PENINSULA HEALTH S COMMUNITY PARTICIPATION PLAN PENINSULA HEALTH VALUES PARTNERSHIP Program An enhanced model of Community Participation

Transcription

1 S PENINSULA HEALTH VALUES PARTNERSHIP Program An enhanced model of

2 Who are our? Peninsula Health s Over 300,000 people live in the Frankston and Mornington Peninsula region of Victoria. The largest group represented in both regions is the yrs age group. The Mornington Peninsula records a significantly larger proportion of people over 55yrs (33%) compared with 23 % nationally. The number of people in the region over 85yrs is expected to rise significantly by 2031 (2006 census Australian Bureau of Statistics). The region has a small indigenous population (0.5%) and has a high Australian born population (71.9%). The main demand for language services at Peninsula Health are Auslan (sign language), Greek, Italian, Dari and Arabic. Of significance, the local population can swell by more than 100,000 people during holiday and peak summer periods. The top health risk factors for the Southern Metropolitan region are tobacco, physical inactivity, high blood pressure, obesity, alcohol, poor diet, high cholesterol, illicit drugs and partner violence. The major causes of death and disability in the catchment are ischaemic heart disease, cancer, depression and generalised anxiety disorder, dementia, stroke, diabetes, chronic obstructive pulmonary disease, hearing loss, asthma, and osteoarthritis. (Working Towards Integrated Ambulatory Health Care - Area Based Planning Report 2008) Peninsula Health consumers are past, present and future consumers and this includes children, women and men, people living with a disability, people from diverse cultural and religious experiences, socioeconomic status and social circumstances, sexual orientations, and health and illness conditions. What services do we provide? Peninsula Health s services Peninsula Health operates 25 public health facilities across 13 sites, including two public acute hospitals, Frankston and Rosebud Hospitals. Services provided include medical, surgical, paediatric, maternity, critical care, mental health, rehabilitation, palliative care, community health & health education, outpatient services, aged care & assessment, investigative and medical support services, allied health and clinical training. (Peninsula Health Annual Report 2009) The Health Service employs over 4000 staff and services are enhanced by the contributions of approximately 1000 volunteers, local community groups, and other organisations involved in service delivery. 2

3 Peninsula Health Sites Michael Court Residential Aged Care Frankston Hospital, Mental Health Services, Frankston Health Centre Golf Links Road Rehabilitation/Palliative Care Mount Eliza Centre Seaford Frankston Mount Eliza Mornington Mornington Centre, Mornington Health Centre Rosebud Hospital, Rosebud Health Rosebud Residential Aged Care Services Rosebud Rosebud Rehabilitation Service Hastings Hastings Health Centre 3 17

4 What is occurs when consumers carers and community members are meaningfully involved in decision making about health policy and planning, care and treatment, and the wellbeing of themselves and the community is about consumers, carers and the community having their say, listening to the views and ideas of others and working together to reach decisions that include a range of perspectives. (Department of Health Policy Doing it with us not for us ) Aim of Peninsula Health s Plan The key aim of this plan is to actively enhance meaningful consumer, carer and community involvement in decision making about health planning, care and treatment through a whole of health service approach that will be demonstrated by improved quality of care and outcomes. Promotion of the plan Peninsula Health s Plan is a sub plan of Peninsula Health s Strategic Plan and directs activities throughout the whole of the organisation via the Operational and Quality Risk Management Plans (OQR s) The plan will be promoted to staff via regular departmental updates, newsletters, Roadshows and will be accessible on Peninsula Health s intranet site. The plan will also be promoted to the community via the Advisory Committee and Advisory Group network. Implementation Monitoring and Evaluation of the plan The Plan has been developed in partnership with community members from Peninsula Health s Advisory Committee and Advisory Groups as well as a number of Peninsula Health staff. Peninsula Health Steering Committee will be responsible for the implementation, monitoring and evaluation of the Plan and Peninsula Health s Advisory Committee will monitor the progress and evaluation of the plan. Peninsula Health will report annually on the plan to the Department of Health (DH) via the Annual Report and also through the Peninsula Health Quality of Care Report and Annual Report. A suite of indicators has been developed to support the plan and these will include the DH Doing it with us not for us participation indicators (refer attached) 4

5 The plan is supported by a number of subsidiary documents including the Cultural and Linguistic Diversity Plan and the Disability Action Plan. The Plan is also supported by two defined committee structure streams which are equally charged with the responsibility of facilitating. The first stream comprises the Advisory Committee and fourteen Advisory Groups which provide community linkage and ensure diverse community representation of specific geographic areas, marginalised and special needs population groups. The second stream comprises the Steering Committee which provides a central driver for activities within Peninsula Health and ensures that Peninsula Health staff plan, co-ordinate, implement and evaluate activities and that these activities occur across all clusters at individual, programme and organisational level. The Values for Partnership enhanced model of guides the future direction for within Peninsula Health. Each project on the Values for Partnership has an appointed Project Leader and will be monitored as a Quality Improvement Activity. Peninsula Health would like to acknowledge the participatory involvement of the CAC Chairperson, key staff from various programmes and departments, and our CAC and CAG community members in the development of this plan. 5

