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The Kilmore & District Hospital Quality of care report 2011 November, 2011 PROVIDING WHOLE OF LIFE CARE FOR OUR COMMUNITY 0 Table of Contents Introduction Our Community Consumer, Carer & Community Participation Accreditation Credentialing and Certification of Staff Quality of Care Major Quality Improvement Projects Health Promotion Safer Systems Patient Satisfaction Compliments and Complaints Services 2 2 3 6 7 7 13 14 15 19 20 21 1 Introduction It is with pleasure that I introduce this year’s (2010/11) Quality of Care Report. The purpose of this report is to inform our community and other interested parties about the services we provide and highlight how we are improving the quality of those services. We are proud of the services we provide, within the context of a Small Rural Health Service. We recognize that we are not the provider of all services. Our vision however is to be your “preferred provider and facilitator for whole-of-life health related services”. If we do not provide the service, we will help you navigate the health system to attain the services you need. We continue to strive to improve the range of services available for our community. In May 2011, we were approved for a $20 million redevelopment which will see our hospital grow from 30 to 60 acute beds. We will also build an outpatient facility which will accommodate a range of community services to improve the continuum of care. To enable wider access to this report, you may obtain a copy though your local doctor’s surgery, pharmacies, post offices, Mitchell Community Health Service, John Taylor Library (Kilmore) or a local real estate agency. The report may also be found on our internet site (www.kilmoredistricthospital.org.au) Bart Ruyter, CEO Our community The Kilmore & District Hospital serves the local community of Kilmore and surrounding areas with an approximate population of 25,000. The area is Taungurung country and was developed as a rural farming area by early Irish and Scottish settlers with sheep and cattle as primary industry. Today, Kilmore's strengths are in automotive, education, health, manufacturing, transport, horse racing, commerce, farming and tourism. Several hundred, mostly professional, people travel to Melbourne to work each day, now about an hour's drive or train ride from neighbouring Kilmore East. (Kilmore mechanics website, accessed 2011) Kilmore is becoming a metro/rural ‘fringe’ town as we are an easy commute to the Northern suburbs and Melbourne. As such there is a growing commuter population entering the area. Population predictions project significant growth in the future. Local Artists partner with the Hospital to add beauty and art to the ambience. 2 CONSUMER, CARER AND COMMUNITY PARTICIPATION In 2008, the Department of Health released the Community Participation Policy “Doing it with us not for us”. The following table outlines our progress to date in meeting the participation indicators. Indicator Standard 1: The organization demonstrated a commitment to consumer, carer and community participation appropriate to it’s diverse communities. % Compliance achieved 37% Standard 2: Consumers and where appropriate , carers are involved in informed decision making about their treatment, care and wellbeing at all stages and with appropriate support. 75% Standard 3: Consumers, and where appropriate, carers are provided with evidence based, accessible information to support key decision making along the continuum of care. 40% Standard 4: Consumers, carers and community members are active participants in the planning, improvement and evaluation of services and programs on an ongoing basis. 66% Standard 5 The organization actively contributes to building the capacity of consumers, etc to participate fully and effectively Descriptive reporting – target not applicable Table 1: Reporting against targets for doing it with us not for us Priority areas for improving our participation indicators include the development of an Equity of Access Action Plan. The objective of this group is to improve access to our services for people with disability either physical or intellectual, of diverse cultures and of Aboriginal and Torres Strait Islander background. We are also working to meet the Key result Areas of the Improving Care for Aboriginal and Torres Strait Islanders. The Taungurung occupy much of country between the upper River and its Dividing Range. west, eastwards to the north and south Dividing Range. Aboriginal tribes accordance with (Daung wurrung) people central Victoria. Their encompasses the area reaches of the Goulburn tributaries north of the From Kilmore in the Mount Beauty, Benalla in to the top of the Great Boundaries with other are respected in traditional laws. 3 The Taungurung people are closely affiliated with the neighbouring tribes, through language, ceremonies and kinship ties. They are part of an alliance with the five adjoining tribes to form the Kulin Nation. Other members of the Kulin Nation are the Woiwurrung, Boonwurrung, Wathaurung, and Djadjawrung. The Kulin Nation group also shares common dream-time ancestors and