REPORT2012 - South West Alliance of Rural Health

QUALITY OF CARE
REPORT2012

contents:
Welcome to the 2011-12
Quality of Care Report................... 3
Vision, Mission & Values................ 4
Our Location................................... 4
Services.......................................... 4
Keynote Improvements.................. 5
Our Community.............................. 5
Consumer Focus............................ 6
Consumer, Carer
& Community Participation............ 8
Quality & Safety............................ 14
Continuity of Care........................ 29
Our Staff........................................ 35
Clinical Risk Management
and Quality Committee
Mr Ray Gilby – Board Member
Ms Anita Rank – Board Member
Mr Jim Harpley – Board Member (resigned)
Mr Ormond Pearson – Ministerial Delegate
Ms Ros Jones – Acting Chief Executive
Mr Frank Megens – Director of Nursing
Mrs Annette Hinchcliffe – Primary and Community Care Manager
Ms Wendy Buckland – Quality Coordinator
Ms Rachel Stoneman – Executive Administration
Distribution
3000 copies of the Quality of Care Report are printed, with 2000 copies
distributed throughout the Glenelg Shire via the Portland Observer.
Copies of the report are also distributed throughout Portland District
Health and GP and dental clinics. An electronic copy of the report is
available to download at Portland District Health’s website.www.pdh.net.
au
Reports are included in information packages for prospective employees
and distributed at the Annual General Meeting.
Contributors
Wendy Buckland, Rachel Stoneman, Ros Jones, Dr. Liz Mullins, Natalie
Herbertson, Gaynor DenBoer, Donna Eichler, Carolyn Malseed, Karen
Madden, Heather Sayner, Annette Hinchcliffe, Jacki Barnett, Loren
Drought, Rick Bayne, Ebony Yuill, Portland Observer.
2

Welcome to the 2011-2012
Quality Of Care Report
Welcome to Portland District Health’s Quality of
Care Report for 2011 / 2012. This report is published
each year in conjunction with our Annual Report.
Whilst the Annual Report focuses on the financial
aspects of our operation, the Quality of Care
Report informs our community about the services
we provide. This report is developed in line with
Department of Health guidelines and minimum
reporting requirements.
you expected. Your comments regarding this report
are welcomed and we try to incorporate suggestions
for improvement into subsequent reports. A feedback
form is provided for your convenience at the end of this
report.
At Portland District Health we continue to monitor our
performance against other like hospitals to ensure our
care is of a high quality. This report outlines the quality
of care that we as a health service are proud of, and
showcases our commitment to further developing the
services for the community.
We want to take this opportunity to thank the numerous
contributors to this year’s report, with particular thanks
to the clients who have agreed to tell their stories and
share their experiences with the community.
We invite you to read this report and reflect on your
experience at PDH. We welcome your feedback as
a means of checking that the services we deliver
either meet or exceed your expectations, or in some
instances, has not given you the desired outcome
Wendy Buckland,
Quality Coordinator
Ros Jones,
Acting CEO
3

The year in brief
Vision:
To be a leading rural health service
Mission:
Portland District Health (PDH) is
dedicated to providing a safe and
accessible health service responsive
to community needs.
Values:
Respect: Is a willingness to show
consideration to ourselves and others
Compassion: Is to acknowledge each
other’s humanity with understanding
and care
Partnership: Is working together to
achieve a common goal
Excellence: Is aiming to exceed
expectations in the provision of health
care and making best use of our
available resources
Equity: Is about fairness, justice and
endeavouring to do the right thing
• Allied Health Services
- Diabetes Education
- Dietetics
- Occupational Therapy
- Physiotherapy
- Podiatry
- Speech Therapy
• Cancer Link Nurse
• Community Nursing
• Community Rehabilitation
• Counselling
• CSSD
• Dental
• Diabetes Supply Scheme
• Dialysis
• District Nursing
• Drug and Alcohol
• Emergency Medicine
• Family Planning
• General Medicine
• HARP (Hospital Admission
Risk Program)
• Infection Control
• Lymphoedema
• Maternity Services
Services
• Operating Suite
- Dental Procedures
- Ear Nose and Throat
- Endoscopy
- General Surgery
- Gynaecology
- Obstetrics
- Ophthalmology
- Orthopaedic
- Urology
• Palliative Care
• Pharmacy
• Planned Activity Groups
• Post Acute Care
• Radiology
• Restorative Care
• Stomal Therapy
• Telecare
• Transitional Care Program
Our location
Portland is located in the Glenelg Shire in south west Victoria
Lake Mudio
Casterton
AUSTRALIA
VICTORIA
Melbourne
Dartmoor
GLENELG
SHIRE
Milltown
Nelson
Heywood
Narrawong
Portland
4

Keynote Improvements
• Implementation of Closing the Gap Steering Committee
• Telemedicine in Emergency Department
• Introduction of stress testing
• Formal adoption of COMPASS and ISBAR following trial
• Development of information sheets for medical imaging
patients
• Whiteboards in patient’s rooms
• Introduction of Person Centred Care policy organisation
wide
• Implementation of Restorative Care
• Implementation of Transitional Care Program
• Implementation of Clinical Management plan in Dialysis
• Private patient information brochure
• Provision of image CD for all impatient and Emergency
Department patients
• Implementation of Victorian inter-hospital transfer form
• Development of computer generated labels for pathology
tubes
• Implementation of national recommendations for labelling
of injectable medicines
• Electronic remote monitoring of drug refrigerators
• High risk food plan reviewed
• Implementation of “Softpacs” in dialysis
• Revision of occupational exposure kits
• Introduction of TB screening tool for new staff
• Development of QuAPP committee to streamline former
User groups.
• Implementation of Riskman Q, electronic recording of
quality activities.
• Implementation of falls recovery program
• Red sock trial
• Implementation of bedside handover
• ALS training on site for staff
• Coronial process education
• Appointment of community GP to board
• Appointment of general surgeon
• Revision of clinical handover between departments
• Beginning of oncology service with onsite consultation
process by Dr Khasraw
• Development of HRSS
• Pharmacy restructure to improve security and
confidentiality
• Implemented system to enable the shutdown of air
conditioning system, (follow chemical spill at Port of
Portland.
Complete review of emergency response system including
• Implementation of ICS
• Review of folders at each operation point
• Installation of glow in the dark evacuation arrows
• Review of site maps
• Re-engineering of manual call points with flashing LEDs
• Staff education including fire extinguisher training
• Mock evacuations
Our Community
Population Profile
The population of the Glenelg Shire in 2011 is estimated to be 19,575, a reduction of 1,292 since 2008. Of this
number 10,635 reside in the Glenelg (Portland statistical local area and 5,838 in the Glenelg (Heywood) SLA..
The Australian Bureau of Statistics indicated there were 5,288 males and 5,347 females residing in Portland.
The Indigenous population in the Glenelg Shire has increased from 359 to 405 from Census 2006 to Census 2011.
Portland Total People
in Australia
Population born in Australia 86.1% 69.8%
People with an Indigenous background 1.9% 2.3%
Lone Person Household 31.3% 24.3%
People Aged 25 and under 30.5% 32.6%
People Aged 25-54 39.3% 41.8%
People Aged 55-64 14% 11.6%
People Aged 65 and over 16.4% 14%
The majority of our population speaks
only English at home; Dutch, German,
Mandarin and Afrikaans are the most
common languages other than English.
5

Consumer Focus
Consumer Stories
Natalie and Joshua’s Story
Natalie has an older child Kate who was born at
South West Healthcare in Warrnambool in September
2010. She booked to have her second child at PDH
and wanted midwife care for this pregnancy. She was
hopeful that PDH would have a service on the day
her baby was born. Matthew Leeson, her partner,
accompanied her to PDH at 5am on the day of the
birth and baby Joshua was born a short time later. She
enjoyed care at PDH for 24 hours and was discharged
home with domiciliary postnatal care.
Richard’s Story
Richard Voss, 40,
weighed 136kgs, had
high blood pressure
problems, high
cholesterol and was
diagnosed pre diabetic.
In order to manage his
escalating problem,
Richard’s GP made
a referral to the LIFE!
Program. The program
consisted of a series
of meetings and focus
groups that discussed
issues including
goal setting, reading
food labels, exercise
programs and weight
management skills.
“I had tried to lose weight in the past through dieting
and joining weight loss programs with minimal success
as I struggled to keep the weight off,” Richard said.
Since undertaking the LIFE program he has lost 50kgs,
and more importantly has been able to keep it off. “I
have been able to set small achievable goals and I
have developed a new philosophy when it comes to
exercise that includes ‘focus on what you can do and
not on what you can’t do’,” Richard said. Since using
this strategy he can now jog 10kms where he could
previously walk only one kilometre.
“Since completing the LIFE! program my cholesterol
has come back to normal, my blood pressure is normal
and I am no longer a diabetic. I am enjoying life and am
pleased to share my experiences and successes that
include helping opening diabetes week in Melbourne
and supporting the local LIFE program,” he said.
6

