AH_QualityOfCare2009.pdf - Alfred Hospital


AH_QualityOfCare2009.pdf - Alfred Hospital

Caring for our Community

Quality of Care Report 2009


Chief Executive’s message

Alfred Health Chief Executive, Andrew Way

On behalf of Alfred Health, I’m pleased to present the 2009

Quality of Care Report. This report is for you the consumer,

patient and carer within the Alfred Health community. This

report outlines improvements that Alfred Health has made and

projects that we’ve undertaken to try and improve the quality

of care for our patients and residents.

While I have only been at Alfred Health for a few months

now - having previously worked in health care in the United

Kingdom – I have always had a great interest in patient safety

and quality. These are two of the key themes of this report

so we can let you know what we are doing to improve our

services and make them safer.

The National Health and Hospitals Reform Commission report

‘A Healthier Future for All Australians’, published earlier this

year, makes several references to the importance of quality

and safety in health care. I am delighted to be able to present

so many projects undertaken by staff across Alfred Health that

would be seen as demonstrating new ideas, establishing what

works well, and continually using improvement methods to

make sure patients experience better services.

I hope you fi nd this report useful and informative and welcome your feedback (see page 22) so that

we can continue to improve this publication – and more broadly – our services to meet your needs.

Hospital introductions

Alfred Health is the main provider of health services to people living in the inner southeast suburbs of

Melbourne and it incorporates The Alfred, Caulfield Hospital and Sandringham Hospital. It provides

a wide range of health services across a range of settings including hospital, home and community

based locations. It is also a major provider of specialist statewide services to the people of Victoria.

Alfred Health strives to achieve the best possible health outcomes for patients and the community by

integrating clinical practice with research and education.

The Alfred is a 638-bed major tertiary-referral hospital providing a comprehensive range of specialist

acute health and mental health services. It is a designated statewide provider of heart and lung

replacement and transplantation, cystic fibrosis, major trauma, burns, HIV/AIDS, haemophilia, sexual

health, hyperbaric medicine, psychiatric intensive care and statewide elective surgical services. It

provides acute and mental health care services to the residents of its local community.

Sandringham Hospital is a 104-bed community hospital with a strong focus on meeting the health

care needs of its local community. The hospital plays an important part in the delivery of elective

surgery services for Alfred Health, including general surgery, colorectal, breast, gynaecological,

orthopaedic, ear nose and throat and urology. It also provides general medical, dialysis, emergency,

women’s health and maternity services including a level two nursery.

Caulfield Hospital is a 347-bed major service provider of aged care, rehabilitation, aged psychiatry

and residential care. It is a designated Centre Promoting Health Independence, established to

provide an integrated range of specialist assessment and treatment options for older and younger

people with complex needs. Caulfield Hospital also has a statewide role in the provision of some

specialist rehabilitation services to people throughout Victoria. Caulfield Community Health Service is

located at the hospital and provides a range of primary care services for residents in the local area.



Chief Executive’s message & introductions Page 2

Contents Page 3


Consumer and community participation Page 4

Feedback & satisfaction Page 5

Health Promotion: P.A.R.T.Y project & strength training Page 6

Innovative safety projects Page 7

Infection control & falls prevention Page 8

Pressure prevention & medication safety Page 9

An Alfred Health patient story Page 10

Enhancing trauma care Page 11

Black Saturday response Page 12

Intensive care at The Alfred Page 13

A focus on Caulfi eld Hospital Page 14

A focus on Sandringham Hospital Page 15

Cultural and linguistic diversity Page 16

Indigenous health Page 17

Accreditation & credentialing Page 18

Keeping patients safe Page 19

Feature: Improving care for patients Page 20

Improving the patient experience Page 21

About our report Page 22

How to fi nd us Page 23



Involving consumers and community members

Alfred Health is committed to involving consumers, carers and community members in a

meaningful way throughout the health service. There are consumers and community members on

a number of key committees and groups such as:

• Ten community / consumer members on the Community Advisory Committee

• Nine community / consumer members on the Cultural Diversity Committee

• Consumers on the Clinical Governance Committee, Infection Control Committee and

Respecting Patient Choices Steering Committee

• Consumer reference groups at Caulfi eld and Sandringham hospitals

Community participation at Alfred Health was commented on at the Australian Council on

Healthcare Standards accreditation survey presentation in June 2009 (see page 18 for more

information). The response was very positive and areas that were acknowledged included our

strong leadership throughout the organisation regarding consumer engagement, and consumer

involvement being demonstrated at departmental and organisational levels.

The role of the Community Advisory Committee (CAC) is to provide advice to Alfred Health’s Board

of Directors to ensure that the views of consumers, carers and community members are taken into

account across the organisation. Some of the key achievements of the CAC in 2008/2009 include:

• Receiving regular reports from all Departments about their community participation activities

and improvements

• Advising on key consumer, carer and community improvement initiatives for inclusion in the

Alfred Health Executive Work Plan

• Input into the Alfred Health Community Participation Plan

• Two CAC members, Sarah Gray and Brett Hayhoe, assisted with the production of this report.

Alfred Health is constantly trying to think of new ways to involve more consumers and community

members in the health

service and one of the key

improvements planned for

2009 is the creation of a

consumer register. This will

be a list of interested people

who can be contacted about

opportunities to participate

in focus groups or on a

short-term working group or


If you would like to be on the

consumer register or want to

know more about community

participation at Alfred Health

please contact Tanya Hendry,

Community Participation

Coordinator, on (03) 9076 2409

or t.hendry@alfred.org.au

Staff working together with Sarah Gray and Brett Hayhoe from the Community

Advisory Committee on the Quality of Care Report


Patient satisfaction

Alfred Health receives feedback from consumers

in a number of ways including receiving letters

telling us what patients liked about their care,

analysing complaints, conducting focus groups

and via the Victorian Patient Satisfaction Monitor

(VPSM) which is conducted by the Department of

Human Services.