creation stories, religious beliefs, economic and social relationships. The Taungurong people were part of nine clans. Key Result Area Key Result Area 1 Establish and maintain relationships with Aboriginal communities and services Key Result Area 2 Provide or coordinate cross-cultural training for hospital staff Key Result Area 3 Set up and maintain service planning and evaluation processes that ensure the cultural needs of Aboriginal people are addressed when referrals and service needs are being considered, particularly in regard to discharge planning Key Result Area 4 Establish referral arrangements to support all hospital staff to make effective primary care referrals and seek the involvement of Aboriginal workers and agencies Progress Participating in Lower Hume Cultural Diversity Group which includes representatives from Aboriginal communities and services. Met with local elders at local health service planning meetings and groups Regional cross cultural training offered to staff Attendance of staff at a number of cross cultural workshops Planned cross cultural inservice for staff Equity of Access action planning underway to identify and implement improvements in this area. Transfer of care project working to develop consistency and cultural sensitivity in discharge planning and referrals. Access of equity working to address this Transfer of Care and supportive care project also working to develop referral systems to meet these needs Table 2: Report on progress against key result areas of Improving Care for Aboriginal and Torres Strait Islanders. 4 The table below lists our progress towards achieving the six minimum reporting requirements of a health services cultural diversity plan as specified in the Victorian Department of Health health service cultural diversity plan guidelines Goal Standard 1 A whole of organisation approach to cultural diversity is demonstrated Standard 2 Leadership for cultural diversity is demonstrated Standard 3 Accredited interpreters are provided to everyone who needs one Standard 4 Inclusive practice in care planning is demonstrated, including but not limited to dietary, spiritual, family, attitudinal, and other cultural practices Standard 5 CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis Standard 6 Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness Progress The Equity of Access working party comprises members from each part of the organisation and extensive representation for the community and culturally diverse groups. This group will work on the Action plan to ensure that there is a consistent approach to cultural diversity issues. Both the CEO and DON are members of the Equity of Access working party and there is executive representation on the Mitchell Cultural Diversity Committee. Each patient admitted to the Hospital is screened to determine the need for an interpreter. Interpreters are booked to be on site during days of surgical procedures in advance and the telephone interpreting service is utilised for unplanned attendances. Care planning for residents and patients identifies cultural needs and are addressed individually through assessment and discussion with the patient or resident. Identified needs are able to be accommodated individually due to the nature of our small rural community approach. Engaging with culturally diverse members of the community in the planning and review of programs occurs wherever possible but is often difficult due to the low numbers of such people in our community. It is however, the aim of the organisation to do so. Staff are afforded time and resource to attend professional development opportunities and such education is encouraged. Uptake, however, is low and reflects the low numbers of culturally diverse members in the community. Table 3: Report on progress of standards for cultural diversity planning 5 ACCREDITATION AREA TYPE OF ACCREDITATION ACCREDITATION PERIOD NEXT SURVEY DUE Acute Hospital areas & DNS Australian Council of Health Care Standards (ACHS) March, 2012 Aged Care Aged Care Standards 3 years and Accreditation Agency (ACSAA) 4 years 2012 Assessment visits annually. Table 4: Organisation accreditation status VOLUNTEERS The Op Shop team continues very enthusiastically to manage their well-stocked shop. Their efforts this year have raised much needed funds for hospital equipment and saw them meet the extraordinary milestone of $200,000 since they opened 6 years ago. Our Ladies Auxiliary serve as volunteers at Caladenia and Dianella or work to arrange the flowers in the hospital along with fundraising has contributed towards vital equipment. They are also strong ambassadors of our Hospital, selling cakes at fairs and fetes and being involved members of the community. The volunteer program for the organization has grown steadily with over 60 regular volunteers and an additional 20-40 students from the International School and Assumption College. They provide over 50 hours of service each week to our Hospital and Aged Care homes. Volunteers are overseen by the Volunteer Steering Committee (members of the volunteer group) who determine priorities, develop systems, identify resources