Bendigo Health COMMUNITY PARTICIPATION PLAN 2014-2016 v.2 The key result areas and actions outlined in this plan are aligned with: 1. Strategic goals of Bendigo Health's Strategic Plan 2013-2018 ('BH ') 2. National Safety and Quality Health Service Standards ('NSQHS'); 3. ACHS Recommendations (November 2013 Accreditation) ('AHCS') 4. The Doing it with us not for us - Strategic direction 2010-2013 ('DoH') 5. Framework for Consumer & Community Engagement in the Bendigo Hospital Project Design and Model of Care Development ('BHP Framework') Key Result Areas Actions Community Advisory Committee (CAC) Role Measures & Targets 1. Bendigo Health's commitment to consumers, 1.1 Consumers and carers are involved carers and community members is demonstrated in the governance of Bendigo Health by governance structures, and policies and protocols that facilitate partnerships with its diverse communities CAC (and/or other community members) are represented at the Bendigo Health key consumer reference groups and other committees with consumer representation. Number of CAC/consumer representatives in the following governing bodies: - Strategic Planning and Population Health Committee: 2 - Quality Care Council: 1 - Acute Services Consumer Reference Group: 1 - Psychiatric Services Consumer Participation Group: 1 - Health Promotion Steering Committee: 1 - Cultural Diversity Advisory Committee: 1 - Disability Action Plan Committee: 1 - Volunteer Services Reference Group : 1 - Advance Care Planning Working Party: 1 BH 1.1 and 3.1 NSQHS 2.1 DoH 1, 1.1, 1.2, 2 and 4.5 CAC has access to meeting minutes of relevant consumer groups and committees, if required. Number of meeting minutes received from BH consumer reference groups and other committees with consumer representation. CAC identifies and advises the Board on priority areas and issues requiring consumer, carer and community participation. Number of issues identified and memorandums addressed to the Board by CAC. CAC develops, monitors and evaluates the implementation and effectiveness of the Community Participation Plan 2014-2016 in Consultation with the Board. Community Participation Plan 2014-2016 that incorporates the National Safety and Quality Health Service Standards, the five key areas of the Doing it with us not for us framework and the Bendigo Health Strategic Plan goals and objectives is developed. Community Participation Plan monitoring is a standing item at CAC meeting agenda. Community Participation Plan progress is monitored regularly, and reviewed annually. CAC approve progress reporting (ie. Drafts of Quality of Care reports) before finalisation. Community Participation Plan progress is reported to DoH, Business Unit Managers and community annually. 1.2 Governance partnerships are CAC memberships reflect the diverse community of Bendigo, and ideally reflective of the diverse range of are representative of mental health, youth, acute, sub-acute, residential backgrounds in the population served by care, Aboriginal health and culturally diverse people. Bendigo Health Progress on Improving Care for Aboriginal and Torres Strait Islander Patient (ICAP) program to be reported to CAC annually. CAC members should ideally include: - one youth rep - one aboriginal rep - one mental health rep - one acute care rep - one sub-acute care rep - one residential care rep - one rep from culturally diverse background Bendigo Health has an Improving Care for Aboriginal and Torres Strait Islander Patient (ICAP) program and meets the four key result areas BH 1.1, 1.2 and 3.1 NSQHS 2.1 DoH 1.4, 1.5, 1.6 Updated 23/10/2014 1
Progress on Cultural Responsiveness Plan to be reported to CAC annually. Bendigo Health has a Cultural Responsiveness Plan that meets the six minimum reporting requirements or its equivalent Progress on Disability Access Plan to be reported to CAC annually. Updates regarding partnerships with extended networks, groups and individuals to be reported to CAC annually. Communication Plan reviewed by CAC. Bendigo Health has an Disability Action Plan as specified under the Disability Act 2006 Partnerships with extended networks of Bendigo Health, and other organisations, groups and individuals in the community, are documented and reported to the CAC annually. Communication Plan and mechanisms developed and implemented. 1.3 Bendigo Health establishes mechanisms for engaging consumers, carers and/or community members in the strategic and operational planning for the organisation CAC is represented at Quality Care Council and Strategic Planning and Population Health Committee. Number of CAC representatives in the following committees: - Quality Care Council: 1 - Strategic Planning and Population Health Committee: 2 CAC to review a report generated by Sycle software which summarises Consumer participation and engagement are demonstrated in the Business consumer participation and engagement activities documented in Bendigo Plans of Business Units. Health business planning. BH 1.1 and 3.1 DoH 1.7, 4.1 and 4.6 CAC receives and reviews executive reports on consumer engagement from CEO and/or Board. Executive reports from the CEO and/or Board on consumer participation included on CAC agendas. 