Beechworth Silver Creek Stanley. Chiltern Staghorn Flat Osbornes Flat Kiewa. Wooragee BEECHWORTH HEALTH SERVICE 2012 CALENDAR

Transcription

1 BEECHWORTH HEALTH SERVICE 2012 CALENDAR Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley

2 BEECHWORTH HEALTH SERVICE Table of Contents Wooragee Beechworth Silver Creek Stanley INTRODUCTION QUALITY & SAFETY Infection Prevention & Control Environmental Report Quality & Safety in Medication Falls Monitoring & Prevention Chiltern Pressure Wound Monitoring & Prevention Staghorn Flat ACCREDITATION AND RISK MANAGEMENT Clinical Governance & Credentialling Osbornes Flat Kiewa Allans Flat Tangambalanga Staff Development Woolshed Valley Yackandandah Making People Better is Risky Business! We Are Listening to You! CONTINUUM OF CARE Continuous Care When Needed CONSUMER PARTICIPATION Consumer & Carer Participation Responding to Diverse Community Needs

3 INTRODUCTION Beechworth Health Service (BHS) has a long and proud history of providing excellence in health care. Commencing in 1856 as the Ovens Goldfields Hospital and moving through several amalgamations and name changes, this finally resulted in the formation of BHS in January 2002 as it stands today. These amalgamations included the coming together of two of the oldest hospitals in north east Victoria, and also part of the original Mayday Hills psychiatric Hospital. BHS has been one of the largest single employers within the local community for many years, so it is important to not overlook the fact that our staff are an integral part of the Beechworth community. We take the view that our community and consumers need to be our partners in achieving high quality services. We also believe they have an inherent right to be our partners. We are always keen to report to our local community on what has occurred in the last 12 months at BHS. We are also looking for new ways to keep you informed, so please contact us with any suggestions. We also seek your comment and opinion through our Quality of Care Report (QoCR) feedback forms. It is hoped that participation in next year s development of the QoCR will also be promoted through our website. In previous years we have used as formats, a recipe book, a calendar and also a pictorial feature focusing on healthy activities that local people undertake. The Report was again made available to local people through a self service arrangement at the Beechworth Surgery, the Beechworth Neighbourhood Centre, our own BHS reception area and all residential care areas, Acute, The Willows and planned activity groups at BHS. A note has also been placed on the contents page of the Annual Report referring readers to the Quality of Care Report. Such strategies to inform and generate feedback from the local community have created greater opportunity for people to be involved in the evolution of our Quality of Care Report over the years. There appears to be little change in the demographics of Beechworth Health Service's catchment. It continues to indicate a diverse community with some 130 people speaking 13 different languages other than English, 48 people who identify themselves as Aboriginal or Torres Straight Islander and a broad population with varied socioeconomic and occupational backgrounds. Addressing the needs of the community requires varied approaches. One of our most important approaches used is that of population health. This is where health improvement is addressed by tackling the underlying causes of poor health such as people s living situations or lifestyles. Health promotion, illness prevention and chronic disease self management programs have been implemented. In 2006, 2007, 2008, 2009 and 2010 we sought comment from readers of the Quality of Care Report on the body of the text of the Report. We did not receive many evaluations back in However, in the past, most readers have rated our QoCR highly. Feedback has included such ratings for the Report as being: Informative Interesting Easy to read This year we have continued the calendar format. This was found to generate more interest by people to obtain a copy of the Report and thus potential for it to be read more often. If you have any comments or ideas for inclusion into next year s Quality of Care Report, please write to us or use the QoCR feedback survey available with this Report. If you have other specific ideas about an alternative format of the QoCR, we would like to hear your views. This Report helps explain the coordinated functioning of our health services and how they are performing, plus our efforts to pursue high standards and ensure the best consumer outcomes. Our Health Service was again successful in the 2011 Australian Council on Healthcare Standards (ACHS) Periodic Review accreditation, where one assessment rating was raised above our own self rating. Since our last report, we have also maintained our Aged Care Standards and Accreditation Agency Ltd. (ACSA) accreditation status. We had our 3 yearly accreditation visit on 14 & 15 September was a sad year for Beechworth Health Service, when its then Chief Executive of 6½ years, Jan Webb, passed away. Jan was renowned for her compassion exceptional leadership qualities and 100% commitment to providing the best possible health care for patients, residents and clients. Jan will be remembered fondly by many for a long time into the future. Greg George, President, BHS Board on behalf of the Board & Staff at Beechworth Health Service Page 3