needed and determine education requirements. The group have expanded the program substantially over the past year. One of the key new initiaitives has been the development of Community bus trips for residents. Our volunteers drive the bus, assist the residents when they are out and help the staff. We also have undertaken several training and education workshops to help volunteers develop and grow their roles. CREDENTIALING AND CERTIFICATION OF STAFF Nursing and Midwifery Registration This year the Health Professions Act came into force and all Nurses, Midwives and Doctors, along with 8 other health professions, are now registered nationally. All Nurses and Midwives must be registered with Australian Health Practitioner Regulation Agency. Nurses and Midwives at the Kilmore & District Hospital fall into three registration classifications: Registered Nurse of Midwife and Enrolled Nurse. Nurses may also hold 6 additional qualifications such as midwifery, emergency, critical care etc. or endorsements such as Medication Endorsement. We currently employ: 87 Registered Nurses Division 1 36 Registered Midwives 37 Registered Enrolled Nurses (Div 2) 19 Registered Authorised Enrolled Nurse (Div 2 - Endorsed) 41 Registered Nurses with additional post graduate qualifications Medical Credentialing The credentialing of medical staff ensures that every doctor appointed to the hospital has appropriate education, training, experience and qualifications for the position to which he/she is appointed, and that doctors only perform work they are competent to do. Local Doctors, Nurses and Paramedics updating their resuscitation skills – an annual requirement There is a comprehensive application form and extensive referee checks in place. No appointment is made unless proof of registration with the Medical Board of Victoria and appropriate medical indemnity insurance is provided. We have 17 general practitioners credentialed, 5 anaesthetists, 14 surgeons in the various disciplines, and 2 other specialists. Personal Care Attendants All employees who work in our Aged Care Facilities undergo police checks. Our Personal Care Attendants are required to have Certificate III or IV in Aged Care Qualification. QUALITY OF CARE The quality framework of an organization describes a quality system which has the consumer as its primary focus and helps the health care team to provide services that are safe, effective, timely and appropriate. Within this system, clinicians work together to produce the best results and understand and are committed to their roles and responsibilities for safety and quality. Aged Care Our vision is that residents will come to see the residence as their home where their individual needs and desires are understood and met and they are treated respectfully as an adult with a lifetime of experience and knowledge. 7 Residents will be physically comfortable and safe, in a pleasant surrounding which identify and meet their personal space and social and wellbeing needs. They will have access to the right care and the right time delivered by the right person. Opportunities to continue activities undertaken in the community prior to admission will be maintained and family and friend relationships will be optimised. Residential aged care at Caladenia and Dianella will provide opportunities to live a purposeful, comfortable, safe and enjoyable life. Relatives and friends of residents will feel welcome and at home in our aged care residences and feel that they are also part of our residential community. They will be genuinely accepted by staff without predjudice. Relatives and friends will feel that their family member is cared about and well looked after. Residents of Dianella enjoyed a day at Werribee Zoo earlier this year Acute Care Our Acute Services patients, however they enter the service, will have their care needs assessed appropriately, receive good information and effective communication about their admission, in hospital care and discharge. We will ensure that patients are referred to primary and community care supports as required and that their needs and the care they have received at our Hospital is effectively communicated to others involved as needed. Patients will feel free to work with the health care team to plan and manage their care needs. The Victorian Clinical Governance Framework was released in 2009 and is to be reported in the Quality of Care Report. Kilmore has partially implemented each aspect of the framework and continues to work towards full alignment with this policy. The four domains of the framework are: 8 consumer participation clinical effectiveness an effective workforce risk management (encompassing incident reporting and management). Figure 1: Victorian Clinical Governance Framework The Acute Ward provides inpatient services for 2,500 patients per year. Rural hospital acute wards are very different to larger Hospital wards in that the staff will provide care for a diverse range of patients at any given time. Patients in the ward will be receiving care for medical conditions, post surgical recovery, cancer care palliative care or because they are having a baby. This means that our staff are incredibly skilled and experienced at managing a variety of health problems. 