, where required, ongoing support to individuals and volunteers to ensure that their ongoing needs for care are identified and addressed; and • support for mental health activities that assist communities to recover psychologically and restore support networks, particularly targeting children and families. 16 Mental Health Perinatal Depression Support at SAH With perinatal depression affecting approximately one in ten women and its significance highlighted by the 2008 National Perinatal Depression Initiative, Sydney Adventist Hospital (SAH) has recognised the importance of perinatal depression and now offers access to the services of a Clinical Psychologist at its allied medical centre. Dr Robert Woodfield came to the SAH in late 2007 and specialises in perinatal care and women’s health. With over 2200 babies born at the SAH each year, the Hospital believes it is important to have available the services of a clinical Sydney Adventist Hospital Clinical Psychologist Dr Robert Woodfield with Mrs Kylie Hinkley psychologist to private outpatients and this service is now available under the Better Access to Psychiatrists, Psychologists and GPs Medicare Benefits Schedule Program (the Better Access program). The 2006 Better Access program followed the 2001 Better Outcomes in Mental Health Care program. The 2001 programme aimed to improve consumers’ access to high quality primary mental health care, was referred to as the ATAPS Programme (Access To Allied Psychological Services) and funded 108 projects conducted by 114 Hospital Divisions of General Practice. The 2006 Better Access program was introduced to improve access, for people with a variety of mental health disorders, to various providers via a series of new MBS numbers. These allow a GP to directly refer a patient for 12 individual sessions per year (or 18 in exceptional circumstances), delivered in groups of six with a review by the referring GP after the first six. The Better Access program was introduced to provide services to patients with mental health disorders, for example: depression and anxiety disorders, alcohol and drug use disorders, sexual disorders, adjustment disorders, posttraumatic stress disorder, eating disorders and sleep problems etc. SAH Obstetrician and Gynaecologist Dr Andrew Booker considers that access to a Clinical Psychologist for his patients at the SAH was long overdue: “Personally I believe the availability of a clinical psychologist has filled a gap in the range of services we can offer patients. Even on conservative estimates I believe that at least 5% of the 270 - 300 women I treat every year would benefit. Almost 100% of those that are 17 Mental Health “Personally I believe the availability of a clinical psychologist has filled a gap in the range of services we can offer patients. Even on conservative estimates I believe that at least 5% of the 270 - 300 women I treat every year would benefit. “ referred, report it’s been a worthwhile positive experience. Robert Woodfield is incredibly insightful and helpful and builds a strong rapport with the women he consults.” Dr Woodfield came to SAH’s allied Fox Valley Medical and Health Centre after 10 years of service in the Division of Women and Children’s Health at Nepean Hospital in Sydney where he Depression in the postpartum period is variously described as Peri Natal Depression, PND and Perinatal Mood Disorder and occurs in approximately 10% of Australian women at any time from conception to one year after childbirth; where applicable, the co-occurrence with anxiety must be acknowledged. Symptoms may typically include: Depressed mood (including irritability with other children etc) with or without anxiety; Sleeping difficulties (irrespective of the baby waking); Loss of appetite or eating for comfort (variable during pregnancy); Loss of enjoyment in usual pursuits; Sense of hopelessness as a mother and being a failure; Feelings of worthlessness and unjustified guilt; Tiredness or loss of energy (if applicable in context); Loss of libido (if applicable in context) and suicidal ideation or planning. Treatment typically involves taking a comprehensive history and having regard to background and current factors in the life of the patient e.g., family support and perceived emotional and practical support from the partner. The impact of PND can be devastating for the women and their families, impacting on the woman’s relationship with her partner and her relationship with her baby. Significant disruption in the mother’s attunement with her baby may have developmental consequences. established the role of Clinical Psychology in Obstetrics and Gynaecology. Patients clearly agree: so happy. With the birth of my second child “An empathic, non-judgmental, caring and “People simply don’t understand how I was referred to my Clinical Psychologist; He supportive approach is essential to any overwhelming it can be,” says Kylie Hinkley, validated what I was feeling and he helped me intervention,” says Dr Woodfield. High School English teacher and now the find the answers.” “It is also important to employ a collaborative mother of 2 young children. By Leisa O’Connor approach to the delivery of care. Such “I had struggled with my first child. I felt like I Corporate Communications Manager an approach may typically include the was going mad. I was just crying all the time… Sydney Adventist Hospital Obstetrician, Midwife, General Practitioner, what made it worse was having no one say Social Worker, Early Childhood Health Nurse there was a problem. There was no one to say and mother baby units e.g. Tresillian and its okay… and I went into a massive slump… Karitane”. I felt so guilty when I was supposed to feel Private Hospital - April 2009 18 APHA Member Mental Health Facilities New Farm Clinic Brisbane Community Outreach Team The New Farm Clinic’s Community Outreach Program has as its’ primary goal to facilitate maximum recovery. The program provides a model of continuum of care the same as an admitted patient to the hospital, but is treated in a non hospital based service. The Outreach Program assists in minimising the effects of illness and as a result reduces the length and frequency of hospital based admission. Outreach clinicians support the patient, family members and carers to manage illness and improve overall quality of life. The Program is designed for people: • Experiencing emotional difficulties • Experiencing difficulties making the transition from hospital based treatment to another treatment location • Facing difficulties in coping with their illness and treatment • Experiencing ongoing difficulties with family and social relationships •M ental Health and risk assessment completed during each visit • I ndividual Patient Care Plans completed in relation to HoNOS Survey • Progress report completed each visit - liaise with Doctors and other Health Professionals as required • Weekly meeting with Medical Director and Director of Clinical Services. The team includes experienced clinicians, such as registered nurses, psychologists or other equivalent health professionals. Safe Practice within the Community Outreach Team A referral is required from the treating Psychiatrist. Aims and Objectives of the Community Outreach Service • An individualised service, providing treatment and support to patients in their home environment • Assist patients and their carers to develop networks with other appropriate community services to meet their individual needs • Provide emergency telephone support/crisis management to patients when required thus decreasing the need for admission/readmission into hospital • Community Outreach staff work collaboratively with treating psychiatrists, patients and their carers (when appropriate) and other multidisciplinary staff, to plan and develop care and relapse prevention plans • Provide education/advice to patients and carers on issues identified by the patient e.g. medication, stress/anxiety management etc. • Weekly case review by the Medical Director, Director of Clinical Services and the outreach staff. Referral Procedure • Referral obtained from Doctor • Appointment made with Outreach Team within 7 days • Current professional registration and issue of Blue Card •A udits of outreach files ensuring completion of all relevant documentation by outreach staff •O utreach staff are authorised mental health practitioners under the QLD Mental Health Act 2000 • E ach day prior to their departure, outreach staff make contact with all patients scheduled to be visited to confirm appointment •O utreach staff makes an additional contact with the Director of Clinical Services during the course of their day to verify their safety and report on any issues/concerns encountered •A ll vehicles have navigation equipment and first aid equipment • Weekly supervision with the Director of Clinical Services provides clinical support • I npatient admission and discharge checklists include notifying outreach staff of patient’s admission and discharge • J oint visits with high risk patients Number of Outreach Visits 1st Half 2006 - 637 2nd Half 2006 - 623 1st Half 2007 - 519 2nd Half 2007 - 907 1st Half 2008 - 1179 2nd Half 2008 - 1226 Private Hospital - April 2009 Comments from Patients & Carers ‘Absolutely essential for my partner to remain at home’ ‘Builds a lot of confidence’ ‘Helps me cope from day to day’ ‘Enormously helpful’ ‘Staff are fantastic’ New Farm Clinic Front of clinic 19 Leaders in their field The Sunshine Coast Private Hospital Ect Database The Sunshine Coast Private Hospital Mental Health Unit has recently developed and is currently trialling the use of an electronic data base as an improvement to recording ECT treatment information. This initiative was instigated by the Unit’s nursing staff, and a multidisciplinary team was formed to ensure the database met all parameters of the project. • research purposes; • monitor and assess the effectiveness of both unilateral and bilateral ECT; • enables monitoring of medication use (especially PRN use) as often PRN use decreases once ECT has begun to be effective; • assessment of the number of received treatments, ensuring the maximum number of treatments is not exceeded without clinical indication; • recording of patient response to treatment ie how many patients go on to receive maintenance ECT. The database is both quantitative and qualitative information, ie. Becks Depression Inventory (BDi), MADRS (Montgomery Asberg Rating Scales) and MMSE (Mini Mental State Examination) are recorded pre, during and post ECT; and Private Hospital - April 2009 • Recording of how we can improve our service Overall, the database brings together the relevant medical and health information of each patient to help us as care providers to be as effective as we can be. This information was previously gathered by hand in a paper based log book, thus making analysis of information time consuming and unreliable. It is envisaged that this data can be used in the future for national benchmarking purposes and improved research into this treatment modality. v The database achieves a number of key objectives namely: • improve and maintain ECT standards through better access to information allowing streamlining of treatments; 20 APHA Member Mental Health Facilities Dudley-Orange Private Hospital In February 2007 Dudley Private Hospital in Orange opened a Mental Health Unit, which has become known as Dudley Clinic. Senior management had the foresight to seize upon the gap in private mental health services in the Central West area and the wisdom to restructure a ward of the hospital to accommodate this. Dudley Clinic can admit up to 15 patients in single and shared rooms. Three psychiatrists and two psychologists work on a part time basis and are supported by three shifts of nursing staff. Those patients who live with mood disorders and anxiety are most frequently admitted to the clinic but diagnoses such as post-traumatic stress disorder, obsessive compulsive disorder, psychosis and co-morbid drug and alcohol abuse are also accepted. The core of the psychological treatment within the Clinic is the therapeutic group program. Groups are held each day and focus on illness education and developing and maintaining effective ways of coping. Learning strategies to help improve sleep, increase motivation, deal with negative thoughts and overcome anxiety are key factors. Patients are asked to take part in exercise sessions, which include walking, a class at the local gym, tai chi and yoga. There is a weekly art group, a healthy eating group and regular relaxation sessions. All these groups help to reduce isolation, improve social interaction and confidence and increase levels of tolerance for new situations. It also reinforces the cognitive work done in groups. Even though it is still a young unit, the reputation of the Clinic is spreading amongst doctors, service providers, helping agencies, consumers, their families and friends. Recently, and for the second year in a row Dudley Clinic topped the annual Inpatient Mental Health Services patient satisfaction survey conducted by Press Ganey. Dudley Clinic caters to patients with a range of general psychiatric disorders. In the most recent survey Dudley Clinic has gone one better than last year with a score of 87.4 (2.6 points higher than last period). This result is an impressive 14.5 points higher than the mean of all other Mental Health facilities and 10.5 points higher when compared to Ramsay Mental Health peers. In addition to the inpatient program Dudley Clinic also offers a high quality Day Program for rural residents who would otherwise be unable to access treatment. Dudley-Orange rotunda Private Hospital - April 2009 We currently offer mood management groups and a Mindfulness Based Cognitive Therapy group. These fill up quite quickly and there is often a waiting list. Group numbers range from 10 to 14. They are closed groups and run for a period of 8 weeks, during school terms. The program is reviewed regularly by the Group Coordinator and all facilitators and each participant completes an evaluation at the end of the 8 weeks. Feedback from patients has been very positive and there are requests for more groups. The second mood management group was introduced as a direct result of information from participants. The Depression & Anxiety Stress Scale is used as a clinical evaluation measure and the patient evaluation as a quality measure. The Day Program offered by Dudley aims to provide high quality treatment options for rural communities and from the feed back we receive and the enquiry from other service providers we are achieving this. 21 Leaders in their field The Northside Group The Northside Group, owned by Ramsay Health Care, comprises Northside Clinic, Greenwich; Northside West Clinic, Wentworthville and Northside Cremorne Clinic with a total of 184 inpatient beds. The Group provides both inpatient and day patient programs for all mental health disorders, and is particularly renowned for their expertise in Mood disorders, Drug & Alcohol Services, Eating Disorders and combat-related Post Traumatic Stress Disorder. As mental health is becoming less stigmatised and more mainstream they are seeing a younger consumer that has different and more service-orientated expectations, as well as wanting a less clinical environment for their mental health treatment. In order to maintain a leadership position and ensure the offering is aligned with changing consumer expectations, the New Northside Clinic was launched to take mental health into the future. Initially introduced at Greewich it will be rolled out at Northside West and Northside Cremorne in the near future. Key components of The New Northside are: Client Relations a concierge-style service that offers patients a more personalised and timely admission, and a defined orientation. It is also a point of contact for patients other than unit staff and coordinates all patient social activities. Carers’ Pack was developed for carers, family and friends to provide education and information about mental illness and how to improve communication with their loved ones. It encourages carers to look after their own well-being and provides details of Carers’ groups held in the Clinic as well as community services that offer ongoing support. Improved Northside Active gym program supervised seven days per week with a range of exercise classes, yoga and optional fee-forservice personal trainer. Improved Dining Experience with a new, invigorated menu offering lighter, healthier meal choices and a range of café-style breakfasts. Private Hospital - April 2009 Life Enhancement product range which includes self-soothing products such as relaxation and daily essential packs, aromatherapy products, self-realisation books, CDs and journals and much more. Improved Social program includes current release movies in our cinema; Friday afternoon live entertainment with refreshments; family and friends BBQ and Sunday High Tea. Internet Lounge for patients’ convenience (fee-for-service). Easy Access is the well-established trademarked admissions service for the Group that provides doctors with one phone call, fast admission and/or assessment of their patients. Ramsay Health Care supports staff education and fellowship, and at The Northside Group they have developed a robust program that also includes Philosophy nights, Book Club, and Film Club. 22 APHA Member Mental Health Facilities Toowong Private Hospital Metabolic Syndrome Assessment Clinic – A Service for Psychiatrists and their Patients It is well recognised that the combination of mental illness and the medication to treat mental illness increases the risk of developing metabolic syndrome. The Metabolic Syndrome Assessment Clinic (MSAC) at Toowong Private Hospital (TPH) recognises these risks and provides a supportive environment for patients with mental illness to be assessed and provided with the educational tools for lifestyle risk changes. This clinic was commenced by the Hospital in June 2005 as literature confirmed that mental health patients were at an alarmingly increased risk of metabolic syndrome (Australian metabolic monitoring standards were published in the MJA in 2004). Many of the treating psychiatrists at Toowong Hospital were concerned that their patients did not actively seek out preventative measures with their general practitioners. The TPH MSAC provides an assessment and educational tool for treating psychiatrists to refer patients also at risk of metabolic syndrome and who are ready, from a mental health aspect, to accept the assessment process. Many patients had been inpatients at a mental health institution and felt comfortable attending the program at TPH as a familiar environment. Patients are referred by their psychiatrist, general practitioner or community mental health case manager with the approval of their psychiatrist. The process involves two visits with a general practitioner with sports medicine training. The initial visit involves a detailed history and examination, with emphasis on risk factors for cardiovascular disease, diabetes, previous and current injuries precluding exercise and exercise history. Patients usually require further assessment with fasting lipids and fasting blood sugars +/GTT. Waist/hip, weight and height measurements are collected. The attending nurse takes a resting ECG and the patient is asked to record a diet diary, as well as daily pedometer measurements, until the second doctor visit. At this visit, results are discussed and patients’ risks outlined. The second visit is followed by an afternoon session with a dietician, an exercise physiologist and a psychologist. A carer is encouraged to attend with the patient if they wish. The patient is encouraged to assess their diet and activity levels during the first week. During the second week the patient then aims to increase activity and make some adjustments to their diet. On completing the program, the treating psychiatrist, treating general practitioner and patient each receive a copy of the report with recommendations for further assessment and management, if indicated. Patients are encouraged to return for reassessment at 3, 6 and 12 month intervals for further review, education and measurements. The MSAC has seen 65 patients up to the end of 2008, the average BMI is 32.3 (ranging from 20.6-49.5) The average waist circumference is 111cm for women and 105cm for men. The average waist hip ratio is 0.917. 53% have abnormal lipids. 15-20% have impaired or diagnosed diabetes. 45% fit the criteria for metabolic syndrome. 32% smoke cigarettes. We have had 4-5 return for follow-up and have an average loss of 3.6kg of weight. The feedback on the clinic and education received is positive. Because this is a new and evolving clinic, we are constantly evaluating new ways to measure long term progress in our patients. This service is a specialised service designed to compliment the patient’s own psychiatrist and General Practitioner. People with mental illness should be encouraged to take an interest in their physical health. Healthy behaviours such as eating a balanced diet, being physically active and not smoking will help prevent metabolic syndrome. An increase in energy contributes to an important sense of total well being. By Dr Madeline Martin, General Practitioner Prominent Cancer Specialist Appointed New Commonwealth Chief Medical Officer Distinguished cancer physician, Professor Jim Bishop AO, has been appointed Australia’s new Chief Medical Officer (CMO). Professor Bishop is currently the Chief Cancer Officer & CEO of the Cancer Institute NSW. Professor Bishop is Professor of Cancer Medicine at the University of Sydney, is Fellow of the Royal Australasian College of Physicians (FRACP) and a Fellow of the Royal College of Pathologists of Australasia (FRCPA) in haematology. Professor Bishop was awarded a Fulbright Scholarship to study medical oncology at the National Cancer Institute (NCI), USA from 1979 to 1981 and from 1981 to 1995 he was a consultant medical oncologist at the Peter MacCallum Cancer Institute in Melbourne. From 1995 to 2003, Professor Bishop was the Director of the Sydney Cancer Centre at the Royal Prince Alfred Hospital and Concord Hospital in Sydney and directed the Cancer Service for the Private Hospital - April 2009 Central Sydney Area Health Service. His particular research interests are in clinical trials, new anti-cancer drug development, new cancer therapies, leukaemia, breast cancer and lung cancer. He has coordinated national clinical trials in leukaemia, breast cancer and lung cancer. He has authored over 230 scientific papers and reports on cancer, 150 abstracts and a textbook on cancer. 