6 PENINSULA HEALTH VALUES (Service, Integrity, Compassion, Respect, Excellence) P A R T N E R S Advocacy Relationships Advisory Committee/ Groups (Elaine Hillis) Consumers on key PH Committees (Elaine Hillis) Patients and Families in Care & Care Decisions (Julie Grant & Kate Varty) Consumers in Staff Recruitment & Appraisals (Kelly Gillies) PH Steering Committee (Elaine Hillis) Consumers in Root Cause Analysis (Sue Goonan) Consumer Register (Helen Wilson) Consumer Consultants (Karen Edis) Our Volunteers (Karen Edis) Peninsula Health & Advocacy Policy (Elaine Hillis) Consumer access to External Volunteer Advocacy (Iain Edwards) Volunteer Consumer Advocates (Elaine Hillis/ Gloria Callery) Welcoming Environment And Open Visiting (Kelly Burns) Patient Goals And Patient Biographies (Noni Bourke & Jane Roberts) Network Mapping (Rob Macindoe & Campbell Rule) Who are We? -Peninsula Health Staff (Public Relations) Promotion of Culture Of Care & Cultural Competencies (Karen Edis) Training and Development Navigation Experience Rights Peninsula Health Values Partnership Roadshow (Elaine Hillis) Customer Services Competencies Walk the Talk (Sue Goonan & Jenni Dickson) Consumer Experience DVD (Sue Goonan) Key Contact Person (Jane Roberts & Acute) Follow Up Care (Paul Colosimo) Access to Service (Karen Ridgway) Concierge at Frankston Hospital (Sharyn Hayles) Motel Slips (Jenni Dickson) VPSM (Jenni Dickson) Residential Care Surveys (Alison Watts) Mental Health Consumer Feedback (Elaine Bennet) Executive Rounds (Jan Child & Elaine Hillis) Customer Complaint Review with NUM s & Consumers (Judi McKee) Capturing the Consumer Experience (Sue Goonan & Jenni Dickson) Gender Sensitive Care (Tracey Tobias) Rights & Responsibilities Information (Sue Goonan & Jenni Dickson) Our Care Contracts (Paul Colosimo &Tracey Tobias) Consumer Consent (Janet Pugh) Open Disclosure (Sue Goonan) H I P Special Needs Hospitality Information CALD Plan (Paul Colosimo) Disability Action Plan (Jodi Jones) Easy English Strategic Plan (Elaine Hillis & Di Collins) Healing Gardens (Simon Ruth) Legend In Progress New Initiatives Our Waiting Rooms (Stephen Ratcliffe) Assisted Mealtimes (Karen Edis) Visiting Volunteers (Elaine Hillis & Helen Wilson) Consumer Friendly Clinical Information (Sue Goonan) Consumer Friendly Corporate Information (John Jukes) Youth Social Networking Website (Peter Dawson) Health Promotion DVD (Christine Burrows/ Emma Harris) Performance Monitoring Consumer Audits (Elaine Hillis) Annual Report (Elaine Hillis) Indicators (Helen Wilson) An Enhanced Model of (MAR 2010) 6

7 1. STRATEGIC GOAL Create a better consumer experience 1.1 STRATEGY Provide care consistent with our values Provide welcoming facilities that positively engage our community Develop referral and entry systems that make it easy to get the right care at the right place at the right time Enhance patient flows to progressively improve the quality, safety and efficiency of high throughput services OPERATIONAL GOAL ACTIONS PERSON RESPONSIBLE TIME FRAME OUTCOMES In consultation with consumers and carers, develop a Peninsula Health and Advocacy Policy that supports and Advocacy throughout Peninsula Health Review other Health Service Policies Review existing Policy and update Facilitate consumer/ carer input into the policy Approve the policy via the Advisory Committee Promote the policy Monitor the number of policy hits on the intranet Facilitate a staff survey to measure staff awareness of the policy Elaine Hillis Programme Manager Jun Sep

8 1.1.2.Develop a Volunteer Concierge Service at Frankston Hospital (Phase 1) and Rosebud Hospital (Phase 2) to welcome consumer/ carers to Peninsula Health and provide support with information/ wayfinding Phase 1: Frankston Identify location, plan and implement required physical environmental changes Review and update Concierge Volunteer Task Position Description Recruit volunteers to operate Frankston Hospital concierge service including volunteers with a second language where possible Provide training Appoint Volunteers trained in: - customer service - communication with people with a disability - Cultural and Linguistic Diversity - aggression management Establish pool of trained volunteers and develop volunteer roster for Frankston Hospital concierge site and defined hours of operation Establish Buddy system with Health Concierge volunteers Implement roster system that supports two people on duty Identify concierge support person Frankston Hospital location (volunteer coordinator) Explore uptake of opportunity for return to work staff Promote concierge service via liaison with Public Relations Develop resources to support concierge service Monitor the number of consumers assisted Sharyn Hayles Volunteer Coordinator Frankston Hospital Jan Jun

