2012/2013 Timboon and District Healthcare Service quality of carequality of care report 1 Contents Preparing our 1 Message from the Quality of Care Report Board of Management and CEO 2 Our Rural Health Service Timboon and District Healthcare Service’s Quality of Care Report has 3 Our Services to the Community been compiled from contributions by a diverse group of staff dispersed 5 Compliance with Victorian Clinical throughout the organisation Governance Policy Framework with input from volunteers and community members. We are 6 Consumer, Carer and Community Participation confident that this report gives a comprehensive overview of our 19 Effective Workforce services provided to consumers throughout 2012/2013. 21 Risk Management 22 Clinical Effectiveness

29 Our Services

29 Concerns & Complaints

Vision Values To be a leader in rural health care providing a Accountable consumer centred, multi-disciplinary service, We show pride, enthusiasm and dedication in everything responding to the needs of our community. that we do. We ensure quality patient care and use resources appropriately. We accept professional responsibility for all our decisions and actions.

Excellence We create opportunities for education and are committed Mission to continuous development. We enable everyone to make To provide a consumer-centred, multi- knowledge-based decisions for service excellence. disciplinary, quality healthcare service working collaboratively within the regional Respectful health system to promote and provide for a We consult and collaborate with others and respect the comprehensive range of services supporting diverse knowledge and skills of our partners; working as health and wellbeing throughout the a team we ensure the best inter-professional patient care. continuum of life via centre and community- We are courteous and respectful to patients, families and based models of care. each other.

Integrity We engage others in a respectful, fair and ethical manner, fulfilling our commitments as professionals and employees. We ensure the highest degree of dignity, equity, honesty and trust.

Compassion Accredited with The Australian We will accept people as they are and display kindness Council on Healthcare Standards and sensitivity to them.

2 Timboon and District Healthcare Service 2012/2013 Message from the Board of Management and Chief Executive Officer

It is with great pleasure that we present the 2012/2013 To enhance our consumer participation in service planning annual Quality of Care Report to the community and and quality of care, a number of consumers have joined the consumers of Timboon and District Healthcare Service. Board’s Quality and Risk Management sub-committee and participated in our review of services and activity on a bi- The following report is provided so that the consumers of monthly basis. the health service in our catchment are given an insight into our systems and processes that show we are able to Our service has continued to participate in planning and provide a quality service that is safe and governed by the partnership activities through the Corangamite Health best management and clinical practices. Planning Project, the Primary Care Partnership and Great South Coast Medicare Local – all of which have helped During the year, the Board has undertaken considerable to ensure better access to services for members of our work in three significant areas: community.

Firstly, the growth of our community-based activity. This has We wish to thank the community for its continued support included the purchase of land from the Baptist Church and of the health service and trust that you enjoy reading the the building of the Timboon Men’s Shed, at a total cost of information enclosed in this report. It is our hope that $375,765.83. Funding is currently being sought to establish the report of our activity will give confidence and greater a community garden in partnership with the Timboon P-12 knowledge to all, and so ensure that Timboon and District School and with the help of Men’s Shed members. Healthcare Service continues to thrive as a provider of quality health services to our district. We were also successful in obtaining funding from the Commonwealth Government and Deakin University to extend the Timboon Medical Clinic. This has provided for a further four consulting rooms and a student study area.

Secondly, Quality of Care and Accreditation. With our National Accreditation Survey due in August of 2013 and the prospect of being assessed against 15 new standards, significant numbers of staff and many thousands of hours John Renyard Wayne Weaire of work were committed to ensure that TDHS was able President Board of Management Chief Executive Officer to adequately respond to these new Quality in Healthcare Standards. It was with great delight that we not only passed the national accreditation, but also achieved numerous mentions for the work being undertaken at all levels of our organisation. Board of Management President John Renyard (left) with CEO Wayne Weaire.

quality of care report 1 Our rural health service

Timboon and District Healthcare Our social demographic SEIFA index Our catchment area of the southern Service provide services within the of disadvantage is 986, which is higher half of the Corangamite Shire extends southern half of the Corangamite than other areas in regional Victoria but from Cobden in the north to the Shire and the south eastern lower than average for both Victoria Great Ocean Road coastline, which section of Moyne Shire. Key towns and Australia. The Timboon and encompasses the tourist icon of The within the catchment area include district area has 3% unemployment. Twelve Apostles. The area provides Timboon, Cobden, Simpson, diverse employment through a range Timboon and District Healthcare Nullawarre, Port Campbell, of primary industries, with dairying Service is an integrated health service Princetown and Peterborough. being most predominant, natural gas administered under the multi-purpose developments along with tourism This area comprises a catchment service model of care for rural health along the coast, commercial and population of approximately 8000 with services. We provide acute, residential community services. Timboon, 50.1% male and 49.9% female. and community aged-care and primary although a small town of some 1000 care services. The age demographics of the people, provides a service hub for the catchment largely mirror that of Victoria Acute and residential aged-care southern part of the catchment and as a whole but unlike many small rural services are provided within a 14 Cobden serves the northern section communities, we do not have a larger flexible bed and six day-stay bed of the catchment area. than average aged population. Our complex with an operating theatre catchment has a high percentage of suite and urgent care centre. Primary 10-14-year-olds, as well 45-49-year- care services are provided both within old residents, with lower numbers of the community health services wing 20-24-year-olds. Our future projections and through community outreach are for a rapidly ageing population. programs. The Timboon and District Healthcare Service owns the building Within the population 0.1%, or seven and jointly manages the Timboon individuals, are of Aboriginal of Torres Medical Clinic and contract General Strait Islander descent, 7.5% of our Practitioners. These facilities are population were born overseas, with adjacent to the health service. 0.2% stating that they do not speak Nullawarre English well.

The top three birthplaces outside Peterborough Australia were the United Kingdom, New Zealand and the Netherlands. A total of 42% of residents currently own their homes outright, 30% are in VICTORIA the process of purchasing their homes and 22% are renting their homes either publicly or privately.

Number of Inpatients by Township Number of Community Health Clients by Township

Timboon/Nullawarre 326 Timboon/Nullawarre 444 Scotts Creek 27 Scotts Creek 41 Port Campbell/Princetown 45 Port Campbell/Princetown 59 Peterborough 24 Peterborough 35 Cobden/Simpson 87 Cobden/Simpson 333 Camperdown 9 Camperdown 40 Terang/Corangamite North 17 Terang/Corangamite North 10 Colac Otway Shire 11 Colac Otway Shire 3 Moyne Shire 14 Moyne Shire 5 Warrnambool 55 Warrnambool 8 Other Victoria including Melbourne 7 Other Victoria including Melbourne 12 Interstate/Overseas 2 Not Stated 65