Consumer Focus
Ken’s Story
When Dartmoor’s Ken Miller received a phone call
asking him to visit his doctor for the results of tests, he
knew the news wasn’t going to be good. “I had a rough
idea there was something wrong,” Ken admits.
Ken had been undergoing treatment for stomach ulcers
but the pills he was taking weren’t easing the pain and
reflux.
After consulting Dr Robin Stewart at Heywood he
was referred to Portland District Health to undergo an
ultrasound. An early stage bowel cancer was detected.
That was two days before Christmas last year. Never
one to shirk a challenge, Ken, 71, was keen to act
quickly. “I just said we’d better get something done
about it,” he said.
On January 9 he had an appointment with PDH surgeon
Mr Thair Abbas and on January 31 he underwent
a bowel resection operation. It was a timely and
successful outcome.
Ken’s successful procedure was the first laparoscopic
bowel surgery undertaken in Portland and he
appreciated not only the quick turnaround but also the
quality of care. The quick action meant Ken’s cancer
was caught and removed in the early stages. Now he
is back in good health and able to support his wife
Rhonda who is facing her own health problems.
“I have nothing but praise for all the nurses and Mr
Abbas. Everything was excellent,” He said.
7

Consumer, Carer &
Community Participation
Consumer Feedback
At Portland District Health we value our community’s
feedback, whether it is a compliment or a complaint.
It is always nice to receive a compliment but
more importantly feedback is the opportunity for
improvement as the information provides us with an
insight into your experiences whilst in our service.
Often a small matter can be resolved swiftly and easily
by speaking to a staff member, such as the need for an
extra blanket or a menu request. Our staff are receptive
to suggestions and should the care not meet your
expectations, you are encouraged to let us know.
Should you wish to make a formal written complaint
there is a process by which the complaint is logged
on a register with a requirement to acknowledge
receipt of the complaint within 48 hours, and to have
all complaints closed within 30 days. This register is
managed by the Quality Coordinator who ensures the
most appropriate manager investigates the issue and
implements any changes or improvements required.
During the 2011/2012 financial year, 40 complaints
were received at Portland District Health. This was an
increase of 5% on the previous year. We believe this
increase is due to our efforts to increase consumer
feedback. We have recently revised our “Compliments,
Suggestions and Feedback” brochure and ensured it is
readily available in all departments.
20
18
16
14
12
10
8
6
4
2
0
Discharge
Privacy
Communication
Clinical / Service Delivery
Other
Consent
2010-2011
2011-2012
“
My treatment as a dialysis patient for 2
weeks whilst on holiday. The staff were very
attentive to my needs. Anne kindly arranged
I
for a doctor to visit me as I was unwell.
Thank You to all! Look forward to visiting
again. Will recommend unit to others.”
Visiting Dialysis Patient
“
would like to compliment the Dr’s and
nursing staff for their work and the way
they looked after me. I found them very
caring and understanding.”
South Ward Patient
8

Consumer, Carer & Community Participation
Victorian Patient Satisfaction Monitor (VPSM)
In addition to internal feedback received from the
community through family meetings, face to face
conversations, complaints and compliments, we
obtain consumer feedback externally through the
Department of Health Victorian Patient Satisfaction
Monitor (VPSM).
The VPSM is conducted by Ultra Feedback for the
Department of Health on a six monthly basis, randomly
surveying patients who have used the services of a
Victorian hospital during that period.
PDH is benchmarked against 16 other Category C
hospitals and our most recent result, to the time of this
report, was for the period July – December 2011. This
report provides us valuable insight into our performance
and helps us identify areas for improvement. The
outcomes are communicated to all staff at PDH and
specific issues forwarded to the relevant department
managers for review and improvement. Our performance
is displayed in the accompanying graph.
It shows PDH exceeds the state average in every
category and exceeds similar Category C hospitals in all
but one category.
Physical Environment
Consumer Participation
Complaints Management
Discharge and Follow Up
Overall Care
General Patient Information
Treatment and Related
Information
Access and Admission
State
Category C
PDH
70 75 80 85 90
“
The staff at PDH are fantastic. I could not
Thankshave
asked for better care. Keep up the
good work everyone.”
Surgical Day Procedure Patient
Dr Baker was a pleasure to deal
with; especially making my 3yo comfortable.
A lovely hospital to visit we’re from Geelong!
“Thank you very much.” Parent of Patient
9

Consumer, Carer & Community Participation
Consumer Participation
At PDH we understand that people who take part in
decisions concerning their health care often have an
improved quality of life, get well faster, and have a
better experience of care.
The National Safety and Quality Health Service
Standards expect three criteria to be addressed and
met when considering effective partnerships with
consumers.
• Consumer partnership in service planning
• Consumer partnership in designing care
• Consumer partnership in service measurement and
evaluation
By addressing these three criteria, PDH believes it
will achieve effective meaningful participation with
consumers, carers and community members.
There are a number of ways to participate in your
care. PDH aims for consumers, carers and community
members to experience a variety of opportunities to
ensure they are central to their care.
Day to day strategies include:
• Patient centred care policy
• Sharing of information
• Family meetings
• Co-signing of care plans
• Whiteboards at patients’ bedsides
• Bedside handover
• Provision of feedback
Consumer Advisory Committee
The establishment of a Community Advisory Committee
is a priority of PDH to increase consumer, carer and
community participation and we have established a
working party to achieve this goal.
This will be an advisory committee to the Board of
Management and will provide a central focus for all
strategies relating to consumer involvement across
PDH. The responsibilities of the committee will be to:
• Promote the value of consumers, carers and
community participation in the delivery of services at
PDH
• Identify and advise the Board on priority areas and
issues requiring consumer participation
• Participate in relevant organisational opportunities
• Facilitate two way communication between
consumers, carers and community groups
• Participate in Quality of Care Report
While no formal qualification is required to become a
member of this committee, members will need to be
active in the community with a sound understanding of
local and regional issues with experience as a consumer,
carer or involvement in a community group.
The PDH working party has drafted a committee
charter, an application process to recruit members and
a position description for those members. It is expected
the Consumer Advisory Committee will commence by
the end of 2012.
10

Cultural Awareness
Raising Staff Awareness of Aboriginal and Cultural
Needs
Portland District Health has systems in place to ensure
all care and services are provided in a culturally sensitive
and appropriate manner for all people from culturally
and linguistically diverse (CALD) backgrounds. PDH has
in place a CALD plan which includes local Aboriginal
people.
Identification of Aboriginal People
At PDH we understand that we cannot guess or make
assumptions about the Aboriginal and Torres Strait
Islander or non-indigenous status of any client. This
can only be clearly determined by asking each and
every client about their Indigenous status. To improve
care for Aboriginal and Torres Strait Islander people,
key PDH staff will be undertaking education and
training to improve self-identification. Some staff have
already attended a trial of this program which is under
development.
Staff Education
Our monthly orientation program for new staff includes
a session on cultural diversity, developed and presented
by a staff member from Dhauwurd-Wurrung Elderly and
Community Health Services (DWECH) and providing
important information on cultural awareness.
In addition, PDH staff present a one day training session
for DWECH staff, which includes infection control,
basic life support, quality systems and fire training. This
provides the opportunity to exchange information and
share ideas to enhance cultural awareness and develop
relationships.
Interpreter Service
Portland District Health staff and patients have access
to telephone interpreting services with supporting policy
and procedure documents on how to access the service
to ensure communication between all parties is possible.
A Culturally Diverse Workforce
Portland District Health understands the importance of
having cultural diversity in the workplace and believes
in giving everyone the opportunity to learn and develop
their personal and professional abilities.
Improving Care for Aboriginal and
Torres Strait Islander People
Closing the Gap is a national strategy to reduce
Indigenous disadvantage, reduce the life expectancy
gap and halve childhood mortality.
In September 2011 PDH and DWECH signed
a Memorandum of Understanding, the specific
agreements of which are:
• to deliver a suitable Aboriginal hospital liaison
service
• to improve Aboriginal self-identification
• build the capacity for PDH to provide culturally
appropriate services
• to construct a seamless transition between DWECH
and PDH for Aboriginal people
• to build the capacity of DWECH and the Aboriginal
community to work in partnership with PDH.
A Cultural Safety steering committee was formed in
partnership with DWECH to monitor achievements
of the bilateral agreement as expressed in the MOU.
Both PDH and DWECH have representatives on this
committee. PDH plans to extend this opportunity and
model of care to other Aboriginal health care services in
the area.
A model of care is being developed to provide a
contracted Aboriginal Hospital Liaison Officer service to
Aboriginal people accessing care at PDH.
The liaison officers will be orientated to the PDH facility
and system and work closely with PDH to provide
advocacy and support to Aboriginal patients.
14%
of PDH staff are
from a culturally and
linguistically diverse
background
PDH employs health professionals from a variety of
cultures, these include:
India, Sri Lanka, Lebanon, Jordan, China, Korean, South
Africa, Zimbabwe, Indonesia, Philippines, Yugoslavia,
Argentina, Syria, Namibia, Ukraine, Canada, Fiji.
11