1.4 Policies and protocols are implemented for partnering with consumers, carers and community members in strategic and operational planning, decision-making about safety and quality initiatives and quality improvement activities CAC to provide input to the Consumer Publications Policy, the Consumer & Community Participation Policy, the Consumer Consultation Recruitment Guidelines, at their review and/or creation. The Consumer Publications Policy, the Consumer & Community Participation Policy, the Consumer Consultation Recruitment Guidelines are reviewed and upto-date as required, and incorporate input from the CAC. BH 1.1, 1.2 and 3.1 2. Access to relevant orientation and training for 2.1 Bendigo Health provides orientation consumers, carers, community members, clinical and training for consumers, carers leaders, senior managers and the workforce is and/or community members to enable facilitated to build capacity to participate fully them to fulfil their partnership role and effectively. Newly recruited CAC members receive orientation about their role at Bendigo Health. If available, CAC representative/s participate in new CAC member orientation to assist transition. CAC members are encouraged to identify training and development opportunities to Chair and Consumer Participation Support Officer for consideration. Number of orientation sessions held and induction packs distributed to newly recruited CAC members. Number of orientation sessions held and induction packs distributed to consumers and community members at Bendigo Health committees. Number of training opportunities provided to consumers. BH 1.1 and 1.2 NSQHS 2.3 and 2.6 DoH 5 2.2 Clinical leaders, senior managers and the workforce access training on person-centred care, on the engagement of individuals in their care, and on the values of and ways to facilitate consumer engagement and how to sustain partnerships CAC is consulted about the Bendigo Health training needs and skills for person-centred care and consumer engagement for the workforce. CAC to provide input to the development of a training curriculum for clinical leaders, senior managers and the workforce. Analysis on training needs and skills for person-centred care and consumer engagement at Bendigo Health is conducted as part of annual evaluation (e.g. SWOT analysis) Training curriculum and schedule on person-centred care is developed and implemented in consultation with consumers (e.g. through GMGR) Number of training sessions held for BH workforce. BH 1.1, 1.2 and 2.1 NSQHS 2.6 DoH 1.8 Updated 23/10/2014 2
Number of patient stories used in training curriculum for workforce. Evaluation and feedback from training sessions is received from participants 2.3 Consumers, carers and/or community members are involved in training the clinical workforce CAC is consulted about the Bendigo Health training needs for personcentred care and consumer engagement for the workforce. Analysis on training needs and skills at Bendigo Health incorporates input from consumers and community members as part of annual evaluation (e.g. SWOT analysis) BH 1.1, 1.2 and 2.1 Records and number of consumers and/or community members actively participating in the delivery of training on person-centred care to the workforce (e.g. in person, through audio-visual media etc). NSQHS 2.6 DoH 1.8 Evaluation and feedback from training sessions is received from consumers and community members 3. Consumers, carers and/or community 3.1 Consumers, carers and community members are provided with evidence-based, members are provided with health accessible information, and consulted on patient information that is relevant, easily information distributed by Bendigo Health, to accessed and understandable. support key decision-making along the continuum of care Australian Charter of Healthcare Rights in Victoria is provided and promoted to all consumers of Bendigo Health. Patient Information Guide is provided and promoted to Bendigo Health patients. BH 1.1, 1.2, 2.1 and 2.2 NSQHS 2.1 and 2.4 Number of languages other than English in which publications and interpretation are available for non-english speaking community. DoH 3 Number of documents translated into other formats, such as braille, audio for consumers with disabilities Consumer information is promoted by increased use of electronic media through articles, ads, blogs, tweets, and posted on Bendigo Health website, newsletters, Facebook and Twitter. CAC vacancies are advertised on BH website and Facebook. Number of CAC advertisements posted on BH website and Facebook. 