The VPSM results for Alfred Health over the

last couple of years have highlighted key issues

around the physical aspects of the hospitals,

especially the lack of privacy and restfulness.

In addition to reviewing the results, Alfred

Health also looks at comments made. Food and

Patient Liaison Offi cers - Ann Howell, Penny Tallents and

Libby Apps

problems associated with shared rooms featured strongly in the negative comments as well as poor

communication and lack of courtesy among a small number of staff. Comments are provided back to

staff and management to guide improvements. There are also positive comments received and some

of these refer to the courtesy, team work, caring and professionalism of hospital staff.


Many compliments are also received from consumers. This helps to see what is being done well, so

that more of this can be done! Some of the compliments received include:

“…The staff deserve congratulations for their care and support. I can’t thank them enough…”

“…I am involved in decisions, the staff talk to me and treat me with respect…”

“…People talk to me, not about me – it’s not like in the old days…”

Consumer feedback

Alfred Health welcomes feedback from patients, families and carers and is committed to learning

from experiences, both positive and negative, to improve the quality and safety of services. In

2008/2009, the Patient Liaison Offi cers received 913 complaints. This was a decrease from the

previous year, when there were 1068 complaints received.

Many of these issues were resolved straight away with the help of clinical and managerial staff,

who are always happy to help. The other cases were investigated in more depth, which helps Alfred

Health agree on bigger changes that will benefi t future patients.

What patients said...

What we did...

• There is not enough car parking at Caulfi eld • A large car parking area has been opened providing


additional spaces, with a car park just for visitors

• We would like more activities for Caulfi eld • A range of activities have been put in place including

nursing home residents

music therapy and lifestyle resources, backed up by

more staff training

• The footpaths at Sandringham are slippery • The footpaths from the main hospital to the

consulting clinic have been resurfaced

• It can be diffi cult to fi nd the right clinic room • Signs have been placed in the consulting clinic to

at Sandringham

allow clear identifi cation of rooms

• I used to have an ambulance bring me to • We are writing a new staff guideline and a patient

The Alfred, but the rules have changed

information sheet about ambulance transport

• It can take a long time for the nurse to • The Alfred is looking into setting up regular ‘ward

answer my call bell

rounds’ by nurses, to check that patients’ needs are

attended to in a timely way



A new way to P.A.R.T.Y.

Victorian students are coming face-to-face

with the devastating effects of traumatic injury

through a unique program that started at The

Alfred this year. P.A.R.T.Y, which stands for

Prevent Alcohol and Risk Related Trauma

in Youth, is an education program that aims

to reduce risk-related death and disability in

senior school students.

As part of the program, students visit the

critical care facilities at The Alfred – including

the Emergency and Trauma Centre, the

Intensive Care Unit and the trauma ward -

and meet some of the young people who are

trying to deal with devastating injuries from

vehicle accidents.

The program is initially being offered to

Melbourne schools at no cost but it is hoped

that students from regional schools and

those interstate might also benefi t in the

18-year-old Harley Doedee regularly talks to school students as

part of the P.A.R.T.Y. Program after losing part of his legs and

suffering severe burns in a car crash earlier this year. Harley is

pictured with fellow amputee, John Gou

near future. The program has been operating successfully in Canada for 20 years, with a 20-year

evaluation showing that teenagers who participated in the P.A.R.T.Y program had a reduced incidence

of major trauma compared to those who did not. The results were statistically signifi cant and clearly

demonstrate the impact this program can have on young people.

Live long, live well

Pumping iron is generally associated with Arnold

Schwarzenegger, but Caulfi eld Community Health

Service’s Healthy Living Centre is overfl owing

with older adults using weight training as a way to

stay fit and to keep up with the grandchildren. The

biggest program of its type in Victoria, the Council

on the Ageing-endorsed Strength Training program

is attended by almost 700 participants twice weekly.

George, 79, describes Strength Training as helping

him to “feel a lot better physically and more alert

mentally”. George’s wife Betty, 77, credits Strength

Training as “a great falls prevention activity where

you can improve your mobility and balance while

having a chat and a laugh with other participants”.

There are numerous opportunities for participants

to have their say in how the Strength Training program is conducted. Through their involvement as

members of the Strength Training Representative Body, 10 participants have helped to improve

exercise programs, enhance the Healthy Living Centre environment, shape the organisation’s

communication approaches and assist with staff recruitment decisions.

Caulfi eld Community Health Service is privileged to work with such an inspiring group of people

who attend Strength Training to maximise their health, wellness and independence to live long and

happy lives! People wishing to join the Strength Training program can contact Caulfi eld Access

on (03) 9076 6776.


Strength Training has had a very positive outcome for George

and Betty, who say they are hardly ever at the GP anymore

Projects tackle the increase of STIs

In response to the increase in sexually transmissible infections (STIs) in Victoria, in particular HIV

infections and the re-emergence of syphilis, the Department of Human Services funded a number of

initiatives to tackle these issues, two of which were at Alfred Health.

The first project is being undertaken by Alfred Health’s Melbourne Sexual Health Centre as a twoyear

pilot project, aiming to enhance and increase the capacity of general practices to provide STI

testing for homosexually active men.

The project employs a Sexual

Health Nurse, who works in the

Centre Clinic and Middle Park

Clinic to provide STI testing

and related services. The nurse

also provides ongoing care for

HIV positive clients. The project

ends in June 2010 and plans are

underway to formally evaluate it.