23 Mental Health Toowong Private Hospital - Mental Health Nurse Incentive Program Pilot The Australian Government’s Mental Health Nurse Incentive Program (MHNIP) commenced on 1 July 2007. In August 2007, the Department of Health and Ageing agreed to pilot a number of private hospital sites to ‘auspice’ the provision of specialist mental health nurses to their local private psychiatry practices. The pilot has been in operation at Toowong Private Hospital for a year and is entering into the evaluation phase of the program in March 2009. mental health nurses working in collaboration with private psychiatrists to provide support services such as monitoring consumers’ mental state, medication management and improving patient links to other health professionals and clinical service providers. The Toowong Private Hospital pilot of the MHNIP has enabled mental health nurses to provide a range of consumerfocused services to assist private psychiatrists in the coordination of treatment and care of their private practice patients with severe mental illness and complex needs. Toowong Private Hospital sought the The MHNIP Pilot has been specifically designed opportunity to be one of a handful of private for GP’s and private psychiatry practices and hospitals nationally to pilot this type of Toowong Private Hospital targeted private program and formally commenced the pilot psychiatrists’ patients engaged in outpatient on 15 February 2008. One hundred and ten treatment. The MHNIP has been predominantly (110) referrals have been made to the MHNIP. delivered to consumers in the community There are seventy five (75) consumers currently as home visits with a small proportion of benefiting from the additional treatment, consumers seen at the hospital. The service is care and support that can be provided by a not an acute hospital (or hospital substitution) mental health nurse in the community. The service and consumers who have required this pilot was to be evaluated at 6 months but the level of clinical intervention and treatment Commonwealth has advised it will now occur are referred to a hospital based service as after 12 months. appropriate. This important initiative has provided the Two full time nurses were engaged to work in opportunity for private psychiatrists who are members of the Toowong Private Hospital the MHNIP initially. This has changed during the past year whereby there are now five (5) nurses meet their clinical needs. The MHNIP has no set catchment area and considers all referrals on a needs basis. The majority of consumers live in the Brisbane area with the remainder residing in Ipswich or the Bayside area which are 30 kms or more from the hospital. When allocating cases a number of factors are taken into consideration. These include location, distance and time taken in travel and seeing the consumer. Nurses will try and cluster visits to consumers in a certain area in order to maximize use of time. Unfortunately this is not always possible which leads to lengthy periods of travel in a day. Consumers who require a phone call are often called by the nurse when travelling from one person to the next. Some consumers prefer a nurse of the same gender and this is accommodated. The specific needs of the consumer are matched with the varying skills a nurse may have where possible. A support group has been formed to address a range of issues common to persons with mental health problems. At present the group is open to all patients of the MHNIP. We are also looking at facilitating similar gender specific groups for both male and female patients aged 18 -30 years of age. There are 11 males and 12 females in this age group respectively. Medical Council to have more intensive working the equivalent of three full time positions. intervention and support for their patients Case loads vary in complexity for all the mental without the worry of managing human health nurses with an equal mix of low, medium resource and industrial relations matters. The and high care requirements. Consumers are Department of Health and Ageing required a seen anywhere from twice a week to monthly. formal agreement between each participating The majority are seen face to face with only two private psychiatrist and the Hospital. To date consumers receiving phone support, due to thirty three (33) psychiatrists have made a the constraints of travelling for both them and formal agreement with the hospital in order to the nurse. They live 200kms or more away and Support to the nurses is seen as a major component in the MHNIP. The hospital has purchased additional cars and mini laptops so the nurses can write their notes directly into a computer rather than waiting till they return to the office. The majority of information in relation to the care of consumers is electronically stored in preference to a chart/ file. This consists of case notes, case reviews participate in the program. the phone contact was considered adequate to and mental health care plans generally. Private Hospital - April 2009 v The MHNIP recognises the importance of 24 v Mental Health Referrals, letters, outcome measures and other allocating case loads and resources, managing The hospital is confident the evaluation of the Clinical information for the MHNIP is stored in use of hospital cars, performance appraisal, MHNIP will be favourable and the program separate files. Only the nurses engaged in the peer review and coordinating case reviews. will be able to continue in to the future. A MHNIP have access to the electronic case files for these consumers. The storage of information electronically has been well received by the nurses and aids in communication to doctors who prefer communication via email. The nurses are actively working towards attaining credentialling with the Australian College of Mental Health Nurses (ACMHN) by the end of 2009 with three of us studying a number of patients have informed the service that it has been invaluable to their wellbeing and recovery and trust that the program will continue. Masters Mental Health Nursing. Advice from This type of service is seen to be a worthwhile Clinical Supervision is provided on a monthly basis the Commonwealth is that payment will only and invaluable adjunct to the care and with the costs covered by the hospital. Monthly be made for those nurses who are credentialed treatment by many including, psychiatrists, peer review and monthly business meetings as at 1 January 2010. consumers, carers and nurses alike. also occur which supports and promotes open communication with the nurses. It will be a challenge for all the nurses to attain credentialling so as they can continue to work By Andrew Butwell I manage the MHNIP with my role being to in the MHNIP. Engaging additional nurses as Community Services Manager coordinate the program by vetting referrals, the MHNIP grows will also be paramount. Toowong Private Hospital Private Hospital - April 2009 25 Private Hospital - April 2009 26 APHA Member Mental Health Facilities Ramsay Health Care (SA) Mental Health Services Ramsay Health Care (SA) Mental Health Services consists of the only 3 private psychiatric sites in Adelaide: The Adelaide Clinic, Fullarton Private Hospital and Kahlyn Day Centre. The Adelaide Clinic The Adelaide Clinic is a leading provider of psychiatric services in South Australia. The hospital, which is a teaching facility of the University of Adelaide, provides a full range of general, acute and specialised psychiatric services. The Adelaide Clinic and Fullarton Private are both in-patient facilities, while Kahlyn has been converted to a Day Only facility for Psychiatric group therapy and out patients. This purpose built facility has been designed to offer the best in privacy and comfort for patients and superior facilities for Psychiatrists. As part of the complex, the Clinic has fully serviced consulting rooms. Between the three sites we are able to offer the full range of Psychiatric treatment for the whole of SA (and interstate as required) except for Closed Ward management. As well as excellence in Private Psychiatric Care, the Adelaide Clinic embodies the Ramsay Health Care ethos of “People Caring for People” hence patient care is the primary concern. Ramsay Health Care in South Australia works very much “for the individual” and is able to achieve excellent outcomes for our patients by providing whatever the best treatment might be for that individual. We have over 120 Psychiatrists credentialed to utilize our services, and have a strong commitment to Community services and Research. We are currently participating in the trial of the Mental Health Nurse Incentive Program, and conducting a trial (under RANZCP guidelines) of TMS (Trans Cranial Magnetic Stimulation) as well as our own internal research project on Bed Accessibility. Last year Ramsay Health Care SA celebrated 20 years of Mental Health Services for the Adelaide Clinic, 10 years for Fullarton Private and over 20 years for Kahlyn. A Gala dinner was held at The Entertainment Centre. We remain committed to continuing to provide excellent care for patients with psychiatric disorders. The Adelaide Clinic offers a diverse range of specialised treatment programs which are developed by staff with input from Psychiatrists, consumers and carers. The Clinic specialises in the treatment of acute adult psychiatric illnesses including; • Mood disorders • Anxiety disorders • Schizophrenia • Personality disorders • Drug & Alcohol detoxification The Adelaide Clinic has specialised areas to which patients can be admitted depending on their needs: • Electro Convulsive Therapy for the treatment of severe depressive illness, mania and other forms of psychosis. The ECT suite has state of the art facilities and is staffed by Registered Nurses experienced in post anaesthetic recovery. • An inpatient programme offers a wide range of groups to facilitate the recovery process and the successful transition from in-patient treatment back into the community. • The outpatient program can be utilized for the treatment of patients for whom an inpatient program may not be suitable. Attendance at the Day Programme can be full day, half day or on a sessional basis. In addition to our specialist group treatment programs, Kahlyn Day Centre provides individually tailored therapy programs, developed in consultation with the patient's psychiatrist. • R ecently discharged patients who may still require support are encouraged to attend the outpatient programme conducted at Kahlyn Private Hospital - April 2009 Day Centre, Magill. An integrated service for problems of drug and/or alcohol dependence and abuse, our Drug & Alcohol Unit is staffed by a highly experienced multi-disciplinary team of health care professionals and offers the following treatment components and options: • Assessment • Detoxification • Rehabilitation and • Outpatient follow-up The Drug & Alcohol Unit is specifically designed to cater for the medically controlled, safe withdrawal of both alcohol and other drugs, whilst minimizing the discomfort experienced by patients. The nature of the withdrawal procedure is determined by the nature and extent of the individual's substance dependence. The relapse prevention program, (provided at Kahlyn Day Centre) commences at the completion of detoxification and includes both group and individual counselling sessions. An outpatient open program at the Kahlyn Day Centre provides general information regarding the physical and emotional problems associated with the use of alcohol and drugs and the development of coping strategies. The outpatient program ensures the provision of ongoing support and allows the early detection for relapse preventive measures to be instigated. Individual and family counselling are important components of outpatient follow-up. Community Services A Community Service is available to patients who the treating psychiatrist feels would benefit from support. As such, the service can assist in early discharge and reduce the need for re-hospitalisation. The aims and objectives of the service are: • M aintain continuity of care by offering Community support after discharge from hospital • Assist patients by giving supportive counselling in the home environment therefore reducing the frequency of hospital admissions • Focus on the individual needs of the patient • Provide support and individual care The Community Nurse provides monthly 27 Leaders in their field RHC (SA) MHS introduced the community mental health service over 10 years ago with a view to reduce the number of in-patient admissions and assist the integration of the private patient back into the community. Patients are referred from two inpatient facilities and directly from psychiatrists’ rooms. Currently the CMHS cares for over 190 patients, with mental health diagnoses ranging from the affective and anxiety disorders to those with a psychotic illness. The admission time frame varies from a month to a number of years for those with a chronic condition. An individual’s care needs are identified in conjunction with the patient, nurse, psychiatrist and if appropriate, an allocated carer. A management plan including strategies and goals with progress evaluated on a 3 monthly basis. The focus of the service is two-fold. The first is to maintain the patient in their home and community setting, while minimising the number of admissions to hospital. The second focus is to integrate the patient into the community, link each individual into a support network and reduce the reliance on our service. With this in mind, discharge planning is an important part of admission as is addressed as part of care planning. the patient's scalp. An electric current passes through this coil that creates a magnetic pulse, which causes small electrical currents in the brain. These currents stimulate nerve cells in the region of the brain involved in mood regulation and depression. No anaesthetic is needed. Additionally, rTMS does not require that patients be admitted to hospital or fast before treatment, and patients are permitted to drive afterwards. possible to determine whether five day rTMS treatments are necessary or whether similar effectiveness can be achieved with three day a week treatments. If it is found that three day a week treatments are as effective as five day a week treatments this will mean less inconvenience to patients. In addition, if three day a week treatments are as effective this will mean fewer rTMS treatments being required to achieve remission. Research indicates that rTMS is effective in the treatment of major depressive disorders and is not associated with any delayed side effects (Fitzgerald, et al., 2006; O’Reardon et al., 2007; Pascual-Leone, et al.,1996; Rossini & Rossi, 2007). Measures being administered during the trial: The aim of the research project is to evaluate the effectiveness of rTMS administered five days a week compared to rTMS administered three days a week in the treatment of Major Depressive Disorder (MDD). All treatments will be administered using the same protocol, developed by Professor Paul Fitzgerald (an international expert in rTMS and a collaborator on this research). In conducting the proposed research it will be Commitment to ongoing Research and Education: The Adelaide Clinic is committed to funding research and supporting ongoing evaluation and outcomes studies in Psychiatric care. The Adelaide Clinic currently funds a half time Chair of Psychiatry (Professor Cherrie Galletly the University of Adelaide's faculty of Health Sciences. as well as a 0.6FTE Research Officer. Current research includes: Transcranial Magnetic Stimulation (TMS) Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new treatment for depression that has been shown to be effective, and to be better tolerated than ECT (Turnier-She, et al., 2006). Like ECT, it relies on direct stimulation of the brain, but uses magnets instead of electric current. rTMS involves holding an electromagnetic coil near Private Hospital - April 2009 • Mini International Neuropsychiatric Interview (MINI) (Sheehan, et al., 1998) at baseline only. • Hamilton Depression Rating Scale (HAM-D) (Hamilton, 1960; Hedlung & Vieweg, 1979). • Montgomery–Asberg Depression Rating Scale (MADRAS) (Montgomery & Asberg, 1979). • Clinical Global Impressions (CGI) (Guy, 1976). • Global Assessment of Functioning (GAF) (Hall, 1995). • CORE Rating of Psychomotor Disturbance (Parker et al., 1990). • S ocial Functioning Survey (Fillenbaum & Smyer, 1981). • ‘Employment Questionnaire’ (a measure of v progress reports to the treating psychiatrist and regular liaison with the doctor as necessary. 28 APHA Member Mental Health Facilities v Fullarton Private Hospital occupational functioning). • Brain Resource IntegNeuro test for General and Social Cognition (Brain Resource Company) (to be conducted at a later date). Bed Accessibility at Ramsay Health Care (SA) Psychiatric Hospitals. Access to beds when they are needed is crucial to the operation of private hospitals and psychiatric hospitals are no exception. An acutely suicidal patient is as much of an emergency as someone with serious physical injuries. A hospital that is believed to have long waiting lists and little capacity to respond to urgent situations will be viewed negatively by admitting specialists and patients. It is therefore important to have accurate information about how quickly patients are admitted after their specialist requests a bed. The Adelaide Clinic and Fullarton Private Hospital, both recently undertook a review of bed accessibility. Besides collecting data about the time to admission, we were also interested in the reasons why patients could not always be admitted immediately. Data was collected for patients referred from June 2008 to November 2008. There were 506 requests for admission. Our first priority was to establish if there were waiting times for urgent admissions. In fact, they were all admitted within 24 hours, which we considered indicated a satisfactory ability to respond to emergencies. Non-urgent patients were offered admission within 3 days (72.3 hours). Twenty percent of these patients declined the bed offer, most commonly because hospital admission was no longer required. (This may have been due to alternate services being offered eg Community/Outreach services or that the doctor may have been unsure if the patient’s condition would deteriorate over the next 24-48 hours to a point that would require admission to hospital). capacity to respond to urgent referrals is an important KPI and we now have accurate data separating out the hospital response, and delays due to other factors. Teasing out all the factors influencing bed accessibility was a useful exercise. As a result of participating in this project, staff responsible for admissions at the two hospitals developed a more streamlined process for listing and managing requests for beds. They also observed that being required to state exactly why a patient could not be admitted at that time has led to changes in practice. Further examination of the bed booking system for the specialised programs may be worthwhile. We could also look at whether we can introduce measures to reduce the delay between the bed offer and admission. The results of the review have been discussed at our Medical Advisory Committee and summarised in a newsletter to all accredited specialists, so our referring doctors now have accurate information about bed accessibility. The 20% of referrals who decline admission may indicate that doctors are requesting beds “just in case” and reassurance that timely admission is generally possible may reduce this practice. The survey has dismissed any comments that suggested patients could not get admitted to our hospitals when they needed to be in hospital. It also highlighted the many variables that contribute to an acute psychiatric admission to hospital. Finally it has improved our triage and admission process. It was well worth collecting the data. By: Professor Cherrie Galletly, Chair Psychiatry University of Adelaide Ms Cassie Burton, Research Officer RHC SA Mental Health Services Ms Carol Turnbull, CEO, RHC SA Mental Health Services Our review found that hospital work load management and staffing issues were not key factors determining the time patients waited for a bed. In fact, these issues were identified as the reason for bed unavailability for less than 2% of patients. The majority of referred patients were not put on the waiting list because there were no beds, but rather because beds had been booked in advance by patients coming in to specialised programs such as the Drug and Alcohol Inpatient Withdrawal Program. The survey has had a number of benefits. The Private Hospital - April 2009 Fullarton Private Hospital provides a full range of general, acute and specialised psychiatric services and also offers a unique Adolescent and Young Adult program. Fullarton Private Hospital specialises in the treatment of acute adult psychiatric illnesses including; • Mood disorders • Anxiety disorders • Schizophrenia • Personality disorders The Adolescent and Young Adult service is available to any Psychiatrist with Admitting Privileges with Ramsay Health Care (SA) Mental Health Services and is coordinated by an experienced Psychiatric nurse, a Consultant physician, a Social worker, Dietician and a Psychologist. This program is designed to address the needs of young people who may be experiencing: • Depression • Suicidal and/or self-destructive behaviour • Anxiety disorders • Reaction to family problems • School refusal • Psychosomatic disorder • S ubstance abuse disorders and eating disorders. 29 Leaders in their field Ongoing management after discharge may be: A Young Adult Day Patient Program which has been developed to reduce the length of hospitalisation and offer the ongoing benefit of support and participation in day program activities while the Young Adult is integrating back into family, social and education environments. A Community Service is available to post discharge patients who the treating psychiatrist feels would benefit from support. As such, this service can assist in early discharge and reduce the need for re-hospitalisation. This service works in collaboration with The Adelaide Clinic’s service. The aims and objectives of the service are: • To maintain continuity of care by support after discharge from hospital • To assist patients by giving supportive counseling in the home environment therefore reducing the frequency of hospital admissions • To focus on individual needs of the patient • To provide support and individual care • To promote self-management The Community Nurse will provide progress reports to the treating psychiatrist. Regular liaison with the doctor as deemed necessary is also part of the service. The cost of the home visit is covered by the major health funds with no costs incurred by the patient. Kahlyn Day Centre There has been a shift in emphasis on how mental health services should be best delivered. Whilst recognising the need for inpatient treatment for the more severe and acute presentations, alternatives to this type of care, including outpatient programs and community services can offer a more appropriate treatment setting. To meet this challenge of delivering mental health care treatment options, Kahlyn Private Hospital has evolved to become Kahlyn Day Centre and offers the following services: • Assessment and treatment of patients with Drug and Alcohol problems •A Clozaril™ Clinic and • I nnovative Day programs, tailored to meet the needs of the individual The Day Patient Program provides day therapy to assist patients in gaining further insight into themselves and their problems. We offer a selection of groups and individual sessions designed to meet the needs of the individual. Some of the programs we offer include; Stress & Anxiety, Personal Growth, Self Discovery, CBT (Cognitive Behaviour Therapy) Emotional Management, Dialectical Private Hospital - April 2009 Behavioural Therapy and the NEWWAYS (Drug & Alcohol CBT based program). The main objective of the Day Program is to provide a supportive environment created by professional staff dedicated to maintaining and enhancing the independent functioning of each patient. The aim of the Day Program is to: • R educe or eliminate the frequency of inpatient hospitalization • D evelop self recognition of symptoms and a management plan • Promote awareness and teach skills, which allow patients to take responsibility and control their own lives. • Assist recently discharged patients who may still require support. The outpatient program can also be utilized for the treatment of patients for whom an inpatient program may not be suitable. ttendance at the Day Unit program can be A full day, half day or on a sessional basis. In addition to our specialist group treatment programs, the Day Unit provides individually tailored therapy programs, developed in consultation with the patient’s Psychiatrist. 