4 QUALITY & SAFETY Infection Prevention & Control INFECTION CONTROL The Infection Prevention and Control Program (IP&C) is an essential part of the quality health care we provide at BHS. Through this program we recognise that clients, visitors and our fellow Health Care Workers (HCW) can be at risk of acquiring and transmitting infections whilst they are in the health care setting. We minimize these risks by providing ongoing staff education, staff vaccination clinics and participation in internal/external surveillance. Our HCW are proactive and innovative in developing strategies to improve our infection control practices in accordance with evidence based best practice guidelines. In , our focus was on protecting our staff from vaccine preventable diseases such as Influenza, Measles and Whooping Cough, as directed by the Department of Health. HCW voluntarily attend the staff health clinic every Wednesday in the Acute Centre for screening and vaccination. Results THE STAFF HEALTH CLINIC IMMUNIZATION DATA Serology Hepatitis B Hepatitis A Diphtheria/ Tetanus/ Pertussis Measles, Mumps & Rubella Varicella Attendees The Annual Seasonal Influenza Vaccination Program continues to improve on previous years in terms of the number of staff being vaccinated. The 2010 Influenza Vaccination Report as generated by the Victorian Hospital Acquired Infection Surveillance System Coordinating Centre (VICNISS) surpasses the state aggregate of 46.8% with a result of 58.8%.The table below details BHS vaccination rates over the last 3 years: INFLUENZA VACCINATION RATES Year Total BHS Staff Vaccinated BHS Clinical Staff Vaccinated Only % 57% % 64.2% % 61.5% Participation in benchmarking audits is a key component of the IP&C program. Each year a clinical areas compliance audit is undertaken (by Hume Region Infection Control-HRIC) - refer to table below. This annual audit assesses compliance of all areas including waste, linen, sharps management, clean/dirty utility rooms, catering, blood exposures and protective apparel. In the last 3 years, BHS has been equal to or above the regional average. Each year BHS participates in a Residential Aged Care Point Prevalence Infection Survey (High Care and Psycho Geriatric units only). The survey is arranged by Hume Region Infection Control Service and is aimed at identifying the number of cases of specified infections in the population during a 24 hour period. The table below summarizes the finding from the previous 3 years. HUME REGION: ANNUAL COMPLIENCE AUDIT Year Month BHS Clinical Areas Compliance Hume Region Average BHS Organisational Compliance Hume Region Average December 97.5% 95% 98% 93% December 97.9% 95.6% 99.23% 93.8% December 98.8% 97.29% 99.2% 95.26% BHS reports to Hand Hygiene Australia with compliance rates three times per year. Our Hand Hygiene Compliance audit results (78.9%) have been consistently higher than the national and state benchmarks of 60% and 72.9% respectively. HUME REGION: ANNUAL COMPLIENCE AUDIT Year Month BHS Clinical Areas Compliance Hume Region Average BHS Organisational Compliance Hume Region Average December 97.5% 95% 98% 93% December 97.9% 95.6% 99.23% 93.8% December 98.8% 97.29% 99.2% 95.26% Page 4

5 JANUARY Sunday Monday Tuesday Wednesday Thursday Friday Saturday New Year s Day Beechworth Farmers Market- Christ Church Chiltern Monthly Market- Recreation Reserve Chiltern Staghorn Flat Osbornes Flat Kiewa Opera in the Alps - May Allans Flat Tangambalanga Day Hills Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley Australia Day December 2011 S M T W T F S February 2012 S M T W T F S