Number of STI screens % of patients screened

March ‘09 39 57%

April ‘09 28 55%

May ‘09 31 54%

June ‘09 32 77%

Screening in Infectious Disease Clinics

The second project was based within the Infectious Diseases outpatient clinics where over 800

people living with HIV/AIDS attend each year. The project involved enhancing STI screening in that

setting, targeting men who have sex with men.

An audit undertaken in 2006 showed the amount of testing undertaken in the outpatient clinic was

23 percent. Since the funding of this project there has been an increase in the amount of testing

being offered or provided (see table above). Not all patients require screening on each visit and not

all patients are appropriate to be offered screening. Screening is monitored and there now appears

to be a stabilisation of new syphilis infections in Victoria.


Reducing radiation dose

The Radiology Department at Alfred

Health has responded to community

concerns around levels of radiation by

undertaking a number of initiatives to

reduce radiation dose as follows:

• Bismuth breast shields are used

at The Alfred and Sandringham

Hospital during CT scans. The

shields are placed across the chest

and there has been a 30 to 50

percent reduction of radiation dose

to the breast tissue

• Mammograms are now done

digitally which produces the same

image quality but with 20 percent

less radiation dose for a standard

sized breast

• Sandringham Hospital is one of

the first hospitals in the southern hemisphere to have software installed on the CT scanner that

produces images of the same quality at almost half the radiation dose

• The Department has recently looked at three months worth of CT scans (several thousand) to set

dose reference levels. Radiographers now use these reference levels to ensure that every scan

is within an acceptable dose range.



Clean hands save lives

Alfred Heath has been participating in the

Department of Human Services Hand Hygiene

Victoria strategy since 2008. This program involves

observing the hand hygiene of health care workers

in a selection of clinical areas throughout the

hospitals, with individual areas receiving feedback

about their hand hygiene compliance.

While hand hygiene initially improved it has been

hard to sustain. For example, in the Intensive Care

Unit (ICU) it has been shown that there are 43.3

opportunities per hour for nurses to perform hand

hygiene. However, if ICU nurses were to be 100

percent compliant it would take 2.5 hours out of

every 8 hour shift and this is not practical in ICU.

In order to improve the sustainability of the hand

hygiene program there was a launch of a new

slogan on International Hand Hygiene Day in May

2009. The new slogan is “Clean your Hands Save

a Life” and there have been innovative ways of

promoting this slogan to staff.

Preventing patient falls

Of all patient incidents, falls have the most

signifi cant impact on recovery time. Alfred Health

continues to work hard to prevent falls at all sites.

A review of environmental audit tools has resulted

in the development of a particular tool which will

help in the identification of areas within the hospital

environment which may contribute to a patient fall.

For example, making sure that beds are at the

lowest height, that the room is free from clutter and

that the fl oor is free of trip hazards.

The use of sleeping pills is known to increase

a patient’s risk of falling. A review of the use of

sleeping medications at Alfred Health has assisted

with the development of specifi c strategies to

reduce this type of prescribing for patients at risk.

The Falls Prevention Clinic at Caulfi eld Hospital

extends falls prevention from the hospital setting

to the community. The clinic has introduced written

feedback letters which provide information to

clients about their falls risk and how they may

reduce it. This initiative was presented as a poster

at the Australia and New Zealand Falls Prevention

Society Conference in November 2008 and the

team won the award for the best poster in the

non-student category.

Cleaning audit results

Having clean hospitals and achieving high

cleaning standards is an important part of

delivering quality patient care. Each year

Alfred Health undertakes independent,

external cleaning audits to make sure that

these high levels of cleaning services are

being provided.

The external audit results (below) show that

once again Alfred Health has continued to

exceed the required standards for cleanliness

set by the Department of Human Services





The Alfred 89.4% 85%

Sandringham 94.6% 85%

Caulfield 92% 85%



set by DHS

Managing swine flu

During the outbreak of H1N1 infl uenza,

commonly known as swine fl u, one of the most

important things that Alfred Health did was to

put strategies in place to recognise, separate

and isolate those patients who came in with

fl u-like symptoms to prevent the spread of

H1N1 in the hospitals. This was in compliance

with the pandemic infection control guidelines.

Physiotherapist, Fiona Harding, is one of the authors of

the winning poster on falls prevention


Pressure ulcer prevention

Pressure ulcer development in hospital is an

area that Alfred Health takes very seriously and

works actively to reduce. Every year Alfred Health

undertakes a study to monitor progress with

reducing the number of pressure ulcers and to

assist with continuing improvement and reduction

of pressure ulcers.

This graph shows that the number of pressure ulcers has


A number of strategies have been completed

over the year to improve pressure ulcer

management including guidelines to assist

nurses with selecting the best mattress for

patients, and devices to prevent pressure ulcers

on heels.

Caulfi eld Hospital has commenced pressure

ulcer wound rounds on wards which all

members of the team attend - medical, nursing,

podiatry and nutrition. This ensures that the

very best treatment for a wound is provided.

Alfred Health is a participant in the Council of

Australian Government Long Stay Older Patient

Initiative for 2006-10 for skin integrity and

nutrition programs. Part of this project involved

the development of a resource booklet to assist

staff in their understanding of how to reduce

pressure ulcers.

National leaders in medication safety


Alfred Health has been recognised as a national

leader in the safe use of medication. This work is

supported by the Centre for Medication Use and

Safety in collaboration with Monash University.

The Centre is directly involved with many

projects to improve the safe use of medication,

reduce the risk to patients and put systems

in place to prevent things from going wrong.

Some of the projects:

1. There are a number of medicines that

present a high risk when prescribed, dispensed

or administered incorrectly. A project to promote

increased awareness of these medicines to

medical and nursing staff across Alfred Health

has encouraged the development of safer work

practices when these medicines are being

prescribed and given to patients.