2 Timboon and District Healthcare Service 2012/2013 Overview of our services to the community

URGENT CARE CENTRE the midwife or general practitioner and A large variety of resources, nursing collaborates with the midwifery team aids and lifting equipment are available Timboon and District Healthcare in planning client management. A on loan to assist in providing a Service operate a 24-hour, seven- total of 133 women received antenatal comfortable environment for client day-a-week urgent care centre. Acute care, five women birthed, 37 women and carers. Providing care to patients clinical staff have seen 2279 patients transferred back post-delivery and during palliative stages in life includes presenting to the urgent care centre 38 women were provided domiciliary supporting patient preference for place in the past 12 months. This equates visits. of care and completion of an advanced to 6.3 patients per day. Acute ward care plan which encompasses cultural, nursing staff work collaboratively religious and life-choice options. with our general practitioners and GENERAL SURGERY AND ambulance officers to meet patient DIAGNOSTIC PROCEDURES care needs in the areas of assessment, RESIDENTIAL AGED consultation, treatment and referral. Visiting medical and surgical specialists AND RESPITE CARE To maintain skills, 78% of registered provide quality care for our community nurses completed their Advanced Life catchment and surrounding areas. Timboon and District Healthcare Support training during August 2012. Our communities receive significant Service has six beds dedicated to This skill is updated annually. physical, mental, social and financial high-care residents and low-care benefits by having access to expert respite. Respite plays an important role specialist services close to home. in providing carers with a rest break ACUTE CARE The efficient management of waiting or the opportunity to take an annual lists has led to reduced waiting times holiday. A number of clients return on Acute care services at Timboon and for surgery of less than 90 days. In a regular annual basis, and one client District Healthcare Services have comparison, Timboon and District has demonstrated her satisfaction with remained active over the past 12 Healthcare Service boasts lower than our service, regularly booking a place months with nursing/medical staff state benchmark for category two at Timboon for the past six years when caring for 634 admissions. The semi-urgent cases of 90 days. her family takes holidays. average length of stay per admission is currently 3.64 days. Of the 634 Current visiting medical specialists Prior to admission, all residential and admissions, the three permanent include Mr Brendan Mooney, Dr respite clients are seen by the Aged general practitioners and nursing staff Chris Charnley, Dr Bridget Clancy Care Assessment Service, which cared for 95% of patient presentations and Dr Elizabeth Uren. Consultant identifies a client’s level of care needs at the healthcare service, with 5% of specialists provide general surgical, and then develops a care plan to be patient presentations requiring transfer ENT tonsillectomies, obstetrics followed while in care. This is followed to a higher level of care (intensive, and gynaecology and diagnostic up by a visit to one of the Timboon coronary or specialist referral) at a procedures. Specialists are supported general practitioners who reviews regional or metropolitan hospital. by our GP anaesthetist Dr Warwick a client’s medications while in care. Rouse. There were a total of four residents and 41 respite clients who were MATERNITY SERVICES accommodated during the past 12 PALLIATIVE CARE months. This equated to 998 bed days Maternity services are based upon of permanent aged-care and 563 bed a low-risk midwifery model of care. Palliative care is provided both within days of respite care (both high and Midwives operate as a team with the the healthcare service facilities and in low care). Respite client placement obstetricians and gynaecologists. the community by our district nurses. Timboon/Nullawarre 444 is coordinated through the Barwon Timboon and District Healthcare End-of-life care is provided and aligned Scotts Creek 41 Health Carer Respite and Care Link Service has six midwives. The with individual patient needs. A holistic Port Campbell/Princetown 59 Service, and we work in association Midwifery unit provides a range model of care ensures the care of Peterborough 35 with the South West Aged Care of services including pregnancy the patient and family is underpinned Cobden/Simpson 333 Assessment Service to ensure clients confirmation, care with a known by respect, compassion and clinical Camperdown 40 are appropriately assessed prior to midwife throughout pregnancy, expertise. The nurses providing Terang/Corangamite North 10 accessing aged-care services. Colac Otway Shire 3 breastfeeding advice and support palliative care are supported in their Moyne Shire 5 in the postnatal period. A visiting role by the regional palliative care Warrnambool 8 obstetrician is available through the consultants and medical specialists Other Victoria including Melbourne 12 Monthly Outreach Obstetrician Clinic based at South West Healthcare Not Stated 65 – On Site for those women referred by Warrnambool.

quality of care report 3 Overview of our services to the community

HOME AND COMMUNITY CARE PLANNED ACTIVITY GROUPS Programs include Tai Chi, Strength SERVICES AND NATIONAL RESPITE CARERS Training, Balance Plus, Gentle PROGRAM Exercise, Stepping Stone, Heartmoves Timboon and District Healthcare and Rehabilitation. Classes for pre and Service administers the joint The Planned Activity Groups operate postnatal women are also offered with Commonwealth and Victorian twice-weekly at Timboon and Cobden numbers varied by needs-basis. governments’ Home and Community to provide an opportunity for older Care program for the southern part of members of the community to the Corangamite Shire and, in addition, socialise and participate in a range of COMMUNITY HEALTH SERVICES provides home care services through activities and outings which encourage our Multi-Purpose Service funding. participants to remain active and In addition to Timboon and District Timboon and District Healthcare involved. This year there has been an Healthcare Service staff, a range of Service directly employs a Home and emphasis on the implementation of Allied Health services are provided to Community Care (HACC) Assessment the Active Service Model, creation of the Timboon and district community Officer, HACC Service Co-ordinator, goal-directed care plans and programs by contracted staff. These staff work HACC personal care and home care that promote independence. The five- within the healthcare service on a workers and HACC Maintenance hour programs also offer carer respite, weekly/fortnightly basis and are an Workers. A focus on improving staff funded by the National Respite Carers integral part of the multi-disciplinary communication during the past 12 Program, during the Friday session in team approach, which provides months has included weekly 15-minute Timboon. services to both inpatients and one-on-one peer support meetings community clients. Their role includes with each worker where challenges, clinical treatment, education and health OHS issues, client wellbeing and DISTRICT NURSING promotion. Changes in the Timboon worker wellbeing were discussed and and District Healthcare Service The District Nursing service provided addressed. organisational structure has seen an invaluable service to 183 clients the appointment of an Allied Health The “HACC Happenings” newsletter this year. This accounted for a total Manager who reports to the Director continues to be published on a of 2250 hours of nursing care. Some of Clinical and Community Services. quarterly basis for all home-care clients receive visits on a regular basis Timboon and District Healthcare consumers, keeping them up to date and are encouraged and motivated to Service directly employ physiotherapy, with news and information. Topics be independent, thus assisting them social work and youth work services. covered have included management to remain in their own home as long as The positions of social worker and in a heatwave and the new Home and possible. Referring agents are typically youth worker have been vacant for a Community Care guidelines. South West Healthcare Warrnambool, number of months during 2013 due Timboon Medical Clinic or internally to staff resignations and difficulties from within Timboon and District with the recruitment of replacement ASSESSMENT AND CASE Healthcare Service. The district nurses staff. Allied Health Services contracted MANAGEMENT communicate regularly with general by Timboon and District Healthcare An increased emphasis on practitioners to consolidate care. Service include dietetics, counselling, assessment, case management and occupational therapy, physiotherapy, care planning via the implementation podiatry, public dental and speech of a goal-directed care plan enables FITNESS AND REHABILITATION pathology. the assessment officer to fully PROGRAMS incorporate the Active Service Model. Timboon and District Healthcare “Physical Activity and Active This improvement is in line with Service provides a range of Communities” has been identified the Common Care Standards that services via community clinical as a priority issue to improve overall Timboon and District Healthcare nurse educators. These include health and reduce health inequalities in Service must follow in their provision diabetes education, chronic disease Victoria. A total of 15 weekly classes of HACC services. All 193 Home and independence program, continence are offered to the community through Community Care Assessment clients nurse, Well Women’s Clinic and the Exercise and Rehabilitation have an assessment plan that meets Community Health Nurse Education Program. With a particular emphasis this model. Clients are reviewed on which includes immunisations and on supporting older adults, the aims a three, six or 12-monthly basis, community programs. of the program include maintaining depending on their level of need. and improving participants’ strength, mobility, falls risk and balance while encouraging social connectedness.

4 Timboon and District Healthcare Service 2012/2013 Compliance with Victorian Clinical Governance Policy Framework

The governance of clinical care occurs within the context of the broader governance of the health service board of management and includes the areas of financial and corporate functions, setting strategic direction, managing risk, improving performance and ensuring compliance with statutory requirements.

Governance of an organisation occurs at all levels and requires a program of review and improvement of internal processes and outcomes at every level from the board, the executive staff, the management team, clinicians and non- clinical staff.

The clinical governance framework focuses on the domains of quality and safety and includes: • Consumer participation; • Clinical effectiveness; • An effective workforce, and; • Risk management.

quality of care report 5 Consumer, carer and community participation Doing it with us not for us: Strategic Direction 2012/2013

Timboon and District Healthcare Service demonstrates a commitment to consumer, carer and community participation appropriate to its diverse communities.

Target Score 75% 75% Numerator – The number of strategies implemented 6 Denominator – The eight specified strategies required 8

• Timboon and District Healthcare • Timboon and District Healthcare • Timboon and District Healthcare Service works closely with Service has a cultural Service is developing capacity of the South West Primary Care responsiveness plan that meets staff to support consumers, carers Partnership and during the the six minimum reporting and community participation, this 2012-2013 year, Timboon and requirements. has included the Board Chairman District Healthcare Service’s Chief and Quality Co-ordinator attending • Timboon and District Healthcare Executive Officer has been the conferences in consumer Service has systems processes Chair of this Partnership. participation. and structures in place to consult • Timboon and District Healthcare and involve consumers, carers Service uses a variety of and community members – approaches to record and these include consumer Board report on consumer, carer and representatives, strategic community participation to the plan, consumer, carer and wider community including the community participation policy, annual Quality of Care Report, executive reporting on consumer Victorian Patient Satisfaction participation to the Chief Executive Monitor Survey Results, Officer, participation in the newspaper articles, Monthly Victorian Patient Satisfaction What’s On, Quarterly Newsletter, Monitor, consumer involvement Timboon and District Healthcare in Quality and Risk Management Service website, Timboon and Meetings and consumer District Healthcare Service involvement in the development of brochures and posters and via all consumer resources developed the Quality and Risk Management by Timboon and District Meetings. Healthcare Service.