6 QUALITY & SAFETY Environmental Report ResourceSmart is a statewide, environmental action initiative launched in 2004 by Sustainability Victoria. The initiative has been disseminated progressively across all state agencies; schools, justice, health care and etc. In early 2009, ResourceSmart was launched as a set of regional consortiums within the healthcare sector, whereupon in 2010 Beechworth Health Service joined the Northeast Region s group. Members of the consortium received training and support in developing their respective Sustainability Action Plans, which set out measurable environmental objectives to be attained over the course of 2011 through BHS has established objectives within the following sustainability domains: Purchasing; Utility Management; Promotion and Education; Policy Development; Waste Management and Data Management. Purchasing BHS focus for environmental sustainable purchasing for the period is on vehicle procurement and travel. The objective of this effort will be to (1) attain a 20% reduction in vehicle-generated carbon-dioxide by July 2013, (2) to increase the use of videoconferencing (as a means of reducing travel) by 50% by July To this end, BHS will: Evaluate the purchase of every vehicle against the intended usage, with a likely increase of reliance on 4-cylinder, LPG and diesel engines. Develop an organisation-wide policy that encourages car-pooling, use of public transport and video conference in lieu of travelling Energy/Utility Management The supply of heating, meals and delivering hot water to our clients utilizes a substantial amount of Liquid Petroleum Gas (LPG). In the financial year, solar panels will be added to the facility as a means of pre-heating water utilised in the hydronic heating and potable warm-water (showers & hand washing) systems. Our goal is to reduce LPG consumption by 20% by July Present consumption of LPG 150,000 litres per year 2013 target consumption of LPG 120,000 litres per year Waste Management BHS has been aggressive in efforts to reduce the volume of non-recyclable waste, and to adopt purchasing practices that support recycling of packaging and waste. As an aged care facility accommodating 75 clients, dignified use of continence aids is a fact of life. Presently, BHS generates litre bins of used continence products per week, i.e. 300 litres. Our organisation is committed to working with the product industry and aged care networks to arrive at a remedy for the currently singular option of disposing non-biodegradable continence products in the landfill. Promotion and Education Ultimately, the most effective means of maximizing our sustainability efforts is by building a workplace culture that supports them. Establishing a culture that embraces environmentally responsible habits and methods requires us to educate staff, and to promote proven, conservation initiatives. Litres By July 2012, 80% of targeted populations amongst BHS staff will receive specific training in environmentally sustainable: Vehicle use Product procurement and use Recycling practices Policy The means of conveying clear expectations throughout an organisation is through a concise vision, a Strategic Plan and subsequent polices that direct effort and behaviour. Beechworth Health Service has developed its 3-year Strategic Plan, wherein one of the key pillars is Sustainability. Subsequent to the Strategic Plan is the development of an Energy Management Policy. A key feature of the policy will be to reinforce each employee s responsibility to engage in environmentally responsible workplace behaviour. By July 2013, the policy will result in a 20% reduction of electrical consumption. Data Management Reliable access to accurate and current data is essential to making informed decisions in environmental management. Therefore, Beechworth Health Service s Environmental Management Plan includes a systematic means for collecting data related to purchasing patterns, energy consumption, e.g. water, electricity, gas, waste management, and vehicle usage. This data will be the source of measuring the attainment of respective targets, and the formulation of future objectives. LPG CONSUMPTION LPG Consumed Litres 30,000 25,000 20,000 15,000 10,000 5,000 0 LPG Consumed Litres Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Month kwh ELECTRICAL USAGE Electrical Usage Electrical Usage , , , , , , , Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Month Page 6

7 FEBRUARY Sunday Monday Tuesday Wednesday Thursday Friday Saturday Beechworth Farmers Market- Christ Church Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Valentine s Day Ash Wednesday Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley S January 2012 March 2012 S M T W T F S M T W T F S Chiltern Monthly Market- Recreation Reserve

8 QUALITY & SAFETY In Medication The syringe drivers purchased in 2010 continue to be used effectively within the Acute Unit, District Nursing and the residential units to help manage clients pain. Client satisfaction with pain management continues to be monitored. The last Victorian Patient Satisfaction results for BHS remain at the 100% level. The Drugs and Poisons Unit of the Department of Health conducted a spot audit at BHS on 29 April The identified issues were reported last year and have now all been addressed. Standing Orders, which are used by registered nurses for initial assessment and, if required, for ongoing management when medical staff are not available to deal with unplanned presentations to the Health Service, have been reviewed and updated as required. MEDICATION INCIDENTS (EST.) BETWEEN 2006 & 2011 Stringybark Lodge Blackwood Cottage The Acacias the reduction in issues over the past two years has shown a marked improvement. It is hoped that the changes made in the first part of 2011 will again show improvements in results. This review is ongoing, but there has also been a review of the medication administration process which we hope will again reduce the incidents further. Medication incidents are common throughout the health industry. At BHS, hundreds of medications may be given to patients and residents on a daily basis. The above table shows medication errors across the bed based aged care units. As you can see, there has been a marked improvement in the number of errors made in the last three (3) years. Our pharmacist is credentialled to carry out medication reviews within the residential units. While this is not a new initiative, the consultation that occurs between the pharmacist, the care staff and the medical practitioners has increased as a result. This ensures that residents are not receiving medications that may interact with each other or that may have an adverse outcome on the residents health status. The medication policy is reviewed annually to ensure that current legislated requirements are captured, particularly in relation to medication management for enrolled nurses which has changed significantly over the past few years. As residential aged care is the clinical program area that administers the largest number of medications at BHS, we have focussed this report on incidents occurring within aged care on this occasion. A review of the medication issues in Stringybark Lodge at the end of 2009 indicated a variety of reasons for these issues. Medication management in this unit continues to be a challenge, but Page 8

9 Sunday Monday Tuesday Wednesday Thursday Friday Saturday February 2012 April 2012 S M T W T F S S M T W T F S MARCH Beechworth Farmers Market- Christ Church Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Labour Day (Vic) St. Patrick s Day Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley Chiltern Monthly Market- Recreation Reserve