Consumer, Carer & Community Participation
Volunteers
PDH volunteers provide invaluable support to a
range of programs. We have 235 active volunteers
within our organisation. These volunteers have
contributed an average of 1,338 hours per month.
This year thanks to Portland Aluminium under its
Partnering Stronger Communities initiative we have
purchased an electronic volunteer database - Volunteer2
IMPACT Enterprise Edition. The database was launched
at our volunteer morning tea held during National
Volunteer Week in May 2012.
To thank our volunteers for their precious time and
effort, two functions were held for PDH volunteers; a
morning tea for National Volunteer Week and an end of
year BBQ held on International Day of the Volunteer.
18,000
16,000
14,000
12,000
10,000
8,000
6,000
5,000
2,000
0
Volunteers Hours
2008 2009 2010 2011 2012
If you would like more information or would like to
be a part of our volunteer team, contact Carolyn
Malseed, Volunteer Coordinator on (03) 5522 1180.
The Telecare team was an award recipient at the
Australian Government National Volunteer awards 2011.
Telecare is a telephone service providing reassurance
and social support to Home and Community Care
clients living at home. This service operates from
Monday to Friday and currently about 30 clients receive
a friendly ‘good morning’ call from a trained volunteer.
The Telecare program is in its 27th year. There are 21
dedicated volunteers involved in the program, with a
number of volunteers being involved in the program for
more than 15 years.
Faith Sutterby was invited to attend a reception at
Government House, Melbourne, which was attended by
Queen Elizabeth II and Prince Phillip in October 2011.
This invitation was extended to Faith as a result of her
winning the Outstanding Individual Achievement award
at the 2011 Minister of Health Volunteer awards.
At the 2012 Minister of Health Volunteers awards,
recognition was given to Claire Stuchbery who was
awarded Winner of Outstanding Individual Achievement.
Claire received this award for her dedicated service
to Meal on Wheels since 1976. Claire is a committed
volunteer; she is reliable and always willing to put herself
forward for any extra work that may be needed.
Clarie Stuchbery receiving her
Outstanding Achievement Award
from the Minister of Health
12

What do our Volunteers think
Volunteer Survey
In order to continue to improve our volunteer program, a
survey was sent to all volunteers for their feedback. The
survey will be sent to all volunteers annually.
Some general comments:
• a towns hospital is vital to everyone’s well being and
confidence so being part of the team is rewarding
• love the friendly atmosphere, my day is an important
part of my week. Friendships that have developed
are very special
• I like to think we as volunteers can make a small
difference being there when we are needed to
do jobs which are time consuming and takes the
employee away from important tasks.
• the meals on wheels is a good service. I am happy
to help to deliver these meals when possible
40
35
30
25
20
15
10
5
0
Satisfied
Enough tasks
Not challenging enough
Feedback on your current volunteer role
with Portland Disitrct Health
Times/days suitable
Need more training
Dissatisfied
Too many tasks
Too challenging
Change in hours, days preferred
Out of pocket expenses an issue
Not enough tasks
Years of service - Volunteers 2012
25 years
• Lyn Buchanan
• Ellie Lane
• Hazel Short
20 years
• Betty Hollis
• Neridah Osborne
15 years
• Heather Buckley
• Yvonne Crooks
• Shirley Earl
• Mary Holland
• Josephine Simpson
• Heather Phillips
• Kevin Phillips
• Patricia Punch
• Lodge of Memories
• Portland Rotary Club
10 years
• Ian Campbell
• Judy Dolheguy
• Linda Kenna
• Jeff Klar
• John Sealey
• Thelma Sealey
• Ida Tevelein
• Margaret Logan
• Ann Parry
• Pat Smale
• Mary Voglino
• Robert Voglino
• Irene Vorwork
• St John’s Lutheran School
5 Years
• Patricia Barker
• Ken Bridgewater
• Joe Goebel
• Julie Hart
• Graeme Hayes
• Carmelite Ruge
• Phillip Ruge
13

Quality & Safety
What is quality, what does it mean
In broad terms, quality of care reflects the extent to
which a health service produces a desired outcome.
It is about the processes and structures which
ensure safe care is provided in an appropriate,
effective, responsive, continuous, sustainable and
accessible manner.
Community and clinicians may value different aspects
of quality care. While the clinical focus is on results of
clinical care and consumers consider aspects relating
to timeliness, access, and communication, they all
agree that the key to providing a quality health service is
about the health service offering skilled and competent
staff, a clean, safe and welcoming environment and the
appropriate service to Portland and district.
Committee Reporting Structure
Board of Management
Internal
and
External
Audits
Quality and Financial Risk
Management Committee
Audit and
Risk Committee
Credentialing & Scope
of Practice Advisory
Committee
Finance
Aged Care
Community
Advisory
Committee
Drugs and
Therapautics
Infection Control
Emergency Response
Health Safety and
Environment (OH&S)
Information
Communication and
Technology
Health Information
& Forms
Medical Imaging
Mortality & Transfer
Primary and
Community Care
14
QuAPP Committee
• Acute
• Sub-Acute
• Emergency
• Maternity
• Theatre
• PCC

Quality & Safety
Clinical Governance
Clinical Governance – What is it
Clinical governance is about being accountable for
providing good safe care and continuing to improve
patient/client safety. The four guiding principles to
effective clinical governance are:
• Build a culture of trust and honestly through open
disclosure in partnership with consumers.
• Foster organisational commitment to continuous
improvement
• Establish rigorous systems to identify, monitor and
respond to incidents
• Evaluate and respond to key aspects of
organisational performance.
The Department of Health released the Victorian
Clinician Governance Policy Framework in 2009 to all
public health services to implement. We continue to use
this framework as a guide to ensure we have systems
and processes in order to ensure safe and effective care
to our community.
The Board of Management of Portland District Health
has a number of committees to ensure a safe and
effective workplace. The committees are:
• Audit and Risk
• Finance
• Clinical Quality and Risk Management
• Credentialing
The Clinical Quality and Risk Management committee’s
primary function is to assist the Board of Management
to ensure a high standard of health care, a continuous
improvement of service delivery, and to maintain an
environment that supports clinical excellence at Portland
District Health.
This committee meets monthly and has a number of
committees reporting to it monthly.
A Safe Workforce
To provide the best possible care to patients and
clients, Portland District Health ensures all staff are
appropriately trained and qualified for the position they
are employed in. The Human Resources Department at
PDH checks the following for all new and existing staff:
• References
• Registration, qualification and skills
• Police checks undertaken for all staff, students and
volunteers for new staff and every three years for
existing staff
• Staff present current practicing certificates or
registration annually
• Yearly staff appraisals
15