2. The Centre has undertaken work to identify

how often medication orders are written using

abbreviations that could lead to the orders

being misunderstood. Pharmacy highlighted this

issue to medical staff and through educational

sessions promoted the importance of clearly

written medication orders. This has encouraged

prescribers to write clear orders and reduce

medication communication errors.

3. When drug companies change the

packaging of their medication, the altered

appearance can cause confusion. The Centre

has set up a working group to evaluate and

communicate these changes. The group designs

medication safety notices and alerts that are

distributed across Alfred Health to reduce any

risks that may be created as a result.

Rowena Fary was recently employed as a Senior Pharmacist to

help expand Alfred Health’s medication safety work



A patient’s experience of elective surgery

The Alfred Centre opened as Victoria’s

fi rst dedicated statewide elective surgery

centre in 2007. Stephen Hoiles recently

had a total hip replacement and shared

his experiences of being a patient at The

Alfred Centre. Stephen is from Bethanga

near Albury / Wodonga and was referred

to The Alfred Centre after seeing a local

doctor about back pain. “I had an MRI

and spoke to an orthopaedic doctor who

said it was a hip problem. I then had more

X-rays and saw the orthopaedic surgeon

who said both my hips had gone.”

Stephen was then placed on the 90-day

elective surgery waiting list and had a

total hip replacement on his left hip in

March 2009. Prior to this Stephen spent

a whole day at the pre-admission clinic. “I

Stephen Hoiles celebrated his birthday at The Alfred Centre with a cake

saw a physiotherapist and occupational

and a card made by staff

therapist, had blood tests, had my heart

checked, spoke to someone about medications and saw a doctor.”

Stephen said, “At the pre-admission clinic they wanted to check if I could have the three day stay in

The Alfred Centre or if I’d need a longer stay at The Alfred. It was all very good but it would have been

better if I had spoken to someone who had been through a hip replacement before as you don’t know

what to expect. It’s not a simple case of just walking in, having the surgery and then walking out again.”

After his three-day stay, Stephen recovered at his son’s home in Melbourne and the Early Discharge

Program sent a physiotherapist to help with rehabilitation as well as a nurse to change his dressings.

Once he had gone back to Bethanga, Stephen said, “There was

good follow-up and there were letters and surveys sent to me and

the hospital arranged for a physio from Wodonga to visit me at

home. My recovery’s been good and I’m now on the waiting list to

have the other hip done at The Alfred Centre.”

Although Stephen had a good experience at The Alfred Centre,

he did say it was frustrating being on the elective surgery waiting

list. “The fi rst time I was on the 90-day list it was a month late and

now I’m on another 90-day list. It’s hard because you put your life

on hold and don’t know when to expect that phone call to come. I

know this is how it is across Victoria but it’s a bit frustrating and I

would like to have my surgery earlier.”

Stephen recovering back at home

Overall Stephen was very happy with the care he received before,

during and after his hip replacement. “I couldn’t fault the care I

received and I feel confi dent that I’ll be in safe hands when I come

to have my second hip done.”


Aiming to improve outcomes for trauma patients

The Alfred’s Emergency and Trauma Centre is undertaking a world-fi rst research project called

‘Trauma Reception and Resuscitation’ to standardise the care for seriously injured patients and to

reduce the likelihood of error and death.

In such a busy, stressful environment, it is common for errors to occur because the correct procedure

or diagnostic test has not been carried out at the right time, in the right amount or in the right order.

Many such errors do not result in harm, however, it is proposed that an approach using computerprompts

to guide staff decision-making during the initial care and resuscitation of trauma patients will

signifi cantly reduce errors. However, little research has been carried out in this area until now.

This 33-month pilot program uses specifi cally designed software to guide staff when treating trauma

patients during the all-important fi rst 20 minutes of trauma reception and resuscitation. Staff can

consult large screens to see immediately what treatment a patient has received, with the screens

providing timely prompts to ensure they carry out all the necessary checks and procedures.

Initial results of this program are promising, with a reduction in error rates of more than 25 percent

in the study group compared to the control group where the computer-prompts were not in use.

Further analysis of the data is underway, with the results showing the potential to signifi cantly

improve outcomes for trauma patients both at The Alfred and around the world.


Trauma teams strengthened by new roles

New trauma leadership roles for Alfred Health were introduced in 2009 to support the teams that

work in this rapidly-developing fi eld.

In recognition of his expertise in the clinical management of trauma patients, the former Director of

The Alfred’s Emergency and Trauma Centre, Associate Professor Mark Fitzgerald, was appointed

as the Director of Trauma Services.

To complement this clinical-based role, The Alfred also welcomed Professor Russell Gruen to the

position of Head of Trauma Quality Assurance. Professor Gruen oversees the clinical and research

work undertaken by trauma staff. He is also the Director of the National Trauma Research Institute

and Professor of Surgery and Public Health at Monash University. The new roles aim to strengthen

Alfred Health’s leading work in trauma care and research as well as providing a strong platform for

staff development, safety and evaluation.

Associate Professor Mark Fitzgerald

Professor Russell Gruen



Black Saturday - The Alfred response

When the Black Saturday fi res descended on communities across Victoria in February 2009, The

Alfred was put on stand-by. While the fi res had caught many unaware, The Alfred was ready. Teams

of highly-skilled specialists trained to deal with large-scale emergencies were quickly on hand. The

well-drilled training, systems and processes to support the care of many seriously ill patients, meant

staff knew what to do.