10 QUALITY & SAFETY Falls Monitoring & Prevention Definition: The World Health Organisation defines a fall as an event which results in a person coming to rest inadvertently on the ground or floor or a lower level. Within the BHS residential care units, falls numbers are dependant to some extent on the health status of the residents. The number of falls has varied across the three residential units over the past few years. Residents falls risks are assessed on an annual basis as a minimum, or is done more frequently dependant on residents health status. The outcome of this assessment provides a rating which identifies the amount of supervision, monitoring and/or assistance the resident may require with mobility or transfers. BHS has continued to report falls as part of the Department of Health Clinical Indicators set on a quarterly basis. These results are recorded in the graph, at right, for the number of falls per quarter across the three residential units. BHS falls results compare very favourably with the state averages. In the community, BHS now runs several exercise and activity groups targeting falls prevention. The One Step Ahead group targets those at risk of having a fall or who have experienced a fall. People are referred by a health professional or even themselves through reading about the group in the BHS Newsletter or local newspaper. This multidisciplinary program takes a holistic approach where participants develop strength, skills and confidence as well as an understanding of the many risk factors involved in minimising falls. Measures of clients progress include functional (which includes strength and balance), specific balance, confidence and risk factor measures. Number of falls RESIDENTIAL UNITS NUMBER OF FALLS PER QUARTER Q1 Q2 Q3 Q4 Quarter of year 2008/ / /2011 The balance activities they are a challenge. I enjoy the improvement I make each week though - One Step Ahead Program participant comment. One Step Ahead 2010/2011 Berg test pre and post program 100% participants increased. Strength pre and post program 90% participants increased. Beyond One Step Ahead participants can move to the Get Up and Go Go group which focusses on further skill and confidence development, with regular home exercise encouraged and supported. Page 10

11 APRIL Sunday Monday Tuesday Wednesday Thursday Friday Saturday Palm Sunday Good Friday Easter Saturday Golden Horseshoe Festival Weekend Beechworth Farmers Market- Christ Church Easter Sunday Easter Monday Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Anzac Day Stanley March 2012 May 2012 S M T W T F S S M T W T F S Chiltern Monthly Market- Recreation Reserve

12 QUALITY & SAFETY Pressure Wound Monitoring & Prevention Definition: A pressure ulcer is defined as a lesion (e.g. wound) caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are an internationally recognised patient safety problem and are largely preventable. ( There are 4 stages to pressure ulcers. Stage 1: Observable pressure related alteration to intact skin. The ulcer appears as a defined area of persistent redness in lightly pigmented skin whereas, in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. Stage 2: Partial thickness skin loss. The ulcer presents clinically as an abrasion, blister or shallow crater. Stage 3: Full thickness skin loss. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. All the beds in the Health Service that have been purchased in the last five years have pressure relieving mattresses. These mattresses assist in providing comfort and reducing pressure on dependant areas for clients who spend a lot of time in bed. Residential Care Multiple research indicates residential care is the area where people are most prone to pressure ulcers as their health status deteriorates. This makes an individual more susceptible to developing a pressure ulcer. BHS places a high priority on minimizing the occurrence and severity of pressure ulcers. As mobility and nutritional intake decreases, the residents care needs are constantly reassessed. Care is provided over the twenty-four hours to ensure skin integrity, nutritional status and hygiene are maintained. Steps taken to manage residents prone to developing a pressure wound include moving them to reduce pressure on any part of the body, reducing the amount of moisture the skin is subjected to, ensuring the health of the skin is maintained and ensuring resident's nutritional status is maintained. Wound Management The BHS wound working group continues to meet. Staff members from all clinical areas, including Allied Health, make up this group. The group continues to oversee best practice measures in regard to wound care, including pressure wounds, both in the community and within the Health Service. This work is complemented by the work being undertaken by the Hume Region Wound Management Consultant. Numerous staff have attended education sessions organised by the Consultant, resulting in better outcomes for our residents and clients. STATEWIDE PRESSURE ULCER RATES (per 1000 occupied bed days. Q = quarter) Stage 1 Pressure Ulcer Rate Stage 2 Pressure Ulcer Rate Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 BHS Rates Statewide High/Low Mixed Rates Stage 3 Pressure Ulcer Rate Stage 4 Pressure Ulcer Rate Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 BHS Rates Statewide High/Low Mixed Rates BHS continues to provide data monthly to the Board and quarterly to the Department of Health (DoH) as part of the Aged Care Clinical Indicators. These figures remain consistent across the years. BHS results, as well as the state wide comparative data, are recorded in the tables. Acute Unit As the age of patients in Acute continues to increase, more emphasis is placed on ensuring skin integrity and nutritional status is maintained, both in hospital and in the community. District Nursing The District Nurses continue to work with the Hume Region Wound Management Clinical Nurse Consultant to better manage wounds and pressure ulcers. This is improving the outcomes and comfort for those with pressure ulcers or wounds. These staff also provide a resource for wound management throughout the Health Service. Page 12