3.2 Consumers, carers and/or community members provide feedback on patient information publications prepared by Bendigo Health for distribution to patients 3.3 Action is taken to incorporate consumer, carer and/or community members' feedback into publications prepared by Bendigo Health for distribution to patients CAC to provide input to the Consumer Publications Policy at its review in 2016, and to other key patient information publications, as required. CAC obtains annual updates of the Publications Register from Communications & Marketing. CAC to provide input for priority actions regarding consumer publications feedback received. The Consumer Publications Policy and the Checklist for Written Consumer Health Information are actively implemented in all publications created or reviewed by Bendigo Health. A Publications Register is maintained by Communications & Marketing, and annual updates are provided to CAC. Number of publications created or reviewed incorporating feedback from consumers and community members, including the 'Consumer Approved' sign. Records of newsletters, meetings or reports provided to the people who were involved in the development and implementation of changes to patient information publications NSQHS 2.4 DoH 4.6 BH 1.1, 1.2 and 2.2 NSQHS 2.4 Accreditation 2013 Updated 23/10/2014 3
4. Consumers, carers and/or community 4.1 Consumers, carers and/or members are active participants in designing the community members participate in the way care is delivered to better meet the patient design and redesign of health services needs and to facilitate informed decision-making about their treatment, care and wellbeing at all stages and with appropriate support. CAC to hold minimum three informal presentation meetings annually. CAC receives updates on relevant design and redesign processes and activities. Number of presentations to CAC by Bendigo Health consumer reference groups held annually. Number of alerts sent from the eletronic Quality Improvement Summary (QIS) to the Consumer Participation Support Officer relating to consumer participation activities. Number of focus groups and/or informal discussions with consumers (e.g. in waiting rooms) to gain feedback. BH 1.1, 1.2, 2.2, 3.1 and 4.2 NSQHS 2.5 and 2.8 DoH 2, 2.1 and 4.2 Feedback boxes and 'Complaints & Compliments' leaflets made available for consumers within the hospital. Number of community events attended and community representatives met to discuss opportunities for improvement. Number of information updates, reports and newsletters disseminated back to the consumers regarding feedback obtained and follow-up taken. Number of BH units where the Consumer Feedback Book is implemented. Patient journey mapped by following consumers through BH to identify where workflow systems can be improved. 4.2 Patient experience surveys are conducted on key areas in the design of health services VHES updates are included as a standing item in the CAC meeting agenda. The Victorian Health Experience Survey (VHES) is implemented at Bendigo Health, and outcomes are incorporated in the design and redesign of health services and used to identify opportunities for safety and quality improvement. Number of Patient Satisfaction Surveys conducted at Bendigo Health. 4.3 Complaints feedback is used to identify good practice CAC receives bi-monthly Complaints and Compliments Reports, and biannual updates on complaints and compliments from the Patient Feedback Coordinator. Number of Complaints & Compliments Reports provided to CAC. Number of complaints & compliments updates provided to CAC by the Patient Feedback Coordinator. NSQHS 2.5 5. Consumers, carers and/or community members are informed about Bendigo Health's safety and quality performance, and contribute actively to the ongoing planning monitoring, measurement, and evaluation of performance for continuous quality improvement. 5.1 Consumers and the community are provided with information that is meaningful and relevant on Bendigo Health's safety and quality performance Quality and Safety report is shared with the CAC on a regular basis. CAC receives updates on relevant safety and quality performance processes and activities. Number of quality and safety reports shared with CAC. Number of information updates or reports posted on BH website, in newsletters, newspaper articles, Visual Display Boards etc. Number of community events or meetings attended where information on BH safety and quality performance was presented. Number of safety and quality performance posters displayed at BH and information sheets for consumers to read within waiting areas. BH 1.1, 1.2, 2.2, 4.1 and 4.2 NSQHS 2.7, 2.8 and 2.9 DoH 4 Updated 23/10/2014 4
