Peninsula Health Quality of Care Report

2 011 Contents

Welcome 1 Reporting to our community 2 Teamwork builds effective communities 3 Teams promoting a healthy community 13 Listening to our consumers 17 Strong governance supports teams 19 Streamlining services 21 Improving quality and safety 33 Continuing care 42

Fast facts 2010/11 Each month at Peninsula Health, an average of: During the year a total of: 203 babies were born 77,875 people presented to our emergency departments 662 children (0–16 years) were admitted to our hospitals for treatment 72,560 patients were admitted to our hospitals 1,266 children (0-16 years) were treated in 15,893 surgical procedures were carried out at our emergency departments Peninsula Health 6,490 patients were treated in our 97,341 community mental health occasions emergency departments of care were provided 2,044 people were admitted for hospital 128,937 community health courses of care treatment from our emergency were provided departments 18,125 allied health courses of care were 408 emergency surgical procedures provided were performed 23,770 dental courses of care were provided 513 elective surgical procedures were 2,612 occasions of service were provided performed at our various diabetes clinics at 7,921 prescription items were dispensed 8,800 X-rays and medical imaging 7,915 drug & alcohol courses of care procedures were performed were provided 8,112 community mental health occasions of care were provided 5,410 community health courses of care were provided 187 inpatient rehabilitation treatments were provided 106 patients were admitted to our Front cover: Joyce Beach, pictured here with nurse Hospital in the Home service, and an Lisa Taylor, receives regular blood transfusions at average of 802 visits were carried out Peninsula Health. See page 33 for details of the 166 cardiac cases were treated ACHS Quality Improvement Award that we received for improving compliance in gaining consent for 294 cancer treatments were provided blood transfusions. Welcome

On behalf of Peninsula Health’s Board of As the leading provider of Directors and our staff, we are pleased to Aboriginal and Torres Strait present the 2011 Quality of Care Report, Islander (ATSI) primary care which outlines our progress in improving the on the Mornington Peninsula, healthcare we provide for the local community Peninsula Health continues in Frankston and the Mornington Peninsula. to experience increases in ATSI inpatient admissions, Thanks to the hard work of our teams of staff, Emergency Department volunteers, consumer representatives and presentations, and Community the Board, our achievements in delivering Health registrations. Our a high standard of care were recognised ATSI Consumer Advisory by the Australian Council on Healthcare Group plays a key role in Standards (ACHS) during the organisation- ensuring that our services are wide EQuIP survey which took place in May accessible and appropriate for 2011. ACHS surveyors awarded Peninsula Indigenous clients. In 2010, we Health 22 Excellent Achievement ratings and acknowledged the passing of commended the systems and processes in Aunty Rhoda Green, a local place in a number of areas. Peninsula Health Aboriginal Elder, and the was accredited for a further four years. wonderful commitment that In this report you will read how our teams are she made to the Health Service. improving healthcare for each consumer who Your feedback is very important accesses our services. A few examples include: to Peninsula Health. It helps us to identify our • The launch of a ‘smoke free’ policy across strengths and weaknesses and to improve the all Peninsula Health sites, with support and quality of the services we provide. We invite you resources for people who want to quit smoking to have a say in your health service by telling us • Implementation of an Acute Stroke Response your concerns and suggestions, and letting us team for patients who present to our know if you are happy with the care provided by Emergency Department with a suspected Peninsula Health. stroke or mini stroke If you would like to take a more active role, • Introduction of a new Ambulatory Clinic in the you can apply to join one of our 14 Consumer Women’s Health Unit for women experiencing Advisory Groups as a consumer representative problems in early pregnancy or, as vacancies occur, the Consumer Advisory Committee. Alternatively, we welcome your • Major improvements to the consent process help, skills and commitment as one of our for blood transfusions, which were recognised wonderful volunteers. with an ACHS Quality Improvement Award • Launch of our Speak Up campaign to encourage patients to be actively involved and informed about their medication management • Enhancement of the Transition Care Program Dr Sherene Devanesen to include patients under 65 years of age with Chief Executive high level care and complex needs • Enhancement of our volunteer training program, and recognition of the dedication of volunteers like Gus de Groot who received an Outstanding Individual Achievement Award in Mr Barry Nicholls the 2011 Minister for Health Volunteer Awards. Chairperson, Board of Directors

Peninsula Health Quality of Care Report 2011 1 Reporting to our community

This year’s Quality of Care Report gives us the opportunity to share information about the initiatives and teamwork involved in improving the quality of healthcare for our consumers.