9 daily as recorded by volunteers Review feedback via VPSM, Motel Slip, surveys, complaints and other consumer/ carer satisfaction surveys re satisfaction with Frankston concierge service Phase 2: Rosebud Site Identify location, plan and implement required physical environmental changes Identify and implement key learnings from Frankston Concierge and establish Volunteer Concierge service at Rosebud site Volunteer Coordinator Rosebud site Jun Jun Facilitate waiting areas throughout Peninsula Health that create a better consumer experience including comfort, support, information and resource Phase 1: Baseline data collection: Conduct environmental audit/mapping of waiting areas across all sites Conduct a literature review and identify areas of best practice Collate data from Motel slip feedback and VPSM data Phase 2: Analyse consumer opinion Review consumer opinion re: physical environment and comfort resource and information provision customer service Develop focus groups as required for additional consumer feedback Develop internal performance targets for consumer satisfaction Phase 3: Identify priority improvement areas to address the needs of consumers Stephen Ratcliffe Redesigning Care Programme Manager Apr Apr

10 Establish local working parties for priority improvement areas that include key staff and consumers Phase 4: Apply for re-development funding as needed Re-develop waiting areas to meet consumer needs for learning, support and resource for consumers - welcome centres Work closely with Volunteer Concierge project to develop task description for waiting area volunteers. Recruit volunteers and train in customer service to support consumers ideally volunteers trained for Concierge project would be appropriate in waiting room roles as a similar skill mix is required measure success via Consumer satisfaction surveys with the area Staff satisfaction surveys with the area Peninsual Health will ensure consumer friendly Our information to you through provision of clinical corporate branded consumer/ carer printed information that has gone through a rigorous development and approval process involving consumers and that is distributed appropriately and made available at relevant sites and at appropriate points on the care continuum Develop the Consumer Information Steering Committee Recruit consumer representation to the Consumer Information Steering Committee Develop a Consumer Information Policy that promotes use of Easy-English and avoids acronyms All new written consumer/ carer information developed with consumer/ carer input and in alignment with the Consumer Information Policy/ guidelines and checklist Develop a centralised list of approved Sue Goonan/ Jenni Dickson Quality Department Jun 09- Jun

11 consumer/ carer information and make available Provide Information regarding a range of specific health conditions Purchase evidence based condition specific information that is regularly updated and available online Monitor the number of information brochures/ pamphlets/ posters that have been developed in accordance with the policy and approved through the Consumer Information Steering Committee Monitor distribution of information via departments/ programmes Audit the actual information being distributed by departments/ programme Evaluate consumer satisfaction with clinical information provision Ensure consumer friendly Rights and Responsibilities information is available & distributed to all consumers Establish a Rights and Responsibilities working group to review existing Rights and Responsibilities information Recruit consumers to the working group Develop new healthcare Rights and Responsibilities information in alignment with Australian and Victorian Charters and in consultation with consumers Draft test on consumers and the community Launch Rights and Responsibilities Evaluate/ Audit methods of providing Rights and Responsibilities information and identify best mechanism Sue Goonan/ Jenni Dickson Quality Department Jun Jun

12 Establish ongoing monitoring and evaluation processes of Rights and Responsibilities information provision Measure the number/ percentage of consumers provided with Rights and Responsibilities information Ensure that Peninsula Health provides consumer friendly corporate information / and has a consumer friendly website Facilitate consumer input into development of corporate information including Peninsula Health s: Research Report Annual Report Strategic Plan Quality of Care Report Facilitate consumer input into other major community information Facilitate consumer input into the website Consider marginalised/ special need groups eg Cultural and Linguistic Diversity, Disability and Older Persons in the development & marketing of information Implement enhanced accessibility features as required Facilitate consumer feedback re key corporate information and the website Evaluate consumer feedback Measure the number of hits on the internet Monitor key pages most frequently used Ensure key information available on website including Annual Report, Strategic Plan, Plan and Quality of Care Report John Jukes/ Public Relations Department CAC/CAG/ network Jun Jun

13 In consultation with consumers develop a Peninsula Health consumer friendly/ easy English snapshot of Peninsula Health s Strategic Plan (Snapshot) Seek consumer opinion re Peninsula Health s Strategic Plan Develop a consumer friendly Strategic Plan Snapshot for the public that is easy to read and understand and that has been tested on consumers Consult with Public Relations Department Seek approval via the Advisory Committee Promote the snapshot Evaluate the uptake of the Strategic Plan Snapshot (where used) Elaine Hillis Programme Manager/ Di Collins Operations Director Planning and Support Dec Mar Who are we? Ensure consumer friendly Peninsula Health staff information (boards/ posters) available across all sites Establish the minimum staff/ site information requirements Conduct mapping exercise of current sites and information available identify gaps in information provision Develop new displays/ information for identified areas of need Implement key staff information boards/ posters across all sites Establish process for regular update of staff information Survey consumers re satisfaction with the information Survey staff re perceived key benefits of having information available to consumers John Jukes Public Relations Jun Jun