30 Mental Health THE PMHA – Dedicated to Improving Private Sector Mental Health Services for Australians The Private Mental Health Alliance (PMHA) is the result of a major restructure of the Strategic Planning Group for Private Psychiatric Services, or SPGPPS as it was known. The SPGPPS was originally established around ten years ago in response to the reforms that were taking place under the National Mental Health Strategy. The recent restructure of that group into PMHA occurred in response to a time of great change in mental health, particularly with the introduction of Broader Health Cover and the recent COAG reform initiatives. After eleven years, the alliance model continues to enable the major stakeholders involved in the funding, provision and receipt of private sector mental health services to come together and determine how best to move forward on many complex and difficult issues. The restructured Alliance is now chaired independently by Mr Philip Plummer and currently includes representatives from the following organisations. • Australia Medical Association (AMA) • Australian Private Hospitals Association (APHA) • Australian Health Insurance Association (AHIA) • Australian Government Department of Health and Ageing (DoHA) • Private Mental Health Consumer Carer Network (Australia) [Network] PMHA provides representation and promotion for the private mental health sector in a coherent and consistent manner and it is not aligned with any particular stakeholder, or vested interest group. The Alliance is committed to ensuring that high quality mental health care is available and accessible to people with a mental illness in a private sector environment that offers a full range of effective and efficient services in a coordinated manner. The PMHA seeks to honour this commitment in several ways. Improving understanding Firstly, the Alliance is working with the Australian Government to improve the understanding of and interface between the private and public sectors. The PMHA is formally linked to the Australian Health Ministers Advisory Council through its position on the Mental Health Standing Committee of AHMAC’s Health Priorities Principal Committee. It also holds positions on that Standing Committee’s Safety and Quality Partnership Sub–committee and its Mental Health Information Strategy Sub–committee. Policy Secondly, the PMHA is involved in the determination of good policy that provides guidance on clinical and funding issues. The Alliance stakeholders work together to formulate collaborative solutions on agreed key issues that affect mental health services in the private sector. That collaborative process, also operates to better inform the policy base of participating organisations. Over the past twelve months, the PMHA has ensured that the private sector has been properly represented and closely involved with an important range of policy issues. Some of those have included the Review of the National Mental Health Policy, the Evaluation of the National Mental Health Plan 2003–2008, and the 2007 COAG Annual Report on Mental Health. Funding Another major area for the PMHA is funding reform. Here the focus is the development of innovative models for funding service delivery that are feasible and effective without compromising the quality and continuity of care. One major discussion paper on Options for Funding Service Delivery for Private Psychiatric Services has already been published and several of the options that were originally canvassed in the very early drafts of that paper have now been implemented. Looking forward, the PMHA has included the establishment of a Collaborative Care Models Working Group as a major part of its work plan for the next few years. The Working Group will examine the impact of the Broader Health Cover initiative and the COAG reforms, and Private Hospital - April 2009 look at where further innovations in funding and service delivery might be possible in the new environment that is emerging. The Working Group will also take account of the previous discussion paper and seeks to involve other relevant professional groups including GPs, psychologists and other allied health professionals. Practice The final major area of PMHA activity involves informing and affecting practice within the sector. For example, the PMHA is responsible for the annual review of the Guidelines for Determining Benefits for Health Insurance Purposes for Private Patient Hospital–based Mental Health Care. These Guidelines assist in determining facility selection and appropriate funding levels for private health insurance purposes. The Guidelines can also be of assistance to State/Territory health authorities and their public hospitals in the treatment of Medicare and privately insured patients. Over the past twelve months the PMHA has also been instrumental in ensuring that the private sector has been involved in the current review of the National Standards for Mental Health Services, which is being conducted by the Australian Council on Health Care Standards. Most recently, it was a PMHA submission to the Australian Government on the Hospital Casemix Protocol (HCP) that resulted in the inclusion of an additional data element and clarification of several others. Other activities PMHA is also involved in two other complementary activities. Firstly, the Alliance provides a unique Centralised Data Management Service (PMHA– CDMS) for the private sector. The PMHA’s CDMS 31 Mental Health works with private hospitals and health insurers to put in place efficient systems for the routine collection of outcomes data that enables the quality and efficiency of mental health service delivery to be evaluated and reported on every quarter. (See page 32 for more on the CDMS). Secondly, the PMHA supported the establishment of the Private Mental Health Consumer Carer Network Australia (Network). Essentially, the Network seeks to improve the participation of privately insured consumers and their carers at the national and local level. The PMHA, its CDMS and the Network are currently operating under a partnership arrangement known as the AMA Agreement for Services 2008–2009. All the stakeholder organisations mentioned before are Parties to this Agreement together with beyondblue Ltd. Under the Agreement, the AMA provides infrastructure support and coordination for the activities of the PMHA, its CDMS and the Network from the offices of the Federal AMA in Canberra. The current support arrangements include the following. •A PMHA Independent Chair, currently Mr Philip Plummer located in Adelaide. •A PMHA Director, currently Mr Phillip Taylor who is located in Canberra. Mr Taylor is responsible for supporting all the activities of the PMHA and provides supervision of the activities of the PMHA–CDMS and the Network. •A Director for the PMHA’s CDMS, currently Mr Allen Morris–Yates, who is located in Adelaide. Private Hospital - April 2009 • An Independent Chair of the Network, currently Ms Janne McMahon OAM, who is located in Adelaide. Parties to the AMA Agreement make funding contributions for the provision of the services required to support the operation of all three entities. For PMHA, all stakeholders, except beyondblue, make equal contributions. The AHIA, APHA and the Australian Government make equal contributions to support the CDMS, and all stakeholders contribute equally to support the Network. By Philip Plummer PMHA Independent Chair 32 Mental Health Evaluation of the Outcomes of Care by Private Hospitals with Psychiatric Beds — the Work of the PMHA’s Centralised Data Management Service Consumers and their carers together with health insurers and others who pay for health services have a legitimate need for answers to certain key questions: are consumers receiving the care they require; is effective care being provided in a safe manner; and are the available resources being used efficiently and appropriately? The answers to these questions should be based on reliable evidence says Allen Morris-Yates, Director of PHHA-CDMS. Allen Morris-Yates, Director PMHA-CDMS Aged Care and the AMA, AHIA and APHA, a be collected are collectively referred to under project to develop a National Model for the the National Model as the Outcome Measures collection and analysis of data which could Protocol (OMP). The linkage of data collected better inform all stakeholders about the under the OMP with the data Hospitals already quality and effectiveness of care provided must collect under the Hospitals Casemix in private hospitals with psychiatric beds. A Protocol (HCP) enables a comprehensive representative working group was formed description of psychiatric patients’ needs for to assist in the development of the model. and responses to care. An initial draft document, outlining in detail options for data collection, submission, and centralised analysis and reporting was The PMHA’s Centralised Data Management Service Hospitals need an effective information presented to Hospital and Health Fund The PMHA’s Centralised Data Management infrastructure that enables questions about representatives at a briefing in September Service (CDMS) was setup by the SPGPPS quality, effectiveness and efficiency to be 1999. On the basis of Hospitals’, Health Funds’ under the auspices of the Australian Medical addressed. That infrastructure has three and other stakeholders’ preferred options, the Association in June 2001. The CDMS is jointly essential components — data collection, final National Model was drafted and published funded by Private Hospitals with Psychiatric data analysis and reporting, and people who in May 2000. Beds, Private Health Insurance Funds, and have the tools and skills needed to use that information in service management and clinical quality improvement. It also has a number of critical attributes, including that it uses a common language, enables comparison of like with like, has adequate reliability and validity, protects the privacy and confidentiality of patients and where appropriate also of providers and payers, and operates in as close to real–time as possible. It must also operate alongside the existing clinical information infrastructure that supports the day–to–day provision of care without compromising the quality of care or imposing undue additional burden on clinicians or costs on hospitals. In its current form, the National Model consists of guidelines that cover the specific data to be collected, the timing and procedures for the collection and submission of data by Hospitals for analysis, the reports to be derived from that data, and restrictions on access to data and information at all stages and at all levels of aggregation. The latter is particularly important as, whilst the need for the protection of personally identified information is well understood, issues related to the use and access to information regarding identified providers and payers also must be addressed if Clinicians, Hospitals and Health Funds are the Commonwealth Department of Health and Ageing under an Agreement with the Australian Medical Association. Under this Agreement, the CDMS is required to: • Assist participating Hospitals with the implementation of their National Model for the Collection and Analysis of a Minimum Data Set with Outcome Measures. • Provide Hospitals and Health Funds with a data management service that routinely prepares and distributes standard reports regarding the quality, effectiveness and efficiency of private hospital–based psychiatric services. to retain confidence in the probity of the The analysis and reporting framework Development of the National Model processes of analysis and reporting. employed by the CDMS operates under the In March 1998 the Private Mental Health The agreed guidelines that specify how Alliance’s (PMHA) antecedent, the Strategic episodes of care are defined for the purposes of Planning Group for Private Psychiatric outcomes assessment, what clinical measures Services, initiated, with funding from the are to be collected, and at what points Commonwealth Department of Health and during the episode those measures should Private Hospital - April 2009 Guidelines specified in the National Model to ensure that the privacy and confidentiality of the participating Hospitals and Payers is protected. Essentially, the guidelines require that aggregate statistics be partitioned on the 33 Mental Health basis of the identity of the responsible Hospital functioning. The items were derived from the for approximately 75% of all private psychiatric and Payer, with each Hospital or Payer then Medical Outcomes Study questionnaire used beds in Australia. only being provided with identified statistical in the Rand Health Insurance Experiment. The information about their patients’ or members’ 14 items also constitute the mental health care. Aggregate statistics about other Hospitals component of the SF–36, the most widely used or Payers may only be provided in a format that patient–completed outcome measure in the ensures the responsible Hospitals or Payers general health sector. Four summary scores cannot be identified. For example, are derived from patients’ responses to the each Hospital’s report is individualised so that 14 items: these are traditionally referred to as they can identify themselves within charts Mental Health, Vitality, Social Functioning and and tables, but are unable to identify any Role Functioning. Who receives care? What can the CDMS tell us about private During that year the 37 private Hospitals participating in the CDMS admitted 19,213 patients for psychiatric care. The demographic profile of those patients is shown in Figure 1. Of those patients, 15,100 had a total of 20,818 separations from overnight inpatient care (excluding brief overnight admissions for sameday procedures) with an average length of stay of 19 days. The diagnostic profile of those patients, based on their principal diagnosis recorded under the HCP, is shown in Figure 2. Of the 8,066 patients who received any care on a Sameday or Outreach basis (referred to under the National Model as Ambulatory care) 3,953 also had at least one Overnight inpatient admission. hospital–based psychiatric care? What are the outcomes of care? and submitted on a quarterly basis to the During the 2007-08 financial year Australia had CDMS in a personally de–identified format for 27 stand–alone private psychiatric hospitals analysis. On the basis of that data, the CDMS and 22 psychiatric units located within private prepares and distributes Standard Quarterly general hospitals. Together these Hospitals had Reports to participating Hospitals and Payers. approximately 1,700 psychiatric beds. Hospitals Under the National Model, the outcomes of care are principally evaluated through comparisons of patients’ clinical status at admission with their clinical status at discharge. The comparisons are reported as effect sizes (standardised change participating in the PMHA’s CDMS accounted scores). Generally an effect size of around 0.2 is other hospital. During the 2007–08 financial year the Under the National Model, Hospitals collect completed measure collection rates for the two measures of patients’ clinical status, the HoNOS were 86% at both admission and HoNOS and MHQ-14, at key points in the discharge whilst for the MHQ-14 they were clinical path — at Admission and Discharge 78% and 80% respectively. These rates are very from episodes of care, and where episodes are good, particularly given that this is a routine of extended duration, at Review every 91 days. collection. That information is linked with administrative and clinical data already recorded by Hospitals under the Hospitals’ Casemix Protocol (HCP), The HoNOS (Health of the Nation Outcome Scales) is a clinician–rated measure developed by the Royal College of Psychiatrists. Its’ twelve scales provide a comprehensive yet brief Figure 1: Demographic profile (Age group by Sex) of patients admitted to participating private hospitals. summary of the clinician’s assessment of the patient’s clinical status over the preceding period (two weeks at admission, three days at discharge). Ratings on each scale may range from 0 to 4: a rating of 0 indicates the problem was not present; ratings of 1 to 4 indicate increasingly severe problems during the period. Each scale is supported by a detailed glossary. Scales 1 to 10 address behavioural, symptomatic and social problems; scales 11 and 12 are about the patient’s domestic and occupational environment, particularly the extent to which it may help or hinder their recovery. The MHQ–14 (Mental Health Questionnaire, 14 item version) is a patient self–report measure consisting of items that address symptoms of fatigue, anxiety and depression and the impact of those symptoms on social and role Private Hospital - April 2009 34 Mental Health described as small, around 0.5 as moderate, and around 0.8 as large. When looked at from the clinicians’ perspective using the HoNOS Total Score (a composite indicator of the severity and complexity of patients’ clinical presentation), the average effect size for episodes of overnight inpatient care is 1.25 — a very large effect. When looked at from the patients’ perspective using the MHQ–14, the average effect sizes for episodes of overnight inpatient care ranges from 1.35 on Mental Health, 1.40 on Social Functioning, to 1.56 on Role Functioning. Clinicians and patients tell a consistent story. To give further context to these results, Figure 3 provides a comparison of patients MHQ–14 summary scores at Admission and Discharge with scores on the measure derived from the Australian Bureau of Statistics’ National Health Survey conducted in 1995. Patients reported mental health, social and role functioning at Admission are worse than 95% of the general Figure 2: Diagnostic profile for separations from overnight inpatient care. population. By discharge they have improved greatly, but are still not as well on average as Figure 3: Comparison of patients’ self–reported clinical status at Admission and Discharge with that of the General Population. the general population. Concluding remarks A comparison of the demographic and diagnostic profiles of patients admitted to private hospital-based psychiatric services to those of patients admitted to public general hospital psychiatric units clearly indicates that a generally different group of people are receiving care in each sector. Both patients’ self assessments and clinicians’ ratings clearly indicate that the patients admitted to private hospitals are not the “worried well”. Unlike some other areas in health care, private psychiatric hospitals do not provide a parallel service to the public sector. Rather, the private psychiatric hospital sector provides effective care to a significant group of patients who are not able to be cared for in public psychiatric units. Private hospitals with psychiatric beds play an essential role in the overall provision of mental health services in Australia. By Allen Morris-Yates, Director PMHA-CDMS Private Hospital - April 2009 35 Private Hospital - April 2009 36 Private Hospital - April 2009 37 A Computer Assisted Data Capture System for Monitoring Outcomes following Psychiatric Hospital Admission: Development and Advantages The cost of mental healthcare services in Australia is high and many are looking to technology usage to assist with cost containment. Technology could be used to decrease the burden of routine procedures and processes; Gomaa et al. (2001) for example, reported that using computer-based personalized feedback and an education campaign results in improved clinical outcomes and cost saving. Research has indicated that compared to paper, computerized assessments require less or comparable time to complete, provide similar data, and result in reliable assessments (Velikova et al., 1999). The need for data entry personnel can be eliminated, resulting in a huge time and cost saving. Studies also indicate that patients’ responses to these systems are favourable, with patients reporting that computer based systems are easy to use (Mullen et al., 2004; Wright et al., 2003), and patient satisfaction generally is high (Taenzer et al., 2000). There is also some evidence that patients are less inhibited when responding on a computer rather than face to face that many clients are more candid in their responding via email or online than when speaking face-to-face (Fiegelson & Dwight, 2000). In addition to potential cost effectiveness and efficiency advantages, there is the potential for clinical assessment to be improved with the assistance of computer assisted systems. Research has shown that both patient and healthcare provider factors may prevent sufficient symptom assessment (Carpenter et al., 2008). For example, some patients do not verbally inform their clinicians about all the symptoms they are experiencing, and additionally, clinicians may not accurately document the symptoms that patients do report. In one study, 52% of 538 patients with cancer had never informed their physician they were experiencing fatigue (Stone et al., 2000). As a result, only 14% had received any treatment for fatigue, and 33% reported that their fatigue was being poorly managed. Velikova et al. (1999) found that patients perceived an increase in the number of issues discussed during consultations with their clinician after completing a computer administered health related quality of life assessment. Also, clinicians enquired more often about daily activities and emotional problems. Another barrier to thorough symptom assessment is financial cost: the costs of data management and the burden of collecting paper-based questionnaire data tends to be high. Innovative solutions are therefore required to meet the needs of healthcare consumers whilst maintaining quality and containing costs. In the oncology arena, Carpenter et al. (2008), suggest that the solution may be a computerized system that standardises assessment, documentation, and management of patient symptoms. Such a system has clear potential advantages for individual patient care. So although it is necessary to individualize each clinical assessment, there are many elements of information that are ``required'' to be collected, either because of a legal documentation requirement, an institutional policy, or because it represents the standard of care. Computerization offers an obvious opportunity to add additional structure to the assessment process (Essin et al., 1998). For example, the Marian centre’s computer based questionnaire system collects the Health of the Nation Outcome Scales (HONOS) and Mental Health Questionnaire-14 (MHQ-14) data which is sent to the Centralised Data Management Service (CDMS) of the Private Mental Health Alliance for external benchmarking. To the best of our knowledge there exists no computer based questionnaire system that fulfils these requirements. A further potential clinical advantage of computer-assisted patient assessment systems is in the realm of outcome measurement, research, and quality improvement. Clear and objective systems for evaluating outcomes in mental health services is becoming increasingly important, and in some cases, mandatory. Without thorough outcome assessment, treatment effectiveness is often unknown, improving quality of care becomes more difficult, and research and benchmarking is impossible. In summary, a computer assisted assessment system may have the potential to facilitate clinical assessment within mental health services by improving the time and cost burden of assessment, improving and standardising clinical assessment, and supporting mandatory Private Hospital - April 2009 reporting, quality, research, and benchmarking activities. The Marian centre, as part of its ongoing quality improvement activities, investigated the introduction of a computer-based assessment system to be used at admission and discharge. The Marian Centre computer based questionnaire system The computer based questionnaire system content was created by staff at The Marian Centre and programmed by TheITHive. The program was designed to run as a stand-alone application on Microsoft® Windows® XP and required no other software. Questions comprise standardised and widely used clinical assessment instruments and ask patients about anxiety, depression, stress, self esteem, insomnia, stressful life events, and quality of life. A patient satisfaction questionnaire was also developed for use at discharge. The computer based questionnaire system comprises a routine element of the hospital’s admission and discharge protocol and complements a routine face to face clinical interview. During admission, the admitting nurse completes the HONOS directly onto the system. Patients are then introduced to the computer based questionnaire system by their admitting nurse and are seated in front of a standard desktop computer to enter their responses. Patients are required to fully complete each questionnaire before continuing. If an item is missed they are prompted to go back and provide an answer before advancing to the next screen. Once an individual questionnaire is completed, patients can leave the computer based system and return at a later stage to finish the questionnaire battery. After a patient completes the assessment, a summary printout is generated for the medical record. Printouts provide a graph of patient scores for each symptom over time. Each graph displays feedback guiding interpretation of each symptom category. A copy is also emailed to the treating psychiatrist. Data from the assessment is also immediately available for analysis of whole hospital data. This allows real- 38 time tracking of trends in patient characteristics and outcomes. Ease of Use and Satisfaction with the System The computer system records the time it took patients to complete it. Patient satisfaction is assessed immediately after completing the discharge questionnaire battery, with 82% of patients indicating that using the system was straightforward. Further, 78% of patients indicated that they would prefer to complete these questionnaires on computer than on paper. From the clinician perspective, the computer based questionnaire system allows comparisons to be easily drawn between time points (admission and discharge, multiple admissions), between patients, and in comparison to norms. The immediate feedback of questionnaire results can be used to ad to face to face assessment either by supporting or challenge a diagnosis or clinical impression, and provides clinical information that may not be adequately covered or accessible within time limits of the clinical interview. At the hospital level, the computer based questionnaire system has proved an invaluable tool for assessing trends in outcomes over time, evaluating quality improvement initiatives, and facilitating research and benchmarking. Future innovations The computer based questionnaire system developed at The Marian Centre has the potential to be utilised in many different ways. For example, it would be possible for patients to complete their questionnaires remotely, allowing the possibility of collection of follow-up data. Additionally, while the computer based questionnaire system printout system is currently designed for clinician use, this feedback could also be provided to patients, a potentially useful tool for maximising their involvement in the assessment and treatment planning process. Conclusions The data capture system was developed in order to facilitate clinical assessment in a standardised, cost effective manner that allows data to be immediately available for individual clinicians and patients, and for quality assurance/improvement, and research purposes. By Dr Melissa J Ree Research Director The Marian Centre References Carpenter , J.S., Rawl, S., Porter, J., Schmidt, K.,Tornatta, J., Ojewole, F., et al. (2008). Oncology outpatient and provider responses to a computerized symptom assessment system. Oncology Nursing Forum, 35(4), 661–669. Christensen, H., Griffiths, K.M., Evans, K. (2002). e-Mental Health in Australia: Implications of the Internet and Related Technologies for Policy. ISC Discussion Paper No 3. Commonwealth Department of Health and Ageing, Canberra. Essin, D.J.Dishakjian,R., deCiutiis,V.L., Essin,C.D., Steen, S.N. (1998). Development and Assessment of a Computer-Based Preanesthetic Patient Evaluation System for Obstetrical Anesthesia. Journal of Clinical Monitoring and Computing, 14 (2), 95-100. Fiegelson, M. E., & Dwight, S. A. (2000). Can asking questions by computer improve candidness of responding? A meta analytic perspective. Consulting Psychology Journal: Practice and Research, 52 (4), 248-255. Gomaa, W.H., Morrow, T. & Muntedam, P. (2001). Technology-based disease management: A low-cost, high value solution for the management of chronic disease. Disease Management and Health Outcomes, 9(10): 577-588. Mullen, K.H., Berry, D.L., & Zierler, B.K. (2004). Computerized symptom and quality-of-life assessment for patients with cancer part II: Acceptability and usability. Oncology Nursing Forum, 31(5), Stone, P., Richardson, A., Ream, E., Smith, A.G., Kerr, D.J., Kearney, N., et al. (2000). Cancer-related fatigue: Inevitable, unimportant and untreatable? Results of a multi-centre patient survey. Annals of Oncology, 11(8), 971–975. Taenzer, P., Bultz, B.D., Carlson, L.E., Speca, M., DeGagne, T., Olson, K., et