200 babies are born at the Hospital each year. This year the babies of 5 of our own staff and 2 grandchildren of staff 9 Pictured is Rebecca and Mark with baby Jesse. Rebecca works as a Nurse in the Acute Ward and Caladenia Nursing Home. were born at the Hospital! That has to be a good endorsement of the care women and families receive at Kilmore & District Hospital. Around 200 chemotherapy treatments are provided to around 50 local people through our Oncology unit. The Operating Theatre performs approximately 1000 surgical procedures each year. Operations range from Ear, Nose and Throat surgery for children and Adults through to Gynaecological surgery for women. 10 The Emergency Department sees upwards of 8000 people each year and is staffed by Nurses 24 hours per day. Our local GPs provide the necessary medical support to the Nursing team and are an invaluable support to our Hospital. The most important quality work the Acute Sector has been part of is the Transfer of Care project. Working together with the Emergency Department, Operating Theatre and our District Nursing Service the objective of this project is to ensure that our vision for quality care is achieved and patients have a seamless journey from entry to care at home. George’s Story George’s story illustrates the importance of this work. George is an elderly man who lived in a bungalow behind his son’s house. George was not an easy man to work with and frequently challenged the community care staff who came to help him. He no longer was able to make good decisions about his care and his son was having difficulty understanding his father’s decline. George would often fall and be lying on the floor for long periods of time, was not eating properly or taking medications. Consequently George would attend the Emergency Department at the Hospital for care. Sometimes he would be admitted to the hospital for a short time and then go home again. The staff at the Hospital were not always aware of the community care providers George had in place at home and vice versa. George would ‘bounce’ between home and hospital with little communication or planning between the services. People like George can slip through the cracks. Those who have difficult and challenging behaviours and social circumstances are at risk of missing out on the services that they really need. The transfer of care committee used George’s case to identify the communication gaps and look at ways to make it easier for staff to identify and communicate with other care providers involved in his care. 11 Living in our aged care community. We are very proud of the care provided to our residents who live in our residential aged care community. Caladenia Home provides complex nursing care for residents with high care needs and Dianella Hostel cares for residents with less complex health and personal care needs. Both residences are committed to providing an environment that helps residents live life to their fullest capacity. Care is underpinned by our philosophy of: Enjoy Contribute Live life Be Secure Relax and feel good 12 Key improvements in the Aged Care area have been the expansion of the volunteer program to help residents achieve individual quality of life goals. It has helped more residents get out and about and to participate in activities that include them more in the community at large. The community bus program now runs up to twice a week to get residents to where they want to go and we have a number of community groups who hold their meetings and gatherings at the homes to enable residents to attend. We have enjoyed our partnerships with U3A and the friendship circle. Along with these lifestyle program improvements we continue to monitor and improve all parts of the personal and clinical care that we provide for residents. Val and Sharon looking at Aboriginal artefacts at the NAIDOC week presentation 13 Scaretactics has become an annual event in which our residents are very pleased to participate – and we don’t do too badly either with winning entry 2009, runner up 2010 and 2011. MAJOR QUALITY IMPROVEMENT PROJECTS We regularly participate in major projects to improve, develop and evaluate the care and services that we offer. Rural Medical Workforce Project This year we have been undertaking a major scoping project, funded by the Department of Health Medical Workforce branch, to review the medical models of care possible for small rural health services. The main activities for the project to date include; Developing and administering a statewide survey. The response rate from rural health services to the Rural Health Services Emergency Department / Urgent Care Survey 2011 was excellent, with 47 surveys returned out of 58 or 81%. Progress on Medical Workforce Profile continues. Progress is also being made on the designing a future medical workforce plan. A template for “Designing a Future Medical Workforce” is being completed with a number of key domains – demographics, models of care, workforce profile, emergency presentations, positions profile and service