All Victorian health services are required to For more information about report on quality activities throughout the our services and programs financial year. This report addresses Victorian Department of Health (DH) criteria for quality Phone Public Relations & Marketing on reporting including new criteria for 2010/11 (03) 9788 1501. for community participation achievements, Or visit www.peninsulahealth.org.au safe management of blood and blood and follow the links for Patient / Visitor products, and health promotion. Information – Services A-Z. In response to feedback from consumers, this Quality of Care Report 2011 includes more information on Community Services Ensuring quality and our Emergency Departments. Accreditation is a process that assesses whether healthcare services comply with recognised standards and quality of healthcare. Accreditation Distribution of the of Australian health services is carried out by Quality of Care Report independent bodies to specified criteria. The Quality of Care Report is distributed each year at Peninsula Health’s Annual General Meeting. We also distribute it to EQuIP review patients, clients, residents in our aged care In May 2011, Peninsula Health took part in a facilities, visitors, healthcare partners, comprehensive, organisation-wide review by GP clinics, and community leaders. the Australian Council on Healthcare Standards You can read the report on our website at (ACHS). The ACHS accreditation process involves www.peninsulahealth.org.au. a four-year cycle of assessments against a set of comprehensive standards (ACHS EQuIP - If you would like to suggest any new areas for Evaluation and Quality Improvement Program). inclusion in next year’s Quality of Care Report, please fill out the enclosed feedback form and Peninsula Health was able to demonstrate safe, send it back to us. We also invite you to give us high quality care when we were surveyed in your feedback at www.peninsulahealth.org.au. May 2011, and ACHS surveyors awarded us 22 Just follow the links for Contact Us. Excellent Achievement ratings. Peninsula Health was fully accredited for another four years.

To pass on a compliment or express a concern ACSAA review All residential aged care facilities must be Phone Customer Relations on (03) 9784 7298. accredited by the Aged Care Standards and Or visit www.peninsulahealth.org.au Accreditation Agency (ACSAA) in order to receive and follow the links for Patient / Visitor funding from the Australian Government. Information – Suggestions and Complaints. Peninsula Health’s residential aged care facilities are fully accredited by ACSAA and will be reviewed again in 2012.

2 Peninsula Health Quality of Care Report 2011 Teamwork builds effective communities

Community participation Our aim is to actively engage with our community, to listen to what it says, and to Community participation at Peninsula Health act on feedback to enhance the quality of care is about consumers, carers and the community that we provide to our community. having their say, listening to the views and ideas of others, and working together to help Community participation within Peninsula Health the Health Service respond to and reflect is supported by an Executive Director and community needs. dedicated staff who support our 857 volunteers, Community Advisory Committee (CAC), and a Peninsula Health’s strong commitment to network of 14 Community Advisory Groups (CAGs). community participation is demonstrated through the involvement of consumers and Our Community Participation Plan focuses on community members in a wide range of person-centred care and has been developed planning and service delivery activities across with input from the whole Health Service the Health Service. Community participation at including the CAC, CAGs and volunteers. Peninsula Health is guided by the Department Consumer ideas and suggestions are logged of Health’s policy of ‘Doing it with us not for us’, onto our newly developed Consumer Register, which grew from the Victorian Government’s which will enhance consumer participation commitment to involving people in decision planning, implementation and delivery of our making about healthcare services. programs and services.

Peninsula Health Board of Directors

Chief Executive

Executive Director of Community Participation

Peninsula Health Community Advisory Committee

Southern Westernport MEPACS Frankston/Northern CAG CAG CAG CAG

Southern Hepatitis Aids Youth Disability Older persons/ Resource Prevention CAG CAG Carers CAG Service (SHARPS) CAG

Cultural and Linguistic Aboriginal and Mental Health Community Diversity (CALD) CAG Torres Strait Islanders CAG Health CAG (ATSI) CAG

Gay, Lesbian, Bisexual, Women’s, Children’s Transgender & Intersex CAG & Adolescent CAG

Peninsula Health Quality of Care Report 2011 3 Teamwork builds effective communities

Doing it with us not for us: our progress

Peninsula Health’s Community Participation The plan describes 50 projects that aim to Plan 2009-2012 was developed with input from ensure a better consumer experience. We have consumers, carers and the community as well completed 21 of these projects, and a further as Peninsula Health staff. 21 are in progress. The remaining eight projects are in the early stages of development.

Priority action Outcomes The organisation All eight strategies in the Department of Health’s ‘Doing it with us not for demonstrates commitment us’ Strategic Direction 2010-2013 have been achieved through consumer, to consumer, carer and carer and community member involvement in the development and community participation implementation of: appropriate to its diverse • Community Participation Plan communities. • Disability Action Plan, CALD Plan and GLBTI Plan Target 75% • Improving Care for ATSI Patients Program Achieved 88% • Community participation systems, processes and structures and capacity building activities • Reporting on community participation to the wider community using a range of approaches including the Quality of Care Report.

Consumers and, where • A Consumer Participation indicator score on the Victorian Patient appropriate carers are Satisfaction Monitor of greater than 75% was achieved at Frankston and involved in informed Rosebud Hospitals. decision making about • 94% of clients /carers were satisfied or highly satisfied with their their treatment, care and involvement in decisions about their care or treatment in our Community wellbeing at all stages and Health centres. with appropriate support. • 79% of achievem