al. (2000). Impact of computerized quality of life screening on physician behaviour and patient satisfaction in lung cancer outpatients. PsychoOncology, 9(3), 203–213. Velikova G, Wright EP, Smith AB, Cull A, Gould A, Forman D, Perren T, Stead M, Brown J, Selby PJ. Automated collection of quality of life data: A comparison of paper and computer touch-screen questionnaires. Journal of Clinical Oncology 1999; 17: 998-1007 Wright, E.P., Selby, P.J., Crawford, M., Gillibrand, A., Johnston, C., Perren, T.J., et al. (2003). Feasibility and compliance of automated measurement of quality of life in oncology practice. Journal of Clinical Oncology, 21(2), 374–382. Private Hospital - April 2009 39 Private Hospital - April 2009 40 St John of God Pinelodge Clinic - Providing Mental Health Services for the Culturally and Linguistically Diverse St John of God Pinelodge Clinic is a 54 bed hospital offering specialised psychiatric and drug and alcohol rehabilitation care, with inpatient and day patient therapy programs and an alcohol and drug dependency recovery treatment program located in Dandenong, Victoria. The City of Greater Dandenong presents a complex demographic that is characterised by an increasing cultural diversity. The City of Greater Dandenong is the most culturally diverse locality in Victoria and the second most diverse in Australia, with residents from over 150 different birth countries and more than 170 different language groups. In relation to clinical inpatient treatment: • There are lower rates of utilisation of inpatient mental health services by those from CALD (culturally and linguistically diverse) backgrounds than ESB (English Speaking Background) communities. Dandenong is rated among the most disadvantaged 1% of Municipalities in the State (Bureau of Statistics 2001 census). This rating is based on incomes, education levels, household and car ownership, occupations, labor force status and other data. Dandenong has higher unemployment compared to other areas in Melbourne and has pockets of extreme disadvantage. • The duration of stay in hospital is longer for CALD than ESB, Identifying the Gap • Duration of outpatient consultations is significantly shorter for people with poor English language proficiency. Several studies conducted by the “Transcultural Psychiatry Unit” at St Vincent’s Hospital Melbourne indicate that: • There are lower voluntary and higher involuntary hospitalisation rates for CALD than ESB clients. In relation to outpatient or community based treatment: • There are lower rates of utilisation of outpatient based mental health services by those from CALD than ESB communities; the underutilisation is more severe for outpatient than inpatient services. • There are more limited treatment options for those clients with poor English proficiency: counselling and therapy is less available to them. In relation to overall treatment: •M ental health staff consider that the quality of mental health services provided to CALD clients is poorer than their ESB counterparts. •M ental health staff consider that clinical outcomes for CALD clients are poorer than their ESB counterparts. For practitioners working in this area there are specific and broad ranging challenges. Specific challenges relate to cultural attitudes toward mental illness, gender issues and the level of mental health literacy in CALD communities. In relation to the family there is the additional challenge of the lack of carer support services and extended family or other family supports. In the area of service provision availability of culturally competent service providers with an understanding of different cultural perceptions of mental health and illness is limited. Overall the above service reviews and consultations highlighted the need for the development of an alternative approach in the delivery of services and supports to the CALD community. After consultation with key stakeholders in the Dandenong community a gap in service provision that specifically addressed and responded to the needs of people from CALD backgrounds that have mental illness was identified and in particular those who have endured war, torture and trauma. This gap also included family, carers and significant others. The Partnership In July 2007 St John of God Pinelodge Clinic formed a partnership with ERMHA to provide specific psychiatric recovery and rehabilitation service to people with a mental illness who come from culturally and linguistically diverse backgrounds (CALD) in Dandenong, Victoria. With Private Hospital - April 2009 41 the support of Pinelodge Clinic the CALD team was formed comprising three support workers and a senior practitioner. ERMHA is a community based Psychiatric Disability Rehabilitation and Support Service that has been providing significant levels of support and assistance to people living with severe and enduring mental illness and their carers, for 25 years. ERMHA has a particular commitment to work with individuals and communities who are isolated and or marginalised within the broader community. In relation to forming a partnership it was important for both organisations to ensure that we could work together in a creative, productive and collaborative way. For a successful partnership the sharing of common values and motivation to address the needs of those on the margins of our community cannot be overstated enough. Aims of the Program: The overall aim of the program is to build on the work being done in this area by developing successful strategies in engaging with local CALD communities and to further develop and articulate a CALD specific, “Model of Service”. The CALD Team works with people in the community within the Psycho Social Rehabilitation Model. This model operates within a framework that combines intensive support with structured group activity and assertive outreach. In working with people, the team focus on ongoing skill development and personal coping skills and strategies. The program is open to people between the ages of 16 – 65 years who have recently arrived in Australia and are experiencing or have recently experienced mental illness or symptoms of mental illness. As well as working with individuals the team also works with family, carers and significant others. handed over to a good cause on behalf of the organization without any further involvement by the organization. This approach adds another dimension to our social outreach activity in relation to how we work together to form a collaborative partnership. For the person with a mental illness the program aims to: • Reduce the incidence of relapse Since the commencement of the program staff from both Pinelodge and ERMHA continue to work collaboratively in nurturing and steering this innovative project. Opportunities have been created for staff from Pinelodge to participate in a one week secondment to ERMHA providing the opportunity for our staff members to not only broaden their horizons, but to share knowledge, expertise and experience. The CALD Team regularly updates and invites comment from Pinelodge staff members about the progress of the project. • Improve adherence to treatment • Improve family functioning • Increase periods of wellness • Improve the person’s quality of life, participation in the community and social adjustment. For family, carers and significant others the program aims to engage them to: • Improve wellbeing • Manage stress • Reduce the burden of care that can happen in isolation • Improve understanding of mental illness, treatment and services. The priority for both St John of God Pinelodge Clinic and ERMHA is to provide a service that meets the specific and unique needs of people from CALD backgrounds who have mental illness and their families / significant others. However another essential component is the partnership itself. A Collaborative Partnership St John of God Health Care’s Social Outreach is about engagement and the formation of collaborative partnerships rather than a kind of philanthropy where resources are The project aims are being met and a specific service model is evolving which will contribute to and benefit practitioners and services that work with people from the CALD community who have a mental illness. In relation to the formation of partnerships, particularly across service providers (private health care organization and a community service provider), a model of good practice is emerging which is also integral to the success of the project. The CALD Project will be formally evaluated by an external reviewer in July 2009 and the results shared with key and interested stakeholders. By Karan Smith Director of Mission, St John of God Pinelodge Clinic Dandenong, Victoria National Medical Director of Organ and Tissue Donation and Transplantation Authority Appointed Dr Gerry O’Callaghan has been appointed as the inaugural National Medical Director of the Organ and Tissue Donation and Transplantation Authority. The National Medical Director’s role is to lead the medical and clinical development of the Authority and work with all stakeholders to achieve a nationally consistent, best-practice approach to organ and tissue donation and transplantation. A key responsibility for the National Medical Director over the coming months will be to oversee the establishment of a national network of clinical specialists and other staff in hospitals who are dedicated to organ and tissue donation activity. States and territories have commenced recruitment to these roles. Dr O’Callaghan is a Senior Consultant, Intensive Care Medicine, at Flinders Medical Centre in Adelaide. He is also chair of the Advisory Group to the NHMRC National Organ Donation Collaborative, a member of the ANZICS Brain Death and Organ Donation Committee, was a member of the National Clinical Taskforce on Organ and Tissue Donation (2007-08), and was a member of the NHMRC Working Party on Ethical Private Hospital - April 2009 Guidelines on Organ and Tissue Donation for Transplantation. In addition, Dr O’Callaghan was recently appointed to the Advisory Council to the CEO of the Authority and will take a leave of absence from his position on the Advisory Council for the term of his position of National Medical Director. 42 Private Hospital - April 2009 43 Telephone based relapse prevention – Perspectives from a private health insurance company Preventive health is increasingly being seen by the Private Health Insurance industry as an important frontier in which they have a role to play. A carefully structured approach to prevention can provide a great deal of value to members in terms of health and well being and can also reduce future claims utilisation. Recent changes to the private health insurance legislation have encouraged health funds to explore preventive health and chronic disease management. In spite of industry risk equalisation arrangements which dissipate the financial benefits of such interventions across the entire industry, many health funds have still launched pilot initiatives in this area. HCF is the third largest private health insurance company in Australia serving over a million lives. As a not-for profit member focused organisation HCF has been exploring this area for the last four years with various prevention programs. HCF has run pilots to reduce single risk factors (for example, obesity) and to prevent complications in members with chronic conditions (for example, cardiovascular disease, obstructive airways disease, diabetes and mental health). Relapse prevention was the main driver behind the “HCF Helping Hand” program – a telephone based support for selected members with mental health problems. Many mental disorders are chronic, and such patients tend to require long periods of treatment, and they often relapse. Frequent admissions, while beneficial in the short term may be deleterious in the longer term as they reduce the expectation of eventual recovery and reduce the ability to cope, both in the patient and in their family. Private sector gaps in the post acute discharge phase and improving support for people in regional and remote areas were also considered important drivers. HCF invited 407 members who had recurrent admissions to private psychiatric hospitals over the preceding 24 months to join the ‘Helping Hand’ program. Members were aged between 19 and 84 and had more than three psychiatric admissions or more than 15 day-only admissions in the previous 24 months. Patients with dementia or anorexia were excluded. 174 decided to join the program and 99 of them remained on the program for one year. The program was branded HCF and delivered under contract by McKesson Asia Pacific. The program was delivered by psychiatric nurses and psychologists who were overseen by a psychiatrist. The program was developed by McKesson’s two co-presidents who are both psychiatrists and it leveraged the experience of McKesson offering similar services in the public space. The focus of the program was helping members identify the triggers of relapse and providing a 24 hour support line they could contact when needed. The program included an introductory telephone call which described the program, confirmed that the member wished to enrol, and confirmed consent for their psychiatrist to be contacted. Each participant was allocated the same mental health professional for all scheduled calls for the duration of the program. A telephone assessment was scheduled for a convenient time in which the clinical history, current treatment, identification of risk factors for relapse, and patient knowledge of strategies for recovery were explored. Each patient completed a widely used measure of psychological distress, the K10. HCF evaluates all health and wellbeing programs on three axes: Health improvement, member satisfaction and financial return on investment. Based on our own internal analysis of the program and an independent external review, the Helping Hand program provided positive and encouraging results in all three areas: •H ealth improvement - There was a mean reduction in the K10 score from 26.8 to 21.3. • S atisfaction – A survey showed median respondents agreed that ‘HCF is concerned for my well-being and lifestyle and helps me make wise health care choices” • F inancially – A small reduction in the average length of stay and a shift towards same-day from overnight admissions (when compared with reference group) indicate that the intervention was financially viable. The HCF Helping Hand program is significant in that it has shown how HCF can provide better support to our members. It has successfully explored the use of an innovative delivery mechanism for proven relapse prevention strategies that improves members’ health, has high satisfaction and has shown to be cost-effective. We are at a new frontier where healthcare is being delivered in new ways and in new settings. As use of home-based care, telemedicine (remote monitoring), Internet, SMS and telephone preventive care become more widespread, private health insurers will need to adapt to this new environment. HCF’s experience in pilots to date has encouraged us that these new frontiers can add great value for members. By Dr Andrew Cottrill, Medical Director, HCF New Chief Executive Officer for St Luke’s Care Mr Mark Compton has been appointed the new Chief Executive Officer of St Luke’s Care, one of Australia’s leading charitable not-for-profit health organisations, following the retirement of Mr George Toemoe from the position. Mr Compton, former National CEO of the Private Hospital - April 2009 Royal Flying Doctor Service and Managing Director of the hospital group Alpha Healthcare Limited, is leaving his current position as CEO of the biopharmaceutical company Immune System Therapeutics to take up the role at St Luke’s Care as of 30 March 2009. 44 Diabetes Blues The symptoms of diabetes are not merely physiological. Living with the disease can also affect emotional and psychological wellbeing, increasing the risk for depression and anxiety. However, there is hope. Diabetes-Depression Link Institutionalisation People living with the daily stress and pressure of managing diabetes are more likely to experience depression or anxiety compared with those who do not have diabetes. Dr Gary Deed, the national president of Diabetes Australia, is all too aware of the relationship between diabetes and mental health. As with other types of depression, the depression brought on by diabetes can become so severe that institutionalisation may be needed. In these circumstances members of staff working in mental health wards need to be aware of a few issues which may arise where people with diabetes are hospitalised with depression. “Diabetes now affects more than 950,000 people in Australia, or 4.3 per cent of the national population,” he says. “Of those, 30 per cent will develop some form of mental illness, the most common being depression and anxiety.” It is paramount that staff have a clear understanding of the patient’s current diabetes management plan ; if they are regularly monitoring their blood glucose levels and taking their tablets or insulin injections. It is critical that people with diabetes keep a check on their blood glucose levels and take their medication when required. If this is not adhered to then the chances of self-harm can be higher in addition to a possibility of going into a diabetic coma. The warning signs that someone living with diabetes also has depression can include social withdrawal, the inability to concentrate, having negative thoughts about themselves and generally feeling overwhelmed and irritable. However, the good news is depression can be managed, and people living with it can live long and fulfilling lives. Seeking Help If you believe that a patient with diabetes may have depression there are some ways you can help them without alienating yourself from the. A guide to diabetes and mental health released by SANE Australia and Diabetes Australia recommends you adopt the following approach: •R emind the person that depression and anxiety disorders are medical conditions and that they are not to blame for how they are feeling. • Give them hope for recovery. Explain that depression and anxiety are very common in people with diabetes and that with help they can get better. • They may need reassurance that you don’t think less of them or think they are weak or a failure. “It is important for people to understand that having diabetes and depression isn’t a shameful or embarrassing thing,” says Helen Edwards, founder and director of Diabetes Counselling Online. “Depression can happen to anyone – and people living with diabetes are more susceptible to it – but there is hope out there.” It is very common for people living with diabetes and depression to have abandoned their diabetes management plan and medications when it reaches a point of institutionalisation. As people in this situation may not be making rational decisions they may need encouragement and help getting back on track with their management plan. This is where the hospitals Credential Diabetes Educator (CDE) will be able to help. In some circumstances insulin dosages can be made against the patients will if there is a current medical court order. The CDE can also help educate the patient’s family how to administer insulin injections, if the patient is no longer willing or able to do it themselves. For many family members it may be the first time that they have played an active hands-on role with administering their loved ones medication. Family members can become fearful and nervous about this new role, as they worry about doing it incorrectly and/or a general fear of needles and blood can make it almost impossible for people to willingly and competently administer the medication. In situations like this the CDE needs to be patient and helpful to the family members Private Hospital - April 2009 and try and understand their point of view. For instance this maybe the first time a family member has been inside a mental health ward, which can be a very daunting experience, add to this the stress of seeing their loved one hospitalised and the entire process can become extremely stressful. At-Home Support Diabetes Counselling Online is the only service of its kind in the world, providing an online environment where people living with diabetes and depression can get together to access help for their situation from qualified counsellors. Diabetes Counselling Online is supported by funding from the National Diabetes Services Scheme (NDSS), an initiative of the Australian Government administered by Diabetes Australia. “Diabetes Counselling Online is unlike anything else out there. I realised that people needed an environment where they were able to express themselves and relate to others in similar situations,” Edwards says. “For some people, their depression can become so bad that they don’t want to leave the house to get help, and with our service they don’t have to. They can get help and improve their situation from their own home.” If you’re concerned that a patient with diabetes may also be experiencing depression or anxiety, seek the advice of a mental health or diabetes professional immediately. Diabetes and depression are common and they can be managed effectively. The critical part is seeking help as soon as it’s needed. Information And Support Diabetes Australia (including free SANE Guide to Good Mental Health booklet) T: 1300 136 588 diabetesaustralia.com.au Diabetes Counselling Online diabetescounselling.com.au Beyondblue T: 1300 22 4636 beyondblue.org.au By Benjamin Graham Diabetes Australia 45 Private Hospital - April 2009 46 quality in focus... with Christine Gee National Hand Hygiene Initiative Aims to Reduce Rate of Patient Infections In this issue, my column provides an overview on the Australian Commission on Safety and Quality in Health Care’s National Hand Hygiene Initiative. Professor Chris Baggoley, CEO of the Commission wrote to all private hospital CEO’s in December 2008 outlining this key area of work and providing the key steps required from hospitals to implement the program within their own facilities. His message “Our goal is to make hand hygiene ‘core business’ for all healthcare workers. We need your assistance to make this program successful in your organisation. We ask that you: 1. Publicly and frequently endorse the program within your organisation and educate boards and relevant committees. 