6 Timboon and District Healthcare Service 2012/2013 Consumer, carer and community participation

Our cultural diversity plan Our catchment is located in an Although only 5.2% of our • Patients of our hospitals; area in which less than 2% of our communities were born overseas • Residents utilising our aged care population is of Aboriginal and compared with 22% nationally, we accommodation; Torres Strait Islander descent. view it as important to have actions • Community clients; in place to ensure we are able to Regardless of this we make sure all accommodate particular health needs • Augmentative and alternative community members have access if they present to our healthcare communication styles for clients to appropriate services. Our Cultural service. A Diversity Plan has been and patients of a non-English Diversity Plan ensures we are developed to identify and understand speaking background; creating a welcoming environment the makeup of our communities, to • Customs and traditions of and providing cross-cultural training establish partnerships with specialist culturally and linguistically diverse for healthcare service staff. During agencies and practitioners, to develop clients, and; planning and evaluation of services staff competencies, and to generate a criteria we ensure cultural needs of the • Employees. responsive and alert organisation. This organisation are assessed and met. plan responds to the needs of: We embrace cultural diversity which • Indigenous clients; ensures we tailor our services to • Clients from Culturally and meet the needs of all the community Linguistically Diverse (CALD) irrespective of cultural background. backgrounds;

Consumer Representative: Kate Healey, 55, Peterborough When Kate Healey suffered a member of the quality and risk brain aneurism and stroke in management committee, which March 2012 her life changed meets monthly. forever. The Peterborough resident says The active, working woman was being able to bring a perspective suddenly thrown into a world of and voice from the community to medical care, hospital isolation the decision-making table of the and rehabilitation. But it was this healthcare service is very satisfying experience, combined with many and fits well with her passion for years working in mental health people and their rights. care and advocacy, that made her “I’ve always had a lot of interest an ideal candidate for the role of in accountability and service ‘consumer representative’ with provision, and generally in people’s Timboon and District Healthcare rights and in policy development,” Service. she explained. The new role was introduced in “People don’t like to whinge in the late 2012 through changes to country but it’s not really about that hospital policy which require public – it’s about having the opportunity consumers to have official input into to create awareness of issues that hospital policy and procedures. affect people, or consumers, in This sees Kate as an integral relation to the healthcare service.”

Kate Healey has brought a breadth of life experience to her role as a consumer representative.

quality of care report 7 Consumer, carer and community participation

Consumers and, where appropriate, carers are involved in informed decision-making about their treatment, care and wellbeing at all stages and with appropriate support.

Target – Acute Score 75% 93% A consumer participation indicator score on the Victorian Patient Satisfaction Monitor of at least 75 93

Victorian Patient Satisfaction Monitor

Timboon and District Healthcare with other Category M Health services Respect for privacy, Opportunity to Service continues to score above and all Hospitals, Timboon and District ask questions, Cleanliness of toilets state benchmarks for all hospitals Healthcare Service scored higher than and showers and Cleanliness of rooms in all areas according to the Wave the Category M average in Wave 23 most frequented. 23 report of the Victorian Patient for all areas which included Overall Consistent with previous ‘waves’, the Satisfactory Monitor. Care, Access and Admission, General majority of patients reported that they Patient Information, Treatment and were helped a great deal by their stay The Victorian Patient Satisfaction Related Information, Complaints in hospital and felt that the length of Monitor Wave Reports help to identify Management, Physical Environment, time spent in hospital was about right. strategies that can improve services Discharge and Follow-up and and patient satisfaction.The report Consumer Participation Indices. enables health services to track their Especially high performance scores performance over time and compare were obtained for Wait time, Courtesy themselves with others. The Wave 23 of Nurses, Responsiveness of nurses, report is from the period of July 2012 Helpfulness of hospital staff in general, until December 2012. When compared

8 Timboon and District Healthcare Service 2012/2013 Consumer, carer and community participation

Chronic Disease Independence Program – A Client Journey:

Keith Green, 58, Glenfyne Client Keith Green chats with Chronic Disease Independence Program Co-ordinator Christie Berry. When Keith Green, 58, of Glenfyne, was hospitalised with chronic lung disease in 2009 it started a chain of events that linked him to several programs at Timboon and District Healthcare Service. He shares his story. “I was very sick and ended up with pneumonia and septicaemia, TB and blood clots on the lungs – it all happened all at once. When I was over the worst I got filtered through to an exercise group in Warrnambool… when that ended I’d achieved great gains – from hardly being able to walk, to being able to move without huffing and puffing. So I looked for options closer to home.

“I knew I had to continue to help about diet, medication and just to 16)… it’s not just a one-person myself – I’d been diagnosed more knowledge on my condition so thing. with COPD (chronic obstructive I can go about caring for myself in “But I’ve used all of the services pulmonary disease) and the best way possible. and programs available at Timboon emphysema through smoking for “I’ve also been able to set exercise and District Healthcare Service some 30-odd years plus being in the goals with Bridie and Tracey and it’s to turn my life around. I’ve had building and construction trade… great to always be working towards amazing support and because of there’s also some asbestos scarring something, experiencing variety this, I’ve been able to replace the there. I met (TDHS) exercise in your program and knowing negatives with positives. co-ordinator Tracey Heeps and you’re being guided by health (physiotherapist) Bridie (Ontronen) “Knowing that I have someone there professionals who understand your and began the Stepping Stone (like Christie) means so much to challenges and limitations but give rehab program for an hour a week, me, because a problem shared is you that time and personal attention which I still do to this day. a problem halved. I had a big fear to get the best out of yourself. In that I’d end up on oxygen and until “I was also linked to chronic addition, I’ve learnt about exercise I talked to a professional I couldn’t disease educator Christie Berry that I can do at home that is get over that fear. who has been an amazing support. sustainable and realistic – like It’s so wonderful to know so much something as basic as walking to “I know my limitations, but those help is available to me. I had a the chook pen, but doing it several limitations are far, far less than they comprehensive assessment with times a day. used to be. Christie in July of 2011 and now “I do tire very easy and I have “I think we’re very lucky here. We we see each other on a somewhat constant shortness of breath; it came from Melbourne nine years casual basis, but often it’s weekly. affects every part of every day ago and I can honestly say we are Through Timboon and District really. It affects the family too; I blessed at Timboon. It’s a really Healthcare Service’s ‘Better Health can’t play cricket or kick the footy personal and caring service.” Self-Management’ course I’ve learnt with the (five) boys (aged 24 down

quality of care report 9 Consumer, carer and community participation

Acute Client Journey: Lisa Kensit, 49, Timboon Lisa Kensit in her art studio. There are few hospitals where you could set up an art studio in your room to help you while away several weeks flat on your back. There are also few hospitals where your colleagues from the neighbouring school could just pop across for a quick visit, or where the nurses know you as a person, and not just as a patient, and call by with a smile and a friendly chat. But this was the experience of local teacher Lisa Kensit who found herself at Timboon and District Healthcare for six weeks from early August this year. “If you are going to be stuck in a hospital then Timboon is the place to do it,” Lisa said with a grin. “The room, the food, the extra care and the fact that they know the local people really is nice. “The nurses were only too happy for me to have my easel and paints set up, so I was able to paint in bed – for my head space, it kept me sane really. “Everyone really looked after me….I got so much encouragement when I started to walk again, it was fantastic. And to have your family so close by…” Lisa’s unexpected admission came about when a pre-existing spinal condition “flared up”, causing intense pain and gastro/flu-like 7 co-ordinator. She is focusing on Some of her artwork is currently symptoms. her health. Part of her rehabilitation on display at the Fat Cow and she Today she is still to gain full will see her spending time at her is also working on the occasional sensation in her right leg and has home-based animal rescue shelter, commissioned piece. taken some time away from her role painting and chilling out with her as the Timboon P12 School year ‘therapy’ animals.

10 Timboon and District Healthcare Service 2012/2013 Consumer, carer and community participation

Client Story: Neil Trotter – Carer, Timboon. Carer Neil Trotter shares a moment with his mum Kath, 95, and her beloved pooch Misty. Neil Trotter once classified himself solely as a ‘carer’. These days he is also a very well-known Corangamite Shire councillor – a role he is passionate about and has been able to dedicate himself to since accessing further Timboon and District Health Services’ Home and Community Care programs for his mother Kath, aged 95. On Mondays, Wednesdays and Fridays Kath is visited by ‘Karla’, a HACC Community Care Worker that she has become very fond of. Karla helps Kath with personal care and undertakes home duties, while also helping Kath to prepare a lunch meal two days a week in the kitchen she has cooked in for the past 40- odd years – allowing her love for cooking to continue. Kath also enjoys the social side of her Thursdays at TDHS’ Planned Activity Group, attends a weekly two-hour gentle exercise class where she is able to maintain her muscle coordination allowing her daily walk with her dog ‘Misty’ to continue. Kath also accesses residential respite at least four times a year, often for a few weeks at a time. These programs and services allow Kath to stay living in her own home “You only have to look to other I’ve been able to take on the role of and provide much-needed social areas to see that the services a councillor while also maintaining interaction and involvement in the available to us here are just my role as her carer. varied programmed activities while amazing,” he said. also providing Neil with respite. “Being a carer has been a wonderful “There’s no comparison and we’re opportunity to get to know my Mum Neil said that without the range very lucky. – but you do need a break – and of support services provided by what HACC services do for mum the HACC services, Kath’s wish to “Knowing that mum is happy and and I is just great.” remain in her home may not have safe and well cared for is very been possible. reassuring. It’s been wonderful that

quality of care report 11 Consumer, carer and community participation

Consumers and, where appropriate, carers are provided with evidence-based, accessible information to support key decision- making along the continuum of care.