Quality & Safety
Medical Workforce
We have an on-site employed staffing model at PDH.
This currently includes six hospital medical officers;
two staff physicians, one staff surgeon, one part
time GP obstetrician and two part time emergency
specialists. We also have more than 35 visiting
specialists who consult and/or operate here.
This model provides our clients with 24 hours a day,
7 days week cover of our in-patient wards and our
busy urgent care centre.
Junior Medical Staff
Our hospital medical officers (HMOs) come from a
diverse range of personal and clinical backgrounds and
provide sound and reliable care. PDH is committed to
ongoing professional development and all of our HMOs
are regularly trained in adult, paediatric and neonatal
resuscitation; they have all completed a rural emergency
services training program. In March 2012, the St
Vincent’s Simulation program undertook a two day on
site program that put all our doctors and emergency
nurses through a rigorous skills development program to
assist them in better managing emergencies.
Senior Medical Staff
Dr Taylor’s long standing services at PDH has now
been complimented by the arrival of staff specialists Drs
Sobtchouk, Abbas and Irshad has enabled us to expand
our specialist medical and surgical services. We are
actively recruiting two anaesthetists to complement our
medical establishment.
We remain very fortunate to have Dr Tim Baker as the
Director of our Emergency Department. He is nationally
renowned for his work in rural and regional settings and
his leadership and guidance of the junior staff is first
class. We are very fortunate that all our specialists have
a keen interest in teaching and mentoring our more
junior staff.
Visiting Medical Officers
We have more than 35 Visiting medical officers (VMOs)
who regularly attend from Warrnambool, Hamilton,
Geelong, Melbourne and Adelaide. We can provide
consulting services in all major specialties including
most general and specialist surgery, cardiology,
respiratory medicine, endocrinology, haematology
and oncology through to paediatrics, obstetrics and
gynaecology.
We are currently developing a Safe Practice Framework
for PDH – this outlines our organisational capabilities so
we are certain that the care we deliver is safe, effective
and reliable. We appreciate our distance from other
large centres and this safety-first philosophy guides our
clinical decisions and puts patient at the centre of our
thoughts. This document will also provide a framework
for us to expand and develop our services as we
resource additional clinical capacity.
Credentialing of staff
The Board of Management has the responsibility
of overseeing the credentialing, privileging and
appointment of medical staff. Credentialing procedures
as determined by Department of Health are used to
verify qualifications of all medical staff at Portland District
Health and to establish their scope of practice known as
privileging, or simply put, ensuring the experience, skills
and qualifications stated by any new medical officer is
true and correct.
Mortality and Transfer Committee
This committee meets monthly to review mortality
and patient transfer data. It has nursing and medical
representation and is the most appropriate platform to
review patient transfer cases to larger centres.
The committee provides a platform to assess whether
appropriate diagnosis and stabilisation for transfer was
made. It is also an excellent learning opportunity for all
staff.
Dr Irshad Dr Abbas Dr Sobtchouk
16

Risk Management
Part of delivering high quality health care for our
community is ensuring our staff are appropriately
trained and skilled around the process of risk
management.
Reporting Incidents that occur and then subsequently
learning from them is an important part of Risk
management. We place great importance on
understanding the cause and the impact of a risk,
example a Fall, and the controls that are documented
to reduce the likelihood and the consequences of a risk
occurring in the future. Risks are placed on a register as
they are identified and accountability is assigned to staff
members who are in a position make effective change.
A site risk survey was undertaken on behalf of our
insurers Victorian Managed Insurance Authority in
early 2012. This site risk survey is an “engineering” risk
assessment to assist us to identify risks and possible
solutions relating to property, public liability and
business interruption risks.
In particular, a site risk assessment assesses the
following areas:
• Hazards
• Construction
• Essential services
• Risk management
systems
• Building services
and equipment
• Public safety
Portland District
Health achieved an
overall rating of Very
Good and all identified
recommendations were
rated low or medium.
Emergency Response and Business Continuity Planning
Preparation for emergencies is an important part
of any organisation’s risk management program.
PDH has made substantial progress in the area
of emergency response and business continuity
planning and has adopted the Incident Control
Systems (ICS) approach.
What is ICS
The ICS incident management system integrates
personnel, procedures, facilities, equipment and
communications into a common organisational structure
used by many first responder groups (fire, police,
ambulance) and government agencies that have roles in
coordinating emergency situations.
The type and scale of an incident does not affect the
principles of the system and can be used in a wide
range of situations.
ICS provides a proactive organisational platform which
maximises the efficiency and effectiveness of critical
business and clinical functions in the event of a major
incident, while maintaining the highest level of safety for
patients, staff and others.
In the event of a catastrophic disaster or emergency
PDH business objectives are:
• To activate the emergency management team to
enable business continuity through rapid response
to managing a substantial event.
• To provide support for immediate daily operational
needs through alternative work rounds or manual
processes.
Actions undertaken to implement ICS
• Emergency response strategy revised
• ICS online training program written
• Mock emergency training program developed
• Display folders with all codes stationed at all
reception desks
• All roles, responsibilities, cheat sheets, vets and
required documentation placed in folders located at
all exit points
• Luminous evacuation direction arrows installed
• External assembly points clearly identified and
signed
• All site maps orientated and located at exits
• Manual call points re-engineered to contain flashing
LED
• Mock emergency exercises conducted and
evaluated
17

Quality & Safety
Patient Whiteboards
If you are a patient or visitor to our acute ward you
will notice a new whiteboard by each bed.
These are customised whiteboards fixed on the wall at
each patient’s bedside. They are designed to improve
the opportunity for patients to be directly involved in
their care and improve communication.
PDH analysed feedback received directly from
consumers and from the VPSM data and implemented
the boards following a suggestion from one of our
doctors.
Information written on the whiteboards includes
• Your nurse is;
• Doctor:
• Discharge date
• Activity level
• Today’s goals/messages
• Other:
Benefits include:
• Improvement in all aspects of communication
• Improved nurse/patient relationships
• Increased patient/carer involvement, compliance
and satisfaction in their plan of care
• Improved continuity of care
• Facilitation of discharge planning and possibly
reduced hospital length of stay times
• Assistance in preventing complications.
Bedside handover
Further to improving our communication and clinical
handover between shift changes, PDH is in the
process of implementing bedside handover in our
acute ward. This is a one-to-one nurse handover in
the presence of the patient at their bedside.
Proposed benefits include:
• Improved time effectiveness and efficiency
• Comprehensive, accurate information being relayed
• Improved safety, including decreased staff omissions
and errors
• Improved continuity of care
• Increased patient/carer involvement, compliance
and satisfaction in their plan of care, therefore
achieving best possible outcomes
• Improved relationships and increased rapport with
patients and their carers/families
• Improved staff knowledge and skills
• Opportunities to educate and support junior staff
The bedside handover project is being led by a
team of five senior ward staff with a clear timeline
for implementation. It was prepared with extensive
research, staff education and pre-trial surveys.
Introducing bedside handover is one strategy we have in
improving effective clinical handover.
18

Accreditation
Accreditation is a recognised process that health
services use to ensure they deliver safe, high
quality health care to established standards for
their patients/clients/residents. It is a continuous
improvement process by which the achievement of
standards must be demonstrated by means of an
independent external peer assessment.
Accreditation is a mandatory process for all Victorian
public acute health services and all providers of
residential aged care services. PDH participates in
a number of comprehensive accreditation programs
including the Australian Council on Health Care
Standards (ACHS) and Aged Care Standards and
Accreditation Agency Ltd (ACASA).
ACHS
PDH is an accredited health care service having
undergone a successful organisational wide survey in
May 2010. The 10 recommendations from this survey
have since been actioned and closed. We look forward
to reporting on our 2012 periodic review in next year’s
quality of care report.
ACAA - Aged Care
Harbourside Lodge, our residential aged care facility, is
fully accredited under the aged care standards. These
standards cover all aspects of residents’ needs from
health, personal care and safety to a range of lifestyle
matters including independence, privacy and dignity. We
are pleased to confirm Harbourside Lodge as a quality
aged care facility achieving full compliance with all 44
aged care outcomes.
Type of
Accreditation
Australian Council
on Healthcare
Standards (ACHS)
Aged Care
Standards
Accreditation
Agency (ACAA)
National Association
of Testing
Authorities (NATA)
Status
May 2010 - Full 4 year Accreditation was
awarded.
44 criterion were assessed and we
achieved the following
3 x EA – Extensive Achievement
40 x MA –Moderate Achievement
1 x SA - Satisfactory Achievement
All 44 outcomes met.
No recommendations made.
4 year accreditation received for our
Medical Imaging Department.
National Standards
Assessment
Program (NSAP)
Our Palliative Care team is working
through this program across all PDH
departments.
National Safety and Quality Health Service (NSQHS) Standards
PDH is preparing to move towards National
Standards which are due to be implemented in 2013.
The Australian Commission on Safety and Quality
in Healthcare developed the standards following
extensive public and stakeholder consultation.
The standards provide a nationally consistent and
uniform set of measures of safety and quality for
application across a wide variety of health care
services.
The NSQHS Standards aim to drive the implementation
and use of safety and quality systems and improve
the quality of health service provision in Australia. The
NSQHS Standards focus on areas that are essential to
improving patient safety and quality of care and include:
1. Governance for safety and quality in health service
organisations
2. Partnering with consumers
3. Preventing and controlling healthcare associated
infections
4. Medication safety
5. Patient identification and procedure matching
6. Clinical handover
7. Blood and blood products
8. Preventing and managing pressure injuries
9. Recognising and responding to clinical deterioration
in acute health care
10. Preventing falls and harm from falls.
19