13 MAY Sunday Monday Tuesday Wednesday Thursday Friday Saturday Beechworth Farmers Market- Christ Church Mother s Day Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley April 2012 June 2012 S M T W T F S S M T W T F S Chiltern Monthly Market- Recreation Reserve

14 ACCREDITATION AND RISK MANAGEMENT Clinical Governance & Credentalling Clinical governance can be formally defined as the system by which the governing body, managers, clinicians and staff share responsibility and accountability for continuously improving the quality of care, minimizing risks and fostering an environment of excellence in care for consumers. What this in fact means is that as an organisation, Beechworth Health Service is committed to providing consumers with health care of the highest possible standard and that we have mechanisms in place to help us achieve this. We use the term consumer to mean any of the following patient, resident, client or carer. Our framework for clinical governance is built around the following: Consumer and Clinical Team Focus Consumer experiences form the basis of our systems as they are central to identifying safety and quality issues that support improvement. Individuals should have confidence that their episode of care is of a high standard. Clinical teams are directly responsible for the safety and quality of care provided. It is therefore imperative that the organisation is focussed on the clinical teams to ensure they are adequately resourced and sufficiently skilled to fulfil their role. Consumer Participation Consumers are actively encouraged to provide input into the organisation in terms of feedback about services and into future planning. A number of the previous clinical governance issues are further expanded on within this Quality of Care Report. CREDENTIALLING When we employ staff, it is critical that we have evidence of their prior learning and experience. For doctors, nurses and allied health staff, this means we need to sight their current qualifications and registration at the time of employment. It also means that we seek and verify at employment and every year thereafter, evidence that the national registration board has registered them for the current year to practise their profession. The Board requires evidence of ongoing education in the specific profession. BHS is pleased to say that 100% of staff have retained ongoing mandatory registration. Clinical Effectiveness This means doing the right thing and doing the thing right. That is, determining and providing the most appropriate clinical service based on evidence and research. Secondly, it means providing that clinical care in the way that it is meant to be provided through adherence to accepted processes and standards. We have various performance measures in place to assist us assess clinical outcomes for consumers. Effective Workforce All staff employed within the health service have appropriate knowledge and skills to fulfill their roles and responsibilities, are provided the opportunity for personal and professional development and training needs are systematically planned and coordinated. Managing Risks Clinical risk management forms a part of our overall organizational risk management system and we seek to minimize the likelihood and consequences of clinical incidents. Page 14

15 Sunday Monday Tuesday Wednesday Thursday Friday Saturday May 2012 July 2012 S M T W T F S S M T W T F S JUNE Beechworth Farmers Market- Christ Church Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Queen s Birthday Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley Chiltern Monthly Market- Recreation Reserve

16 ACCREDITATION AND RISK MANAGEMENT Staff Development Within the dynamic sectors of health and aged care, BHS aims to support its staff to be appropriately skilled, competent and confident. Since the last Quality of Care report in , staff have participated in a diversity of training within the broad areas of: Technological Advancement Aged Care Mental Health Accreditation Assessment And Initial Management (Aim) Management And Leadership Disaster Planning Diabetes Food Safety Medication Competency Parkinson s Disease Palliative Care Currently BHS has a number of trainees from Administration, Aged Care, Mental Health and Services departments undertaking studies in their chosen fields. It is expected that BHS will continue to seek further opportunities for government sponsored training in the foreseeable future. Finally, and importantly, with the recognised trend of an ageing population and in order to meet the high expectations of the community, BHS will continue to seek innovative and cost effective training solutions to enable staff to provide the best possible care for its community. In addition to the above, and as part of our risk management approach, BHS is providing training in Focus Charting documentation methodology. This methodology will support clinicians in provision of concise, accurate and person centred documentation in medical records. In 2011, Beechworth Health Service continued to extend its Australian Quality Training Framework (AQTF) aligned program to include the mandatory training Infection Control as a certificate based unit of competency for staff. The sessions are being scheduled on a monthly basis and it is anticipated that more than 60% of staff will have completed this AQTF unit of competency by the end of In , BHS plans to align its remaining mandatory training, Manual Handling, to the AQTF. In respect to workforce planning and development, BHS aims to incorporate flexibility and sustainability as key guiding principles. It can do this by supporting staff to reach their potential and to pursue their personal and professional goals. BHS has been proactive in participating in both Victorian and Commonwealth Government funded programs to support traineeships within the workplace. Page 16

17 JULY Sunday Monday Tuesday Wednesday Thursday Friday Saturday Beechworth Farmers Market- Christ Church Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley June 2012 August 2012 S M T W T F S S M T W T F S Chiltern Monthly Market- Recreation Reserve