2. Work with your Senior Managers to implement this program within your hospital.” was an invitation to the private sector to become engaged and support this vital work aimed at reducing healthcare associated infections. Hand hygiene in health care is important because at any one time over 1.4 million people worldwide are affected by healthcare associated infections (HAI) with the risk in developing countries 2-20 times higher than in developed countries. Globally, there are about 59 million healthcare workers with up to 10 million hands treating and touching patients, up to 15 times a day. These hands can be the mediators of harmful microbes; each touch putting patients lives at risk. The Australian Commission on Safety and Quality in Health Care has been established to lead and coordinate national improvements in safety and quality and focuses its work on areas of the health system where current and complex problems or community concerns could benefit from national consideration and action. One such area is healthcare associated infection as it is a major and growing issue in health care for both the hospital and community settings requiring national action. The highest priority to reduce the risk of healthcare associated infections is improved healthcare worker hand hygiene. In order to achieve this improvement, reliable mechanisms for the wider implementation of hand hygiene practices and for monitoring hand hygiene are essential. These elements form the basis of the national hand hygiene initiative. The National Hand Hygiene Initiative is based on groundbreaking Australian research that shows using alcohol-based hand rub is likely to be the single most effective intervention in controlling Staphylococcus aureus or ‘golden staph’ disease. The initiative is being rolled out by Hand Hygiene Australia, which is headed by Professor Lindsay Grayson, on behalf of the Australian Commission on Safety and Quality in Health Care. It draws on the World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care which is based on the 5 Moments for Hand Hygiene. The key aims of the National Hand Hygiene Initiative are to develop a national hand hygiene culture-change program that will: • S tandardise hand hygiene practice and placement of alcohol-based hand rub so that all health care workers undertake hand hygiene in the same way and find alcoholbased hand rub in the same place in every Australian hospital On Tuesday 5 May 2009 Australia will be joining in on the World Health Organization’s (WHO) SAVE LIVES: Clean Your Hands Day. The aim of this day is to have all WHO member states pledge their commitment to hand hygiene by 2010 and to have 5000 hospitals registered to take the message of “hand hygiene at the point of care” to as wide a global healthcare audience as possible. Australia is taking part in this day by promoting the National Hand Hygiene Initiative, a simple but highly effective program to improve hand hygiene in every public and private hospital in Australia. If you would like to register your hospital for the World Health Organization’s (WHO) SAVE LIVES: Clean Your Hands Day please visit http://www.who.int/gpsc/5may/en/index.html Hand Hygiene in the Private Sector Hand Hygiene Australia is in the process of employing a coordinator to work specifically with the private health care sector to roll out of the national hand hygiene program. •R educe the rates of healthcare associated infections The program has endorsement from the Commission’s Private Hospital Sector Committee which has national representation of the private hospital sector. The Commission has also written to all the private hospital Chief Executives to inform them of the national program and how they can support and implement this in their hospital. •D evelop an effective education and credentialing system to improve knowledge about hand hygiene and infection prevention and control The Commission is also working closely with the Australian Private Hospitals Association on specific private hospital sector issues to ensure the success of the program. •A chieve sustained improvements in hand hygiene compliance rates •A ccurately measure rates of staphylococcal disease – a key outcome measure of the program •M ake hand hygiene and infection prevention ‘core business’ for all healthcare institutions and the wider Australian community Hand Hygiene Australia will work closely with existing strategies and campaigns to maximise the success of the Initiative. The program will also include an online education program to educate all healthcare workers about infection control and hand hygiene, and will push for all Australian medical and nursing curricula to include training on the importance of effective hand hygiene. Private Hospital - April 2009 For further details please visit www.safetyandquality.gov.au and Hand Hygiene Australia www.hha.org.au I welcome your feedback on this column and on any matters relating to quality and safety and the Australian Commission on Safety and Quality in Health Care. I can be contacted via the APHA Secretariat – [email protected] 48 Private Hospital - April 2009 49 Safety and Quality in Health Care – Initiatives and Priorities for 2009 The APHA Safety and Quality Committee was established by the APHA Council to progress safety and quality issues and initiatives on behalf of members. Late in 2008, each committee member agreed to steer one of the nine initiatives of the Australian Commission on Safety and Quality in Health Care through its implementation phase this year in the private sector. Review of National Safety and Quality Accreditation Standards APHA Safety and Quality Committee Member: Sue McKean, Corporate Risk and Quality Manager, UnitingCare Health Group In April 2008 Health Ministers gave in principle endorsement to the Commission’s Alternative Model for safety and quality accreditation in health care. The Alternative Model proposes a range of reforms to existing safety and quality accreditation processes, including the new Quality Improvement Framework, formal obligations to comply with accreditation requirements and improved data and information collection about accredited health services. The Ministers’ endorsement followed an extensive consultation process about possible improvements to safety and quality accreditation of health care. The Commission acknowledged the important contribution stakeholders had made in the reform process. The Commission is now in the next phase of its work, including developing a preliminary set of Australian Health Standards, and preparatory work on implementation of the Alternative Model. Australian Health Standards are being developed related to Patient Identification (relates to ensuring Intended Care), Infection Prevention and Control, Medication Safety and Clinical Handover. Public consultation on the draft standards is expected in June - August 2009. Pilots of short notice and patient journey surveys commenced in October 2008, with ACHS awarded the tender for these. Evaluation results will be presented to the ACSQHC and will be used to determine the role these type of surveys would have in the Accreditation framework. Siggins Miller are progressing research into Surveyor management which includes a literature review and industry consultation with the results to be used to assist further discussion regarding surveyor workforce requirements and sustainability. The final report on the Review of National Safety and Quality Accreditation Standards February 2008 is available at: www. safetyandquality.gov.au>programs>accreditation National Open Disclosure Standard APHA Safety and Quality Committee Member: Christine Gee, Chief Executive Officer, Toowong Private Hospital In April 2008 Australian Health Ministers agreed to work towards the implementation of the National Open Disclosure Standard in all health care facilities. The Commission will support jurisdictions and facilities to implement the standard by: • M aximising the value of the external evaluation of the national pilot by using it to develop practical guidance about open disclosure and related processes, in the form of fact sheets for staff and a guide for patients, carers and families; • Obtaining expert advice on overcoming legal barriers to open disclosure by finding legal solutions that will enable health services to fully investigate adverse events, to share information with patients about what went wrong and to provide clinicians with surety; • Collecting and studying the experiences of one hundred Australian patients with open disclosure to develop patient centred indicators of open disclosure; and • Developing a full implementation guide to assist health care facilities and clinicians to implement the standard. This will be informed by external evaluation of the pilot, the legal advice and the one hundred patient stories; and • Conducting ongoing monitoring of the effectiveness of implementation of the standard and reporting on this to Health Ministers at the end of 2009. Private Hospital - April 2009 The Open Disclosure Standard is available on the ACSQHC website: www.safetyandquality. gov.au>programs>Opendisclosure Australian Charter of Healthcare Rights APHA Safety and Quality Committee Member: Stephen Walker, Chief Executive Officer, St Andrew’s Hospital In July 2008 Australian Health Ministers endorsed the Australian Charter of Healthcare Rights. The Charter was developed after wide consultation by the Australian Commission on Safety and Quality in Health Care and with considerable involvement by the Consumers' Health Forum. The Charter specifies the key rights of patients and consumers when seeking or receiving healthcare services. It applies to the whole healthcare system and allows patients, consumers, families, carers and services providers to have a common understanding of the rights of people receiving healthcare. It is applicable to all health settings anywhere in Australia, including public hospitals, private hospitals, general practice and other ambulatory care environments. The ACSQHC have established a working party (that includes Private Hospital Sector Committee representative Stephen Walker) to agree on a coordinated approach to communication and dissemination of the Charter. The working party met for the first time on February 20 and discussed a number of methods on how best to disseminate the information. There are however a number of private hospitals who have been proactive and already implemented the new charter. The Commission will communicate their approach soon. The Charter is available on the ACSQHC website: www.safetyandquality.gov.au>program s>PatientIdentification Specifications for a Standard Patient Identification Band v Below, S&Q Committee members give a brief outline of progress to date in their area and what the private sector should expect in 2009. v 50 APHA Safety and Quality Committee Member: Dr Mark Stephens, Chief Executive Officer, Chesterville Day Hospital In July 2008 Australian Health Ministers endorsed the final draft of the Specifications for a Standard Patient Identification Band to be used by public and private health services nationally. Wristbands containing patient information have been the standard method of identifying patients in hospitals for many years. There is evidence, however, that suggests that there are difficulties associated with the use of wristbands. Patient identification bands are a critical tool to prevent errors associated with mismatching patients and their care. Although patient identification bands are present in all Australian hospitals there has not previously been a standard national approach regarding their use. The ‘specifications for a standard national patient identification band’ set out standards for the useability, content and colour of patient identification bands in Australia. The specifications are based on design requirements developed by the United Kingdom National Patient Safety Agency. Specifications cover colour, size, usability, method of recording Patient identifiers, presentation of information and use of new technology. The specifications recommend that the bands have black text on a white background and that different coloured bands are NOT used to signal allergies or other warnings and that only one wristband is used. The principal purpose of that wristband is identification of the patient wearing the band. The Commission considered that it is safest to only use a white identification band. If it is considered necessary to use a coloured band then only red is used with the patient identification information contained in a white panel. The meaning of the red alert should not be included on the band but be recorded in the history. The patient data specifications are contained on the Commissions website (www.safetyandquality.gov.au). These specifications may require modification of software used in the Hospital. Software providers need to be aware that the changes are the result of the introduction of an Australian Standard. Implementation of the Standard and possible education of staff may need to be considered. The timetable for the introduction of any changes may well be dependent on State Health Departments. A National Approach to the Prevention of Staphylococcus Aureus and Other Virulent Micro-organisms in Hospital Settings APHA Safety and Quality Committee Member: Bernadette Lyons, National Risk and Quality Manager, Healthe Care In December 2008 Australian Health Ministers agreed to a national approach to surveillance of Staphylococcus Aureus blood stream infections (including MRSA) and other virulent microorganisms. All hospitals will establish healthcare associated infection surveillance and monitor and report on Staphylococcus Aureus (including MRSA) blood stream infections and Clostridium Difficile infections, through their jurisdiction, into a national data collection. In their December meeting Ministers also noted that hand hygiene is one of the key elements in reducing healthcare associated infection and endorsed a national approach to the implementation and monitoring of hand hygiene standards and a standardised national audit tool auspiced by the Commission. The national hand hygiene initiative will build on work already being undertaken by jurisdictions. The Surveillance document ‘Reducing harm to patients from healthcare associated infection: the role of surveillance’ is available on the ACSQHC website: www.safetyandquality.gov. au>programs>healthcare associated infection Proposed National Standardised Terminologies, Abbreviations and Symbols to be Used in Medicines Prescribing and Administering in Australian Hospitals APHA Safety and Quality Committee Member: Kim Knoblauch, Group Clinical Risk Manager, Ramsay Health Care In December 2008 Australian Health Ministers agreed to a standardised approach to medicines prescribing and administering in Australian hospitals which will promote patient safety through clear and unambiguous prescribing of medicines. The standardised approach is set out in a document approved by the Commission on entitled ‘National Terminology, Abbreviations and Symbols to be used in the Prescribing and Administering of Medicines in Australian Private Hospital - April 2009 Hospitals’. The Commission will manage maintenance of the document through a register of issues on its website. See www.safetyandquality.gov. au>programs>medication safety Other Programs Information Strategy The Commission is committed to recommending national data sets for safety and quality; and reporting on the state of safety and quality in health care. The program is working to deliver: • A suite of national indicators for safety and quality in health care; • An inventory of data sources for safety and quality in health care ; • A framework for safety and quality data standards development; • Support for data-specific and E-Health elements of other Commission programs. The Commission is also working with a series of partners to develop, test and validate specific re-use of existing coded hospital and health system information to provide more detailed insights into both health care safety and quality of care. Concurrently, the Commission is working with the National E-Health Transition Authority (NEHTA), Federal, State and Territory Governments to embed safety and quality within the national health information and E-Health agenda. For instance, the Commission has developed technical and operating standards for clinical quality registries in partnership with NEHTA and Monash University which, over the coming year, will be tested and validated by a group of national registries. Falls Prevention Guidelines In December 2007 the Commission agreed to review the Falls Prevention Guidelines following a number of requests from States and Territories and from the National Injury Prevention Working Group. The review is taking place in 2008 and reviewed guidelines will be available for implementation in early 2009. It is expected that the review will result in three guidelines, each addressing a specific care setting; acute, residential aged and community. In addition, smaller versions of the guidelines will be developed as guidebooks. 51 An Expert Advisory Group of academics and practitioners is advising the Commission on the review. Comments are invited until mid-November 2008 and are sought from all health professionals who have used the Falls Prevention Guidelines. Patients at Risk APHA Safety and Quality Committee Member: Jo Bourke, Epworth HealthCare The Commission has commenced a new program to improve the identification and management of patients at risk of critical illness and serious adverse events. The actions canvassed in this program come within a broad model of care known as a “rapid response system”, which is a mechanism for identifying warning signs that may signal deterioration early, and responding to these signs quickly to prevent further deterioration or events. There are three initiatives included in this program: • The development of a standard observation chart that supports recognition of deterioration and prompts action; 3. Developing a National Peer Review Standard. Clinical Handover APHA Safety and Quality Committee Member: Dr Leon Clark, Chief Executive Officer, Sydney Adventist Hospital The purpose of the National Clinical Handover Initiative is to identify, develop and improve clinical handover communication. The Initiative currently has fourteen pilot projects underway that are developing evidence-based clinical handover solutions for use across public, private, primary and ambulatory care settings. The Commission will be disseminating the information learnt through the pilot program by: •D eveloping a standard and guide to clinical handover; •C oordinating two one-day workshops for health professionals on how to use the clinical handover tools and solutions being developed; • S ponsoring a supplement issue of the MJA on clinical handover; and • E ngaging with stakeholders to promote handover solutions. • The development of minimum standards for rapid response systems; and • E xamination of the way in which concepts arising from the work on patients at risk and rapid response systems can apply in primary care. Underpinning this work is the recognition that there are a number of different recognition and response models and organisational implementation is dependent on the environment in which a hospital or health service operates. The program will also consider educational needs to support implementation of these initiatives and opportunities for further research. Current literature suggests a number of emerging themes including: • Two tier systems requiring early intervention by the patient’s primary care team and MET calls for patient at risk of rapid deterioration; and • The use of track and trigger observation charts and early warning scoring and response processes triggered by on a range of vital sign and other physiological measures. The program of work is expected to be completed by late 2010. Credentialling APHA Safety and Quality Committee Member: Stephen Walker, Chief Executive Officer, St Andrew’s Hospital The Commission was charged with a role to develop an implementation plan for the Standard for Credentialling and Defining the Scope of Clinical Practice. A National Standard for Credentialling and Defining the Scope of Clinical Practice of Medical Practitioners, for use in public and private hospitals, was released by the former Australian Council for Safety and Quality in Health Care in 2004 and it was included in the Commission’s five year work plan. Implementation of the Standard is underway in all jurisdictions. However, there is some variation as to how States and Territories have put in place structures and processes to support local credentialling. National work to be considered by the Commission to assist the effectiveness of credentialling includes: 1. Engaging with medical colleges on their involvement in the development of national outlines of scope of practice; 2. Engaging with the National Registration body to maximise the potential for this process to support credentialling; and Private Hospital - April 2009 52 The Destiny of Day Surgery 3 – 6 July 2009 Brisbane Convention and Exhibition Centre IAAS (the International Association for Ambulatory Surgery) is dedicated to the global exchange of information and advancement of ambulatory surgery, encouraging the development and expansion of high quality ambulatory surgery across the world. It acts as an advisory body for the development and maintenance of high standards of patient care in ambulatory surgery facilities (www.iaas-med.com). The first international congress was held in Brussels in 1995 followed successfully by London, Venice, Geneva, Boston, Seville and Amsterdam. This year’s Congress is being hosted and organised by members of the Australian Day Surgery Council and is the first time the event will be hosted in the Southern Hemisphere. The Congress represents an exciting opportunity for Australasian professionals involved in day surgery to enjoy the benefits of an internationally recognised event right on our doorstep. The theme of the Congress is ‘The Destiny of Day Surgery’ and the program has been designed by and for surgeons, anaesthetists, nurses, day surgery managers and other health professionals working in day surgery centres/ units throughout the world. With an invited faculty of over 60 international and local speakers, we will hear of the challenges, developments and initiatives in day surgery across the globe. Plenary topics cover the themes of; Ambulatory surgery in the future – models and controversies; Risk management in day surgery centres; Worldwide expansion of day surgery; How will medical practitioners and nurses be trained in the future and the Horizons of day surgery. Concurrent sessions have been streamed to include a broad cross section of relevant topics specifically for surgeons, anaesthetists, nurses and managers. Topics covered in the Management concurrent sessions include: Insurance Issues for Day Hospitals; Reconfiguring Existing Day Hospitals to Improve Patient Flow; Managing Bariatric Patients in a Day Hospital Environment – Risk Management Issues to Consider; Re-engineering Skillmix in the Day Surgery Operating Suite to Cope with a Global Nursing Shortage; Quality Assessment in Day Surgery – a Global Perspective; and Alternative Models of Ambulatory Care. Of particular interest to Day Hospital Managers will be a pre-congress Medico-Legal Workshop focussing on Discharge, Consent and Duty of Care. Additional concurrent session themes include; Major abdominal and pelvic operations; Orthopaedic, Hand and Plastic Surgery; Ophthalmology, ENT and facio-maxillary; Surgery and interventional radiology; Nursing – paediatrics and Nursing – clinical excellence. We are also excited to welcome the contribution of the Society For Ambulatory Anesthesia (SAMBA) who will present two sessions. We invite all health professionals interested and involved in the future of day surgery to attend this important Congress. Dr Hugh Bartholomeusz Convener and President, Local Organising Committee 8th International Congress on Ambulatory Surgery Register Online: www.iaascongress2009.org Private Hospital - April 2009 53 Private Hospital - April 2009 54 Designing Healthy Physical Environments – the do no harm principle Physical planning in developed countries, such as Australia, has already shifted to address many changes in service demand. The move from inpatient to outpatient care and the allowance for frequent repeat occasions of services are familiar. The acute care physical changes are reflected in building high cost intensively serviced hospitals. Pre and post acute care is reflected in community based care and aged residential facilities. The process of acquiring health assets reflects the importance of service driven capital planning and it is essential that we shift focus to understand how spaces we build, when done well, can provide a non-pharmacological therapeutic environment. Although Australia invests close to $2 billion annually on capital for equipment and buildings there are continuous complaints about the buildings’ designed. Departments of Health across the country try to regulate and control the processes of planning to ensure efficient use of public resources. Yet there are opinions informed by Post Occupancy Evaluations, expressed by consumers and staff surveys plus anecdotal evidence, that as much as 10-15% of these funds are poorly allocated and wasted. There appears to be dissatisfaction with the buildings that we produce. This is described as spending on too large of spaces in some areas, or cutting departmental areas to dysfunctional levels in others, building for areas that are not a high priority, and having design solutions that need to be altered after completion. We know that people feel hospitals in particular are unattractive, have unfriendly spaces and are cold and sterile. We also know that in attempts to control costs, limits are placed on what can actually be built in one time period. To determine the priority for what should be spent, more emphasis is being given to the technical needs of the facility as defined by the professional carers and less emphasis being placed on the social concerns of patients and staff. There is evidence from studies done in Sweden, UK, USA and Europe that building designers are failing to meet the expectations of the patients and the families who use these facilities. One of the important effects of the health system reforms in health service delivery is recognition that consumers and the public have a need to be more involved. They have become more informed about health care and have increased their overall expectations of what they expect in built environments. Of great concern is the view that many of the buildings we create have had little thought given to the psychosocial elements that provide a supportive environment. We must create places that are now considered essential to promoting patient wellness. Concern has been growing about the effects of poor environments on the work places of staff that spend the longest time in them. Patient Focused Care (PFC) has evolved and is reflected in the design of facilities. Its objectives are aimed at changing the views of planners to a realisation that historically the service flows and functional priorities have only addressed the priority of staff convenience not of those of the patients. This PFC evolution has been enabled through new technology that requires less patient movements, its’ recognition of the need for family participation, and it’s viewing work flow from the patient perspective. It has also enabled designers to develop new ways of thinking about technical functioning and to evolve hospital designs that reflect reduced patient discomfort, indignity and anxiety. But do we know if the spaces we provide can actually support healing as is claimed? Focus on the Psychosocial Dimensions of Design For generations, health care has been sickness oriented and the buildings have reflected this concern. The health buildings of this next millennium must reflect the whole issue of health, including WHO’s well know definition reflecting not just the absence of disease but providing complete physical, psychological and social well being. As views about health delivery move from the narrow medical model with its pathogenic focus, so must the buildings in which the new medicine is delivered. In the same way that the multifaceted causes of disease becomes Private Hospital - April 2009 better understood so we must begin to see the relationship between building environments and the emotive states of the patients, family members and the staff who occupy these spaces. What can we Learn About Holistic Health Facility Design? One significant aspect of the research shows that people develop high levels of stress if they believe they have lost control of their physical environment. This stress has been shown to have negative effects on healing. The evidence base for design of interior and exterior spaces shows solutions can be provided that will give people a sense of security, control and will counteract stressors which lead to prolonging the effect of disease. The research being done primarily in the USA, UK and Sweden points to a number of aspects of the environment over which designers do have control. There are some important environmental characteristics shown to have impacts on wellness creation in acute situations. Clearly many of these also have effects in longer-term care situations such as in aged care facilities. Simple fundamental principles are easily applied to any design solution and they are as follows: 1. Making the space planning work We need to consider how the spaces work together to reduce anxiety and help people enjoy the arrival rather than sitting anxiously waiting for treatment. This might mean large arrival spaces and hubs that can be made exciting and welcoming at the same time. We see this in railway stations, airports, shopping centres – all evoking familiar spaces that can just as easily be hospital spaces. These spaces 55 are non-threatening and don’t build anxiety. We can evoke the feelings of these familiar kinds of spaces if we stop thinking of them as hospital spaces and think of them as activity zones. The use of healing gardens where people can engage with nature has shown to be positively distracting and helpful in the amelioration of stressful states including relief from prolonged pain. 2. Scale in Design The scale of the space needs to change depending on the activity that is being housed. This also provides an opportunity to consider what the space feels like. We use this to assist with mood changes. Waiting areas and meeting spaces need to be intimate, with a human scale so occupants don’t feel overwhelmed, screened by landscape so they don’t feel exposed, acoustically zoned so they don’t feel overheard. All this is derived from thinking about the psychosocial impact of these spaces on people using them. 3. Brightness and Light Control Research clearly shows that humans are influenced through their parasympathetic nervous systems in response to light. We are diurnal animals who use light to influence activity in the day time and sleep in the night. The endocrine system effects mood in response to darkness. Anxiety and depression can occur from prolonged levels of darkness (prevalent in northern country winters). Alternatively excess light will lead to agitation. To deal with this, one needs to anticipate the mood of the users both patient and staff and use different light levels to achieve customer satisfaction. Light, brightness, external outlook and integrated landscapes, are all tools used to reduce anxiety and stress. This consideration applies equally to staff and visitors and all the people who use the hospital regularly or perhaps even rarely. 