environment The Department of Health also funded a project officer position to look at ways to make the transfer of care more seamless between agencies. We have been the lead agency for reviewing and developing consistency for the Transfer of Care between health and community agencies across the Lower Hume Primary Care Partnership (PCP) team. Work continues on a number of elements in the admission and discharge process and care planning process for the acute sector as well as community health; Meetings have progressed onto “activities” of care planning that occur including the complex care meetings and bedside handover Admission and discharge policies and literature are under review Referral codes have been identified Referral numbers to community using a common referral tool are being collated The main been the that occur care the gaps in Supportive Cancer Hume Integrated Services outputs have discussing activities alongside planning and the process. care for Clients Regional Cancer funded a 14 project to introduce supportive screening using a validated screening tool for all people who come into our service with a Cancer diagnosis. This screening meets the requirement of the Victorian Cancer Action Plan and will ensure that people struggling with Cancer are offered all the services at their disposal. Consumer representative, Shirley Carrington, with crafted items called S*$% bags – each has a notepad and bag for cancer sufferers to write Their unhappy feelings on and tuck away. HEALTH PROMOTION The health promotion committee priority areas align with key health issues facing our community. The committee aims to undertake activities which: Minimise the impacts on health of smoking Promote healthy eating and reduce obesity Improve health and fitness Promote emotional wellbeing This year we declared the site a non smoking site and offered staff support to Quit. Emergency Department runs staff health checks which were well supported. Healthy breakfast week was a great success, providing our staff with healthy breakfast options and an opportunity to catch up on a social basis. 15 Night duty nurses enjoying their healthy breakfast.....or is that dinner? The workplace wellbeing project reviewed the social and emotional wellbeing of staff and received feedback about organisational barriers to staff wellbeing. SAFER SYSTEMS Incident reporting Incidents are events that occur that do not align with good care. Incidents might have actually happened or very nearly did happen. This includes things such as: Medication errors such as wrong dose, wrong medication, medication not given or illegible orders. Falls Pressure ulcers Hazards Unexpected events Policy and procedures not followed. Trends from recent years show a constant reporting rate, demonstrating a culture of willingness to report. All incidents and risk assessments are reviewed by the Risk Coordinator, and Risk and Quality Committee. Where possible, action is taken to reduce the risk of an adverse event reoccurring. Total Incidents 600 500 400 Series1 300 200 100 0 Yesr 2003 Year 2004 Year 2005 Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 Graph 1: Total number of incidents (measured by financial year) Falls Monitoring and Prevention 16 As people grow older there is increased risk of falling due to loss of muscle strength, balance, vision and bone density. Research shows that falls seriously contribute to disability and loss of independence and quality of life and even death for older people. For these reasons we focus on reducing the risk of falls occurring and the seriousness of injuries sustained. All patients and residents are assessed to ascertain the level of risk of a fall occurring. Appropriate falls minimisation strategies are put into place. Some Strategies include: Alarms that alert nursing staff to any unexpected movement of patients / residents who are at risk of falling Increased physiotherapy sessions Strength training Monitoring and supervision of patients / residents who require mobility aids. Environmental Audits to reduce clutter etc Strengthening and mobility exercise classes. Review of time, place and activity when falls occur – to identify trends. Review of injuries sustained due to fall – eg skin tears, bruises and fractures to identify trends and develop reduction strategies eg skin protectors have been implemented when there is poor skin integrity. Total Falls Organisation Wide 250 200 150 Series1 100 50 0 Series1 Year 2008 Year 2009 Year 2010 138 131 207 Graph 2: Number of falls by year (financial year period) Pressure Ulcer Prevention Pressure ulcers impact on quality of life of patients and residents. All patients and residents are assessed on admission and regularly throughout their stay to reduce the incidence of a pressure ulcer developing. Pressure Prevention strategies are put into place. These include: pressure reducing mattresses, skin integrity management, provision of a nutritional diet and proactive nursing practices 17 The Pressure Ulcer Committee reviews all pressure ulcers reported with aim of identifying gaps and recommending improvements in the provision of care. Our approaches to pressure ulcer management have helped to contain pressure ulcers to stage one with few progressing further. Medication Management Fortunately medication incidents have been minor without adverse outcome. Medication Related Incidents 2011 90 80 70 60 50 Series1 40 30 20 10 0 Year 2008 Year 2009 Year 2010 Year 2011 Graph 4: Mecation Incidents by year (financial period) Infection Control Improved health care worker hand hygiene is a vital component of reducing health care associated infections. The national campaign stems from the World health Organizations health alliance patient safety campaign “clean care is safer care”. 