18 ACCREDITATION AND RISK MANAGEMENT Making People Better is Risky Business Knowing our risks! BHS has effective systems in place to identify, monitor and address real and potential risks. We identify our risks by either looking at historical data and/or through brainstorming processes. It is important to look at how often incidents have occurred in the past (i.e. volume), their possible cost or impact (i.e. financial and other) and the likelihood of a particular risk re-occurring. Our major clinically related risks can be summarized as follows (not necessarily in order of priority): Falls by residents/patients Aggression/assault events Medication errors Appropriately skilled and available workforce Workplace injury is always a risk in the health industry and BHS is no exception. Risk management is promoted to all staff as a proactive step in fostering a positive culture of identifying, reporting and reducing risks. From the first day of orientation at BHS, new staff are provided with an awareness to identify and report any risks that may cause harm. Examples of new initiatives, and our positive attitude to managing risks in , include the following: BHS initiated Risk Management Workshop, facilitated by our insurer, the Victorian Management Insurance Authority (VMIA). From this we were able to formulate a refreshed Risk Register for Introduction of a web based incident reporting and management system (Victorian Health Information Management System (VHIMS) Riskman.net.) This allows all staff to report an incident from anywhere across the organisation at any computer. During BHS also conducted Open Explanation (Disclosure) training relevant for senior staff. This links with risk management and our partnering with consumers to improve health outcomes. The new software will be monitored and evaluated later in We have previously evaluated our systems and continue to focus on developing the following aspects of our risk management processes: Listening to and taking into account views of staff, volunteers, consumers and the community Maintaining knowledge and awareness about risk management Fostering shared responsibility for managing risks Identifying and treating our risks Monitoring systems for recording and reporting risks Monitoring how we manage legal compliance Using Australian Standards when relevant What else have we done? The ongoing pursuit of clinical safety is an important risk management responsibility for us. This includes adopting an open disclosure policy. We have implemented a more appropriate and relevant title for open disclosure and that is open explanation. We aim to achieve full transparency with our explanations of clinical incidents. We have been a participant in the statewide Limited Adverse Occurrence Screening (LAOS) program. The aim of LAOS is to identify and minimise preventable adverse events in acute care settings. We submit selected de-identified clinical files for review by an independent panel to ensure we had provided optimal care. LAOS provides recommendations on how processes could be improved. What results and outcomes can we show for our efforts to reduce clinical risk? Our risk management and incident policies are maintained current to ensure their integrity and relevance. You will see specific details of how we have managed in some of the main areas of clinical risk, such as falls and medication, on other pages in this Report. The risk of workplace assault from clients has continued to be addressed through providing mandatory Behaviour Management training to all staff. As at 30 June 2011, an estimated 75% of all BHS staff were current with this training. Our Behaviour Management training (HLTCSD306B) is aligned against the Australian Quality Training Framework. This training continues to have a positive impact in terms of a declining number of reported incidents for aggression/assault. The incidence of aggression/assault, for both staff and non staff, over the last five years is recorded in the graph below, which shows approximately a 29.6% improvement between and INCIDENTS (TREND) FOR AGGRESSION/ASSAULT LAST 5 YRS 150 Number of Incidents YEARS Page 18

19 Sunday Monday Tuesday Wednesday Thursday Friday Saturday July 2012 September 2012 S M T W T F S S M T W T F S AUGUST Beechworth Farmers Market- Christ Church Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley Chiltern Monthly Market- Recreation Reserve

20 ACCREDITATION AND RISK MANAGEMENT We are listening to You! Consumer involvement is highly important in ensuring we develop an insight into the issues rated as important by our patients, clients and residents (i.e. consumers). We encourage active feedback from our consumers and are thinking of more and more ways to allow consumers to provide their views and comments. These include: Launch of the BHS Facebook page Feedback, complaints, compliments, comments form onto the BHS Website Circulation of the Complaints Registration Form to the same location points as our Opportunity for Improvement (OFI) Forms. As a support to staff, we have a comprehensive policy and set of processes providing guidance on receiving, registering and taking action on any complaint received. The computer software from the Victorian Health Services Commissioner has assisted us to record and monitor complaints up to 30 June From 1 July 2011 complaints will be registered within a newly developed computer module (Feedback) within our incident reporting software (Riskman). The comparative figures in the table below show the number of complaints received by the Health Service s Complaints Liaison Officer (CLO). Complaint and compliment data is also formally reported to the Quality Committee and Board. There was further significant improvement in the number of complaints submitted. Although this is particularly pleasing, we want to test the validity of this low number of complaints. We have therefore increased the ease with which consumers can provide feedback through the initiatives listed in the first paragraph above. The Quality Committee examines the frequency at which complaints occur and how they are processed. The name of the complainant is never provided to committee members. After a complaint has been investigated, any systems that need corrective actions are targeted for change in an endeavour to improve service delivery and outcomes for our consumers. COMPLIMENTS RECORDED AT BHS BETWEEN Number of Compliments YEARS The Opportunity for Improvement (OFI) Form assists community members, as well as staff, patients and residents, to make comments about the Health Service. We encourage people to feedback to us any way they like. We want your comments, compliments, OFI forms as well as complaints. All three forms of feedback assist us in Doing Things Better at BHS. We not only need to record and learn from complaints, we also believe there is a need to appropriately record any compliments we receive. These are made up of cards expressing appreciation, notes on paper or s through to formal letters of appreciation. The graph below shows the number of documented compliments recorded between 1 July 2006 and 30 June Additional to this were 43 favourable verbal compliments and 25 minor concerns about food received from our residents/clients in The graph at left, plus the positive feedback received on meals, is encouraging and seems to indicate a sustained level of good outcomes. We hope it is also reflecting the increasing attention we endeavour to give to the consumer/client, as well as improved record keeping at BHS. A few examples of improvements resulting from consumer/staff feedback or complaints include: OH&S Committee created a new committee that is designed to review assault/aggression issues and make recommendations on strategies to assist in their reduction both in numbers & in severity. Laminated signs created in pink for special diets have been placed on Acute ward to keep Kitchen staff informed and to be observant of these signs. Developed discharge envelope with tick sheet to ensure all relevant information is sent with the patient on transfer. Some organizations may not encourage patients & clients to have a say, but at BHS we do want to hear what your views are. Source: Guide to Complaint Handling in Health Services, Health Services Review Council, Page 20