4. Environmentally Sustainable Design The responsibility for minimizing our impact on the environment is also a key consideration in today’s planning. This involves use of energy efficient technology, but also means we can reduce the amount of recycled air conditioned spaces with the introduction of 100% fresh air. It means we increase the amount of light entering a space without the increase in heat which has to be cooled. Reduction in material’s “off-gassing” as they age which gave rise to “sick building syndrome” has been given increased concern in recent years. 5. Staff Considerations All staff require good support to carry out their technical and caring tasks through proper orientation, effective task lighting and sound functional design. We can create bright cheerful places away from the pressure of the patients and the public that allow staff to be comfortable within their workplaces. Private Hospital - April 2009 We believe the successful hospital design of today will be judged on its ability to engage the community of people who use it, making the hospital an employer of choice that retains top quality people. 6. Interior space design Flooring materials, colour and texture, and the effect on the general environment has been researched for some time now. The advent of new materials specifically for hospital purposes has shown positive benefits through the overall feeling of wellbeing in the environment. Benefits derived from carpets were quite clearly indicated in some places in support of the feeling of familiar comfort and safety from slipping. Furniture and its arrangements have normally been determined by function need. Changes to layouts, which create social support through interaction, have provided benefits that show the importance of furniture for both functioning and self-care. We believe the successful hospital design of today will be judged on its ability to engage the community of people who use it, making the hospital an employer of choice that retains top quality people. The application of some simple principles to the design process can make the difference between a facility which supports health and one that does not. Prepared by: Professor Ian Forbes, Director of the Research Unit, The Group for Health Architecture and Planning, at the University of Technology, Sydney. 56 Review of EQuIP 4 for Day Procedure Centres The Australian Council on Healthcare Standards (ACHS) regards day procedure centres as an important part of its membership. They are the fastest growing section of the healthcare market, which now performs around 60% of all acute surgical procedures in Australia. In response to the rapidly-developing needs of this market and feedback of members, ACHS is reviewing the Evaluation and Quality Improvement Program (EQuIP 4) to create a Day Procedure Centre (DPC) version of EQuIP standards. The DPC standards are expected to be released mid 2009. This will be the only evaluation and quality improvement program in Australia specifically designed for this important industry sector and will include revised guidelines to support each criterion within the standards. The DPC standards will be for use in stand-alone day procedure centres and are not intended for use in a DPC centre within a hospital. organisations, clinicians and other staff working within DPCs from all states and territories as well as all sectors. Representatives from peak industry bodies including ADSC, ADHA and ADSNA were also requested to provide feedback. The draft DPC standards retain all 14 of the mandatory criteria in EQuIP 4. Mandatory criteria are those where a rating of Moderate Achievement (MA) or higher is required to gain or maintain accreditation. A mandatory criterion is one where it is considered that without evaluation, the quality of care or the safety of people within the healthcare organisation could be at risk. EQuIP was developed by the ACHS to assist healthcare organisations to strive for excellence. The program provides a framework for establishing and maintaining quality care and services. The DPC requirements are being re-designed to simplify the self assessment process by modifying a number of critieria and elements and by providing guidelines specific to DPCs, whilst of course preserving the integrity of the EQuIP program. Following the completion of the field review, further adjustments will now be made to the standards, criteria and elements. All comments received have been considered by the ACHS to guide the draft DPC standards to prepare a version for pilot testing through desk-top audits in volunteer DPCs. In addition, on-site pilot test surveys are planned in each state and territory of Australia, prior to the release of the final version of the DPC standards. The ACHS undertook a field review of the draft EQuIP 4 DPC standards in December 2008, which was completed in late February. Feedback was sought from member The review of the DPC standards includes development of a DPC specific Electronic Assessment Tool (EAT ), which will be released at the same time as the DPC standards. Due to the retention of mandatory criteria, the results derived from the new version of the self-assessment tool will be included in the comparative reports on industry performance, providing valuable data to DPCs. The ACHS is the only health services accreditation provider in Australia that is able to offer comprehensive benchmarking information to DPCs from a long standing clinical indicator program, allowing them to compare performance with similar organisations and national averages. The changes to the EQuIP standards to develop the DPC standards include deletion of references to volunteers, removal of the criteria for ongoing care and mortality management as well as minimisation of the requirements for falls and pressure ulcer management systems. Criteria relating to consumer participation have been changed to better reflect the relationship that DPCs have with consumers. Further information on the review of EQuIP 4 for DPC specific standards, as well as the review of EQuIP 4, is available from the ACHS website at www.achs.org.au or alternatively, contact the ACHS by email at [email protected] By Deborah Jones ACHS Senior Project Officer - Development Private Health Insurance Premiums Rise Private health insurance premiums will increase by an average of 6.02 per cent from 1 April 2009. This year’s increase is the result of increased benefits paid to patients, rising health service costs, and investment losses from the global financial crisis. Premium increases will vary across individual insurers with policyholders experiencing larger or smaller increases, depending on their product. A 6.02 per cent increase would on average raise the cost of a combined hospital and general treatment policy (‘ancillary’ or ‘extras’) for a family by about $3 a week, after allowing for the 30 per cent rebate. Peoples’ rates will differ according to their policy. In scrutinising applications, the Government was conscious that its actions should not drive reductions in benefits. In 2007-08, private health insurers paid more than $10 billion in benefits to members, an increase of 10.5 per cent compared with the previous year ($9 billion). Benefits paid to members are around 85 Private Hospital - April 2009 per cent of total premiums paid. Many insurers are also improving the benefits they offer. The date for lodging applications for the 2010 premium round will be brought forward to 20 November 2009. This will allow more time for the Government to analyse and assess applications to ensure that the increases sought by insurers are necessary. It will also allow more time for negotiations with insurers, if required, and still ensure sufficient notice is able to be given to policyholders of any changes. 57 Private Hospital - April 2009 58 policy patter... with Barbara Carney Policy Development: Never One Right Way In my first column for the magazine I take the opportunity to introduce myself to members and talk a little about how I see policy development. I’ve taken a bit of a roundabout route to get to the position Director, Policy and Research at APHA. When the job was advertised, I was in the role of Manager of Government Relations for the Institute of Chartered Accountants in Australia, representing the Institute in Canberra and dealing with tax, superannuation, and financial reporting and regulatory issues. Before taking up that position in 2006, I was Head of Government Relations and Policy for Insurance Australia Group, which includes the NRMA and CGU brands. I dealt with issues ranging from supply chain management across company acquisitions to new product development to customer concerns. General Insurance is a wide field. But before I entered it, I spent a busy, rewarding and unforgettable eight years in Parliament House in Canberra. For most of that time I was Senior Policy Adviser and then Chief of Staff to Health Minister Dr Michael Wooldridge. It is difficult to capture the intensity that surrounds a senior Ministerial office, especially when that Minister has the added responsibility of being a member of the Expenditure Review Committee of Cabinet, the body that oversees the Federal Budget. Dr Wooldridge had this responsibility for his entire time as Health Minster, and I was fortunate enough to be chief policy adviser to him in this capacity. I also had the opportunity to work on issues ranging across the whole health portfolio: the 30 per cent rebate, life time health cover, PBS reforms, the establishment of MSAC, the Wills Review of medical research, childhood immunisation, and of course, Commonwealth-State funding. Working at the point where policy and politics intersect (and sometimes conflict) was always a challenge, sometimes a battle and often a joy. So I was delighted to be given the opportunity to come back into the health arena, not only to have the chance to apply what I’ve learned about policy development in a range of roles, but also to learn more about the sector, get to know APHA members, to understand the challenges you face in Australia’s health system and work with you on how you meet them. I think one of the most important things I’ve learned in many years in and around public policy in a range of sectors is that there is never only one right answer to an issue or problem that needs government intervention. It is important for policy advocates, such as industry organisations, to go to government with a solution, but they should be prepared to be flexible in how that solution is applied. The road from issue identification to policy to legislative outcome can be long and rocky one. Competing interest groups are found everywhere along the road: industry competitors, politicians at Federal and State level, bureaucrats. You have to know how to sort out which groups are likely to have the most influence and listen to their messages as well as your own. I think the APHA demonstrated this ability in negotiating a reduction to the Medicare Levy Surcharge thresholds introduced last year. This is not to say that a body like APHA should always go for consensus or compromise. When governments make bad policy, such as the current moves in NSW to charge private hospitals for blood and blood products, they should be opposed. To do this successfully requires solid evidence, persistence and “I think one of the most important things I’ve learned in many years in and around public policy in a range of sectors is that there is never only one right answer to an issue or problem that needs government intervention.” Private Hospital - April 2009 consistent, clear messaging. Again, I think the APHA has demonstrated its commitment to these precepts in its determined efforts to oppose this measure. One of the other things I’ve learned by experience is the need to do the hard yards in the policy space. There is really no substitute for quality data. We are hearing a lot at present from governments about “evidence based policy”, which I hope can be taken to mean that governments will demand the same standards of themselves as they do of organisations like the APHA. We have an excellent reputation for high quality policy work based on rigorous research. I am writing this after only a few days in the role, but I’m already gaining an appreciation of the time and effort members of the Council, Board and Taskforces put in to ensure this reputation. I’m looking forward to playing my part in maintaining and enhancing our position as a policy leader in private health. I’m also looking forward to meeting as many members as possible in person and virtually. Please call or email me if there is anything you’d like to discuss. I can be contacted on 02 6273 9000 or at [email protected]. 59 Private Hospital - April 2009 60 Private Hospital - April 2009 61 Partnership Approach to Assure Patient Safety in Operating Theatres The Medical Technology Association of Australia (MTAA) is training medical company representatives (MCRs) in the Australian College of Operating Room Nurses (ACORN) Standards for visitors to the perioperative environment as a way of ensuring the safety of patients and MCRs. It is important that this training is complemented at health care facilities through increased awareness and understanding among health care professionals of the importance and implications of standards and associated protocols relevant to scope of practice for industry personnel. MCRs play an important role in the operating theatre. As product specialists they deliver education and guidance to hospital staff about the use of new and complex technologies during surgery. This specialist support is vital to ensure the safe and effective use of medical technology. MCRs have varied backgrounds, from new graduates with little or no health experience to qualified operating room nurses. Safe and appropriate integration of these personnel into the operating theatre team relies not only on their product knowledge but confidentiality and occupational health and ACORN standards and discusses industry- safety. A practical component provides the specific scenarios has also been well received. opportunity for participants to work through Upon successful completion of the training, typical scenarios in a simulated operating participants are issued a photo ID that allows theatre environment and allows hand washing them to demonstrate to healthcare facilities to be practised and evaluated. In addition that they have completed training in the to delivering ACORN-approved training for ACORN Standards. industry personnel, these workshops provide an opportunity for MCRs to clarify issues of A partnership approach to uphold standards concern. Workshops run to date have been The potential for industry personnel to evaluated positively. A half-day update module participate in or contribute to direct patient for more experienced MCRs that refreshes care while in the operating theatre represents participants’ understanding of relevant a risk to both the patient and to health care also on their familiarity with relevant standards. Standards and guidelines exist to protect patient rights, and ensure the safety of patients and staff in the operating theatre. Maintenance of these standards is the responsibility of both the medical technology industry and the healthcare profession. The ACORN standards provide guidance for industry and operating theatre staff with the aim of limiting risk of infection, ensuring patient and staff safety and maintaining patient privacy and confidentiality. Other relevant policies include state health department policies on infection control and occupational health and safety, company policies, the MTAA/MTANZ Code of Practice and local healthcare facility protocols. MTAA is working with ACORN, industry and experienced perioperative nurse educators to deliver training in operating theatre protocols for industry personnel. A 1-day introductory workshop provides an overview of relevant standards, covering topics such as aseptic technique, infection control, patient Private Hospital - April 2009 v Training industry in relevant standards 62 Private Hospital - April 2009 v 63 facilities. Participation by MCRs in the MTAA pass without consequence. However, in the The MTAA is the national peak industry body training is one step towards abrogating this case of an adverse event or complication, representing companies in the medical risk. However, upholding the standards is not participation of a non-registered individual in a technology industry. MTAA works to ensure the sole responsibility of industry. Lack of patient’s care becomes a serious issue. The line effective access to the benefits of modern, clarity by operating theatre staff about the role between product support and clinical advice innovative and reliable medical technology of industry personnel can contribute to the can often be a grey one and both health care with the aim of providing better health likelihood of MCRs undertaking tasks within and industry professions are responsible for outcomes to the Australian community. the perioperative environment that go beyond ensuring that the line is not crossed. their scope of practice. Participation of industry personnel in relevant By Anne Trimmer, Medical Technology The temptation to ask a MCR to undertake a training represents a commitment to upholding Association of Australia and Alison Evans, seemingly minor task is all too real. For MCRs, the standards. By requesting evidence of such Alison Evans Consulting lack of awareness of the guidelines, or more training and respecting the scope of practice commonly, a reluctance to appear unhelpful, of industry professionals, health care facilities means that tasks may be undertaken that are taking an important step in protecting could be construed as contributing to direct the safety of patients and reducing the risk of patient care. In many cases, such activity may litigation. Private Hospital - April 2009 64 pharmacy focus.... Safety and Quality with Michael Ryan A Pharmacist’s Role in Mental Health Care Providing appropriate care for patients with mental illness necessitates a multidisciplinary approach. The frequency with which mental illness occurs in Australians (i.e it affects one in five at some time in their lives) demands that the specialist skills of many health professionals including pharmacists needs to be enlisted to deal with the complexity of issues so often seen in this group of patients, not the least of which is drug therapy. Standards for the practice of psychiatric pharmacy A pharmacist’s role and responsibilities in caring for people with a mental illness is outlined in The Society of Hospital Pharmacists of Australia’s Standards for the Practice of Psychiatric Pharmacy (‘the Standards’).1 Although published in 2000, the document remains relevant, describing the contribution by the pharmacist as ensuring ‘drug therapy is rational, safe, cost-effective and acceptable to patients’. Since drug therapy forms an integral part of treatment for mental illnesses, a pharmacist having extensive training in pharmacology, pharmaceutics and pharmacokinetics, is well placed to provide input toward optimising drug therapy and patient compliance. Patients and other health professionals should look to pharmacists to provide advice such as: • usual dose of the medicine, route(s) of administration, and common duration of therapy; • special precautions that should be considered prior to commencing treatment; • common adverse effects that can reasonably be expected in the context of routine treatment; • other adverse effects that are less common but are particularly serious or troublesome; • drug interactions including those with complimentary therapies, and including drug interactions with a pharmacokinetic or pharmacodynamic basis; • pharmacokinetic issues including delay in onset of action, ‘washout’ periods, and issues related to discontinuation of therapy; • possible effects of treatment upon co-morbid medical or psychiatric conditions; • requirements for modified approach to treatment in the context of advanced age, renal impairment or severe hepatic dysfunction; • use of drugs in special cases (pregnancy, during breast-feeding, perioperative use); and • critical patient counselling issues. These practice elements are consistent with an effective clinical pharmacy service and apply to the pharmaceutical care of patients with any medical condition. However the nature of mental illnesses and the challenges inherent in their management make some of these elements of pharmacy service particularly important. Patients affected by mental illness have been identified as being at risk of adverse drug reactions and other medication-related problems and pharmacists can and should play an important role in detecting, preventing and managing these unwanted effects. The potential for drug interactions involving psychotropic medications is high since many of these agents influence hepatic drug metabolism. Many patients with mental illness require drug therapy for other coexisting medical conditions and these may be profoundly influenced by concurrent treatment with psychotropic drugs. Patient education and counselling on medication is especially important in patients with mental illness since poor compliance and adherence to prescribed regimens commonly leads to negative treatment outcomes. The care of patients with mental illness is not restricted to the specialised psychiatric care setting – a setting where pharmacists usually posses advance psychiatric pharmacy skills. The high incidence of co-morbidities in the patients with mental illness means that they frequently require treatment in a general medical or surgical ward. In these cases the pharmacist can provide valuable assistance to nursing staff and medical practitioners through information and advice on the psychotropic drugs being used, their effect on other drugs and conditions, and the potential for drug interactions. Private Hospital - April 2009 Mental Health Tertiary Curricula Initiative A recent initiative of the Council of Australian Governments (COAG), the Mental Health Tertiary Curricula Initiative which was developed as part of the National Action Plan on Mental Health 2006 – 2011, is aimed at enhancing the mental health skills of the newly graduating health workforce. The objective of the program is to improve current training programs for health professionals by expanding the mental health components of undergraduate health training. Through the initiative, graduates from undergraduate health courses including nursing, dietetics, pharmacy and occupational therapy will gain a greater understanding of mental health issues and further skills in the assessment, management and referral of people with a mental illness. The application of the SHPA Standards by current pharmacy practitioners and the outcomes of changes to the undergraduate pharmacy curriculum in the future, provide the means by which pharmacists, within and outside the specialised psychiatric care setting, can increasingly apply specialist medicines knowledge to enhance the care of patients with mental illnesses. Michael Ryan1 and Rosina Guastella2 Director, PharmConsult and 2. Analyst / Consultant, PharmConsult 1 PharmConsult is Australia’s pre-eminent hospital pharmacy consultancy advising hospitals on the operational, financial, professional, service, and legislative issues associated with hospital pharmacy services. Telephone: 03 9813 0580 Email: [email protected] References The Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Psychiatric Pharmacy. SHPA standards for the practice of psychiatric pharmacy. Aust J Hosp Pharm 2000; 30(6): 292-95. 