Target Score Score 85% 100% Numerator – The number of new information resources produced, revised or adopted over last year which met at least 30 of the 40 items on the Checklist for Assessing Written Consumer Health Information, including at least five items from section D 25 Denominator – The total number of new consumer, carer or community information resources produced, revised or adopted in last year 25

Target Score Score 85% 100% Numerator – The number of respondents who rate the written information on how to manage your condition and recovery at home, Question 16b) on the Victorian Patient Satisfaction Monitor, as being ‘good’ to ‘excellent’ 26 Denominator – The total number of respondents to Question 16b) on the Victorian Patient Satisfaction Monitor 28

Keeping you informed

The continued implementation printed and distributed within ‘The have also been maintained, with at of the communication strategy Cobden Timboon Coast Times’ least four articles per month printed reflected on the importance each quarter, available at local in local newspapers during the of multiple types of mediums establishments and electronically sent 2012/2013 financial year. The Annual to provide information to the to an extensive email distribution list. Report is provided to residents who community. A monthly ‘What’s On’ newsletter is attend the Annual General Meeting or also distributed via the ‘The Cobden request a copy. The ‘Quality of Care Outcomes from the strategy have Timboon Coast Times’, provided to Report’ is distributed to residents in a resulted in the printing of a Timboon local establishments and electronically community mail-out. The Timboon and and District Healthcare Service sent to those who have subscribed District Healthcare Service website has ‘Quarterly’ publication which to receive health service information. been redesigned to focus on news, showcases services, activities and Regular ‘good news’ media articles publications and service provision. special events. This newsletter is

12 Timboon and District Healthcare Service 2012/2013 Consumer, carer and community participation

Maternity Journey:

Rebecca Couch Rebecca and Brad Couch relax at home with their children Charlotte, 6 months, and Jack, 2. When Rebecca Couch fell pregnant with her second child she was able to take a relaxed approach to the birth. The Brucknell dairy farmer’s wife had experienced the comfort and convenience of being able to deliver her first child, Jack, in Warrnambool and then return soon after to her local healthcare service, and she planned to again do the same. Her plans fell into place on March 24, 2013, when Charlotte was delivered without complications at South West Healthcare. Some six hours later she was back in Timboon in her own private hospital room, just minutes from home, and her husband Brad and son Jack, then 18 months. “It’s an absolutely wonderful service with a very positive environment, friendly staff, the convenience of being close to home and because you’re a local you know everyone’s faces at the hospital,” she said. “And because Brad’s a dairy farmer there was a great ease knowing that he could come and go and continue to run the farm. “On top of that, I had a wonderful big room and lovely meals – I think care at TDHS and was very satisfied “I started going after Jack was born we’re really very lucky here.” with the continuity of care provided and now I take both children,” she by registered nurse/registered said. Rebecca was at Timboon and midwife Toni-Ann McLennan and “It’s great to meet other mums… it’s District Healthcare Service with visiting obstetrician Dr Elizabeth great from a social side and does Charlotte for three nights, and Uren. previously stayed for four nights great things for your fitness and when Jack was born on September In addition, Rebecca has seen the your mental health. maternal and child health nurse and 6, 2011. “Everything (at Timboon and District enjoyed taking part in the “Bounce Healthcare Service) is so close to The community health nurse said Back With Babes” exercise classes home – it’s just so easy.” she had also accessed pre-natal for mums with new babies.

quality of care report 13 Consumer, carer and community participation

Consumers, carers and community members are active participants in the planning, improvement and evaluation of services and programs on an ongoing basis.

Target Score Score 75% 100% Numerator – The number of dimensions or specified activities where consumers, carers and community members are active participants 5 Denominator – The six dimensions or specified activities 5

• Timboon and District Healthcare • Timboon and District Healthcare • Consumers and community Service involved four consumers in Service has consumers on the members are involved in the its open Board meeting. quality and risk management review of consumer information. committee which reviews • Timboon and District Healthcare feedback, complaints and clinical Service has involved consumers and corporate governance. in the development of community programs such as the Timboon • Consumers are involved in the Men’s Shed, Timboon clinic review of the annual Quality of extension, Timboon Community Care Report, review of services as Garden development. part of community development forums and in patient satisfaction surveys.

Ac#vi#es and Achievements Feedback on 2011-2012 Quality of Care ReportAc#vi#es andn=26 Achievements 84.62% Ac#vi#es andn=26 Achievements

It is our strong belief that the Healthcare Services activities and 84.62% n=26 community should have access achievements, was well presented, 84.62% 7.69% 0.00% 3.85% 3.85% 0.00%

locally to a high quality healthcare easy to read and provided useful 7.69% excellent good average0.00% 3.85%fair poor3.85% Did0.00% not answer service which includes hospital, information. Consumers indicated that 7.69% excellent good average0.00% 3.85%fair poor3.85% Did0.00% not aged and community services. they found the report interesting and answer excellent good average fair poor Did not Feedback received from our were happy with the range of services Report is easy to read answer community allows us to reflect on provided. Community members liked Report isn=26 easy to read n=26 and strengthen our services and the human interest stories from staff 80.77% Report is easy to read n=26 practice to ensure this goal is met. and clients and reported that they 80.77% 15.38% 80.77% would like them to again appear in the 0.00% 3.85% 0.00% 0.00% The 2011-2012 Quality of Care 15.38% next report. excellent good average0.00% 3.85%fair poor0.00% Did0.00% not Report was designed to provide 15.38% answer excellent good average0.00% 3.85%fair poor0.00% Did0.00% not our community, consumers, carers, Some consumers felt that the answer excellent good average fair poor Did not patients and residents an insight into graphs in the report could have been Graphs are easy to understandanswer the systems and processes in place presented more clearly. Graphs are easyn=26 to understand to deliver safe and quality services. 73.08% Graphs are easyn=26 to understand It is important to us that this report Several consumers felt that a greater 73.08% n=26 15.38% range of support groups for new 73.08% 7.69% is valuable and informative for our 3.85% 0.00% 0.00% 15.38% mothers, new community members 7.69% intended audience; therefore the excellent good average 3.85%fair poor0.00% Did0.00% not 15.38% answer and youth would be useful at Timboon 7.69% community are asked to provide excellent good average 3.85%fair poor0.00% Did0.00% not and District Healthcare Service. The Report is well presented answer feedback on the quality and excellent good average fair poor Did not n=26 answer appropriateness of the report. other areas for development were more aged care, expansion of respite 88.46% In summary, approximately 90% of services, more off-street parking, a

7.69% consumers felt that the 2011-2012 home handyman service for small 0.00% 3.85% 0.00% 0.00%

quality of care report was an accurate home jobs and a community bus. excellent good average fair poor Did not reflection of Timboon and District answer

14 Timboon and District Healthcare Service 2012/2013 Confidence in choosing care n=26

80.77%

7.69% 3.85% 3.85% 3.85% 0.00%

excellent good average fair poor Did not answer

The report provided useful informa#on n=26

81.48%

7.41% 3.70% 3.70% 0.00% 0.00%

excellent good average fair poor Did not answer Consumer, carer and community participation