Miracle reunion amidst the ashes

The Alfred’s Emergency and Trauma

Centre was the surprise setting for a

remarkable union amidst the fury of

the Black Saturday fi res. Separated in

the Kinglake inferno as they fl ed their

home, both Bill and Sherrill Carta feared

that the other was dead. Suffering

serious burns, they were among 20

patients transported to The Alfred in the

immediate aftermath of the fi res.

Bill was transported by helicopter and

Sherrill by road ambulance – arriving

at the hospital within seconds of each

other. But it wasn’t until Bill called out

his wife’s name upon arrival in the

emergency department that he received

the best surprise of all. Amidst the

chaos and devastation, they found each

other despite suffering serious burns.

Bill and Sherrill - a symbol of hope.

Photo thanks to Herald and Weekly Times

“It was great,” Sherrill says. “I could tell him by his big toe because it looked like the only piece that

wasn’t burnt at the time.” Their story became a symbol of hope and the couple’s reunion featured in

papers, on radio and TV across Victoria, Australia and overseas - providing a much-needed reminder

that miracles do happen!

The Burns Unit: striving for excellence

Throughout Victoria’s history, The Alfred’s Burns Unit has played a key role in caring for patients

from major disasters such as Ash Wednesday and the Bali bombings. The Unit continually strives to

provide the very best care for a group of patients who typically have some of the most complex and

challenging health care needs.

The Alfred Burns Unit played a pivotal role in the establishment of the Bi-National Burns Registry

in 2008. This enables clinicians in Australian and New Zealand burns units to collect data on burns

injuries in order to compare treatments and outcomes, providing information on best clinical practice.

Around the time of Black Saturday, the Burns Unit was also introducing several groups of graduate

nurses onto the ward. During an extremely busy period like this, the need for graduate nurses to

possess a solid understanding about dealing with patients with complex burns was reinforced. As a

result, a three-month education program will be developed for graduates and new staff to the Unit.


New state-of-the-art Intensive Care Unit

In late 2008, The Alfred opened Australasia’s largest and most advanced Intensive Care Unit (ICU).

The sophisticated design of this facility, which has seen it grow from a 36-bed unit to a 45-bed

centre, includes a central layout, larger cubicles and plenty of external light.

The facility includes best-practice design principles which address human behaviour, staff and

patient well-being, indoor environment quality and patient safety.

Complementing the sophisticated design are a range of innovative patient safety features and

initiatives that helped to ensure a seamless journey for the nine seriously injured burns patients

from Black Saturday who were cared for in the

ICU, as well as the thousands of critically ill

patients who rely on this facility every year.

Such initiatives include a custom-built software

application called ICUActive. This ensures

information is quickly accessible to staff, is

stored securely in one location and provides

increased protection of privacy.


Sarah Gray, one of our regular volunteers who was

part of the team during Black Saturday

From the Black Saturday tragedy has

come several other initiatives, including

the creation of specialist roles such as an

ICU Burns Resource Nurse, and education

for emergency staff to assist in developing

pathways for burns referrals.

ICU volunteers acknowledged with State award

The Alfred’s Intensive Care Unit (ICU) volunteer team won a prestigious new State award earlier

this year in recognition of the services provided during Victoria’s worst bushfi res. The ICU team was

awarded equal fi rst at the inaugural 2009 Minister for Health Volunteer Awards.

On 8 February, family members who had been affected by the devastation of Black Saturday found

their way to The Alfred’s ICU – many arriving traumatised, having witnessed destruction on a scale

never seen before.

According to Volunteer Manager, Gillian

Wilson, one of the most important benefi ts

of having volunteers in place was that it

allowed nursing staff and social workers to

better manage the needs of patients and

family members.

As a small group of eight, they worked

an amazing 222 hours in just 14 days,

listening, comforting and offering support to

the family members of burns victims injured

in the Black Saturday fi res.

The Alfred Intensive Care Unit Volunteers accepting their award

from Minister for Health, Mr Daniel Andrews MP



Helping older patients

Alfred Health was selected by the Department of Human Services to receive funding support to carry

out the Council of Australian Government Long Stay Older Patient Initiative in 2008/09. This aims

to provide improved care for older people during their hospital stay by focusing on the prevention of

functional decline. Functional decline is the reduced ability to perform activities of daily living and is

important to address as between 34 – 50 percent of older patients may experience functional decline

during a hospital stay.

Implementation of strategies commenced on AC3, an acute medical ward at Caulfi eld Hospital

in February 2009. All staff from the interdisciplinary team are involved. Ten care areas have

been selected as they are known to be important to an older person’s functioning. The ten areas

are: person-centred care, assessment, nutrition, skin integrity, depression, delirium, dementia,

medication, continence and mobility, vigour and self care.

Two staff were employed to run a seven-day program to assist patients to become more independent

and maintain their pre-hospital level of function. The program includes individual and group activities

and retraining of simple domestic and personal tasks, supporting patients to meet nutritional

requirements and activities to improve strength, balance and functional mobility. Through supporting

and encouraging older patients to be as active as possible while in hospital, potential diffi culties they

may experience when they go home are reduced.

Reflecting consumer and carer views

The Carer and Consumer Reference

Group has been assisting staff at

Caulfi eld Hospital since March 2008 to

hear the voice of the consumer.

Peta Reeve, who has been a member

of the group since it began, believes

that whilst there are a lot of failings in

the health system, consumers are able

to recognise where things go wrong and

take a common sense approach to try

to rectify some of the issues.

Peta is using her experience of Alfred

Health services, and her background

as a nurse “many years ago”, to assist

staff at Caulfi eld Hospital to improve

the quality of the services by providing

the unique perspective that only a

consumer can bring.