5.2 Consumers, carers and/or CAC representative appointed to Quality Care Council. community members are actively involved in decision-making about safety and quality 5.3 Consumers, carers and/or community members participate in the analysis of organisational safety and quality performance, and planning and implementation of quality improvements CAC receives updates on relevant safety and quality performance and improvement processes and activities. Number of CAC and/or other consumers and community members represented at Quality Care Council. Records of review of processes and structures which consider organisational safety and quality performance information to identify level of consumer engagement. Records of meetings, forums and workgroups that demonstrate involvement of consumers in the analysis of organisations safety and quality performance information. Records of review of processes and structures to identify level of consumer engagement in quality improvement activities. BH 1.1, 1.2 and 3.1 DoH 1.7 BH 1.1, 1.2, 2.2, 4.1 and 4.2 NSQHS 2.8 DoH 4.3 Records of meetings that demonstrate involvement of consumers in quality improvement activities. Number of consumers represented on the Bendigo Health Ethics Committee. 5.4 Consumers, carers and/or community members participate in the evaluation of patient feedback data, and in the planning and implementation of quality activities relating to patient feedback data CAC receives updates on relevant patient feedback quality processes and activities. Records of BH committees and/or groups provided with patient feedback data and tasked with evaluating and commenting the data. Number of agenda papers, meeting minutes and/or reports of relevant committees that document consumer engagement in planning and implementing quality activties based on patient feedback. BH 1.1, 1.2, 4.1 and 4.2 NSQHS 2.9 DoH 4.4 5.5 Bendigo Health uses a variety of approaches to record and report on consumer, carer and community participation to the wider community, including an annual Quality of Care Report The CAC provides input to the contents and design, and advice in the development, of the annual Quality of Care Report. CAC receives updates on relevant processes and activities implemented to record and report consumer participation and engagement to the wider community. Quality of Care Report is produced annually in October. Number of newsletters produced by BH units about their activities for the consumer and the community. Number of consultation processes and information sessions held with consumers, carers and community members BH 1.1 and 1.2 DoH 1.3 Records showing that information provided is acted upon by Bendigo Health and fed back to consumers, carers and/or community members Updated 23/10/2014 5
6. Consumers, carers and community members are active participants in the Bendigo Hospital Project (BHP) 6.1 CAC provides input to guide and contribute to planning for development of the new Bendigo Hospital. Review the CAC Terms of Reference to reflect its oversight/advisory role in achieving consumer and community engagement in BHP. CAC to review and update the Framework for Consumer Participation in the Bendigo Hospital Project. Terms of Reference of CAC reviewed and endorsed. Framework for Consumer & Community Engagement in the Bendigo Hospital Project reviewed and updated. BHP framework Number of reports from BHP team and/or Exemplar Health outlining how they have responded to consumer suggestions for improvements shared with CAC. 6.2 The broad community including diverse groups are represented through the CAC in BHP Recruitment of new CAC members conducted in a targeted fashion to match the needs for the BHP project, i.e. mental health, acute, sub-acute and residential care. Number of CAC members representing diverse groups (e.g. mental health, acute, sub-acute and residential care, Aboriginal, culturally diverse). The CAC to develop a skills and profiles matrix to reflect the strenghts, skills and roles of its members. BHP framework 6.3 The CAC facilitates an information interface, a feedback mechanims and recommendations to other Bendigo Health consumer groups and to the community CAC to facilitate the creation of an information interface and a feedback mechanism for consumer groups in BHP. CAC input to reporting framework. Information interface and feedback mechanism established. Reporting framework to CAC reviewed. BHP framework CAC works with BH consumer groups and the Communications & Marketing team to ensure a feedback mechanism to the community. Number of newsletters produced by consumer groups and/or BH departments. Number of website updates and/or articles on consumer information published by Comms & Marketing. CAC has access to meeting minutes of relevant consumer groups and committees, if required. Number of minutes of meetings by BH consumer groups shared with the CAC. Updated 23/10/2014 6