My Time on the Board of Management: Catherine Marr – Long-Serving Board Member Catherine Marr at home in her garden. Serving on Timboon and District Healthcare Service’s Board of Management was always on the agenda for Catherine Marr. The former business owner and former Corangamite Shire councillor had “a deep sense of gratitude” to the health service she said had served her well through many stages: the birth of her three children, the care of her eldest child through chronic illness and, later, with support services for her frail, elderly mother, who lived with her during the last few years of her life. She believed becoming a Board member would provide the opportunity to “give back” to her community and share the knowledge and perspective she had gained as a community member and service user. It’s 12 years since she was approached to take on the role and now – some 100+ Board meetings later – she said she still felt as passionately about her involvement as when she attended her first meeting, enjoying the breadth of Catherine said the important role relationships with community opinions and ideas brought to the was one she embraced. groups; the continued involvement discussion table. of so many volunteers in varied “I enjoy the challenge – I have “We have an excellent rapport with roles, and the opening of the new certainly learnt a lot. our fellow Board members and all men’s shed facility. respect robust discussion – and we “I’ve met some wonderful people In addition to her role on the do our very best to act with honesty (and) it’s also very fulfilling. I felt Board, Catherine has also served and integrity,” she explained. enormous satisfaction when the on several sub-committees over new community health building “Because we were in business the years and is currently on the was opened; it has been a work in and because I’ve been a (shire) finance/audit committee, the quality progress for the Board over many councillor I’m aware of the and risk management committee years.” importance of managing risk, and the Men’s Shed sub-committee. budgets and strategic direction. Catherine said she had also gained Her current three-year term on the It’s a fine balance but ultimately immense satisfaction from the Board runs until June 2014. we have to maintain our services, fantastic team effort that achieved expand our services and improve recent successful accreditation “Importantly, I’m just as excited upon our services…that’s really why outcomes; the current work about going to a meeting as when I I’m there.” being done to form close working started,” she said.

quality of care report 15 Consumer, carer and community participation

Timboon Men’s Shed: Timboon Men’s Shed Co-ordinator David Pringuer Co-ordinator, David Pringuer embraces his time with the men at the shed. When David Pringuer took on the role of Timboon Men’s Shed co- ordinator in May 2013 he was very excited about the possibilities that lay before him. As a former welfare worker and having had experience with the Warrnambool Men’s Shed, he knew the difference the shed could make in men’s lives. “It’s a very special place,” he explained. “It’s a place where guys come together to tackle a project on their own or with other people. They can chat and socialise and support each other in the project, share some common interests and life experience. “It allows men to talk about problems and issues that might have come up in their lives; they can share experiences, get support from other guys and learn new skills. “I mean, put a group of women in a room and they’ll talk for hours… blokes don’t generally talk face-to- face – but put a project in front of them and that all changes.” David sees 20 “regulars” at the newly established shed headquarters on Bailey Street, who meet on Tuesdays and Thursdays, enjoying morning tea together on both days and lunch as well on Tuesdays, thanks to volunteer shaped seats for children and he desired because he “wanted to “cooks”. gumboot removers, as well as make a difference”. restoring a beautiful old table. The men are aged from their late “(From the outset) I could see the 30s to late 80s and have worked on David said he loves the potential to make an impact to a diverse range of woodworking- inclusiveness, atmosphere and change lives and bring benefit to based projects, including Christmas spirit of the men’s shed and his the shed and its members, and I’m reindeers, letter boxes, duck- role within it. He said it was a job excited to be part of it.”

16 Timboon and District Healthcare Service 2012/2013 Consumer, carer and community participation

The organisation actively contributes to building the capacity of consumers, carers and community members to participate fully and effectively.

Descriptive Reporting

Consumer representatives and Service programs. We express our important role in assisting older volunteers within the organisation sincere appreciation to the valuable members to remain within the are provided with an information group of volunteers who give their time community. This year Timboon and manual when they commence with to assist the frailer members of the District Healthcare Service recognised Timboon and District Healthcare community via the following programs: and thanked its volunteers during Service. • 101 Meals On Wheels volunteers; a morning tea held in Volunteers’ Week. Volunteers were provided with • 6 Planned Activity Group This includes information on a certificate of sincere appreciation volunteers; confidentiality and orientation of the in recognition of their efforts. Without program they are working in. They • 23 Community Transport the help of our volunteers, many of are also provided with information Volunteers; the services and programs offered regarding their rights, responsibilities • 2 Friendlies volunteers; at Timboon and District Healthcare and role within Timboon and District • 41 TOPS Opportunity Shop Service could not be run. Our annual Healthcare Service. A volunteer co- volunteers; volunteers’ Christmas lunch was also ordinator role was introduced in April, held for Timboon and Cobden Meals • 3 Consumer Representatives. 2013, to co-ordinate this process. on Wheels drivers. A total of 176 volunteers support These programs rely heavily upon the Timboon and District Healthcare volunteer support and play an

Volunteer Sue Wilson makes ‘cuppas’ for Planned Volunteer: Sue Wilson, Timboon. Activity Group members during a Thursday session. Sue Wilson knows very well that ‘to a lot of the people within the give is to receive’. community before they became clients. The retired school teacher and long-time Timboon and District “After my own father passed away Healthcare Service volunteer I felt a calling to help older people spends each Tuesday at the TOPS get out of their homes and not feel Op Shop, Thursdays in the Planned socially isolated. Activity Group (“PAGS”) and one “It’s lovely to have a real sense of day a month on the Meals on community within our town and Wheels distribution circuit with her there’s a feeling of inclusiveness husband, John. that I feel right throughout the The commitment is one she hospital. celebrates and appreciates, feeling “(After retiring) I wanted to feel I a deep sense of fulfilment and was giving something back to the connection to her community community that had always been so through the giving of her time and of good to me, particularly given all the herself. services given to my husband. “I’ve been coming to PAGS for “I always feel very welcome here about five years,” she said. (at Timboon and District Healthcare “It’s really lovely to have known Service).”

quality of care report 17 Consumer, carer and community participation

Exercise Program: George Hautot, 82, Timboon – Planned Activity Group member; exercise class participant. George Hautot loves living an active life. Keeping on your toes is the secret to living a long life of lustre, according to young-at-heart 82-year-old George Hautot. And the retired dairy farmer means that literally. Up to four nights a week he can be found taking to the floor of dance halls in Colac, Warrnambool, Cobden and Kolora. Indeed, he recently travelled “over 700 kilometres” in just a few weeks in pursuit of his hobby. “I just love it,” he said, “I love being on the floor, with the music and the company you meet there.” But all this spinning and foxtrotting wouldn’t be possible, George admits, without the amazing programs run by Timboon and District Healthcare Service that ensure his health is the best it can be. Three times a week George can be found participating in exercise classes with exercise co-ordinator “Doing the classes means I stay considers that he keeps “very well” Tracey Heeps, including gentle fit and strong which helps me to and says he just “forgets about exercise, strength training and do other things that I love, like my these things”, goes to the doctor men’s strength. He has been taking dancing.” when he needs to and focuses on part for the past three years since “living healthy and keeping active”. returning to the district and can’t George also attends the Planned speak highly enough of the gains he Activity Group twice a week, “I mostly eat a vegetable-based has experienced. enjoying the activities, outings and diet, with just a little bit of meat, I’ve general socialisation – as well as the never smoked and I’ve never tasted “When I get on the dance floor I’m meals. beer,” he said. fitter now than I was when I was 35 – and I put that down to exercise Despite having been diagnosed with “I like to keep my mind active and co-ordinator Tracey Heeps and prostate cancer 13 years ago, CLL be out doing things. There’s no (physiotherapist) Bridie (Ontronen),” leukaemia six years ago and facing point just sitting there talking at the he said. emphysema and asthma, George television, is there?”

18 Timboon and District Healthcare Service 2012/2013 Effective Workforce

STAFF CREDENTIALLING People Matter Survey SERVICE AWARDS Timboon and District Healthcare Timboon and District Healthcare Timboon and District Healthcare Service verifies the credentials of Service participates in The People Service has many staff who have all registered practitioners annually Matter Survey which is an employee served the organisation for extended through public access websites opinion survey. The survey gathers periods of time. and via staff presentation of their information on a broad range of Staff recognised for reaching registrations. people-management issues such milestones in the last financial year as employee commitment and job As of 30 June, 2013: include: satisfaction. • All registered and enrolled nurses 35 years: had registration through AHPRA; Timboon and District Healthcare • Corry Kerr • All allied health staff were Service staff consider human rights appropriately registered through when making decisions and providing 15 years: AHPRA; advice. They also understand how • Lyn Russell • All medical staff were appropriately the Charter of Human Rights and 10 years: credentialed and registered Responsibilities applies to work at • Lesley Henriksen through AHPRA; Timboon and District Healthcare • Vickie Stevens. • All staff had a police check. Service. They responded that the organisation provides high quality services to the Victorian community General Staff Meeting and feel encouraged by colleagues to report any patient safety concerns During 2012-2013 the ‘whole-of- they may have. Staff indicated that staff’ meeting (which was initiated they don’t see gender as a barrier to during 2011 and is held bi-monthly) success in their workgroup; that they continued. This meeting enables the receive help and support from other Chief Executive Officer, Directors members of their workgroup and that and staff to communicate and working in the Victorian public sector is discuss relevant Timboon and District a good career choice. Healthcare Service business. Continuous Improvement opportunities Timboon and District Healthcare have been identified around issues Service had five ‘whole-of-staff which include: meeting’s during 2012-2013 with an • Feedback average attendance of 29%. Minutes • Bullying of these meetings are displayed in the • Commitment and Retention. staff tea room and emailed to staff, for Long-serving Timboon and District Healthcare Service staff (from left): Corry Kerr (35 years – District Nursing), those unable to attend. Vickie Stevens (10 years – Enrolled Nurse) and Lesley Henriksen (10 years – Environmental Assistant).