21 SEPTEMBER Sunday Monday Tuesday Wednesday Thursday Friday Saturday August 2012 S M T W T F S October 2012 S M T W T F S Beechworth Farmers Market- Christ Church Father s Day Chiltern Woolshed Valley Wooragee Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Yackandandah Beechworth Silver Creek Stanley Chiltern Monthly Market- Recreation Reserve

22 CONTINUUM OF CARE Continuous Care When Needed BHS aims to provide seamless care between all areas of the Health Service. From the consumer's perspective, this means no problematic barriers will exist between, say, the Allied Health Team through to the Acute unit (which now includes Transitional Care as well as the Urgent Treatment Room) and then residential care for either respite or permanent care. The expansion of community based groups that foster chronic disease self management increased the opportunity for continuity of care for 81 people to move from one-on-one clinical services to self management to independence in the community. Last year 65 people participated in these groups. Community based allied health services have enabled greater continuity of care by adding to the Service s existing Planned Activity Groups in Yackandandah and Tangambalanga, providing clinical services, health education, chronic disease self management programs and multiple community developed exercise groups ( Zumba ) with over 100 participants. Strength and balance programs and a health coaching based program, My Health, My Life, enable participants to explore and address their barriers to moving from clinical services to achieving better health and independence. The Transitional Care Program was introduced to the Acute unit at the beginning of This program allows for intensive Allied Health involvement in the client care which is aimed at the person being better able to manage at home. This ensures that they stay in their own home environment longer. Since the introduction of this program, six community members have used this service which has enabled them to return to their homes and remain there for a longer period of time. Ageing in place occurs in Stringybark Lodge. This is a system that enables people who are admitted to that unit as low care clients to remain there as their care needs increase. This ensures that residents are provided with ongoing care by staff who know them and who have been involved in their care for a period of time. Families are usually happy with this arrangement as well. However, there may come a time when their care needs are such that the resident needs to be cared for in a different environment. While BHS tries to accommodate these changing care needs with BHS, at times family members may be asked to find a high care bed Active Transport Participants % Beechworth School Population Number of Registered Children Term 3, % 26 Term 4, % 39 Term 1, % 59 Term 2, % 65 elsewhere. Another option is prolonged placement in the Acute unit which is to be avoided if possible. Volunteers continue to play an important role in our Health Service. Volunteers within the residential facilities provide outings, support and different faces for these long term residents. Volunteers continue their important role in our Health Service with an increase in community based volunteering occurring in the past year. The Active Transport program (previously known as the Walking School Bus) has expanded from 2 volunteers and 5 participants in November 2009 to 21 volunteers and 65 participants in June The strength of this volunteer base has seen increased membership demand despite the program reaching its current capacity. Volunteers continue to play an important role in our Health Service. Page 22

23 OCTOBER Sunday Monday Tuesday Wednesday Thursday Friday Saturday Beechworth Farmers Market- Christ Church Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley September 2012 November 2012 S M T W T F S S M T W T F S Chiltern Monthly Market- Recreation Reserve