Quality & Safety
Introduction of Stress Testing at PDH
Exercise stress testing is used to diagnose coronary
artery disease, rhythm problems or other heart
conditions. Previously Portland patients had to travel out
of town to Hamilton or Warrnambool to have this testing
provided.
PDH purchased a function specific stress testing
machine and three nursing staff received training in
assisting the physician who performs the test. Initially
we provided a service once a fortnight but due to the
increased need we now provide the service weekly.
Referral is made via GPs to our physician through the
Specialist Centre.
Telemedicine
Telemedicine equipment has been installed in the
resuscitation bay of the Emergency Department. Due
to the isolated geographic location of PDH we are often
placed in clinical scenarios that require specialised
clinical back up. Traditionally advice, consultation and
referral have occurred over the telephone to services
such as ARV, NETS, PETS. A video link up has been
established which provides PDH with visual and verbal
communication from those support services remotely.
The service providing us support and advice is able to
visually assess the patient and support the staff
20

Preventing and controlling healthcare associated infections
The aim of the Infection Control Department at
Portland District Health is to provide a safe and
healthy environment for patients, visitors and staff.
To provide quality care the department focuses on
prevention of transmission of infections, monitoring
and investigating spread of infection and continually
educating staff on up to date best practices.
PDH has achieved favourable results through many
areas of the comprehensive program.
Surgical Site Infection
In Australia surgical site infections are the second
most common type of adverse event occurring in
hospitalised patients. These infections can cause
increased hospitalisation, disfigurement, long term
disability and are a financial burden on the health
service.
Surgical site infections are reported monthly by health
care facilities to VICNISS Healthcare Associated
Infection Surveillance Co-ordinating Centre. Portland
has not had a reportable surgical site infection since
October 2009.
This impressive outcome is due to multidepartment
initiatives that include:
• High level of compliance with cleaning audits
• High level of compliance with hand hygiene
• Appropriate hair removal from surgical site
• Use of air warmed blankets in theatre department
to ensure the patient’s temperature is maintained or
returned to within normal limits as soon as possible
• Appropriate use of prophylactic antibiotics are
used to prevent surgical site infections in those
procedures deemed to be at high risk.
• To ensure these antibiotics are most effective,
the drug of choice, timing of administration and
duration of use is critical. PDH audits and reports
the appropriateness of prescribing to VICNISS. (See
audit results over page).
Antibiotic Choice
Compliance
Antibiotic Duration
Compliance
Antibiotic Timing
Compliance
100% 100% 100%
90% 90% 90%
80% 80% 80%
70% 70% 70%
60% 60% 60%
50% 50% 50%
40% 40% 40%
30% 30% 30%
20% 20% 20%
10% 10% 10%
0% 0% 0%
2010 2011 2012 VICNISS Aggregate 2012
21

Quality & Safety
Antimicrobial Stewardship
Prevention and control of healthcare associated
infection is an essential element of patient
safety. Improving the safe and appropriate use
of antimicrobials in hospitals is an important
component of preventing healthcare associated
infections.
An effective approach to improving antimicrobial use
in hospitals is an organised antimicrobial management
program known as antimicrobial stewardship. This
program aims to optimise antimicrobial therapy, be cost
effective and improve patient outcomes while minimising
bacterial resistance.
The Australian Commission on Safety and Quality
in Healthcare provided antimicrobial stewardship in
Australian hospitals in 2011. PDH has developed
a working party consisting of Infection Control Coordinator,
pharmacist and physician to implement
guidelines. Strategies include auditing with feedback to
provider, education and antibiotic restriction.
Items completed include:
• Decision to adopt St. Vincent’s “traffic light model”.
This has been reviewed to reflect antibiotics used at
PDH.
• Conducted audit on antibiotic prescribing trends at
PDH.
• Draft of authorisation documentation and reviewed
Antibiotic Restriction Policy.
Hand Hygiene
Hand hygiene has been shown to be the most
effective method of reducing transmission of
infections. PDH has been actively involved in
the global hand hygiene initiative called the five
Movements of Hand Hygiene. Staff are observed
performing their daily care duties and hand hygiene
practices noted. PDH has consistently achieved
compliance scores above the national average.
Visitors to PDH are also assisting in reducing the
transmission of micro organisms in the facility. Alcohol
hand rub products are available for use at all entrances
to the facility with highly visible requests for use. High
product usage indicates that this has been a valuable
addition to the hand hygiene program.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Hand Hygiene Compliance
PDH Hand Hygiene %
National Hand Hygiene %
May
06Jan
10
Mar 10
May 10
Jul 10
Sep 10
Nov 10
Jan 11
Mar 11
May 11
Jul 11
Sep 11
Nov 11
Jan 12
Mar 12
May `12
Jul 12
PDH Compliance
VICNISS Aggregate
Staff health
Health care workers are at high risk of exposure to
vaccine preventative diseases such as influenza.
Providing vaccines to all staff is one measure used
at PDH to prevent the transmission of Influenza to
and from health care workers and patients.
PDH provides staff and volunteers influenza vaccination
clinics and also a mobile vaccination service that this
year resulted in PDH having 68.3% of staff vaccinated.
PDH has consistently achieved compliance greater than
the state average in this area.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0
PDH Influenza Vaccination Uptake
2001 200220032004 200520062007 200820092010 201120122013
20142015
PDH Eligible Staff % VICNISS Aggregate %
22

Cleaning
Portland District Health is maintaining its status as
one of the cleanest health services in Australia.
PDH recorded a near-perfect score in 2012, in the
Victorian Public Health Facilities External Cleaning Audit
with a rating of 98.8 per cent.
Hospitals are required to reach an acceptable quality
level of 90 per cent in very high risk areas and 85 per
cent in high risk and moderate risk areas. PDH easily
surpassed this figure across the board.
The independent audit was conducted by Cogent
Business Solutions and took a random sample of 15
cleaning criteria across 82 rooms throughout the health
service.
PDH scored 99.1 in `very high risk’ areas such as
the operating theatre and intensive care unit. The
benchmark for very high risk areas is 90 per cent.
The hospital also excelled in high risk areas with a score
of 98.5 and in moderate risk areas with 98.9, both well
above the 85 per cent benchmark.
The audit found that all departments examined complied
with acceptable quality levels and said the PDH internal
cleaning audit regime meets all the terms of the cleaning
standards for Victorian health facilities.
To be able to maintain such a high level of cleanliness
is a real compliment to the dedication and commitment
of the Environmental Services team and should reaffirm
the local community’s confidence in PDH’s abilities to
provide a clean and safe environment, which is a vital
component in the provision of efficient health care.
“This latest audit confirms what a great
job our environmental services team
does, full credit to them,”
(Ms Ros Jones, Acting CEO)
Medication Safety
Medications can help us stay healthy, cure some
diseases, relieve symptoms of disease and improve
quality of life. But, like any form of treatment, they
are not without risks. Monitoring how we safely
prescribe, dispense and administer medication is
a key component of the Clinical Risk Management
program at Portland District Health.
Medication Reconciliation
At PDH we have a system in place which alerts staff
of patients taking high risk medication. A Medication
Reconciliation Form (MRF) is completed by the
pharmacist when documenting medication prior to
admission.
The data recorded includes checking all medications
which the patient may have brought from home,
obtaining a current list from the patient’s community
pharmacy, and clarifying times of administration with the
patient or carer. These sources of information are pooled
together in the reconciliation process.
The use of complementary medications is also included
on the MRF, thus a comprehensive, current and
accurate medication history is recorded by the clinical
pharmacist.
The MRF is a valuable communication tool as it is
utilised throughout the patient’s stay to record any
medication changes such as addition of a new drug
or cessation of a drug which have been written on the
medication chart by the prescribing medical practitioner.
REPORTING
Staff are encouraged to report any medication incidents
or near misses on our electronic reporting system.
Reports are studied closely to address any systematic
problems. The more common types of errors reported in
the past 12 months included:
• Delayed administration
• Medication missed or not given
• Wrong dose or drug given
• Wrong dose or drug prescribed
• Medication not available
Summary Of Improvements
• Redesign to pharmacy entrance area to
improve security and confidentiality
• Introduction of remote monitoring of drug
refrigerator temperature, eliminating manual
monitoring with thermometers
• Implementation of the national
recommendations for labelling of injectable
medicines
• Introduction of pharmacy newsletter
“The Tablet’
• Complete review of patient controlled
analgesia policy and monitoring charts
23

