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Annual Safety & Quality Account Annual Safety & Quality Account 2019-20 REPORT 2020-21 FUTURE PRIORITIES 2019-20 REPORT / 2020-21 FUTURE PRIORITIES / 1 Acknowledgement of Country The District operates on the lands of the Dharawal and Yuin nations, which encompass five language groups: Wadi Wadi, Dharawal, Wandandian, Walbanga and Yuin. These groups have lived in the Illawarra and Shoalhaven region for millennia, and their cultures, laws, ceremonies and connection to the land and waterways are strong and enduring. We pay our respects to Elders both past and present and acknowledge that Aboriginal people are the oldest living continuous culture and have been here for over 65,000 years. They have remained strong, resilient and resourceful and have a continuing connection to our culture, lands and waterways. The District’s approach to improving the health of Aboriginal residents includes the development and implementation of strategies to enhance health service provision that incorporate accessing both mainstream and supplementary Aboriginal specific services. Artist: Aunty Cecily Wellington-Carpenter 2 / ANNUAL SAFETY & QUALITY ACCOUNT Message from the Chief Executive & Board Chair SAFETY AND QUALITY ACCOUNT FOR ILLAWARRA SHOALHAVEN LOCAL HEALTH DISTRICT The 2019-20 Safety and Quality Account has been endorsed this report signals plans for continuing improvements to by the Board of the Illawarra Shoalhaven Local Health safety and quality into the future. District (ISLHD). Responsibility for ensuring effective clinical The District has decided to participate in the short notice governance frameworks rests with the ISLHD Board. These accreditation assessment process, where we will be frameworks support the maintenance and improvement of measured against the National Safety and Quality in standards of patient care and the services we provide. Healthcare Standards (NSQHS). For that reason, a key focus The report that follows demonstrates the commitment of over the coming year is preparation for accreditation of our ISLHD to improving healthcare for the people of the District. Local Health District against those standards. In addition to reporting on achievements over the past year, Professor Denis King OAM Ms Margot Mains Board Chair Chief Executive 2019-20 REPORT / 2020-21 FUTURE PRIORITIES / 3 CONTENTS 1. ABOUT ISLHD ............................................. 6 2. ACHIEVEMENTS IN • Commitment to Safety and Quality SAFETY & QUALITY ................................14 • Our Core Values Commitment • Planning Processes • About us • Governance Structures Clinical Governance - National Standard 1 • The people who live here • Improvements achieved in Safety & Quality • Our Health - Our COVID-19 Pandemic Response • Our Strategy at a Glance - Suicide Prevention Collaborative • Our Vision and Purpose - Osteoarthritis Chronic Care Program. Taking • Improvements in the quality of Control – Improving Quality of Life in Patients health service provision with Appropriate Conservative Care Options A Snapshot of Achievements over - Time is Brain. Implementation of BEFAST the previous 12 months - Implementation of a Chest Injury Care Bundle Prevents Adverse Events - Reducing the incidence of severe perineal trauma in childbirth • Progress on planned activities from the 2018-2019 Safety & Quality Account - A ‘Coping with Pain’ Program for Arabic speaking and refugee women in the Illawarra Shoalhaven - Transforming Healthcare through Outcome Measures for Rectal Cancer - Osteoporosis Re-fracture Prevention - Delivered improvements to oral health services for vulnerable and Aboriginal families > Mum and Boori’s Mouths Matter > Our Mia Mia Front page aerial photograph courtesy Andy Zakeli. 3. IMPROVING THE PATIENT 5. OUR PERFORMANCE ..............................46 EXPERIENCE .............................................31 Key Performance Indicators for Formal Results Partnering with Consumers - National Standard 2 • Strategy 1: Keep People Healthy • Patient Reported Experience • Strategy 2: Provide World-class Care • ISLHD’s Partnering with Consumers Framework Where Patient Safety is First 2018-2021 • Strategy 3: Integrate Systems to • Partnering with Consumers in Governance, Planning Deliver Truly Connected Care and Design • Strategy 4: Develop and Support Our • Patient information Portal (PiP) Review People and Culture • Partnering with Consumers Intranet Page • My Care Boards 6. FUTURE PLANS – SAFETY AND • Achievements in Improving the Patient Experience QUALITY PRIORITIES 2020 ..................64 - Drug and alcohol film resources for community • Annual Focus Areas and Priorities for Performance members from new and emerging language Improvement backgrounds • Safety & Quality priorities and initiatives 2020-2021 - Chatty Children – Working with