quality of care report 19 Effective workforce

Jan Burkhalter: Hotel Services, 31 Years of Service Jan Burkhalter was committed to her role at TDHS for more than three decades. Jan Burkhalter began cleaning work Jan said the friendships she had with the Timboon doctors clinic of made would form her most enduring the day after a local doctor invited memories. Jan said it was “time” her to take on the role – at the age she retired, at age 65, and would of 34. continue to live the Timboon country life that she so loves, would Times were a “little different back enjoy getting into her garden and then”, Jan said, and she fondly would continue to care for her recalls undertaking all kinds of 90-year-old mother. She certainly ‘non-official’ work, from helping won’t miss her 6am wake-up call podiatrists to make casts and though, she guaranteed! assisting exercise clients, to filling in on the front desk when other staff were away.

Graduate Nurse Program: Darren Edgell – Division 1 Graduate Nurse

Darren Edgell knows that nursing and District Healthcare Service to Darren Edgell has embraced his graduate nursing position. is not a typical male vocation. But undertake his graduate year, which after driving taxis, milking cows began in February 2013. and running his own hobby shop, The year has been spent his future career came to him like a consolidating all he learnt in his “lightning bolt” moment. studies, plus completing further “I’ve always been the sort of person education and supervised training. who looks out for other people and Darren said he felt he was at an who wants to care for people,” he “absolute advantage” to have explained. secured a graduate position within “I realised I was at an age where a smaller hospital as it allowed I wanted to forge out a career him to gain much more “real-life for life and I spent considerable hands-on” experience than in larger time analysing my strengths and centres, and across a broader range interests…and then it hit me. I’m not of areas. religious, but I definitely feel like I’ve “I really enjoy working with different found my calling.” personalities and nursing at Darren studied the Bachelor of Timboon certainly gives me a lot of Nursing for three years through personal satisfaction. I really see Deakin University in Warrnambool this as a career for life,” he said. before being accepted by Timboon

20 Timboon and District Healthcare Service 2012/2013 Risk Management

CLINCAL RISK • To accept the tabling of finalised Occupational Health and Safety Policy MANGAGEMENT clinical and community documents and this ensures we meet and exceed as signed off by the Director of the Occupational Health and Safety Timboon and District Healthcare Clinical Services and Community Act 2004 (Vic) legislative requirements. Service decided to adopt the Health Services; Our Occupational Health and Safety RiskManQ Management system policies and procedures form the during the 2011-2012 year. The • Review progress towards foundation of our organisation and RiskManQ Management system will compliance with the National are reviewed regularly in consultation enable the reporting and capturing of Safety and Quality Health Service with employees and signed off by our reactive risk management practices of Standards. Chief Executive Officer, formalising our incident management and complaints During 2012-13, 11 of 12 scheduled commitment to our legal and moral reporting along with the proactive meetings were held. obligations. These documents include risk and quality planning activities. improvement targets, measures and The organisation underwent training induction training and consultation at the beginning of May 2012, with a Quality And Risk standards. ‘go live’ and full implementation of the Management Committee RiskManQ system occurring the next Occupational Health and Safety is a week. All staff are able to access the This committee operates to assist standing item on all management and RiskManQ system via a logon and Timboon and District Healthcare staff meeting agendas. Occupation password enabling easier reporting. Service in fulfilling its responsibility to Health and Safety Meetings are Staff are no longer able to access the ensure the continuous provision of convened on a monthly basis for paper-based reporting system since high quality and safe patient care. The the Occupational Health and Safety the online system went live. committee operates in accordance committee. All staff members who with Timboon and District Healthcare make up the Occupational Health and The benefits to the organisation of Service’s strategic directions and the Safety Committee have completed a the RiskManQ system have included: safety, quality and risk management five-day course in Occupational Health decreased time from incident to report, system which forms our quality and Safety. easier reporting and analysis and a and risk management framework. single system for risk management, The committee meets bi-monthly Mandatory training in the use of fire incident management, feedback and as a subcommittee of the Board of extinguishers was conducted in May quality reporting. Management. During the year seven 2013 with 72% of staff attending. quality and risk management meetings Manual Handling assessment and occurred. training continues to occur on an CLINCIAL PRACTICE COMMITTEE annual basis for all staff, with 70% The Clinical Practice Committee has attending manual handling training been established to monitor and OCCUPATIONAL HEALTH AND during the past 12 months. review clinical services in order to SAFETY The organisation ‘Do No Harm’ identify opportunities for improvement Timboon and District Healthcare workshop was also run for all staff within the service. The main functions Service is committed to exemplary either as an update or a full session of the committee include: practices in Occupational Health and for new employees, with 76% of staff • To assess and evaluate the quality Safety towards all employees, visitors, attending. of health services, including the patients, clients and contractors and review of clinical practices; considers meeting its obligations A regular orientation program is offered to staff bi-monthly and this is attended • Monitor policy, guideline, an important part of delivering high by all new staff. protocols housed on the PROMPT standards of healthcare services to system to ensure compliance its community. Timboon and District A mock evacuation occurred in and currency. This includes Healthcare Service has not had a February 2013 for all rostered development of new documents WorkCover claim since 2005 and staff. This allowed staff to practice as identified, review and update of continues to be vigilant in staff and emergency procedures. existing documents, and archive contractors’ occupational health and of documents as required; safety while at work. • To delegate responsibility for the Management is accountable for review of policies, procedures and the implementation of Timboon clinical guidelines; and District Healthcare Service

quality of care report 21 Clinical Effectiveness

Quality And Safety

ACCREDITATION Standard 2 - Partnering with Standard 7 - Blood and Blood Consumers Products The Australian Commission on Safety & Quality in Health Care • Consumers will be encouraged • A signed (both patient and Doctor) to provide feedback on patient Consent Form for each transfusion The Commonwealth and all State information available needs to be presented to the and Territory Governments have • Participation in the design and hospital on admission. agreed to national reform of Australia’s redesign of health service health system over the next five Standard 8 - Preventing and years. The reforms aim to improve • Participation in planning Managing Pressure Injuries health outcomes and ensure the and implementing quality • Increased assessment and sustainability of the health system. One improvements. information on admission. of the changes involves health service Standard 3 - Preventing and Standard 9 - Recognising and accreditation. Controlling Healthcare Associated Responding to Clinical Deterioration The Australian Commission on Safety Infections in Acute Health Care and Quality in Health Care developed • On admission staff will be asking • Education on admission the National Safety and Quality Health the consumers if they have any importance of communicating Service Standards (NSQHS) against infectious or potentially infectious concerns and signs of which all areas of care will eventually condition deterioration be measured. • Continued hand hygiene • Increased use of Advance Care Compliance with the 10 new national awareness Plans. standards becomes mandatory for • Decrease in the use of antibiotics Standard 10 - Preventing Falls and this Service from 1 January 2013 • Increase in information available. Harm from Falls and has been integral to our Quality Improvement efforts. Accreditation Standard 4 - Medication Safety • Increase in falls risk assessment status which will be mandatory and • Consumers will be required to & prevention plans made in to fail the process will have grievous provide a full medication history consultation with patients financial penalties. We intend to on admission. It comprises ACHS Additional Standards will meld our Accreditation systems to a list of all current medicines address: encompass the National Safety and including all current prescription • Standard 11 - Service Delivery Quality Health Service Standards and non-prescription medicines, with the assistance of our partner complementary healthcare • Standard 12 – Provision of Care organisation, the Australian Council on products and medicines used • Standard 13 – Workforce Planning Health Care Standards (ACHS). intermittently; recent changes to and Management medicines; past history of adverse ACHS has launched EQuIP National • Standard 14 - Information drug reactions including allergies; which is designed to meet the 10 Management and recreational drug use. National Standards as well as adding • Standard 15 - Corporate Systems five extra standards which will bring Standard 5 - Patient Identification and Safety and Procedure Matching an organisation-wide approach to our Combining the Commonwealth Accreditation process. • Staff will be required to ask the Standards and the Australian Council consumer their name, date of on Healthcare Standards (ACHS) birth, address (three identifiers) will ensure risk to our organisation is National Standards: when they access the service or minimised. Standard 1 - Governance for Safety have any procedures performed. and Quality in Health Service Standard 6 - Clinical Handover Organisations • Increase involvement in clinical • Increased awareness of consumer handover between staff, where rights and responsibilities relevant to the situation. • Support to document clear advance care directives • Additional avenues for patient feedback.