14 Peninsula Health will ensure a care environment that is receptive to consumer needs and welcomes family/ carer support including open visiting Map current processes that invite and welcome visitors/ carers Map other service visiting policies/ processes Review environmental audits conducted to date (including cognition audits) Review VPSM and motel slip data and surveys to identify visitor/ carer satisfaction with care environment Identify areas of excellence and gaps and actions required Promote a staff culture that welcomes visitors Facilitate staff training in customer service Implement flexible open visiting where appropriate Develop sustainable processes re open visiting Liaison with personnel re building works to ensure they create a welcoming environment Secure funding to undertake required environmental improvements Ensure environmental changes focus on visual prompts- eg murals/ photographs/ and use of names instead of numbers Ensure focus in keeping with calm natural environment Review motel slips/ VPSM and additional consumer/ carer surveys to evaluate satisfaction with visiting and the care environment Conduct a staff survey re the care environment and evaluate results Kelly Burns Clinical Nurse Consultant Cognition Jun Jun

15 Peninsula Health will develop a Volunteer Visitor Programme that will enhance the consumer experience Map other health services Volunteer Visiting programmes and identify key learnings Consult with Peninsula Health staff re areas of need Consult with consumer/ carers re need Develop Volunteer Task descriptions Recruit volunteers to programme Provide orientation/ training Develop a Volunteer Visiting Programme for areas where need identified Elaine Hillis Programme Manager Helen Wilson Programme Liaison Officer Jun Jun 2012 Phase 1 Pilot programme Identify site/ area to introduce Trial Programme Survey consumer satisfaction via consumer/ carer surveys Evaluate volunteer role Evaluate staff satisfaction with the programme Peninsula Health will develop a Volunteer Advocates programme to enhance advocacy for consumers Conduct a Literature review re best practice model Identify key learning from other health services Develop a Volunteer Advocate Position Description Recruit volunteers Develop orientation programme and advocacy training for volunteers Develop a resource/ tool kit for volunteer advocates, patients and staff. Elaine Hillis Programme Manager Gloria Callery Volunteer Coordinator Health Dec Dec

16 Implement a pilot programme Evaluate consumer feedback Evaluate volunteer advocacy role Evaluate staff satisfaction with the programme Peninsula Health will ensure robust mechanisms for capturing the Consumer Experience: (1). Peninsula Health Motel Slip Provide training to volunteers and introduce into relevant areas to assist in feedback collection Ensure feedback reports are made available to consumers and staff and via the CAC/ CAG network, local displays and via Peninsula Health intranet Ensure feedback reports are linked into staff appraisal processes and ward/ programme evaluations Develop a mechanism to provide theming of feedback data Evaluate volunteer role Evaluate motel slip content to ensure consumer understanding Jenni Dickson/ Sue Goonan Quality Department Jenni Dickson (Quality) Ongoing (2). VPSM Ensure VPSM feedback available to consumers and staff via CAC/ CAG network, local displays and via Peninsula Health intranet Ensure VPSM feedback reports linked into cluster/ department, OQR s and ward/ programme evaluations Ensure VPSM feedback including themed consumer comments made available Jenni Dickson (Quality) 16

17 (3). Residential Care Surveys Conduct additional Peninsula Health residential care surveys Ensure feedback is made available to consumers and staff via CAC/ CAG network, local displays and via Peninsula Health intranet Ensure feedback reports are linked into cluster /department OQR and ward/ programme evaluations Alison Watts Operations Director Occupational Therapy and Continuing Care (4). Mental Health Consumer feedback Monitor the effectiveness of current mechanisms used to collect feedback Review current mechanisms of obtaining feedback Map other services (benchmark) key learnings/ Conduct a literature review re best practices/ what works well Develop and implement an improved mechanism to obtain feedback Engage consumers/ carers in consultation process Engage staff in consultation (coal face) Consult with Peninsula Health s Mental Health Advisory Group Monitor feedback response rate Evaluate method of collecting feedback Measure response rates Pernita Taylor Mental Health services May May

18 Peninsula Health will implement Executive Rounds Undertake discussions with Executive Directors for each cluster re face to face Executive consultation with inpatients and their carers Undertake discussions with Departmental Senior Managers re process Determine frequency and locations of Executive Rounds by individual Executive Directors Disseminate Executive Directors Memo to inform broad range of staff explaining clear purpose re improving communication/ direct feedback/ action Develop feedback cards for Executive Directors to distribute to consumers involved in process Recruit and train volunteers to collect feedback cards Trial Executive Rounds for three months then evaluate Identify the issues that required action via Executive Director Monitor the number and location of issues identified that required Departmental Senior Managers action Evaluate feedback from Executive Directors and Senior Departmental Managers as to whether process improves communication Evaluate feedback from consumers/ carers as to whether that process was useful for them Evaluate feedback via current measures of Elaine Hillis Programme Manager Jan Child Executive Director May May

19 consumer feedback include VPSM/ motel slip/ feedback evaluation and complaints process. Measure the number of Executive Rounds conducted Monitor the number of consumers/ carers involved in the Executive Rounds Measure the number of issues identified that required senior Departmental Manager action Measure the number of issues identified that required Executive Director action Identify key actions implemented Peninsula Health will develop a consumer/ carer DVD Walking in my Shoes that can be used as a teaching aid to promote consumer experience and family centred care to all staff Establish a Communication working party Secure expertise to develop DVD Identify key staff to support development of DVD Recruit Consumer/ carer participants Develop a participant consent process Coach/ train participants as required Review consumer journey stories and select Develop DVD and test via key staff and consumers Promote the launch of the DVD and roll out to staff Conduct a pre and post survey evaluation including evaluation of take home message to staff Measure the number of staff who viewed DVD Review VPSM/ Motel slip/ Complaints trends re staff not listening to/ respecting consumer/ Sue Goonan Quality Department Feb Feb