18 The Kilmore and District Hospital’s hand hygiene compliance rates are consistently high and have been above the Victorian average of 71.7% Graph 5: % Hand Hygiene compliance by year (financial) Cleaning Anybody who has looked closely around our Hospital and Aged Care Residences can see how impressively clean they are. External audits confirmed what we knew – our cleaners are above average! Our scores are consistently above 95%, significantly higher than many other health organizations. Congratulations go to our environmental services team. Phil and Tina regularly audit our patient and resident care areas to ensure that we keep up our high standards of cleanliness. PATIENT SATISFACTION The Kilmore & District Hospital participates in the Victorian Patient Satisfaction Monitor. Each 6 months a sample of patients are sent questionnaires to complete about their experience here. Our results show that patients are more satisfied with their overall care than those at all hospitals but slightly less satisfied than patients of similar organisations. 19 COMPLAINTS AND COMPLIMENTS Feedback, both good and bad, helps us to improve our service and is an important mechanism for change. Compliments encourage our staff to continue to do great work; we all like to be appreciated! Compliments are measured from January to December and reflect 2010 figures. Total Complaints % complaints actioned within 14 days Average days taken to close Type of complaint Lack of information Communication Concerns about care Other Environment *U=Unavailable 2010 30 100% 2009 24 100% 2008 20 100% 2007 16 100% 2006 23 60% 9 4 5.2 3.81 11 2008 % U U U U 2007 % 6 31 37 31 2006 % 31 30 13 19 2010 % 0 20 30 26 23 2009 % 0 22 16 16 46 Feedback from patients and residents has led to a number of reviews and improvements. The following are examples: 20 Comprehensive clinical case review leading to the identification of issues and actions to prevent the events being repeated. Actions include review of policies, procedures and guidelines, education of staff, changes to risk management guidelines, changes to workforce profiles and clarifying roles and communication structures. Regular meetings between the food services manager, residents and aged care managers to maintain an ongoing discussion about menus and food service provision. Refurbishment of the ED including the provision of a television in the waiting room. Painting of Caladenia 73 Compliments are on file for 2010. It is impressive that many people feel moved to pen their thanks for the care received. I believe it demonstrates the efforts our staff go to to meet the needs of our patients and residents. Compliments were spread fairly evenly throughout the organisation with the exception of Acute which received the highest number of compliments. PLEASE GIVE US YOUR FEEDBACK ON THIS REPORT Email: [email protected] Phone: 5734 2000 Letter: The Kilmore & District Hospital, Reply Paid 185, Kilmore 3764 Website: www.kilmoredistricthospital.org.au Services MATERNITY SERVICES Comprehensive Maternity Services provided. Models of care provided are GP led care, public antenatal care and Know Your Midwife care. Referral through GP or self referral possible DISTRICT NURSING SERVICE Home nursing care provided including personal care, specialist wound care, administration of intravenous medication, post surgical follow up care. Referral through GP, Hospital or self referral. URGENT CARE Our Emergency Department is open 24 hours per day and staffed with experienced Nurses who are able to provide first line care. Local General Practitioners support the department on an on call basis. ACUTE WARD 30 bed inpatient ward – medical, surgical, maternity and palliative care. OPERATING THEATRE Types of surgery include Ear, Nose & Throat, Orthopedic, Gynaecology, Urology and General surgery. RESIDENTIAL AGED CARE Providing residential aged care for elderly people with high nursing care needs and also those who require assistance with their activities of daily living. Referral through local GP to visiting specialists. Referral via local GP 21 Applications can be made directly to Dianella Hostel and Caldenia Nursing Home once the Aged Care Assessment Team has undertaken the required assessments. DIAGNOTIC SERVICES Healthscope Pathology undertake blood tests and Electrocardiograph testing on site. CONSULTANT SPECIALISTS Gynaecology, General Surgery, Cardiology, Cancer, Urology Referral via local GP Capital Health Radiology provide xray, CT scanning and Ultrasonography. Referral via local GP 22