1 66 Get to Know Your Medicines with the NPS Medicine Name Finder Each year 140,000 people are hospitalised because of adverse events relating to medicine. Many of these cases could be avoided if people had a better understanding of how their medicines work. To help people get to know their medicines, the National Prescribing Service Ltd (NPS) has developed an online tool, NPS Medicine Name Finder, which identifies the active ingredient* in a prescription medicine and the brand names it is known as. “This unique tool has been designed to help people learn how to quickly and accurately identify important information about prescription medicines. Understanding your medicines can help reduce the likelihood of an adverse event and enable you to have informed discussions with health professionals about managing your health,” NPS CEO, Dr Lynn Weekes said. When a brand name is entered into the NPS Medicine Name Finder, the active ingredient name appears and vice versa when the active ingredient name is entered. Consumers are then prompted to record their medicine details on a downloadable Medicines List or print the information to discuss it with their health professional. A link is also provided to the Consumer Medicine Information (CMI) leaflet which contains more details about the medicine. ingredients are marketed under which brand names,” Dr Weekes said. “Some medicines are known by a number of different names. The NPS Medicine Name Finder will help both consumers and health professionals quickly identify which active * The active ingredient is what provides the therapeutic effect, i.e. makes the medicine work in the body. Sometimes medicines are marketed as their active ingredient name but other times as a brand name. Private Hospital - April 2009 The data supporting the online tool is provided by the Pharmaceutical Benefits Division of the Department of Health and Ageing and updated monthly. It does not cover over-the-counter, natural or herbal medicines, nor medicines not listed on the Pharmaceutical Benefits Scheme. The NPS Medicine Name Finder is available to both consumers and health professionals at www.nps.org.au/medicine_name_finder. 67 Strong growth in health and community services workforces Australia's health and community services labour forces are continuing to grow strongly, according to a report released by the Australian Institute of Health and Welfare. Between 2001 and 2006 the health workforce increased by almost 23% while the community services workforce grew by 36%. 'However, for the health workforce there was a fall in supply in very remote areas,' Mr David Braddock, Head of the AIHW's Labour Force Unit said. 'There the health workforce supply decreased by 346 workers per 100,000 people (from 1,725 to 1,379). Conversely, there was a rise in the supply of community services workers in very remote areas, from 1,252 to 1,696 workers per 100,000 people.' According to the report, Health and community services labour force 2006, around 843,000 people were employed in health and community services occupations in Australia in that year - 65% were health workers and 35% were community services workers. 'Across the nation there were 2,649 health workers for every 100,000 people, and 1,422 community services workers per 100,000 people,' Mr Braddock said. The supply of health and community services workers combined was highest in major cities at 4,155 workers per 100,000. Inner regional areas had 4,076 health and community services workers per 100,000 people, and outer regional areas 3,609 per 100,000. The lowest supply, as expected, was in very remote areas, with 3,076 health and community services workers for every 100,000 people. The number of Aboriginal and Torres Strait Islander workers in health and community services occupations grew at double the rate for Australia as a whole between 2001 and 2006. Growth in the number of Indigenous health Private Hospital - April 2009 workers was almost 45%, while for Indigenous community services workers the numbers rose by almost 73%. Indigenous Australians were under-represented in the health labour force, but well-represented in the community services labour force. 'Just over 15,000 Indigenous Australians were employed in health and community services occupations in 2006', Mr Braddock said. 'Of those, just over 5,500 Indigenous Australians were employed in the health workforce, comprising just 1% of health occupation workers - well below the 2.5% Indigenous representation in the population.' There were around 9,500 Indigenous Australians working in community services, or 3.2% of all community services workers. 68 Private Hospital - April 2009 69 Adverse Outcomes of Labour in Public and Private Hospitals in Australia: A population-based descriptive study The birth rate in Australia is increasing, with more births in 2006 than any year since the early 1970s. This trend has coincided with an increase in the number of births occurring in private maternity hospitals, which now comprise 31% of all deliveries.1 The reasons for a trend towards private hospital maternity care are likely to be complex, but government financial support for private health insurance premiums might partly explain this phenomenon.2 to compare the rates of serious adverse birth outcomes between private and public hospitals for women delivering at term. Methods Data were extracted from the National Perinatal Data Collection (NPDC), a population-based Studies published to date have emphasised the difference in intervention rates between private and public hospitals, yet maternal and neonatal outcomes have received little attention.3,4 An assumption has been made that “in these low risk populations there are no differences in perinatal mortality or morbidity associated with these practices [obstetric interventions]”.5 However, such an assumption may not necessarily be valid. A comparison of intervention rates without reference to maternal and neonatal outcomes might mask information that would be of great interest to pregnant women making a choice between private and public hospitals as places to give birth. For example, a recent populationbased study in Western Australia found that patients treated for colorectal cancer in private hospitals had significantly improved survival outcomes compared with those treated in public hospitals.7 With this in mind, we aimed Private Hospital - April 2009 cross-sectional pregnancy and childbirth data collection. Information is included in the NPDC for all babies born in Australia, both live and stillborn, of at least 400g birthweight or at least 20 weeks’ gestation. Our study included women who gave birth in hospital during the 4-year period from v Almost all women in Australia have free access to public hospitals, where intrapartum care is usually provided by a mixture of midwives, junior medical officers, specialty trainees, and specialist obstetricians. In contrast, women choosing to deliver in private hospitals have their care directly managed by specialist obstetricians. Compared with public hospitals, birth in Australian private hospitals is characterised by a higher rate of obstetric interventions such as induction of labour, episiotomy, instrumental delivery, and caesarean section,3,4 and this has attracted criticism as being unnecessary.5,6 In view of the government financial support available to women who take out private health insurance, it would be an obvious concern if the private hospital, obstetrician-led model of care, with its increased rates of medical intervention, did not provide measurable benefits for women and their babies when compared with the public hospital mixture of “all” models of care. 70 v “Studies published to date have emphasised the difference in intervention rates between private and public hospitals, yet maternal and neonatal outcomes have received little attention.” 1 January 2001 to 31 December 2004, and their babies. As pregnancies complicated by multiple gestation or prematurity have greatly increased rates of adverse outcomes, only singleton births occurring between 37 and 41 completed weeks’ gestation (the definition of “term” for the purposes of the NPDC) were included. A number of births occurred in public hospitals to women who had private health insurance, and in private hospitals to women who were uninsured. There are likely to be many reasons for this crossover, including women using their private insurance to secure a single room and women whose insurance only covered private specialist care in public hospitals. To exclude cases where women who were anticipated to have serious adverse birth outcomes were booked to deliver in public hospitals by their private obstetricians, we excluded all cases where women reported as “private” delivered in public hospitals (44 937 births, 4.8%), as well as uninsured women who delivered in private hospitals (10 417 births, 1.1%). We also excluded cases where the hospital sector was not stated. Thus, “public” here represents all women who gave birth in a public hospital as a public patient, and “private” represents all women who gave birth in a private hospital as a private patient. Two smaller jurisdictions were excluded from analyses because of incomplete data for some of the key variables. In total, 14.3% of women who gave birth in hospital to a term singleton baby during 2001–2004 were excluded. Maternal demographic characteristics were compared for public and private patients, including age, Indigenous status, parity, smoking during pregnancy status, any reported pre-existing or pregnancy-related diabetes or hypertension, remoteness of usual residence (assessed with the Accessibility/Remoteness Index of Australia8), and method of birth. Third- or fourth-degree perineal tear was the only maternal outcome with data available for study. Differential data quality, including missing data, precluded assessment of postpartum haemorrhage. For babies, the severe adverse perinatal outcomes examined were: low Apgar score (defined as an Apgar score < 7 at 5 minutes); admission to a neonatal intensive care unit or special care nursery; requirement for high level of resuscitation (defined as endotracheal intubation and/or use of external cardiac massage and ventilation); and perinatal mortality. Descriptive and logistic regression analyses were conducted. Crude and adjusted odds ratios and 95% confidence intervals were calculated using SPSS, version 15.0 (SPSS Inc, Chicago, Ill, USA). Ethics approval was granted from the Australian National University (LESC-CMHS 2007/0036), the University of New South Wales (HREA ref 9_03_91) and the Australian Institute of Health and Welfare Ethics Committee. Results During the 4-year study period, 789 240 term singleton births were recorded in Australia, of which 247 489 (31.4%) occurred in private maternity hospitals. Demographic differences between the groups of women delivering in public and private hospitals are shown in Box 1. Women delivering in private hospitals had a higher mean age and were more likely to be having their first baby. A much greater proportion of multiparous women delivering in private hospitals reported a previous caesarean section. Larger proportions of Indigenous women and those who lived outside major cities delivered in public hospitals. To allow adjustment for potentially influential variables, these demographic differences were compared (Box 2). The proportion of teenage women giving birth was much higher in the public hospital group, whereas private hospitals had about twice the proportion of women aged ≥ 40 years as public hospitals. Self-reported smoking was much higher in the public hospital population, and medical complications of pregnancy (diabetes and/or hypertension) were also more common. The rates of induced labour (30.7% v 24.0%), instrumental vaginal birth (16.0% v 9.1%) and caesarean birth (35.6% v 21.9%) were all higher in the private hospital group. The rate of third- or fourth-degree perineal injury was higher in public hospitals (0.8% v 1.4%; OR, 1.81; 95% CI, 1.72–1.91). After adjusting for maternal age, Indigenous status, parity, smoking during pregnancy Private Hospital - April 2009 71 After adjusting for the same maternal variables, serious adverse neonatal outcomes showed similar differences between the two hospital groups. Term babies born in public hospitals were more likely to require high levels of resuscitation, to have an Apgar score < 7 at 5 minutes, and to require admission to a neonatal intensive care facility or special care nursery (Box 3). Perinatal death was twice as likely for babies born in public hospitals. Even using a composite for adverse perinatal outcome (patients with at least one adverse outcome), the unadjusted OR was 1.30 (95% CI, 1.28–1.33) for public hospital deliveries. When the adverse perinatal outcomes were compared individually by method of birth, the differences between public and private hospital sectors persisted for all the adverse outcomes studied (data not shown). For example, for spontaneous vaginal births, the rate of Apgar score < 7 at 5 minutes was 0.9% in the public group compared with 0.6% in the private group. The differences for forceps deliveries (1.6% v 1.1%), ventouse deliveries (2.1% v 1.4%), and caesarean sections (1.3% v 0.5%) showed a similar pattern. The rates of perinatal death were similarly lower in private hospitals for each method of birth: spontaneous vaginal birth (0.2% v 0.1%); forceps delivery (0.5% v 0.2%); ventouse delivery (0.2% v 0.1%); and caesarean section (0.3% v 0.1%). Indigenous women giving birth, women who lived outside major cities, and women with medical conditions such as hypertension or diabetes. However, after adjusting for the potentially confounding variables available in the NPDC, we found that, in comparison with public hospitals, delivery of a singleton baby at term in an Australian private hospital is associated with a significant reduction in the rate of important adverse outcomes for babies. This finding was noted for all of the adverse outcomes studied, including a composite measure of perinatal health, with no adverse outcome less common in public hospitals. There are obviously potential limitations imposed by the data available in a national population-based study of this nature. It is not possible to identify the proportion of women delivering in each group with important comorbidities such as obesity, which increases the risk of adverse outcomes9 and is common in Australia.10 However, obesity is associated with diabetes and hypertension,9 so our adjustment for these comorbidities might have partially addressed the clinical effect of obesity on pregnancy outcome. Similarly, women at social disadvantage will be over-represented in the public hospital population.1 Social disadvantage and socioeconomic status are clearly important influences on pregnancy outcome, and individual assessment of this effect for women was beyond the scope of this study. The major adverse outcome associated with social disadvantage is low birthweight,11 and there were more babies with a birthweight < 2500 g delivered in public hospitals (2.1% v 1.1%, P < 0.05), but the absolute numbers were small. Other surrogate markers of social disadvantage such as tobacco smoking,12 teenage pregnancy,13 and Indigenous status14 were controlled for in the analysis. The quality of self-reported data regarding smoking status during pregnancy is open to question, but has been previously addressed in detail.15 It should be noted that after adjustment for the variables available in the Australian national dataset, the differences in adverse outcome rates not only persisted, but actually increased. Another potential confounding influence is that obstetricians may have transferred women with an expectation of complications to public hospitals, whereas no transfer was possible from the public hospital sector. However, the 1 Demographic characteristics of women who gave birth in private versus public hospitals, 2001–2004 Maternal characteristic Private (n = 247 489) Public (n = 541 751) Mean maternal age (years) 32.0 28.2 Indigenous 0.2% 4.2% Major cities 82.2% 64.6% Regional 16.6% 32.4% Remote 1.2% 2.9% Born in Australia 68.1% 61.6% None 44.2% 39.5% One 38.3% 33.0% Discussion Two 13.3% 16.4% This study of term singleton births in Australian public and private hospitals over a recent 4-year period found that women giving birth in public hospitals were younger, with a greater proportion admitting to smoking tobacco during pregnancy. Public hospitals also had a higher proportion of first births, Three 3.1% 6.5% Four or more 1.1% 4.5% Previous caesarean section* 30.1% 19.8% Area of usual residence Parity * Reported by multiparous women. Private Hospital - April 2009 v status, reported diabetes or hypertension, remoteness of usual residence, and method of birth, the adjusted odds ratio (AOR) for perineal injury also favoured private hospitals (AOR, 2.28; 95% CI, 2.16–2.40). To confirm that this difference was not an artefact of the adjustment for method of birth, resulting from the lower proportion of vaginal births in the private hospitals group, we directly compared the rates of third- and fourth-degree tears by individual method of birth: the rates for spontaneous vaginal birth (0.6% v 1.3%), ventouse delivery (2.3% v 4.7%) and forceps delivery (3.7% v 7.9%) were all lower in private hospitals. v 72 commonest circumstance for such transfer is likely to be prematurity, and these births were excluded from the study. A number of important birth outcomes were not available for analysis in this dataset, including rates of breastfeeding, postpartum 2 Comparison of characteristics of women who gave birth in private versus public hospitals, 2001–2004 Maternal characteristic Private (n = 247 489) No. (%) Public (n = 541 751) No. (%) OR (95% CI) Maternal age 25-29 years 57 695 (23.3%) 168 842 (31.2%) 1.00 < 20 years 965 (0.4%) 35 486 (6.6%) 12.57 (11.78-13.41)* 20-24 years 8 619 (3.5%) 111 164 (20.5%) 4.41 (4.30-4.51)* 30-34 years 114 219 (46.2%) 149 700 (27.6%) 0.45 (0.44-0.45)* 35-39 years 55 999 (22.6%) 63 572 (11.7%) 0.39 (0.38-0.39)* ≥ 40 years 9 968 (4.0%) 12 977 (2.4%) 0.45 (0.43-0.46)* Not Stated 24 (0.0%) 10 (0.0%) - 246 820 (99.7%) 518 933 (95.8%) 1.00 Indigenous 543 (0.2%) 22 738 (4.2%) 19.92 (18.29-21.69)* Not Stated 126 (0.1%) 80 (0.0%) - Multiparous 137 978 (55.8%) 327 487 (60.4%) 1.00 Primiparous 109 371 (44.2%) 214 155 (39.5%) 0.83 (0.82-0.83)* Not Stated 140 (0.1%) 109 (0.0%) - 115 641 (46.7%) 216 755 (40.0%) 1.00 5 819 (2.4%) 66 503 (12.3%) 6.10 (5.93-6.27)* 126 029 (50.9%) 258 493 (47.7%) - 222 103 (89.7%) 478 719 (88.4%) 1.00 Diabetes/hypertension 22 514 (9.1%) 58 112 (10.7%) 1.20 (1.18-1.22)* Not Stated 2 872 (1.2%) 4 920 (0.9%) - Spontaneous vaginal 119 764 (48.4%) 374 023 (69.0%) 1.00 Assisted vaginal 39 523 (16.0%) 49 030 (9.1%) 0.40 (0.39-0.40)* Caesarean section 88 160 (35.6%) 118 656 (21.9%) 0.43 (0.43-0.44)* 42 (0.0%) 42 (0.0%) - Indigenous status Non-Indigenous Parity Smoking Status Did not smoke Smoked Not Stated Medical Conditions/ complications No Diabetes/hypertension Method of Birth Not Stated OR = odds ratio. *P < 0.05. Private Hospital - April 2009 depression, maternal satisfaction, and measures of severe maternal morbidity. Previous studies have suggested that breastfeeding rates are lower in public hospital populations.16 Furthermore, it is not possible for a study such as this to provide a cost–benefit analysis in terms of the interventions. The differences in the rates of intervention between the two hospital settings confirms findings of previous studies from NSW in the 1990s.3,4 In our study, birth in a private hospital was associated with increased rates of induced labour, instrumental delivery, and caesarean section. This is an important consideration, as each of these interventions should increase the risk of adverse outcomes for either mother or baby. For example, induction of labour has been associated with increased rates of epidural anaesthesia, emergency caesarean delivery, and adverse neonatal events such as requirement for resuscitation and admission to a special care nursery.17,18 Similarly, instrumental delivery is a strong independent risk factor for third- and fourth-degree perineal injuries.19-21 Caesarean delivery itself is associated with an increased risk of respiratory morbidity in babies, even after 37 weeks’ gestation.22 Importantly, we found that a much greater proportion of women delivering in private hospitals had a history of previous caesarean section, which alone increases the risk of adverse maternal outcomes in subsequent pregnancies.23-25 It is thus a notable and unexpected finding that in private hospitals with higher rates of interventions, each of which would be predicted to increase the risk of adverse outcomes, the rates of serious adverse outcome were, at a population level, lower overall than those in public hospitals. Although it remains possible that there were confounding factors that were not accounted for, the results were robust after adjustment for all variables known to influence obstetric outcome available in the national dataset. It is a long-held orthodoxy that increased rates of obstetric intervention are “bad” for women and their babies. Our results show that although the model of obstetrician-led care is characterised by increased rates of intervention, outcomes for women with a single baby delivered at term are no worse, and further studies may determine there are benefits for women and their babies. This is consistent with findings from both the United Kingdom26 and developing countries27 that 73 increases in the rate of caesarean section are associated with a reduction in the rate of perinatal mortality. Previous smaller studies comparing obstetrician-led intrapartum care with other models have focused on rates of intervention, with no reference to outcomes.3-6 The strengths of our study are that it used data from a large and comprehensive cohort of births, and that well defined objective outcomes (perinatal death and third- or fourth-degree perineal injury in particular) were used. The weaknesses relate to the subjective nature of some of the data available for study, and the nature of some of the exclusion criteria. For example, there is a possibility that avoiding a potential bias introduced by women transferred from private hospitals to public hospitals for care by excluding them might introduce another bias. As there is no way of knowing the individual circumstances of women with private insurance who delivered in public hospitals, the effects 3 Perinatal outcomes for babies of women who gave birth in private hospitals compared with women who gave birth in public hospitals, 2001–2004 Public OR (95% CI) AOR* (95% CI) Private No. (%) No. (%) 685 (0.3%) 2 886 (0.5%) 1.99 (1.82–2.16)§ 2.37 (2.17–2.59)§ Apgar score < 7 at 5 minutes‡ 1 914 (0.8%) 6 686 (1.2%) 1.59 (1.51–1.68)§ 1.75 (1.65–1.84)§ Admitted to NICU/SCN‡ 21 114 (8.5%) 58152 (10.7%) 1.29 (1.27–1.31)§ 1.48 (1.45–1.51)§ Perinatal outcome High level of resuscitation†‡ Perinatal death 343 (0.1%) 1 377 (0.3%) 1.84 (1.63–2.07)§ 2.02 (1.78–2.29)§ OR = odds ratio. AOR = adjusted odds ratio. NICU = neonatal intensive care unit. SCN = special care nursery. * Adjusted for maternal age, Indigenous status, parity, smoking during pregnancy status, reported diabetes/hypertension, remoteness of usual residence, and method of birth. † Endotracheal intubation and/or external cardiac massage and ventilation. ‡ Includes live births only. § P < 0.05. Private Hospital - April 2009 v 74 could only be resolved by detailed prospective study. Despite these caveats, adjustment during analysis actually increased the ORs, and all the differences favoured obstetrician-led care. We hope that the results of this population-based study will stimulate further research into the effect of different models of intrapartum care on pregnancy outcome. Author details: Stephen J Robson, MPH, MD, FRANZCOG, Associate Professor 1 Paula Laws, BAppPsych(Hons), Senior Research Officer2 Elizabeth A Sullivan, MB BS, MPH, MMed(Sexual Health), Associate Professor and Director2 Department of Obstetrics and Gynaecology, Australian National University Medical School, Canberra, ACT. 1 2 erinatal and Reproductive Epidemiology P Research Unit, University of New South Wales, Sydney, NSW. Correspondence: [email protected] References 1. Laws P, Abeywardana S, Walker J, Sullivan EA. Australia’s mothers and babies 2005. Perinatal Statistics Series No. 20. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2007. (AIHW Cat. No. PER 40.) 2. Shorten B, Shorten A. Impact of private health insurance incentives on obstetric outcomes in NSW hospitals. Aust Health Rev 2004; 27: 27-38. 