20 carer choices/ decisions and involving consumes/ carers in care planning and decision making Peninsula Health will conduct Customer Complaints and Compliments reviews that involve NUMs and consumers Develop a Complaint Management Policy & make available on the Peninsula Health intranet Liaise with other health services re complaints management/ practices/ process/ feedback loop and learnings Review current Peninsula Health complaints processes and identify opportunity for consumer/ carer involvement in complaints and compliments committees and processes Develop a framework that supports consumer representative at relevant complaints committees/ meetings Recruit consumer representatives via expression of interest and selection process Develop an orientation and training package re complaints process and provide to consumer representatives Establish regular complaints meetings/ forums with NUMS and consumer representatives Provide staff education re complaints management policy Review consumer opinion of feedback loop to consumer and others that are involved Monitor the number and nature of complaints with consumer representation involvement Monitor the number of complaints committees/ meetings with consumer Judi McKee Customer Relations Manager Mar Mar

21 representation Utilise patient narratives to enhance staff understanding of the consumer experience via training and education Conduct an external scoping exercise of Consumer Ombudsman/ independent Consumer Advocate position to identify potential benefit for Peninsula Health consumers Peninsual Health will promote Customer service Competencies Walk the Talk Review of VPSM/ Motel Slip Data re Peninsula Health customer service issues Establish a customer service/ communication working party that includes consumer representation Review and update Corporate Orientation presentation with an emphasis on customer service and communication Develop a staff modular Communication training package Monitor and evaluate the number of staff provided with education Monitor consumer feedback in relation to customer service provision Ensure customer service principles reflected in Peninsula Health Values and Mission statement Monitor the number of complaints in relation to customer service Sue Goonan/ Jenni Dickson Quality Department Mar Dec

22 Peninsula Health will ensure patient and families involved in Care and Care Decisions throughout the care continuum (patient/ family centred care working in partnership ) Map current processes that involve consumers and carers in care decisions including sign off of care plans by patients and carers, and family meeting processes. Review current assessment processes to ensure that they recognise consumers /carers as holders of vital care information Conduct a gap analysis and identify areas of excellence and areas for improvement, actions required Develop a process that ensures documentation of family meetings Map consumer/ carer involvement in bedside handovers Identify areas of best practice and gaps, actions required Map consumer/ carer Involvement in ward rounds and areas of best practice and gaps identified, actions required Implement actions required Conduct a literature review re benefits of medication printouts to individual patients each am Develop a pilot project to trial and evaluate within Peninsula Health Develop process for Bedside notepads - Things to Ask My Doctor- Pilot Bedside notepads and evaluate via staff and consumers Identify key Nurse Unit managers and charge with the responsibility of finding their own consumer/ family advisors for their own Julie Grant/ Kate Varty Social Work Mar Mar

23 individual units Measure the number of key staff person/ champion identified for each area Conduct audits on the number of Care Plans signed off by consumers/ carers Conduct audits on the number of Care Pathways signed off by consumers/ carers Develop systems that enable consumers carers/ family to prepare written advance care plans where appropriate ( Respecting Patient Choice Programme) Ensure processes in place that ensure relevant verbal and written information provided at key points in the care continuum to assist care decision making Develop processes for appropriate support and advocacy ( note special needs population groups) Map current patient and family access to care plans and clinical information, Identify areas of best practice and gaps Develop processes to enhance access Explore development of electronic personal health records and patient portals Peninsula Health will develop a Healing Garden Space Develop a pilot programme at Frankston Hospital with a view to expanding to other areas following evaluation Identify designated area at Frankston Hospital Consult with consumers/ carers Consultation to include Koori Programme and Simon Ruth Director Complex Care Services Jan Jan

24 Pastoral Care Consumer/ volunteer involvement in planning and development of a Healing Garden Space Develop plans and seek approval Secure funding Creation of a Healing Garden Space Promotion and launch of a Healing Garden Space in consultation with Public Relations Conduct a consumer/ carer evaluation Conduct a staff evaluation Consider extending project to other sites Ensure a Advisory Committee/ Advisory Group organisation structure that supports and enhances throughout Peninsula Health Develop overall / volunteer governance structure Appoint Executive Director for Develop and Advocacy policy Develop a Steering Committee Identify CAC/ CAG Executive Sponsors, Convenors Chairpersons and other relevant staff Recruit CAC/ CAG service providers and community members Appoint adequate Resource Implement a number of Advisory Groups Ensure process that promotes diversity of groups Develop CAC/ CAG processes for Elaine Hillis Programme Manager Jun