Peta Reeve provides a unique perspective to hospital staff

Peta feels that the group’s involvement in the introduction of new name badges for staff has been one

of the most signifi cant achievements to date. These badges offer a design with a bigger font, meaning

that the names and departments of staff are easier to read. They can be worn on clothes, closer to

eye level, making it easier to see than the photo identity cards.

Peta is also excited about the current major project which is the development of a staff forum,

focusing on sharing and learning from the experience of consumers.


Testing identifies babies at risk of hearing loss

Since January 2009, more than 580 babies born at Sandringham Hospital have undergone hearing

tests within days of their birth thanks to a State Government program to detect hearing impairments.

Two of those babies were referred to Audiology

for follow-up but returned normal results.

The infant screening program, provided in

partnership with the Royal Children’s Hospital,

was introduced at Sandringham Hospital this

year. The program aims to identify babies at risk

of hearing loss to enable early diagnosis and


In Victoria, 70 babies are born each year with

a permanent congenital hearing impairment

of moderate or greater degree. By the end of

2010 all babies born in Victorian public and

private hospitals will have the opportunity to be

screened for hearing loss within the fi rst few

days of birth.


A vital community link

For as long as he can remember, Sandringham local, John Holstock, has been putting his hand up

to volunteer with all manner of groups. It is, he says, just part of his nature.

So it is not surprising to fi nd that John has been a member of Sandringham Hospital’s Consumer

Reference Group for the past seven years.

Having a daughter with cerebral palsy with high support needs also means that he has had plenty

of contact with hospitals over the years but it is the family’s local hospital which he has the greatest

connection to.

His daughter has a good relationship with the staff at Sandringham Hospital and they all know her

by name – it is this type of ‘people focus’ that means a lot to John.

“The group is really a sounding board for

the hospital,” he says. “Sandringham is

a great community hospital and I enjoy

playing a part in strengthening those

community links.”

Some of the recent key achievements of

the Consumer Reference Group include

providing input into the Patient Information

Handbook, archiving 45 years of history at

Sandringham Hospital and the development

of an honour board to acknowledge people

who have contributed their time to the


John Holstock with Sandringham Hospital Executive Director,

Marguerite Abbott



Cultural Diversity Week

Cultural Diversity Week was celebrated at Alfred Health in March 2009 with an event at Caulfi eld

Hospital. Staff listened to a variety of presentations while feasting on Russian piroskis and blintzes,

Japanese sushi, Turkish delight and Greek baklava.

At the event, staff were also shown how to access the new Cultural Diversity and Interfaith

Resources webpage which provides a range of cultural and religious information such as the

Multicultural Care at the Time of Death and Dying resource tool and the Alfred Health cultural

diversity plan.

Committee member provides valuable insight

Mary Chydiriotis is the newest member of the Alfred Health Cultural Diversity Committee after

joining in August 2008. As well as living locally and coming from a Greek background, Mary

works as the Home and Community Care Access and Equity Program Coordinator at New Hope

Foundation and is therefore able to provide a valuable insight into issues faced by people from a

range of culturally and linguistically diverse (CALD) backgrounds.

When asked why she wanted to join the Committee Mary said, “I wanted to advocate on behalf of

CALD communities and clients and highlight some of the barriers that people face when accessing

the health system”.

Mary hopes the Committee will continue to focus on effective language service delivery and

accessible information. “I would like to see health information that is accessible with translated

materials being available, multifaith considerations and sensitivity regarding the migration


Mary noted that some of the key achievements of the Committee in 2008 – 2009 were:

• Getting regular reports from all services throughout Alfred Health to make sure they are

considering the needs of CALD clients

• Reviewing the information given to CALD clients regarding the Totally Smokefree strategy

• Providing comments about the Caulfi eld Community Health Service Cultural Action Plan

Mary Chydiriotis

The Alfred

Caulfi eld




Top five countries

1. Greece

2. England

3. Russian Federation

4. Poland

5. Italy

1. Poland

2. England

3. Greece

4. Russian Federation

5. Italy

1. England

2. Greece

3. New Zealand

4. Italy

5. South Africa

Top five languages

1. Greek

2. Russian

3. Italian

4. Cantonese

5. Arabic

1. Russian

2. Greek

3. Polish

4. Italian

5. Hungarian

1. Russian

2. Greek

3. Mandarin

4. Italian

5. Arabic

This table shows the top fi ve countries of birth other than Australia and the

top fi ve languages other than English of patients across our three hospitals

from 2007 - 2008


Connecting to Country

In July 2008, as part of NAIDOC*

week, Alfred Health commissioned a

local artist, Reko Rennie, to produce

a mural based on the Aboriginal

languages of Victoria map.

Reko Rennie (Gwaybilla) is a

Kamilaroi / Gamilaraay / Gummaroi

man who was born in Victoria. Reko’s

choice of medium is a can of spray

paint and his artworks are known for

their vibrant colours, line work and

intricate stencil imagery. Through his

stencil art, Reko focuses on what it

means to be an urban Aboriginal man

in contemporary society. Reko’s mural

is on display in the main entrance at

The Alfred.

The mural with Sharon Bolger (Aboriginal Liaison and Access Worker),

Bridget Wall and John Ashfi eld (Managers of Patient & Family Services)


Supporting Aboriginal & Torres Strait Islanders

Since May 2007, Sharon Bolger has worked as the Aboriginal Liaison and Access Worker. Based

at The Alfred, the position aims to provide face to face, on-site assistance to Aboriginal and Torres

Strait Islander (ATSI) patients and their families. The position also aims to increase the capacity of

Alfred Health to employ, support and retain ATSI staff, provide informal education and strategies to

staff working with ATSI patients and their families, and advise on strategies to improve the physical

environment at the three hospitals to encourage use of the service by the local ATSI community.