Quality & Safety
Preventing Falls and Harm From Falls
At PDH we have a number of strategies and initiatives
in place to prevent falls and harm from falls.
Identifying risk:
We do an assessment when patients come to hospital
and we monitor our compliance with performing these
assessments properly
Reducing the risk of falls:
• Education of staff in falls prevention strategies
• If patients are identified as “at risk” for falls we
use alert systems to ensure they get the help and
supervision needed
• Use of special equipment such as hi/low beds,
sensor beams and mats
• Provision of a clutter free environment
• Referrals are made to allied health professionals
(physiotherapy, occupational therapy) where
appropriate
• Appropriate footwear
• Assessment of home risks for when you go home
Monitoring:
• Falls are reported on our electronic incident reporting
system
• We monitor results over time and compare to other
health services
9
8
7
6
5
4
3
2
1
0
Jul
Falls
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Acute Sub Acute Aged
Falls Recovery Program
This is a new program initiated on our sub-acute
ward co-ordinated by Penny Wallis, Clinical Nurse
Specialist.
The goal of the Falls Recovery Program is to
educate clients on the safe and effective methods in
independently transferring themselves to an ambulatory
position, and if injured during a fall to provide them with
strategies to minimise further risks.
All clients assessed as medium to high falls risk will be
referred to the physiotherapy department to determine
their safety and suitability for the program. Once
assessed as being a suitable participant, the client
must consent to be involved and will be given written
information and education.
The client is taught what to do if they fall and how to
safely get up from the floor following a fall. Staff are
receiving education on the program and the patient
information has been developed. There will also be
liaison with discharge planning services to ensure
appropriate falls recovery services are implemented on
discharge form hospital.
Preventing and Managing Pressure Injuries
While pressure injuries are preventable adverse
events, they continue to remain a problem in all
health care settings.
In addition to the significant financial costs (to health
services and patients), pressure injuries are associated
with significant social cost in terms of increased
morbidity and mortality, pain, discomfort, decreased
mobility, loss of independence, social isolation and lost
work time.
All pressure ulcers are monitored using the Waterlow
pressure ulcer prevention/treatment form.
3.5
3
2.5
2
1.5
1
0.5
0
Jul
Pressure Ulcers
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Admit with Hospital acquired Aged
24

Red Socks
The Red Sock trial is a six month trial funded
through Improving Care for Older People The socks,
designed by a physiotherapist and clinically tested
in Australia, aim to prevent slips and falls.
They are a distinctive red colour which provides an
immediate visual alert to staff, volunteers, and visitors
that the wearer is at “high risk” for falls. The soles are
covered with unique gripping dots which assist the
person wearing them to grip when walking, moving
about or even in bed.
During this trial we are targeting high falls risk patients
over the age of 65. If the trial proves successful we
plan to expand both the usage and age limits across the
hospital. To date there have been no falls with anyone
wearing the socks.
Safe Use of Blood and Blood Products
Over the past few years in Australia there has been
a strong focus and investment in ensuring blood
and blood products are of exceptional quality and
administered safely.
The Department of Health, in conjunction with Australian
Red Cross Blood Service, Blood Matters and Victoria
Cancer Action Plan have funded the part-time role of
the blood transfusion trainer across health services in
Victoria.
The role of the blood transfusion trainer at PDH
includes:
• Conducting audits related to compliance with best
practice and standards
• Policy development and review
• Supporting clinical staff to complete the Blood Safe
education package annually
• Education of staff on specific issues related to blood
and blood products
• Liaison with pathology provider and develop
education for staff to address issues
• Updates and review of documentation used for
monitoring blood and blood product transfusions
• Liaison with other health care organisations to
exchange ideas, tools and education in order to
further built safe transfusion practice for patients
and staff.
This year, PDH staff
have been spreading
the message of Blood
Safe further afield. We
developed expo “show
bags” for the graduate
nurse expo and included
several ID lanyard cards
for them related to
blood and its safe use.
The audits conducted
by our transfusion
trainer are reported
monthly to the Board
of Management and
every six months to the
hospital’s accreditation
agency, ACHS. The Blood Transfusion Trainer, Gaynor DenBoer
data collected includes
three key areas of blood product administration;
significant adverse events related to a blood transfusion,
transfusion episodes where informed patient consent
was not documented and administration of blood to
patients with a Hb of 100g/L or less.
25

Quality & Safety
Recognition of The Deteriorating Patient
PDH is very proud of the achievements made in the
past 12 months around the response to the clinically
deteriorating patient.
In June 2011 the Compass program was rolled out at
PDH. The aim of Compass is to identify deteriorating
patients and to action appropriate treatment.
As part of the project, new observation charts were
developed for adults and paediatrics and several other
forms were reintroduced. The scales on these charts
match the age group and allow meaningful observations
and timely actions to be taken in line with the policy and
the escalation process implemented.
Compass documentation and actioning was trialled
for six months. During this time compliance audits
were conducted to ensure staff understanding and
compliance. This in turn allowed staff to action
deteriorating patients’ treatment appropriately PDH
formally adopted Compass in February 2012.
Since the Compass trial, ongoing audits have been
conducted to ensure compliance and highlight specific
areas needing additional education. Education of
Compass and these issues are included in orientation of
new clinical staff.
Compass was trialled in emergency and theatre, but
was not suitable to the nature and instability of patients
in these areas. Theatre has since adopted a modified
version of Compass as part of their documentation for
patient in recovery.
In the Emergency Department, once a patient is
confirmed for admission to the ward, the Compass
observation chart is activated and a MEWS (Modified
Early Warning System) score recorded.
The Compass project has enabled health care
professionals:
• To recognise the deteriorating patient
• To initiate appropriate interventions
• To initiate timely interventions
• To facilitate teamwork within the multidisciplinary
team
The Compass project adopted by PDH is in conjunction
with Standard 9 - Recognising and Responding to
Clinical Deterioration in Acute Health Care of the
Australian Council on Health Care Standards. These
standards replace EQuIP version 5 from Jan 2013.
PDH proactively implemented Compass earlier than
mandated, in order to provide excellence in patient care
and staff support.
Registered Nurse Angela Lane
Insert: Registered Nurse Ranjana
Puwakwathta with patientMr
Leslie Breen
26

Staff Development Unit
A vital component in maintaining standards of safe
and high quality care is through the training and
education of staff.
PDH has an education team who organise, coordinate
and support education for our trained staff, as well as
the many numerous students who access our service
from external organisations.
Ongoing Education
The Staff Development Unit has supported staff
education by:
• Advanced life support training for medical and
nursing staff
• Simulator course from St Vincent’s’ Hospital for
medical and nursing staff
• WebEx education for staff to enhance learning
• Visits to Epworth Hospital for HMOs
• Staff enrolled in Diploma of Management, Diploma
of Practice Management and Certificate III in Health
Services.
Graduate Nurses
Portland District Health employs five graduate nurses.
The graduates are rostered in clinical areas throughout
PDH to ensure exposure to a wide variety of clinical
situations to promote well rounded and informative
experiences in preparing for a long and rewarding career
in nursing.
PDH participates in the Victorian South West
Collaborative Graduate Nurse Program. The three
graduate nurses employed under this program rotate
through three health services, namely PDH, Western
District Health (Hamilton) and Moyne Health Services
(Port Fairy).
Students
In 2011-2012 there have been 107 students doing
placement at PDH from a variety of disciplines including
nursing, medical, allied health and health information.
Comments from students
“Overall I loved my work placement. It has made me
think a lot about my future and what I want to do…
thanks Portland District Health for having me.”
“I would like to thank you so much for opportunity you
have given me to explore and learn what it means and
what is involved in health care and nursing.”
“I had an incredibly enjoyable and worthwhile learning
experience, and would welcome the opportunity to
spend more time in Portland if the opportunity arose”
“I especially enjoyed following a patient through from
day surgery right through to the ward the next day”
“All staff were great and I would recommend Portland
for any students”
Environmental Staff
Seven of PDH’s environmental staff completed
a Certificate 3 in Health Services this year. This
qualification is part of the health training package.
It covers workers in a range of roles who provide
assistance to health professional staff with the care of
clients.
Education Unit at work
Management training
PDH recognises the need to plan for future leadership
within the workforce and has supported interested
staff in their professional development in management
training. Nine staff members at PDH have successfully
completed a Diploma in Management through Skills
Training Australia over the past 12 months.
Administration Training
A number of administration staff are enrolled in a
Diploma of Practice Management through South West
TAFE. Two staff are undertaking a clinical coding course
with Health Information Management Association
of Australia. PDH has also offered a number of
opportunities to staff to improve their computer skills.
27