Community to Improve Speech Outcomes for our Boori’s, Child - Short Notice Accreditation Assessment Program and Family Service (SNAAP) - ED Transformational Redesign Program - A Patient Reported Outcome Measure (PROM) 4. WORKPLACE CULTURE THAT for Diabetes with Aboriginal Communities in the Southern Shoalhaven region DRIVES SAFE AND - Virtual Community Care Centre QUALITY CARE .........................................39 - Choosing Wisely – promoting appropriate • Improvement Science Program diagnostic ordering practices • Effective Leadership in Health Program • Achievements in improving workplace culture - Our Attitudes Matter. Enhancing ISLHD’s Culture 7. APPENDICES ............................................74 of Safety • ISLHD Attestation Statement - The SEED Program • 2019 & 2020 Quality Awards • 2020 Excellence in Nursing and Midwifery Awards • 2019 Staff and Volunteer Recognition (SAVR) Awards • 2019 NSW Premier’s Awards 2019-20 REPORT / 2020-21 FUTURE PRIORITIES / 5 1. About ISLHD The Illawarra Shoalhaven Local Health District (ISLHD) provides health services for the residents of the Illawarra Shoalhaven region, NSW COMMITMENT TO SAFETY AND QUALITY Statement on safety and quality from the ISLHD Chief Executive The delivery of safe, reliable and equitable health care, where people are the primary focus, is the core purpose of the Illawarra Shoalhaven Local Health District (ISLHD). Despite the many challenges and unprecedented circumstances that we’ve faced over the past 12 months, the District’s The COVID-19 pandemic has added both challenges and commitment to ongoing improvements in safety and quality opportunities to our objectives. There’s little doubt that the across all of our services has never been stronger. I am innovations developed during COVID to support safe and quality incredibly proud of the dedication and steadfast resolve of our care will have lasting impacts on the way we deliver services to staff, who’ve intensified their focus on safety and quality in the our communities. This includes the use of virtual and telehealth face of adversity, and at a time when our resilience has been technology, which will continue to be advanced over the next year. continually tested. Our patients, consumers and carers have again played an We should all be proud of the significant enhancements to important role in shaping the District’s improvement plans. safety and quality over the 2019-20 period, which have led Engaging with consumers provides valuable insights that are to real benefits for our patients and their health outcomes crucial to safety and quality improvements, and the District will including; Shoalhaven Hospital becoming the first in Australia to continue to develop these partnerships as a key priority over the implement a specialised stroke assessment tool where time to next 12 months. treatment is crucial. The District’s other key areas of focus will include improving The District has made great inroads with our vulnerable patient experiences in our Emergency Departments, further communities including; improvements to oral health services for developing our integrated care delivery and addressing diabetes Aboriginal families, which supports new mothers to access vital within the local Aboriginal community. dental care for their families, while a dedicated program has seen I am pleased to present the Safety and Quality Account for 2019- the establishment of a culturally safe pain rehabilitation pathway 20, which summarises the District’s progress over the past year. for local Arabic women. I invite you to review the Account and provide feedback, as we The implementation of a chest injury program to prevent adverse work collectively to strengthen our services and meet the health events has earned a nomination in the NSW Premier’s Awards, as needs of our growing communities, now and into the future. has the program that’s working to improve outcomes for women Ms Margot Mains by reducing perineal trauma in childbirth and work undertaken Chief Executive measuring the safety culture across ISLHD. 6 / ANNUAL SAFETY & QUALITY ACCOUNT 2019-20 REPORT / 2020-21 FUTURE PRIORITIES / 7 ABOUT US The Illawarra Shoalhaven Local Health District (ISLHD) provides COLEDALE health services for the residents of the Illawarra Shoalhaven BULLI region – around 400,000 people. The Illawarra Shoalhaven extends WOLLONGONG from Helensburgh in the northern Illawarra to North Durras in the PORT KEMBLA southern Shoalhaven and covers the Local Government Areas of SHELLHARBOUR Wollongong, Shellharbour, Kiama and Shoalhaven. The region’s landscape concentrates residential areas into a narrow strip of KIAMA suburban communities and coastal towns. DAVID BERRY ISLHD is one of the region’s largest employers with a workforce of more than 7,300 staff.
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