22 Timboon and District Healthcare Service 2012/2013 Clinical Effectiveness

Type of Accreditation Outcome

Australian Council of Healthcare Standards Full accreditation status received – four (4) years provided in 2009; (EQuIP National) • Periodic Review in 2011; • Supported Self-Assessment in 2012 endorsed ongoing accreditation; • A self-assessment, across all Functions, Standards and Criterion to be • submitted in October 2013; • Organisational Wide Survey conducted against EQuIP National in August 2013. TDHS obtained full accreditation and met all mandatory and developmental standards in this accreditation process. Community Care Common Standards • In August 2013 the Service’s HACC programs will be surveyed (Home and Community Care) against the National Community Care Common Standards; a self- assessment was being completed in preparation for the survey; • The last assessment undertaken against National Community Care Common Standards occurred in 2009 with a rating of 19.20 out of 20; • Results from August 2013 assessment demonstrated that TDHS met all 3 Common Care Standards. and Community Care National Respite for • The Commonwealth Department of Health and Ageing reviewed Carers Program (NCRP) the NRCP program last in 2009; • The programs successfully met the standards at the time of the review; • An Accreditation survey is to be undertaken by the Commonwealth Department of Health & Ageing in October 2013 against the National Community Care Common Standards; • Full accreditation status is expected.

Timboon and District Healthcare Service Quality and Risk Co-ordinator Melanie Green (left) and chairman of the Board John Renyard (right) celebrate the organisation’s accreditation survey success with The Australian Council on Healthcare Standards’ surveyors Maria Stickland and Arthur Wooster, flanked by TDHS staff, board members and volunteers, after survey feedback was delivered in early August, 2013.

quality of care report 23 Clinical Effectiveness

Preventing and Controlling Healthcare-Associated Infections

The introduction of the National Safety stewardship is in the prevention to the Immunisation of staff prevents cross and Quality Health Standards has emergence of antimicrobial resistance. infection of staff to patients and vice increased the focus of infection control Antibiotic prescribing should be versa. during the past 12 months with areas supported by clinical evidence and, Hand Hygiene such as ‘aseptic non-touch technique’, where possible and practicable, and antimicrobial stewardship’ laboratory tests. Treatment should Healthcare-associated infections being added to the infection control be limited to bacterial infections (HCAI) are an increasing issue in the program which previously focused using antibiotics directed against quality and safety of health care, in on hand hygiene, cleaning, storage, the causative agent given in optimal both the hospital and community food services and notification of dosage, interval and length of settings. The hands of all staff remain infections. Managing the hospital treatment with steps taken to ensure Hand Hygine Compliance Results environment to support the prevention maximum patient compliance with 100.00% 90.00% and control of health care associated the treatment plan and only when the 80.00% 70.00% 60.00% infections involves all staff from all benefit of treatment outweighs the Timboon Quarterly 50.00% Results 40.00% Acceptable Quality Level disciplines. Continuous auditing of individual and global risks. Timboon 30.00% 20.00% the environment and staff practices and District Healthcare Service 10.00% 0.00% is supported by staff education to has been involved in a regional Mar-­‐13 Jul-­‐13 Nov-­‐13 Apr-­‐14 Jul-­‐14 improve staff actions whilst providing working party which has focused patient. on appropriate use of antibiotics. the most common case of cross- Involvement has included area hospital infection. Improved healthcare worker Aseptic Non-Touch pharmacists and infectious disease hand hygiene is the highest priority Technique physicians with a focus on improving area to reduce the risk of healthcare- The assessment and introduction of medical practitioner prescribing habits. associated infections. the Aseptic Non-Touch Technique Infection Prevention and Auditing Hand Hygiene compliance (ANTT) has been developed during Control by Health Care Workers is essential to the year. The use of ANTT prevents assess the effectiveness of the Hand nosocomial infection from transferring Timboon and District Healthcare Hygiene program and education. from person to person. Staff have Service participates in the Victorian Timboon and District Healthcare completed a self-directed learning Study, VICNISS monitoring hospital- Service has adopted the ‘five moments package followed by a practical acquired infection rates in public of hand hygiene’ as a reminder to staff competency assessment. This will hospitals. Results from the past five as to the most appropriate times to ensure that staff skills are kept up to years indicate that Timboon and use hand hygiene. We have continued date in the provision of this technique. District Healthcare Service does not to score well above the accepted As of the 30th June 2013, 69% have any infections in the categories standard with a score of 85.3%. The of clinical staff had completed the that are included in this audit. accepted standard is 65%. While self-directed learning package and Staff Immunisation these scores are good, ongoing 54% had completed the practical vigilance needs to occur in regard to competency assessment. Staff are offered immunisation against the importance of hand hygiene in influenza annually; 80% of staff Antimicrobial Stewardship healthcare facilities. participated. This is well above the The key component of antimicrobial Victorian Government’s goal of 65%.

Compliance Rate by Moment - Timboon & District Hospital

Audit Period: NHHI Audit One 2013 Organisation:: Timboon & District Hospital

Correct Total Compliance Lower Confidence Upper Confidence Name Moments Moments Rate Interval Interval Timboon & District 58 68 85.3% 75% 91.8% Hospital

Correct Total Compliance Lower Confidence Upper Confidence Name Moments Moments Rate Interval Interval 1 Before Touching A Patient 9 16 56.2% 33.2% 76.9% 2 Before Procedure 4 4 100.0% 51.0% 99.9% 3 After a Procedure or Body Fluid 5 5 100.0% 56.6% 100.0% Exposure Risk 4 After Touching a Patient 23 24 95.8% 79.8% 99.3% 5 After Touching A Patient's 17 19 89.5% 68.6% 97.1% Surroundings

24 Timboon and District Healthcare Service 2012/2013 Clinical Effectiveness

Environmental and Food All patient care areas including theatre, Food Services Services central sterilising areas, urgent care The Food Services department centre, day surgery, individual patient Regular internal audits are performed continue to excel with their food rooms and lounge rooms are audited. throughout the year by the preparation ensuring that patients environmental staff. External audits The standard of cleaning at Timboon and clients in the community receive are also conducted by the regional and District Healthcare Service is well the best in regards to meal content Infection Control Consultant on an above the acceptable quality level. and meeting nutritional needs. An annual basis. Standards have been maintained at a important part of this service involves very high standard, receiving an overall cleanliness of the environment and Cleaning Services hospital score of 98% - well above staff members. The importance of maintaining a clean the AQL of 85%, which is an excellent The Food Hygiene Australia External and hygienic environment is monitored outcome. Audit for all food service areas of through external cleaning audits which External Cleaning Audit Results Timboon and District Healthcare conform to the Department of Health 98.00% 98.00% 100.00% 97.00% 97.00% Service Kitchen, Timboon Planned standards, comprising of one external 95.00% Activity Group Kitchen and Cobden audit and two non-external audits per 90.00% Overall Hospital Score Planned Activity Group Kitchen year. An internal audit is conducted 85.00% Acceptable Quality Level complied with requirements of the monthly by a Timboon and District 80.00% Food Act 1984. Healthcare Service accredited auditor. 75.00% Yr 2010 Yr 2011 Yr 2012 Yr 2013

Nurse Unit manager Michelle Selten practises effective hand hygiene.

quality of care report 25 Clinical Effectiveness

Preventing falls and harm from falls

Falls prevention strategies within our Health Service are extensive. TDHS Falls 2012-­‐2013 Prevention of falls starts with a screen via the Nursing Clinical Risk % 1000 bed days Assessment. If a risk is identified 18 then a thorough assessment of the 16 16.78 16.67 potential for a patient or a resident 14 12 to fall occurs. 11.58 10 9.2 8 It is our philosophy, particularly in 6.39 6 5.38 aged care, that our patients and 4 3.85 3.07 2.67 3.61 residents are free to move about but 2 0 0 0 this freedom must come as safely as possible. For this reason we make every attempt to provide an environment free of obstacles, ensure footwear of residents is well fitting and appropriate to the surface they are multifactorial prevention plan. attained. walking on and, most importantly, that patients and residents can call staff What have we done to What we plan to change? easily when they need help. improve? We plan to introduce technology to During the past 12 months Timboon We have intensified our efforts in assist nurses in being alerted when a and District Healthcare Service has preventing falls through rigorous patient moves from a position of safety had 24 falls. Falls are converted to multifactorial prevention plan between without the supervision or assistance the benchmark of falls per 1000 bed Nurses, General Practitioners, they need to remain safe. days with an aim of falling within the Physiotherapist, Occupational benchmark of 2- 7 falls per 1000 Therapists and Exercise Co-ordinator. bed days. Timboon and District Healthcare Service managed the Planning the care of each person benchmark on 8 out of 12 months. is centred on each individual. The The months where Timboon and methods we use for each patient or District Healthcare Service was unable resident focus on reducing falls and to meet this benchmark were due the severity of the consequences of to single inpatients or residents with the fall if/when they do occur. While health-related conditions causing them maintaining safety and encouraging to fall. All of these patients or residents maximum independence is difficult, had completed a falls assessment and a balance between the two must be