25 recruitment and retention Develop and review CAC/ CAG orientation processes Develop individual CAG Terms Of Reference Distribute individual CAG meeting agendas and minutes Develop an overarching CAC/ CAG Communication Strategy Involve consumers n service planning and development across all clusters Develop CAC/ CAG Action Plans and outcomes monitored Involve and evaluate consumers and the community in key clinical governance structures and committees Involve and evaluate consumers a number of working parties Evaluate effectiveness of Consumer Consultant roles in Mental Health Develop Consumer Consultant roles to support components of projects Ensure consumer/ community membership on key Peninsula Health Committees Map key Peninsula Health sub Board/ Governance Committees and key Peninsula Health programme level committees Map Peninsula Health working groups/ committees Promote consumers on committees Identify number of potential and actual consumer roles on committees Map current consumer membership of Elaine Hillis Programme Manager Dec Dec

26 committees and identify gaps Promote consumer involvement Monitor the number of consumers involved in Peninsula Health Committees Evaluate consumer role on Peninsula Health committees via staff and consumer surveys Identify changes/ actions implemented as a result of consumer input Peninsual Health will develop a Peninsula Health Consumer Register Review other health service Consumer Register processes and key learnings Conduct a literature review re best practise models Identify key staff and key processes Consult with the Volunteer Steering Committee and Steering Committee Liaise with Public Relations Develop and promote a Consumer Register to the community and to Peninsula Health staff Advertise and recruit consumers to register Establish Consumer Register Monitor the number of consumers on the Consumer Register Monitor requests and supply of consumers via the register to areas / departments Explore linkages with Health Issues Centre Consumer Register Evaluate effectiveness via number of consumer requests and supply as per individual requests Elaine Hillis Programme Manager Helen Wilson Liaison Officer July July

27 Peninsula health will ensure consumer access to formal external advocacy Ensure formal external advocacy services information made available across sites/ departments including advocacy brochures, posters displayed at each site and via the Peninsula Health website. Develop a Peninsula Health consumer friendly brochure that outlines/ summarises the external advocacy services available Consult with Health CAG re content of brochure/ posters Develop a mechanism to ensure advocacy service information is updated (annual review of Peninsula Health brochure content) Review and act on recommendations identified via consumer feedback i.e. VPSM, motel slip surveys, in relation to provision of external advocacy material Iain Edwards Director Chronic Disease and Ageing Dec Development of a Peninsula Health Steering Committee to drive the implementation of the Peninsula Health Plan ( ) Convene a workshop with staff and consumers to promote interest Rollout a Roadshow to promote interest Identify key staff from all clusters to participate including all Values for Partnership project leaders Develop Terms of Reference Select membership in alignment with Terms of Reference Develop meeting schedule Steering Committee Elaine Hillis Programme Manager Start May

28 to oversee Plan implementation Monitor the number of meetings held Distribute meeting agendas and minutes Record outcomes/ actions Development and implementation of a Peninsula Health Disability Action Plan Establish the Peninsula Health Disability Advisory Group Identify four key outcome areas of plan as Disability CAG priority : 1. Reducing access barriers 2. Reducing employment barriers 3. Promoting inclusion and participation 4. Tangible changes in discriminatory attitudes and practices Train key staff and consumers in Disability Action Plan development via Disability Services Conduct Peninsula Health focus groups with people with an intellectual disability and their carers and staff Complete and distribute focus group report Develop a twelve month timeframe calendar to compile and develop Disability Action Plan including internal and external consultation Develop draft plan and test on Disability CAG members and key staff Launch and promote the plan Develop the role of the Disability CAG to oversee implementation and monitor effectiveness of the Disability Action Plan Review of VPSM/ motel slip / complaints Jodi Jones SACS Manager Jan Jan

29 data/ other surveys re disability issues/ themes Ensure Disability Action Plan actions evidenced via cluster and local OQR s Evaluate the effectiveness of the Disability Action Plan annually Facilitate Youth engagement via the Youth CAG and development of a Peninsula Health Social Networking website Establish a Peninsula Health Youth CAG Explore Youth Engagement Strategies Develop Youth CAG friendly Terms of Reference/ Position Descriptions Recruit additional Youth members to Youth CAG Develop a Social Networking Website policy with input from Legal Council and IT Develop a webpage with Youth CAG members Utilise the website at Youth CAG meetings to engage youth opinion re Peninsula Health and to get information about Peninsula Health services out into the youth community Monitor the youth community feedback Conduct an evaluation of the webpage and youth engagement Peter Dawson PENDAP manager Dec Develop and implement a Volunteer Assisted meal times program incorporating a Consumer Consultant model Dietician & Speech Pathologist to visit Sydney hospitals with successful programs Report of hospital visitation to be generated & will be used to inform design of Peninsula Health s pilot program/ project Work up a Submission for Evaluating Karen Edis Director Nutrition & Dietetics & May May

30 Effective Partnerships funding to support the pilot project Develop a Project brief for the Consumer Consultant Appoint a Consumer Consultant with a key role in the multidisciplinary project management team Recruit and train an adequate number of suitable volunteers Explore opportunities for a mentoring / buddy program for the volunteers Develop processes for identifying those patients requiring assistance and the level of assistance needed Develop and implement Outcome evaluation measures for both the pilot project and Consumer Consultant role Ensure that all consumers from a Cultural and Linguistic Diversity background receive equal and open access to Peninsula Health services Develop a CALD plan that ensures the organisation provides for consumers from culturally and linguistic diverse backgrounds, marginalised populations, and special needs populations Ensure consumer involvement in the development of Peninsula Health s CALD plan Convene a Peninsula Health staff working party Develop a CALD plan that is supported by the CALD policy Ensure consumer input into CALD policy CALD CAG to oversee implementation and Paul Colosimo Director Social Work ongoing 30