Quality & Safety
Dental Services
Dental Clinical Quality Indicators
No Treated
No Returned
Restorative retreatment within 6 months 1980 64
Unplanned return with 7 days of extraction 575 0
Endodontic retreatment within 6 months (repeat endo treatment) 26 0
Endodontic retreatment within 12 months (by extraction) 29 1
Fissure Sealant retreatment by repeat sealant – within two years 725 19
Fissure seal retreatment by multiple treatment modes within two years 725 17
Pulpotomy retreatment by extraction within 6 months 47 3
Service Performance
Actual
Target
Individuals treated 1932 2056
Access Performance
Actual
Target
Adults General Wait List – waiting time (months) 8.3 23
Adults Denture Wait List – waiting time (months) 12.8 22
Adults Denture Wait List – high priority – waiting time (months) 0.1 3
28

Continuity of Care
Sub-Acute Services
Over the past 12 months Sub-Acute Services has
promoted the philosophy of Person Centred Care,
implementing a organisational wide policy that aims
to ensure all patients are treated as individuals.
We continue to work with the Department of Health
(DoH) initiative Improving Care For Older People.
Inspirational speaker and stroke survivor Emma Gess
has spoken to hospital staff about person centred
care. Emma suffered a stroke at 24 and has achieved
excellent results through collaborative goal setting and
determination.
What is Person Centred Care
Person centred care is treatment and
care provided by health services that
places the person at the centre of their
own care. It is also known as patientcentred
care or client centred care. The
advantage for those receiving care is that
health care workers need to get to know
the person beyond the diagnosis and build
relationships with patients and carers.
Sleep Studies
Our sleep service has continued to provide testing
and support to a large number of patients from the
region.
We have recently updated our CPAP equipment to
smaller units and increased the number of masks used
for patient comfort and testing. We currently have five
staff trained as sleep technicians who work under the
direction of sleep physician Dr Andrew Bradbeer Manse
Medical Hamilton).
Transitional Care Program
Portland District Health has been allocated six
transition beds; 4 Inpatient beds on the Sub-Acute
Ward and two community beds.
The Transition Care Program is available to patients for
12 weeks, with a possibility of extending to 18 weeks
if needed. The program provides short-term case
management that seeks to optimise the functioning
and independence of older people after a hospital
stay. Transition care is goal orientated, time limited
and therapy focused. It provides the participants
with a package of services that includes low intensity
physiotherapy, occupational therapy services, social
work if required, and nursing support or personal care.
Clients must be assessed by the Aged Care Assessment
Team (ACAT) to access the program.
Restorative Care
Restorative care is a model of care that enables
people to complete their restorative process,
optimize their functional capacity and if required,
finalize longer term care arrangements.
Patients are supported by a multi-disciplinary team and
are provided with, at a minimum, low intensity therapy,
case management and either nursing support and/or
personal care.
Restorative care operates as a bed based service, and
is modeled on the TCP model of care. The primary
difference between TCP and restorative care is that an
Aged Care Assessment Service (ACAS) is not required
to access restorative care and direct admission to the
program is possible from the community where the
individual is not managing and is at risk of a hospital
presentation.
29