Preventing and managing pressure injuries

In 2012/2013 TDHS has focused potential to develop TDHS 2012-­‐2013 on pressure injury detection and pressure injuries and how Number and Severity of Pressure Injuries prevention. to develop a prevention 2.5 plan. The implementation of the Clinical 2

Risk Assessment which includes Additional education 1.5 the Waterlow Pressure Injury Risk for staff in relation to 1 Assessment Tool and Daily Patient pressure injuries and Skin inspection has prevented further wound management was 0.5 pressure injuries from developing. delivered by our area 0 Work has also occurred in the Wound Care Specialist Near miss / No harm Mild Moderate Severe education and informing of the clinical Nurse based at Western injuries reported on our RiskmanQ workforce about pressure injury District Health Service. Incident system. With no occurrence of prevention, accurately assessing Timboon and District Healthcare a Stage 3 or Stage 4 injury – the most patients and residents for their Service had three detected pressure severe. An excellent outcome!

26 Timboon and District Healthcare Service 2012/2013 Clinical Effectiveness

Safe use of blood and blood products

Clear policies and procedures ensure that blood and blood products are safely administered to the designated patient when clinical need indicates. These policies were reviewed this year to ensure compliance with NSQHS Standard 7, Blood and Blood Products and the Department Of Health Victoria, Blood Matters Program. Our Medical Practitioners meticulously determine the clinical need for the patient to receive blood or blood product as it is in such short supply and correct and timely use is paramount. Time is taken to discuss with our patients the need for blood or blood products and this year there has been 100% consent from patients to such care. Blood is stored in a designated fridge and monitored. All monitoring for the blood fridge will be recorded by twice a day at 0800 and 2000 hours any incidents where the wrong type of the RFID Tag located in the fridge. and temperatures are recorded. blood was administered to a patient It is monitored 24/7 by a computer or any adverse reactions to blood and Staff participate in annual mandatory program which sends alerts to the blood products. education online. This year 72% of nurses pagers and the maintenance Registered Nurses and Medication We are unwavering in our commitment officer via a text message when Endorsed Nurses completed the to ensuring the safety and quality of temperature alerts are outside range. Bloodsafe education package. our care with regard to use of blood When blood is stored in the blood and blood products. fridge, the fridge is monitored manually, During 2012-2013, there were not

Management of nutrition

During the year Timboon and clients through the District Healthcare Service has engagement of multi- reviewed its nutritional management disciplinary healthcare of clients. The intent is to ensure teams, as well as that all acute inpatient, residential retaining a positive and respite clients receive nutrition mealtime experience for screening and assessment. acute patients/residents and respite clients of This is due to the importance of Timboon and District good nutrition in overall wellbeing. Healthcare Service. All patients, residents and clients admitted to the health service undergo Auditing of our the malnutrition screening tool as implementation of this • Our recommendations presented part of their clinical risk assessment. process concluded that: to nursing staff concluded that: This process ensures that all clients • 75% of patients had their weight • Ensure weight is recorded on at risk of malnutrition are referred to documented on admission; admission for all patients, and : our dietician. The outcome of this • 75% of patients underwent the • Ensure risk screen occurs for all process maximises nutritional care of malnutrition screening tool. patients. acute patients/residents and respite

quality of care report 27 Clinical Effectiveness

Medication safety

Accurately dispensing and administering medications to TDHS Medica,on Incidents patients and residents in our care is 2012-­‐2013 critical for their safety. By Severity Over the last 12 months the number of medication incidents has increased 23 each month, with six incidents 25 reported in May and five in June, 20 compared to lows of 0 and 1 in September and October 2012. The 15 10 increase in reported incidents is due 10 to improvements in staff knowledge 5 0 0 on correct medication management procedures in adherence to NSQHS 0 Standard 4, Medication Safety. Overall Near Miss/ No Harm Mild Moderate Severe Timboon and District Healthcare Service had 33 reported medication and provided to the patient or carer. APPROPRIATE DISPOSAL OF incidents with 23 being no harm/near This information includes changes MEDICINES miss and 10 being mild. The reported made to the medicines during the To ensure accountability for all incidents have occurred during staff episode of care. auditing and checking procedures. medications and to reduce medication This indicates that these procedures wastage, Timboon and District are occurring and need to continue to REVIEW OF MEDICATION Healthcare Service developed an ensure medication policy compliance. MANAGEMENT POLCIES appropriate disposal of medications system. This involves a Pharmaceutical This has ensured that the appropriate On each occasion a medication Waste Log whereby a record is kept of legal and safe practice with respect to incident occurs, the Nurse Unit drugs and reasons for their disposal. medication administration practices Manager and clinical team discuss This enables a three-monthly analysis within Timboon and District Healthcare the error and detailed actions are of medication disposal and will improve Service and outlines the procedure for put in place to ensure the safety pharmacy maintenance. of the patient, either by additional storage, supply, disposal and security patient observation or providing the of medications. Policies are now in line drug when the omission has been with NSQHS standard 4, Medication recognised if appropriate. Safety. Other improvements around medication safety have included the ROTATION OF STOCK introduction of: Rotation of Stock via the introduction MEDICATION HISTORY AND of a coloured coding per year to MANAGEMENT PLAN ensure out of date medication is not The introduction of the medication used and disposed of appropriately history and management plan (MHMP) and that the drugs closest to expiry has ensured all acute patients have are used first to minimise medication a documented medication history waste. This process allows for timely and on admission. At the end of each ordering of common medications and episode of care the verified information reduces the likelihood of overstocking is transferred to the next care provider or expired stock on shelves.

28 Timboon and District Healthcare Service 2012/2013 Our Services Meeting the needs of the Timboon and Cobden communities

Acute Hospital Care Home and Community Care - Primary Care Services • 24-hour Urgent Care Centre Aged & Disability Support • Audiology (private) • Day Surgical Procedures • Assessment and Case • Counselling • Diagnostic Procedures Management • Chiropractic (private) • General Medicine • Delivered Meals • Nutrition • Midwifery Services • Domestic Assistance • Dental (public & private) • Obstetrics/Gynaecology • Home Maintenance • Occupational Therapy • Palliative Care • Personal Care • Osteopathy (private) • Respite Care • Physiotherapy Diagnostic Services • Community Transport • Podiatry (public & private) • Pathology • Planned Activity Groups • Social Work • Radiology • Visually impaired group • Speech Pathology

Aged Care – Residential and Exercise and Rehabilitation Support Groups Home-Based Services Programs • Arthritis • Aged Residential and Respite • Body Balance • Diabetes Support Care • Bounce Back with Babes • Visually Impaired • Community Aged Care • Strength Training & Circuit • Chronic Illness Peer Support • Services to older persons in their • Men Only Strength Training own home • Tai Chi Youth Services • Strong Women • Counselling Community Nursing • Heartmoves • Youth Activities • Continence Resource • Balance + • Youth Access Centre • Chronic Disease Management • District Nursing Health Education We work closely with regional • Diabetes Education • Childbirth Classes and specialised health services to • Maternity Outreach/Domiciliary extend and coordinate the scope Visits Health Promotion of services available to our local • Palliative Care Nursing • Asthma Education community • Post Acute Care • Community and school-based • Women’s Health education programs • Health Screenings

Concerns or compliments Timboon and District Healthcare Service invite any comment you may have about the care or service provided by our health service; this provides an opportunity for service improvement. Concerns or compliments may be directed to the Chief Executive Officer on 03 5558 6000 If the matter is not resolved to your satisfaction, the Health Services Commissioner who assists with complaint resolution, can be contacted on 03 9655 5200.

quality of care report 29 21 Hospital Road, Timboon, VIC 3268 p: (03) 5558 6000 f: (03) 5598 3565 e: [email protected]

www.timboonhealthcare.com.au

30 Timboon and District Healthcare Service 2012/2013