31 monitoring of the CALD Plan Develop Peninsula Health Cultural competencies Promote the Interpreter service Monitor trends/ usage of interpreter service Provide Cultural Awareness training to all staff and to volunteers as required Conduct external community consultation with CALD communities Develop CALD specific information that is readily accessible Evaluate the effectiveness of the CALD plan Ensure patient Goals and Biographies reflect person centred care. Improve identification of patient goals through increased clinician skill base in establishing and setting patient centred goals; documentation that facilitates patient centred goals and increasing clinician awareness of principles of person centred care within interdisciplinary teams Facilitate meaningful documentation of patient / carer goals and relevant patient biography within the Interdisciplinary Care Program Care Plan Facilitate meaningful documentation of patient / carer goals and relevant patient biography within Clinical Pathways Develop a Resource Manual and education/training program to support the Interdisciplinary Care Program in subacute with particular focus on patient centred Noni Bourke Project Manager Improving Care for Older People & Jane Roberts Director Physio and Sub Acute May May

32 interdisciplinary care & team goal setting. Develop an education/training program to support patient focused interdisciplinary care in acute Monitor and evaluate through Interdisciplinary Care Program KPIs; Clinical Pathway audit; Motel Slip & VPSM data Follow Up Care Peninsula Health will seek feedback from patients at all key points of discharge Conduct a scoping exercise to ascertain existing gaps Work with individual service areas to address these gaps Develop consistent criteria across the organisation of appropriate persons to contact. Key measures include follow up response rates, as well as appropriately recording instances where further follow up and support were required Paul Colosimo Director Social Work Start Mar Our Care Contracts Peninsula Health will work with all relevant stakeholders to ensure that expectations of both consumers and staff are made clear at the earliest possible stage. Staff able to professionally provide consumers with the appropriate information in all instances. Number of care contracts required following the implementation of education. Staff and consumer opportunity to contribute to the development of care contracts A mapping exercise is taking place identifying the areas of complexity with regards to and inpatient stay relating to discharge, transfer and care planning. Paul Colosimo Director Social Work Tracey Tobias Operations Director/ Principle Nurse ICU and medicine Jun Jun

33 Key areas of complexity to be identified, with a focus group specifically addressing issues relating to their areas of expertise. Conduct multiple site audits including a process map of inpatient stays including barriers to timely discharge. Common care expectations and responsibilities to be established and rolled out as a consistent Peninsula Health message, ensuring consumers receive the right care at the right time in the right place Assist staff to ensure their daily practice reflects a culture of care by implementing a set of core cultural competencies Conduct a literature review & identify areas of best practice Review other health organisational practice Assess current staff practice, attitudes and beliefs, utilising a combination of tools including survey, focus groups & observational audit Obtain consumer feedback / opinion utilising existing tools together with focus groups and survey Develop training / educational module and rollout to staff Incorporate into existing staff orientation and training processes to ensure sustainability Conduct outcome evaluation and liaise with related CP Plan projects including A Care Environment Karen Edis Director Nutrition & Dietetics & Jun2010- Jun

34 Peninsula Health will further develop the Key Contact Person Role Define Key Contact Person roles (including case management) Map current Key Contact Person roles Obtain consumer feedback regarding Key Contact Person role Identify gaps/ expertise/ priorities Explore development of an E learning package on interdisciplinary care programme (IDCP) Develop a process to implement the revised key person contact role Include key contact person role in IDCP resource manual Monitor IDCP Key Performance Indicators Motel slip/ VPSM data and evaluate role through these indicators Jane Roberts Director Physio and Sub Acute Mar May Peninsula Health will ensure Consumer input into Consumer Consent processes Develop a Consent policy (6.1.03) and make available via the Peninsula Health intranet Conduct an annual consent audit Develop processes to ensure documentation complies with policy Recruit team of people including consumers to interview patients re understanding of consent Purchase standardised point information brochures re procedures/ops Disseminate results to Quality and Clinical Governance Janet Pugh Patient Safety Officer

35 To embed Open Disclosure throughout Peninsula Health Develop an Open Disclosure policy Present Policy during Patient Safety Week Ensure Patient Safety Week focus Educate staff re Open Disclosure Key staff attendance at Open Disclosure workshop Consumer attendance at Quality Conference workshops Sue Goonan Quality Department Sep Sep Peninsula Health will utilise interactive DVD s in waiting areas to enhance health promotion Establish working group Develop questions Trial questions Conduct a scoping exercise across sites to identify potential areas Consult with consumers carers Consult with staff Identify key areas/ benefits Identify existing resources and additional required resources Write report on findings Emma Harris Health Promotion Christine Burrows Health Promotion April 2010 June Peninsula Health will consider gender sensitive needs in bed allocation within the Frankston Acute Care area Develop a Peninsula Health Gender Sensitive Care policy Review consumer feedback (motel slip/ VPSM/ complaints data and any additional surveys) to identify key issues around gender sensitivity in relation to bed allocation in the Frankton Hospital acute area Benchmark data against other like health organisations Tracey Tobias April Aug