Continuity of Care
Palliative Care
The Community Palliative Care team is comprised of
two part time clinical nurse consultants in palliative
care and a volunteer coordinator. There are six
specially trained volunteers who can provide a range
of services to Community Palliative Care clients and
their families in the clients own homes.
The team is supported by a sub-regional team from
Warrnambool consisting of a medical director of
palliative care, a clinical nurse consultant co-ordinator,
a palliative care psychologist and a palliative care
counsellor/educator.
The team works in conjunction with primary care
practitioners such as general practitioners, nurses, allied
health, Glenelg Shire Council and other community
services.
The team provides specialist palliative care to clients in
the community that includes physical, psychological,
social and spiritual assessment and management.
The Portland District Health Community Palliative Care
team has been actively involved in improvement projects
such as:
• Ongoing involvement in the National Standards
Assessment Program (NSAP). NSAP rates Palliative
Care services against the 13 national standards for
delivery of palliative care in Australia. The team is
preparing for peer mentorship from the NSAP team.
• Ongoing involvement with the Link Nurse program
providing palliative care education to nurses in aged
care.
• The implementation of Palliative Care Electronic
Records Management (PERM). PERM is an
electronic record management system that ensures
continuity of care for palliative care patients over the
SWARH network.
• Ongoing provisions of advance care planning for
palliative care clients to ensure their wishes are met.
• An eight week palliative care volunteer training
program for volunteers interested in becoming a
trained palliative care volunteer.
• Participation in the annual Victorian Palliative Care
Satisfaction Survey (VPCSS). The team rated very
highly on the VPCSS.
• Usage of the Unassigned Bed Fund (UBF) to provide
equipment and supplies for clients to make it easier
for them to remain at home if this is their chosen
place of care.
In 2011/2012 the Community Palliative Care team had:
• 42 registered community palliative care clients.
• 764 direct contacts with clients were made.
• 780 indirect contacts with care providers of the
clients were made.
Palliative Care Memorial Service
On 21 May 2012, the PDH Community Palliative Care
team held its first memorial service since 2008.
The purpose of the memorial service is for bereaved
family members, Community Palliative Care nurses and
volunteers to come together to remember the family
loved ones we have cared for.
Community Palliative Care is a specialised health care
provided to patients with a life limiting illness, and their
families, to support the patient to continue living at
home.
Palliative Care Memorial Service
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Evaluation of Palliative Care Service
PDH received feedback conducted by the Victorian
Palliative Care Satisfaction Survey (VPCSS) funded by the
Department of Health. This research captures feedback
from adult patients, carers and bereaved carers from both
community and inpatient palliative care settings.
PDH Palliate Care Service performed very well in this survey
with our top five areas being
1. The level of expertise of people involved in the
patients care
2. Satisfaction with response to needs from nurses
3. The level of respect shown towards the patient as
an individual
4. Satisfaction with involvement in making decisions
about care
5. Availability of the palliative care team to the
patients carer/family members.
What have been the best things about your
palliative care experience
Always available. Care given high standard.
Caring attitude, ease of access, provision of info on pain
relief and management.
Cheerful cooperation of the visiting nurses.
Nursing help available. Dr available. Minimalized help.
The care of [Patient] himself by the palliative team and
nurses in hospital when admitted.
The care.
The constant support from palliative care/district nurses has
been wonderful for wound dressing and various supplies
needed for him.
There always there when I need support and there so easy
to talk to.
Hospital Admission Risk Program (HARP)
The Hospital Admission Risk Program (HARP) aims
to prevent avoidable hospital presentations and
admissions. It targets people with chronic disease;
aged and/or complex needs that frequently use
hospitals or are at imminent risk of hospitalisation
and could benefit from coordinated care.
Clients with a Chronic Illness Pre HARP Post HARP
ED Presentations 19 9
Hospital Admissions 13 10
Length of Stay 100 45
PDH participates in an annual snapshot survey
conducted by the Department of Health which provides
a state-wide picture of the program. The summary of the
last survey provided some useful feedback on our HARP.
PDH HARP reported:
• The service’s general allocation was higher than the
average range
• The average cost per episode was close to the
average range for a local service
• Client recruitment is targeted affectively
• The number of new referrals’ history of presentations
is within the overall average range
HARP helps people who have been diagnosed with
chronic and complex medical conditions. The program
ensures clients are having their health care needs met in
the community. It is designed to ensure people receive
the right care in the right place at the right time, that
clients understand their condition and become involved
in the monitoring and management of their condition.
• Clear pathways and processes for HARP clients
• Identified appropriate gaps and priorities and has a
plan to work on these in 2011-2012.
• 100% compliance with development of care plans
• 100% completion of care plans
• 100% of clients had ongoing management plans
documented
HARP comments and compliments
I have found the visits for HARP very beneficial, assisting
in the use of my medications and helping me to cope
with my illness.
I feel this is a great program. Very helpful to all
concerned
I found that it was a great help. And I thank everyone
concerned (thanks)
This has been a wonderful service
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Continuity of Care
Rural Consumers Travelling for Care
PDH consumers have access to a range of support
schemes when travelling away from the district to
receive care.
In partnership with Western District Health Service, the
Southwest Community Transport program has compiled
a brochure specific for each town in the south-west,
including Portland, which identifies support available
including a taxi program, Victorian Patient Transport
Assistance Program and a list of contacts for services in
the area.
A comprehensive booklet has also been published
which includes information on
• Travelling to Melbourne
• Public transport services
• What to do to prepare for a trip away
Vulnerable Children and Families
PEARL: Portland Early Assessment Referral Links
HEARL Heywood Early Assessment Referral Links
The purpose of of PEARL and HEARL is to network
between agencies, to identity and reduce gaps within
service delivery, and to link clients into local services to
provide a continuum of supportive care.
PDH staff recognise the importance of preventing
problems before they occur in the households of
vulnerable families in Portland by forging closer links
between the various early childhood services and
providing greater access.
A partnership representing maternal and child health
services, parent groups, midwifery and Aboriginal health
was initially established in July 2009 and continues
to meets monthly to discuss vulnerable families and
Dialysis
• Where to park if you are driving
• Contact numbers and maps
The Southwest Community Transport program can be
contacted on (03)5551 8461
PEARL team receiving Early Years Award
establish support systems for them, ideally before an
expected baby is born.
The resultant Portland Early Assessment Referral Links
program is experiencing success, with a decrease in the
number of vulnerable families referred to the Department
of Human Services, an increase in those accessing
early childhood services and one of Victoria’s best
immunisation rates amongst the Aboriginal and Torres
Strait Islander community.
PEARL was a successful winner at the 2011 Early
Years Award under the “Better Access to Early Years’
Service’ awarded by the Department of Education and
early Childhood Development. Following the success of
PEARL which demonstrated the model to be sustainable
and transferrable a second group was implemented in
Heywood which also meets monthly.
Dialysis nurses Anne Mewha and Lisa Barby
The PDH dialysis unit has continued to provide a
valuable service and numbers are up considerably
on the past financial year.
This included holiday clients and patients from Mt
Gambier who have all provided positive feedback. Our
four staff continue to provide excellent patient focused
care.
The PDH Dialysis unit has proudly helped its
neighbouring units in times of need, recently opening
our chairs on extra days when patients could not be
treated in their own home town.
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Cancer Link Nurse
The role of the Cancer Link Nurse has increased in
the past 12 months with the support of a grant from
United Way Glenelg. With this extra support Elaine
Norton has increased the time that she is able to
support people with cancer.
There have been two ‘Look Good Feel Good’ programs
held in Portland during the year with 18 people
attending. Another session is being planned.
These programs have been made possible with financial
support of $5,500 from Western District Employment
Access.
The Cancer Support Group continues to meet on a
regular basis with participants enjoying a number of
guest speakers and social outings. Elaine has had 89
registered clients.
Chemotherapy Unit
PDH provides support for nearly 200 cancer patients
each year and Glenelg Shire experiences a higher
than average incidence of cancer in both males and
females.
Progress is being made towards the establishment of a
day-stay chemotherapy unit at PDH which will be a huge
relief for an increasing number of local people battling
cancer and having to travel far distances for treatments
and reviews.
June 2012 saw the completion of the chemotherapy
working group whose brief was to explore the feasibility
of establishing a day stay chemotherapy unit at PDH.
The first stage of the provision of chemotherapy on site
has been put into place with the introduction of a visiting
oncologist, Dr Mustafa Khrasraw, to PDH once a month.
It is anticipated that the in patient service will see low
and medium complexity patients undergoing varying
chemotherapy regimens.
The unit will consist of
two treatment chairs
and one bed and would
initially operate at one day
per week, increasing to
two days per week in the
future.
Closely supported
by the Barwon South
Western Regional
Integrated Cancer Service
(BSWRICS), PDH is
working to ensure training
of staff is established and
equipment sourced for
the establishment of this new service.
Dr Khrasraw
Health Promotion
The PDH Integrated Health Promotion plan is in the
evaluation phase for 2011-2012.
The Health Promotion team has continued to lead the
way with health promotion in the areas of food security
and oral health.
• Deadly Teeth Family Oral Health tip sheets produced
in partnership with Winda-Mara Aboriginal Health
service have been distributed all around Australia.
• The Deadly Teeth project was shortlisted in the
2011 Victorian Public Healthcare Awards under
“Improving the health and wellbeing of Aboriginal
people”.
• 22 dental staff attended training in Portland
facilitated by Dental Health Services Victoria on the
“Management of Children and Adolescents with
Special Needs”. This was the first time this training
had been held outside the metropolitan area.
• 97 people attended the “Oral Health and Nutrition
forum“, supporting oral health and nutrition for
people with a disability. This was organised in
partnership with the Glenelg Disability Health
Promotion Action Group.
• Delivery of the “Good Food Program” to support
agencies around access to fresh fruit and vegetable,
in line with the outcomes of the Food Security
working group.
• 100% participation of the early childhood sector in
the Smiles4Miles program before funding ceased
in December 2011.
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Continuity of Care
Residential Aged Care – Harbourside Lodge
Harbourside Lodge is a bright and welcoming 30
bed high care facility.
Staffing at Harbourside Lodge includes a Nursing Unit
Manager, registered nurses, medication endorsed and
endorsed nurses, activity staff and office administrators.
In June of this year we welcomed Faye Tippett to the
team as our new Nursing Unit Manager.
In August this year we passed all 44 standards of our
accreditation.
A Culture of Quality Improvement
At Harbourside Lodge we pride ourselves
on a continuous improvement culture. These
improvements are reported to residents, family
members and staff through various meetings,
including resident-relative meetings.
We are also involved in annual resident relative
satisfaction surveys which are conducted via QPS
and benchmarked against other facilities. Other areas
we use the QPS reporting tool for are average ACFI
Funding, ACFI Scores, skin tears and medication errors.
Very positive comments have come out of these surveys
this year which include:
• Very pleasant and homely environment
• Has an extended family atmosphere
• The food is of a very high standard offering variety,
nutrition and freshness
• Visiting hours are very accessible and we are
welcome at any time during the day or evening
• Family member is in a wheelchair but there is plenty
of space to move around.
Medication safety has been a focus at Harbourside
Lodge over the past 12 months. We have increased our
audits to monthly which assists in identifying areas for
improvement. Improvements included staff education,
and visual aids on medication charts to indicate time
of patch replacements, short term medications, phone
orders and any changes from the normal medication
orders. Webster packs will soon be implemented to
assist in the reduction of medication errors
Several physical improvements have been made to
Harbourside Lodge in the past 12 months. Residents
are now able to enjoy the recently purchased outdoor
settings with monthly barbeques held outside weather
permitting. The garden area has also had a makeover
with many new plants and the garden wall painted a
vibrant blue.
We have commenced our plan for continuous
improvement for 2012/2013. Many of these are
already well underway and include a specific focus
on education. A 24 month education planner is to be
implemented which will ensure that all staff are provided
education to cover all areas of the aged care standards.
A sleeper chair has been sourced and ordered thanks to
fundraising efforts and is expected to arrive in December
2012. This chair will be a valuable asset to Harbourside
Lodge, enabling family members a comfortable space
to sit and sleep with residents.
Other improvements include:
• More interaction with local pharmacies
• Windbreaks in the courtyard to enable more outdoor
activity in the winter
• Installation of a ramp to ensure smooth flow of traffic
in the event of an evacuation
• Purchase new equipment which would include
lifters, tub chairs, BP Machine and mattresses.
Aged care resident Mr
Lionel Atwell and Registered
nurse Sheralee Radley
Harbourside Lodge entrance
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Our Staff
Recognising Staff
PDH acknowledges the effort of all staff members
from all departments and areas To show our
appreciation we give special recognition to the
individual effort of employees on a regular basis with
an employee of the month/year award.
This is an opportunity to acknowledge services above
and beyond the call of duty by staff within PDH – the
genuine smile, the helpful advice, the caring attitude –
because this is what makes Portland District Health a
great place to be.
Portland District Health prides itself on the quality of
staff committed to providing safe, professional care
to Portland and the wider community. The length of
service of each individual contributes to the culture of
knowledge and experience in the organisation as well
as providing support and mentorship to a younger
generation of workforce starting at PDH. As testament
to this, we acknowledge staff achieving significant
milestones in their careers at the hospital.
Years of Service
45 Years
Beverley McIlroy
30 Years
Carolyn Speed
25 Years
Debbie Adams
Lindy Bremner
Dianne Johnson
Julie Marsh
Helen Richardson
Elizabeth Rundell
Monica Treloar
20 Years
Majella King
Debra Tozer
Erica Clarke
15 Years
Pamela Thomas
10 Years
Carol Berkeley
Rhonda Bowers
Elizabeth Farnsworth
Patricia Goodes
Renae Jarrett
Michelle Jenner
Roslyn Jones
Carolyn Malseed
Laurel Morrissey
Robin Parry
Glenda Whitbourn
Employee of the year
Janine McIvor
Each month PDH presents an award for
employee of the month which recognises the
work ethic, personal commitment and dedication
to excellent service of staff members above and
beyond normal duties. At the end of the year one
monthly winner is selected for the annual award.
Congratulations to Janine McIvor, 2011 Portland
District Health employee of the year.
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Portland District Health
Ph: (03) 5521 0333
Email: pdh@swarh.vic.gov.au
www.pdh.net.au
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