Some of Sharon’s achievements to date are as follows:

• Established links with the local community and attended community events to provide

information about the role

• Sent fl yers to all Aboriginal Health Services across Victoria so that outpatients can be linked to

the service beforehand

• Regular contact with patients’ case workers from their local community health organisation to

ensure continuity of care

• Coordinated and provided several in-service training forums for nursing staff in the Emergency


• Organised displays at the hospitals during NAIDOC week in 2008 and 2009 including

displaying the Aboriginal fl ag. The Alfred also had an artist in residence in the foyer which

received great feedback

• Liaison with all Admitting Staff to remind them of the importance of ‘ticking the box’ when a

patient of ATSI descent has been admitted

Further to this work, a review will be conducted to examine the current partnership between

the local ATSI community, Inner South Community Health Service, Caulfi eld Community Health

Service and Alfred Health to determine the effectiveness of current programs in working with local

community members to improve health and well-being. The review will make recommendations

that will guide the directions of future partnerships.

* NAIDOC (National Aboriginal and Islander Day Observance Committee) Week is held annually to

celebrate the history, culture and achievements of Aboriginal and Torres Strait Islander people.



Accreditation receives top marks

All public health services must successfully

complete regular accreditation to ensure

they deliver high quality safe care, centred

on evidence based standards. Alfred

Health received a glowing review after its

accreditation survey was conducted over one

week in June 2009 by the Australian Council

on Healthcare Standards.

The survey, which provided an analysis

of key processes and strengths across all

three Alfred Health sites, resulted in the

recommendation to award fi ve outstanding

achievement ratings.

The team of 15 surveyors said they were

impressed with Alfred Health, and made

particular mention of the display of teamwork

shown both within and across the sites.

The surveyors also conducted an in-depth mental

health review and feedback from this was very

positive. The surveyors said that it was a privilege to

witness the multidisciplinary approach to care and

strong culture of continuous improvement, refl ecting

the ongoing innovation and dedication shown by

Alfred Health staff.

Home and Community Care services underwent

review at Caulfield Hospital and achieved full marks -

another excellent result. Medication safety initiatives

were described as “leading the way” and this area

received an outstanding achievement.

Residential care services are reviewed by the Aged

Care Standards and Accreditation Agency. Onsite

visits from surveyors resulted in all three Alfred

Health nursing homes being judged fully compliant

with the 44 required standards.

The right people for the job

Alfred Health makes sure that all staff have the right qualifi cations, skills and experience to match

the needs of the work they are employed to do.

To strengthen this process Alfred Health has recently reviewed its method of credentialing and

defi ning the scope of clinical practice of senior medical staff.

Credentialing is the process of making sure that staff have the right qualifi cations and experience

necessary to provide safe and high quality health care within specifi c areas of the hospital.

Scope of clinical practice defi nes the range

of clinical activities and procedures that an

individual clinician can competently undertake

within the hospital.

A revised credentialing and scope of clinical

practice process has been developed and is

now incorporated into the appointment and

re-appointment process for senior medical


Links to the Innovations Committee also

ensure that new procedures and technology

are introduced safely and that the senior

medical staff have the appropriate credentials

to provide these services.


Keeping Alfred Health safe

Alfred Health aims to provide the safest environment possible for patients and staff, an

environment where everyone is conscious of safety.

In 2008 a safety culture survey was completed with staff to measure Alfred Health’s patient safety

culture and to allow improvements to be measured in the future. Safety walk arounds occur

regularly at all three hospitals, where senior staff visit wards and departments to talk to and listen

to staff about safety concerns. Action plans are developed and implemented to address any issues.

Incident reporting is completed using an online incident reporting system and the Clinical

Governance Unit works closely with staff to review and analyse incidents, to help staff learn from

them and to improve the safety of the health service, thereby ensuring continuous improvement

and a safer environment for patients and staff.


MATS supporting older people in their homes

Alfred Health’s Mobile Assessment and Treatment

Service (MATS) aims to provide an assessment

of older people in their own home and establish

an appropriate care plan. Associate Professor

Mark Fitzgerald, Director of Trauma Services said,

“MATS provides us with a practical and valuable

alternative to hospital admission. It has helped

reduce the pressure on hospital beds and has

reduced the number of patients from residential

care coming to the emergency department.”

MATS achieved some excellent results in 2008.

They had 103 early discharges from hospital due

to providing medical and nursing assessment

and treatment in the home, they prevented 438

patients coming to the Emergency Department

and they prevented 220 multi-day admissions

where a patient would have been admitted to

hospital for treatment.

Due to the ongoing hard work and excellent

results that the MATS team has been able to

achieve, they received a Premier’s Excellence

Award at the 2008 Victorian Public Healthcare

Awards and received a highly commended in the

Minister for Health’s Awards.

The MATS program was also showcased at a

symposium at the Congress of the International

Association of Gerontology and Geriatrics in

Paris in July 2009 with an invited presentation

by Associate Professor Peter Hunter, Director

of Subacute Services, on preventing avoidable

hospital admissions.

The MATS team have been key players in developing a

program to better meet the needs of older people

Alfred Health’s MATS Team receiving their award




Improving the care of diabetes

Diabetes is one of the fastest growing chronic conditions in Australia and is one of the main causes of

admission to hospital within the inner south region of Melbourne. Sue Wyatt, Diabetes Clinical Nurse

Consultant / Coordinator and her team, work with many patients to help them manage their diabetes.

Sue shares her experience of one particular patient success story.