36 Develop processes that will enable monitoring of single gender room allocation including: development of an audit tool development of an audit schedule recruitment of a volunteer/s to conduct audit development of volunteer task description develop training programme for volunteer/s that will include buddying up with staff member initially and supervision as required Implement volunteer role to conduct audits Consult with NUMS and service managers re audit process Identify and implement processes that will reduce mixed gender ward allocation, including promotion of single gender rooms and staff education Evaluate consumer feedback against previous and monitor trends Evaluate volunteer role April Dec

37 2. STRATEGIC GOALS Provide timely and appropriate healthcare 2.1 STRATEGY Develop services to meet increased demand in the Frankston and Mornington Peninsula catchment Develop capacity to meet demand making best use of existing capacity including staff and facilities Progressively increase the range and complexity of specialist services where quality, volume and efficiency benchmarks can be met Support service partnerships with public and private providers to achieve better continuity of care, where care is shared with other agencies Expand outpatient services consistent with Department of Human Services policy directives Develop the capital infrastructure to meet healthcare demands and achieve efficient use of available resources OPERATIONAL GOAL ACTIONS PERSON RESPONSIBLE TIME FRAME OUTCOMES Peninsula Health will review and improve service access processes for consumers Conduct a Service Access review Develop Review Recommendations Implement Review Recommendations Confirm a Suite of Access Key Performance Indicators implement reporting process Measure waiting time to service and include in KPI suite Confirm and document referral protocols for all access points to and from community health and sub acute services Karen Ridgway Access & Service Improvement Manager Health Mar Mar

38 3. STRATEGIC GOAL Care for and develop our workforce 3.1 STRATEGY Position Peninsula Health as an employer of choice Create a workplace climate that reflects Peninsula Health values Develop and implement an organisational wide workforce development strategy Improve communications with our workforce Support and develop volunteer roles to engage a broad cross- section through the community Provide excellent training opportunities for new graduates, international medical graduates and those re-entering the health workforce OPERATIONAL GOAL ACTIONS PERSON RESPONSIBLE TIME FRAME OUTCOMES Our Volunteers Peninsula Health will provide support, training and recognition to volunteers Develop a Volunteer Policy Develop an Auxiliary Policy Support and develop volunteer roles through robust recruitment/ orientation/ training (including privacy, fire, manual handling and hand hygiene training) processes Develop and provide relevant additional training programmes as required (customer service, aggression management, cultural awareness, communication) Develop and implement Volunteer Task Descriptions Implement a Recognition Programme Develop volunteer retention strategies Ensure volunteer (including CAC/ CAG member) data centrally available via Volgistics database Karen Edis Director Nutrition & Dietetics & Jan Jan

39 Develop processes to evaluate volunteer roles Review, develop and implement volunteer resources Peninsula Health will utilise Consumer Consultant roles to enhance Identify key projects that would benefit from consumer consultant involvement Develop task descriptions Secure funding Develop orientation and training programmes Advertise and recruit to position Provide orientation and training Identify key support person for Consumer Consultant role Evaluation of Consumer Consultant role Karen Edis Director Nutrition & Dietetics & May May Peninsula Health will introduce consumer involvement in staff selection panels, staff appraisals and in CAC/CAG member selection processes Research and benchmark consumer processes in relation to staff recruitment and appraisals with other health services Review current Peninsula Health policies/ procedures relating to recruitment and appraisals as to clarity around consumer involvement Review recruitment and appraisal templates/ tools with the consumer perspective considered Identify potential programmes for consumer involvement Select and pilot programme Evaluate success and feasibility of ongoing Kelly Gillies Human Resource Senior Officer Mar Mar

40 involvement for consumers CAC to take a greater role in the monitoring and evaluation of Activity (Health Outcomes International recommendation) Develop and enhance model/ organisation structure encompassing volunteers Develop CAC community member position descriptions and Develop and review Terms of Reference Provide opportunity for CAC input into Peninsula Health s Strategic Plan, Plan and and Advocacy Policy Facilitate CAC ongoing monitoring role of the Plan via half yearly reviews re progress Expand CAC membership as required Develop and implement CAC roles on individual CAG s Develop CAC/ CAG representative position description Complete Annual CAC self evaluation and identify actions required Establish CAC working party to action key issues including : 1. Schedule CAC meetings at different sites and to include site tours 2. Provide CAC member training and education re Peninsula Health services quality processes and electronic health records 3. Develop mentor programme for new CAC

41 CAC members 4. Review the CAC Communication Strategy and Board feedback mechanism Develop and promote Peninsula Health Values Partnership Roadshow Phase 1 Promote Values Partnership philosophy Develop Roadshow presentation Rollout to staff Promote staff interest Evaluate sessions Elaine Hillis Programme Manager Jun Dec 2009 Phase 2 Promote and implement Values Partnership projects Rollout Roadshow presentation to additional staff Promote community participation activity at a local level Evaluate sessions Jun Dec