24 CONSUMER PARTICIPATION Consumer and Carer Participation Listening to the community is important and is a key strategic objective of Collegiate in the new BHS Strategic Directions. Key targets have been allocated to measure our achievements against participation under this strategic objective. Community Input In mid 2010, a number of health issues relating to young people in the community were identified, so the BHS Primary Health team set out to determine the actual need through consultation with community members and relevant service providers. To assist this process, a service provider reference group was established in late 2010 and in May 2011, a youth advisory group, the Youth Health Crew, was established. The Youth Health Crew has representation on the reference group as well as an active role in the development of a survey of the adolescent community and parents and the subsequent development of a proposed youth health clinic. Community Information Provision The BHS Newsletter continues to provide health information and advice to community members three times a year. Program participation and volunteer applications have increased directly through Newsletter readership. New clients to the program are encouraged to visit the unit with their family or interested parties prior to deciding whether the service will suit their needs. Case conferences are held with clients being readied for discharge, with support from a variety of external services. Letters of introduction are sent to family members that also gives people a point of contact during the admission. A visiting psychiatrist also has a standing invitation to any family member wishing to speak with them. A regular newsletter is also sent out to families informing them of current activities and news. In 2011, BHS also launched itself on Facebook. This medium provides benefits for members of the community who would otherwise not access health service information. Residential Unit Consumer Input The Residential units provide a bi-monthly newsletter to residents and families. This is usually accompanied by the planned activity program for the following month. On the alternate months, a resident/relative meeting is held. The activity program is also distributed at this time. Family and friends make suggestions for activities as well as participating in the activity program. Volunteers play a vital part in the residents lives. They are involved in a wide range of individual and group activities. This provides the residents with different local faces and conversations. Over the past 12 months, BHS has developed a social inclusion program called Count Us In. This has provided residents with an opportunity to talk to friends and family using computers. Residents can now use Skype and as well as browse the web. They are assisted in this by school students as well as more mature volunteers. Mental Health Consumer Input In The Willows Community Care Unit, there is active participation by consumers in care planning, leisure and lifestyle activities. There are monthly house meetings where the clients can discuss any issue with regard to their perception of the service, for example meal delivery, repairs and maintenance. Issues are actioned by the unit staff or the Program Manager. Count Us In....provides residents with an opportunity to talk to friends and family using computers. Residents can now use Skype and as well as browse the web... Page 24

25 Sunday Monday Tuesday Wednesday Thursday Friday Saturday October 2012 December 2012 S M T W T F S S M T W T F S NOVEMBER Beechworth Farmers Market- Christ Church Melbourne Cup Chiltern Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Woolshed Valley Yackandandah Wooragee Beechworth Silver Creek Stanley Chiltern Monthly Market- Recreation Reserve

26 CONSUMER PARTICIPATION Responding to Diverse Community Needs BHS services a diverse community. There is 2.4% of the BHS catchment s population who speak some 13 languages other than English and 0.01% (48 individuals) of BHS catchment population identify as being Aboriginal or Torres Straight Islander. In addition, BHS provides contracted services to the Beechworth Correctional Centre which offers an even more diverse population that is constantly changing. Although it is acknowledged that the number of community members from culturally and linguistically diverse backgrounds is not high, this makes it even more important to provide those individuals with culturally appropriate and flexible services to provide all community members with the best experience when accessing its services. BHS new Strategic Directions has a key strategic objective of Access. Under this objective an action area of Diversity states: The community and stakeholders have the confidence that there is access to health related service when needed BHS services meet the needs of a range of community members. It is a community venue that enables all people to access quality health care services acceptable to them and supports them to learn about their health needs and how to better take care of themselves. Previously, BHS cultural diversity planning was developed from the Home and Community Care (HACC) services Cultural Plan. The HACC plan was very specific to HACC program activities and, consequently, it limited the organisation s ability to respond appropriately to wider community needs. Acknowledging these limitations, the organisational plan in was developed into the BHS Cultural Responsiveness Plan. This plan also now directly addresses the six standards of the Department of Health s Cultural Responsiveness Framework. BHS achieved 12 out of 15 key performance indicators relating to the new BHS Cultural Responsiveness Plan to the end of June 2011 Future aspirations are to enhance BHS cultural competency under the Cultural Responsiveness Plan to better serve the local Aboriginal community. Cultural Responsiveness Plan KPIs Achieved Not achieved Partially Achieved Achieved Further diversity in the community is being addressed in the coming financial year with the development of an organisational wide Diversity Action Plan. This plan will determine the key goals to be addressed around disability and access by BHS clients. BHS Services a Diverse Community Page 26

27 Sunday Monday Tuesday Wednesday Thursday Friday Saturday November 2012 S M T W T F S January 2013 S M T W T F S DECEMBER Beechworth Farmers Market- Christ Church Chiltern Woolshed Valley Wooragee Staghorn Flat Osbornes Flat Kiewa Allans Flat Tangambalanga Yackandandah Beechworth Christmas Day Beechworth Community Christmas Lunch Silver Creek Stanley Boxing Day Chiltern Monthly Market- Recreation Reserve New Year s Eve