3. Roberts CL, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: population based descriptive study. BMJ 2000; 321: 137-141. 4. Roberts CL, Algert CS, Douglas I, et al. Trends in labour and birth interventions among low-risk women in New South Wales. Aust N Z J Obstet Gynaecol 2002; 42: 176-181. 5. King JF. Obstetric interventions among private and public patients [editorial]. BMJ 2000; 321: 125-126. 6. Shorten A, Shorten B. Perineal outcomes in NSW public and private hospitals: analysing recent trends. Aust J Midwifery 2002; 15: 5-10. 7. Morris M, Iacopetta B, Platell C. Comparing Private Hospital - April 2009 survival outcomes for patients with colorectal cancer treated in public and private hospitals. Med J Aust 2007; 186: 296-300. <eMJA full text> 8. Commonwealth Department of Health and Aged Care. Measuring remoteness: Accessibility/ Remoteness Index of Australia (ARIA). Revised edition. Canberra: Department of Health and Aged Care, 2001. (Occasional Papers: New Series No. 14.) 9. Mighty HE, Fahey AJ. Obesity and pregnancy complications. Curr Diab Rep 2007; 7: 289-294. 10. Callaway LK, Prins JB, Chang AM, McIntyre HD. The prevalence and impact of overweight and obesity in an Australian obstetric population. Med J Aust 2006; 184: 56-59. <eMJA full text> 11. Hodnett ED, Fredericks S. Support during pregnancy for women at increased risk of low birthweight babies. Cochrane Database Syst Rev 2003; (3): CD000198. 12. Andres RL, Day MC. Perinatal complications associated with maternal tobacco use. Semin Neonatol 2000; 5: 231-241. 13. Fraser AM, Brockert JE, Ward RH. Association of young maternal age with adverse reproductive outcomes. N Engl J Med 1995; 332: 1113-1117. 75 14. Humphrey M, Holzheimer D. A prospective study of gestation and birthweight in Aboriginal pregnancies in far north Queensland. Aust N Z J Obstet Gynaecol 2000; 40: 326-330. 15. Laws P, Grayson N, Sullivan EA. Smoking and pregnancy. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2006. (AIHW Cat. No. PER 33.) 16. Yeoh BH, Eastwood J, Phung H, Woolfenden S. Factors influencing breastfeeding rates in southwestern Sydney. J Paediatr Child Health 2007; 43: 249-255. 17. Boulvain M, Marcoux S, Bureau M, et al. Risks of induction of labour in uncomplicated term pregnancies. Paediatr Perinat Epidemiol 2001; 15: 131-138. 18. Gülmezoglu AM, Crowther CA, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 2006; (4): CD004945. 19. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001; 98: 225-230. 20. Christianson LM, Bovbjerg VE, McDavitt EC, Hullfish KL. Risk factors for perineal injury during delivery. Am J Obstet Gynecol 2003; 189: 255260. 21. Dandolu V, Chatwani A, Harmanli O, et al. Risk factors for obstetrical anal sphincter lacerations. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16: 304-307. 22. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008; 336: 85-87. 23. Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low-risk planned caesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176: 455-460. 24. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat caesarean deliveries. Obstet Gynecol 2006; 107: 1226-1232. Private Hospital - April 2009 25. Villar J, Carroli G, Zavaleta N, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007; 335: 1025. 26. Matthews TG, Crowley P, Chong A, et al. Rising caesarean section rates: a cause for concern? BJOG 2003; 110: 346-349. 27. McClure EM, Goldenberg RL, Bann CM. Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries. Int J Gynaecol Obstet 2007; 96: 139-146. By: Robson SJ et al. Adverse outcomes of labour in public and private hospitals in Australia: a population-based descriptive study. MJA 2009; 190: 1-4. ©Copyright 2009. The Medical Journal of Australia - reproduced with permission 76 since the last issue... Since the Last Issue of Private Hospital... Much has occurred in the health arena since our last issue of Private Hospital in December. Here is a wrap-up of the major activity by APHA. Release of the NHHRC’s Interim Report The interim report of the National Health and Hospitals Reform Commission (NHHRC) was released on 16 February 2009. The report is divided in 15 chapters and contains 116 “reform directions.” The Commission sought feedback on these reform directions which APHA developed and subsequently submitted. APHA representatives met with the Commission in March to discuss our feedback and Dr Christine Bennett, Chair of the NHHRC, attended the APHA Council meeting held 16 March. Award Modernisation Work on this issue is being undertaken by Private Hospitals Association Queensland (PHAQ) on behalf of APHA. The APHA President and CEO met with the Health Minister, a senior adviser to the Deputy Prime Minister and Health adviser to the Prime Minister in November 2008 to discuss the issue. Following hearings in December, the Australian Industrial Relations Commission issued a Draft Award in January. Analysis of the impact of the Draft Award was undertaken by PHAQ which found of the $142 million per annum additional cost they identified, $126.8 million (inc. on-costs) (89%) related to 4 issues as under: Nurses Occupational Award •A nnual Progression – not linked to minimum hours of service for part time and casual staff ($21.2 million p.a. + on costs) • 5 weeks basic annual leave with no public holiday offsets – i.e. 5 weeks annual leave plus 250% penalty for all public holidays worked. ($21.3 million p.a. + on costs) Health Professionals & Support Services Industry & Occupational Award •P art timers to be paid overtime rates for all work outside of minimum guaranteed contract hours. ($43.9 million p.a. + on-costs) • I ntroduction of flat 15% shift penalty and relaxed definition of a shift worker which will entitle many more staff to a 5th week of annual leave ($19.3 million + on costs) The focus of the verbal submission to the AIRC was on these 4 items plus: •P otential for demarcation disputes re: Nursing Assistants/Personal Care Workers • Lack of definitions and skill descriptors in the Health Professionals and Support Services Award which make it impossible to know how employees would be appointed to a level or progress through the levels. Unless clarified and some parameters put around annual progression for part time and casual staff this could be a substantial additional cost to employers but due to lack of information we have been unable to quantify the potential impact at this stage. Submissions on the Draft Award were made by 13 February and further hearings were held on 23 February. At the time of going to print, a decision regarding the final content of the draft awards by the AIRC was expected on 3 April. NSW Blood Tax APHA Member hospitals met with NSW Department of Health in March to discuss the feasibility of collection of a blood tax on blood used in private hospitals. APHA has written to NSW Health Minister Della Bosca to request a meeting to discuss this initiative and as the magazine goes to press is awaiting confirmation of this meeting. Health Workforce Taskforce A new APHA Committee, the Health Workforce taskforce, met for the first time in January. The Taskforce is chaired by APHA Board member, John Amery and will look at training models, workforce initiatives and identify areas where the private sector can add value to processes. APHA Council Meeting The first APHA Council meeting of 2009 was held on 16 March in Sydney. The Council were briefed on the work programs of each of APHA’s committees and taskforces as well as the work of the Secretariat. National Measurement and Reporting of Safety & Quality Indicators The APHA Safety and Quality Committee has appointed Edgebox to manage the data collection for the Private Hospitals Indicators project. Commencing in April, the pilot project will involve 30 facilities and will collect data on 12 indicators and Sentinel Events from 2008. Private Hospital - April 2009 79 Private Hospital Member Benefits Contact our membership team now – 02 6273 9000 or [email protected] AHPA Benefits Angela Hook joined the Canberra based APHA secretariat staff this March as the new Member Services Manager. Angela was born in Australia but grew up in California and has also lived in Italy, Turkey, and Senegal for work or study. Having first come back to Australia to do an MBA at Bond University in 2005, she subsequently moved to Canberra for work. She is very happy to now be a part of the APHA secretariat and is looking forward to working closely with members to ensure they are taking full advantage of the benefits of APHA membership. Taking careful note of the feedback from last year’s Member Survey, she will endeavor to make services, like the widely requested Leadership and Management Training Workshops, a reality and an accessible resource for APHA members. Angela is also looking forward to meeting APHA members at this year’s National Congress and can be contacted for any membership enquiries on [email protected]. The 29th Annual APHA National Congress will be held this year at the Grand Hyatt in Melbourne, from 11 – 13 October 2009. This year’s Congress promises to be an engaging and thought-provoking event that will draw together leaders from across the country to explore the issues facing our industry and inspire creativity as we move into the future. The Trade Exhibition will showcase the most exciting developments and innovation in healthcare today. Further details about the 29th Annual APHA National Congress will be released via the website: www.apha.consec.com.au. Be sure to register as a delegate or exhibitor quickly. Affiliation with APHA allows private hospitals and non-hospital members to unite their common interests. APHA is the combined voice of the private hospital industry influencing public policy, engaging industry players, and facilitating an environment for members to further their business objectives. Being a part of the largest and most influential Private Angela Hook Member Services Manager Hospital industry association offers a large array of benefits from contacts and networking to information services and awards for excellence. APHA members are also able to take advantage of exclusive commercial agreements and deals. Contact Member Services Manager, Angela Hook, for more information about how your organization can reap the benefits from our relationships with Qantas, Accor Hospitality, and Hertz. Phone (02) 6273 9000 or email to [email protected] APHA Members Take Advantage of Commercial Benefits with: • APHA/Qantas Business Travel Scheme equals discounted corporate rates for you • Discounted corporate rates for Qantas Club • Accor Away on Business program offers discounted rates at over 300 hotels across the Asia Pacific • Easy online booking Private Hospital - April 2009 • Corporate Rates on Hertz hire cars throughout Australia & globally • Complimentary membership in Hertz #1 Club 80 Private Hospital - April 2009 81 Women with Early Breast Cancer to Receive the Most Up-to-Date Information Available National Breast and Ovarian Cancer Centre (NBOCC) has recently released the eagerly anticipated revised version of its Guide for women with early breast cancer. The comprehensive, 200 page resource provides information to support women with early breast cancer* in making decisions about their treatment and care, as well as advice for family and friends. The Guide walks women through every step of their breast cancer journey and is broken down into five key areas: Breast cancer: the facts, Making sense of test results, Treatment, When treatment is over, and Finding support. CEO, National Breast and Ovarian Cancer “This resource compiles all the information a woman with early breast cancer will need in order to understand her diagnosis, treatment and follow-up care,” said Dr Helen Zorbas, their understanding and decision-making. It Centre. Based on NBOCC’s Clinical practice guidelines for the management of early breast cancer, the consumer guide incorporates the latest evidence in a new, user-friendly, spiral bound format. First released in 2003, the Guide is one of NBOCC’s flagship resources, provided free of charge to women at diagnosis to assist has been in consistently high demand with over 110,000 copies disseminated since its first release. Private Hospital - April 2009 “The Guide provides women with reliable, upto-date and easy to understand information in a compact booklet that they can take with them as they go through their treatment,” said Dr Zorbas. To download or order copies of the Guide for women with early breast cancer, visit NBOCC’s website www.nbocc.org.au. Orders can also be taken over the phone on 1800 624 973. * Early breast cancer is cancer that is contained in the breast and may or may not have spread to lymph nodes in the breast or armpit. Super and share markets: what can you do? How’s your super doing? This question means a lot in times of economic uncertainty. Your super’s an investment, and investors everywhere are feeling the effects of market volatility. What can you do when share markets seem unstable? The best response depends on your goals. Keeping your cool Super is best viewed as a long-term investment — even if you retired tomorrow, you might stay invested for another 30 years. Although you may consider investing conservatively to try to avoid future downturns, reacting after market fluctuations occur might not be ideal. It may cause investors to sustain losses that they could have avoided if they’d maintained their investments until the market recovered. They might also miss the benefits of upswings that may occur as economic uncertainty subsides. Where to invest now? Market fluctuations shouldn’t change your goals — you’ll still need super to enjoy retirement. Investment in undervalued assets can give you the chance to benefit from any future market gains. And super’s concessional tax rate makes it an outstanding long-term investment. History shows that, on average over the long term, shares have delivered returns above the inflation rate more often, and more consistently, than cash. That’s essential if the value of your super is to grow in real terms over time. Get a better grip Get a better grip on your super in five steps. 1. Work out what kind of investor you are. Complete the quick Risk Profiler at www.hesta.com.au/ calculate to get an idea of your current attitude to investment. 2. Decide if your investment matches your profile. Compare your personal risk profile with that of your chosen investment option using Your HESTA investment choice guide at www.hesta.com.au/yourchoice. Do they match? Would you be happier with another option? 3. Consider making voluntary contributions. Use the salary sacrifice and co-contributions calculator at www.hesta.com.au/calculate to see what a difference extra savings can make to your super. 4. R eview your insurance. Download Your HESTA insurance guide from www.hesta.com. au/insure and make sure you have enough disability and death cover to meet your needs. 5. Consider speaking to a superannuation expert. HESTA provides members with free advice about superannuation. To make an appointment, free call 1800 813 327. Looking to the long term Super is a long-term proposition, so it’s important to ensure you’re comfortable with your investment choices. Visit www.hesta.com.au for more. Issued by H.E.S.T. Australia Limited ABN 66 006 818 695 AFSL No. 235249 and is about HESTA Super Fund ABN 64 971 749 321. It is of a general nature. It does not take into account your objectives, financial situation or specific needs so you should look at your own financial position and requirements before making a decision. You may wish to consult an adviser when doing this. Please note that investments can go up and down. Past performance is not a reliable indicator of future performance. Consider our Product Disclosure Statement before making a decision about HESTA – free call 1800 813 327 or visit www.hesta.com.au for a copy. 83 Private Hospital - April 2009 84 legal matters... with Alison Choy Flannigan Mental Health - Legal Issues to Consider When Dealing with Aggressive Mental Health Patients We have been asked on a number of occasions to provide legal advice on the duties and rights of hospitals and healthcare providers in relation to the treatment of aggressive mental health patients. Hospitals are required to balance a variety of legal duties. In relation to aggressive mental health patients, this commonly involves balancing: • the rights of the patient to be treated in the least restrictive environment; against • the obligation of the hospital to ensure the health, welfare and safety of patients and staff and the right of the hospital to protect its property from damage. The legal rights of patients include: • The right to be provided with medical and healthcare services with reasonable care. Problems arise for health care professionals when: • I t is difficult to ascertain whether or not the patient has the mental ‘capacity’ to consent to the treatment. • The patient actively refuses to participate in the treatment and the mental health treatment requires an interview with the patient. • I f there is a disagreement between a primary carer and the medical practitioner as to the best interests of the patient. • R ights under privacy law in relation to the collection, use and disclosure of a patient’s personal information. • I n some cases, a patient may be temporarily ‘mentally disordered’ by being affected by drugs or alcohol, and therefore ‘at risk’ of further harm, however, the patient’s state is not such that involuntary detention is required or appropriate. • The right to not to be assaulted or battered. Consent • The right to be charged the correct fees for services. • The right to be informed of the risks of medical treatment. • The right to be safe whilst admitted. • The right to not be detained against the patient’s will. • Contractual rights - under contracts entered into between the hospital and the patient or organisations such as health funds or the Department of Veteran’s Affairs, on their behalf. With mental health patients, there are additional rights, including • Statutory rights under Mental Health legislation - for example the right not to receive electroconvulsive therapy or psychotherapy or special medical treatment (such as sterilisation) unless the appropriate approvals have been provided. • The right to not be involuntarily detained or ‘Scheduled’ unless the appropriate approvals have been provided. • As under many State Mental Health laws, the right to receive the best possible care and treatment in the least restrictive environment enabling the care and treatment to be effectively given and the right to not be illtreated (for example sections 68 and 69 of the Mental Health Act 2007 (NSW)). Provided a mentally ill patient has capacity, that patient can consent to medical treatment or refuse medical treatment. Some medical treatments, such as electrotherapy therapy, require compliance with statutory requirements before those treatments can be provided. There is also the ability for a hospital to seek substituted consent in certain cases, such as under Guardianship laws. Acceptance of enduring powers of attorney or advanced health directives must be done with care to ensure that they comply with the relevant statutory requirements as to form and execution and that they have become ‘active’, that is, the patient is no longer able to provide consent themselves. associated with discharge. In many cases, hospitals require the patient to sign a waiver, however, these will not be effective in all circumstances. It is possible for hospitals to be sued for the false imprisonment of mentally ill patients, and therefore it is important that hospitals follow the procedure as provided under the relevant State Mental Health laws when involuntarily detaining persons. In some cases, a practical solution may need to be sought, for example, to delay the patient until they have become sober or to discharge the patient into the care of a responsible relative or carer. Again, it is important to document the assessment made and the reasonable steps to ensure the safety of the patient. Balancing conflicting duties Sometimes the hospital may need to make a decision to ascertain the greatest risk. It may be appropriate in these circumstances to consider the best interests of the patient. For example, we have advised on cases where hospitals have risked a claim for false imprisonment of a patient, but have ultimately saved that patient’s life. In relation to aggressive acts by patients, the hospital does have a right of self-defence and to ensure the health, welfare and safety of staff and other patients; and the right to preserve its property, provided that the conduct is a reasonable response in the circumstances. Discharging and detaining mentally ill patients If a mentally ill patient is capable and demands to be discharged against medical advice, it is advisable to have the patient at least assessed as to whether or not they should be involuntarily detained under the mental health laws and to clearly document the information provided to the patient, including the risks Private Hospital - April 2009 For more information, please contact: Alison Choy Flannigan, Partner Health, Biosciences and Pharmaceuticals DLA Phillips Fox Tel +61 2 9286 8629 [email protected] 87 on the ground... ….with Jason Lynch What is your current position and how long have you been there? I am the Surgical Clinical Educator. I have been at St Andrew’s for about 12 years, although this has not been continuous as I have taken some time out to pursue my animation career too but I always come back to St Andrew’s. How did you come to be both an animator and a nurse? I had always wanted to do something artistic but my Mum felt that I needed to have a solid, dependable career under my belt so I went into nursing. Now I am so glad I listened to her because it is very hard to make a living out of animation alone. Instead I have had a secure job at St Andrew’s and in the meantime studied animation at University. I then decided to go to the UK to try my luck over there where animation is truly in a league of its own. I worked as a nurse while I was over there so I could pay the bills and then went door knocking to see what work I could get in animation. A position came up to work on the Wallace and Gromit movie and I was lucky enough to get the job and I haven’t looked back since. I learnt more working for them than during my whole time at University. It was an incredible experience. Private Hospital - April 2009 How are you able to manage two careers simultaneously? St Andrew’s has been absolutely fantastic in this regard and has fully supported my animation career alongside my nursing career with them. I took a whole year off to work in the UK in 2003/2004 and then another last year to work on Mary and Max. The only reason I could do this was because the hospital guaranteed a place for me when I had finished. It is the most incredibly supportive hospital in this way. They really understand and support their staff and this is the same attitude they have to education in nursing too. I have never known a hospital that is so supportive of its staff and that allows nurses to extend themselves in so many different ways. v Animator and claymation expert Jason Lynch has spent the last 12 months working alongside director Adam Elliott in Melbourne on the movie Mary and Max, but has now returned, not only to his home town of Brisbane, but also to his normal job as a nurse at St Andrew’s War Memorial Hospital. 88 v on the ground... Do you ever use skills from one job to assist you with the other? Yes. I have just designed a simulated patient together with the Clinical Educator for Cardiac Services at St Andrew’s, Shauna Northwood. Shauna approached me because she wanted to find a way to make her training course unique and she wanted to be able to offer nurses a way of practising their necessary skills as many times as they liked so they could be completely confident before having to go onto the wards and deal with real patients. I used all my animation skills to create a simulated patient that can bleed, has a pulsating pulse and can even develop a haematoma. It is the only training model of its kind and is unique to St Andrew’s and has been so successful that we are now looking to develop them commercially for the medical market. Mary and Max has just opened nationwide. Give us a quick synopsis of the film. MARY AND MAX is a claymated feature film from the creators of the Academy Award psychiatry, alcoholism, where babies come from, obesity, kleptomania, sexual difference, trust, copulating dogs, religious difference, agoraphobia and much much more. winning short animation HARVIE KRUMPET. It What is your favourite scene from the movie? is a simple tale of pen-friendship between two From a technical point of view it is the scene where the chicken truck is screaming along the freeway, but from an emotional point of view it’s the scene where Mary’s Dad cuts her hair with the garden shears. That one really gets to me. very different people; Mary Dinkle, a chubby lonely eight year old girl living in the suburbs of Melbourne, and Max Horovitz, a 44 year old, severely obese, Jewish man with Asperger’s Syndrome living in the chaos of New York. Spanning 20 years and 2 continents, Mary and Max's friendship survives much more than the average diet of life's ups and downs. Like Harvie Krumpet, MARY AND MAX is innocent but not naïve, as it takes us on a journey that explores friendship, autism, taxidermy, Private Hospital - April 2009 89 Private Hospital - April 2009 90 Private Hospital - April 2009