“I fi rst met Olga Whotton after she was

referred to me at The Alfred after the loss

of her fi rst baby seven months into her

pregnancy due to diffi culty with managing

her Type 1 diabetes. Many women with

Type 1 diabetes are unaware that intense

management and tightly controlled blood

glucose levels are required in order to

conceive and avoid complications during


“I explained to Olga that it was possible for her

to have a successful pregnancy with the help

of a continuous subcutaneous insulin infusion

pump (CSII), which was the best option to

stabilise her glucose levels. Olga successfully

conceived and continued CSII throughout her

pregnancy, which was much smoother using

this technology. She delivered baby Lucas Determined to create a miracle - Sue Wyatt with Olga Whotton,

in early 2009 – seven weeks premature but Ian Whotton, and baby Lucas

healthy and with no ill effects from his mother’s


Insulin is used in many patients admitted to hospital and is a high risk medicine because giving the

wrong dose can result in signifi cant harm to a patient. An innovative project with involvement of nursing,

pharmacy and the endocrinology medical unit has resulted in the development of a process to identify

patients who may be on signifi cantly high doses. The process involves staff confi rming high doses of

insulin with an independent second source such as the patient’s regular doctor. This has enabled Alfred

Health to have additional safety steps in the use of insulin and develop safer practices with its use.

Working in partnership to help cancer patients

Southern Melbourne Integrated Cancer Service was established in 2004 to provide seamless,

multidisciplinary care that improves the patient’s experience and improves outcomes for adults affected

by cancer.

Some improvements made in the last 12 months include:

• Introduction of Breaking Bad News Workshops for medical staff where staff update their skills and

increase their confi dence in delivering bad news to patients

• Introduction of ‘multidisciplinary care’ as a key aspect in providing best practice treatment and care

for cancer patients through the introduction of a Multidisciplinary Team project offi cer in late 2008,

which has improved patient outcomes

• Introduction of supportive care for cancer patients which refers to support services that may be

required for those with cancer, their family and carers.


Learning to see from a patient perspective

Alfred Health continues to apply a new approach to improving the services it delivers to patients. The

‘Redesigning Care Program’ builds on a range of improvement initiatives being undertaken across the

health service, which are resulting in improved outcomes for patients.

Improvements that have been made include:

The Alfred Specialist Consulting Clinics

• A snapshot study of the time spent standing in

a queue on a day in June 2008 compared to a

similar day in December 2008 after improvements

had been made showed that queuing time

decreased from two minutes to nine seconds

• Reception staff immediately fl ag patients’ arrival

electronically to nursing and medical staff

• Nursing and medical staff are able to see

patients’ appointment times electronically, making

it easier to see patients in the correct order

• Staff are able to view an electronic record of

patients’ referrals to the clinics, making it easier

to respond to patients’ queries

The Alfred inpatient wards

• Information about a patient’s stay is more

readily available to staff, allowing for

more streamlined decision making and

improved communication between clinical


• The wards are being reorganised to

support the work of clinical staff, reducing

the time staff spend searching for things,

and allowing them to spend more time in

direct care for patients


Feedback from patients visiting the Specialist Consulting Clinics since the improvements have been

made have been very positive, with comments such as: “New layout and reception area much more

effective”; “Much more pleasant, not crowded, less waiting” and “Queues went back as far as lifts on

my fi rst visits in the last two years…waiting times have improved”.

Fast-track on Emergency Department patients

In late 2008 a fast-track initiative was introduced at

Sandringham Hospital’s Emergency Department with the

aim of improving the availability of services for people

with less serious illnesses or injuries.

The fast-track initiative speeds up the treatment process

by identifying patients who are unlikely to need admission

to the hospital and require straightforward treatment -

such as patients with simple wounds, fractures, sprains

and strains.

These patients are referred to a designated fast-track

area where an allocated doctor and nurse will assess,

treat and discharge the patient.

Fast-tracking has been shown to reduce waiting times

for people with straightforward complaints, and reduce

waiting room bottlenecks.



Producing the report

If you have any feedback about any aspect of this report please feel free to contact our Community

Participation Coordinator, Tanya Hendry. You can call Tanya on (03) 9076 2409 or email her at


It is important that we receive feedback about this report to make sure we are producing an easy to

read, interesting publication. In previous years we have had a tear-out feedback form in the report but

have had a low return rate so this year we thought we would try something different. As well as being

able to provide feedback directly to Tanya, we will also have a feedback link on our website and our

volunteers will also talk to patients to see what they thought about the report.

This year we used feedback from last year to help us improve the design and content. For example,

last year we were told that people found it hard to read white font on a coloured background so we

have avoided that this year.

Distribution of the report

The Quality of Care Advisory Group, a combination of staff members and consumers, has suggested

ways that we can make sure patients and community members have access to this report. They have

suggested that the report be placed in key locations throughout the three hospitals e.g. in waiting

areas and next to lifts and that the report is sent to the media (with a media release), local councils

and other key stakeholders.

Bundles of the report will also be sent to local health and community organisations for their waiting

areas with a letter saying how they can request more copies. These organisations include local

doctors’ surgeries, Maternal & Child Health Centres and Neighbourhood Houses.

If you would like extra copies of this report please contact the Clinical Governance Unit at The Alfred

on (03) 9076 2804 or visit our website at www.alfredhealth.org.au


This report was compiled by the Quality of Care Advisory Group, made up of the following members:

• Libby Apps, Clinical Governance Coordinator, Sandringham Hospital

• Tracey Ellis, Public Affairs Manager, Alfred Health

• Sarah Gray, Community Advisory Committee member

• Brett Hayhoe, Community Advisory Committee member

• Tanya Hendry, Community Participation Coordinator, Alfred Health

A wide variety of staff throughout Alfred Health contributed to the report and many people, including

consumers and community members, were involved in providing feedback. The Advisory Group would

like to thank everyone who was involved and particularly the following people:

• Caroline Hedt, Visual Communications Manager

• Jill Sewell, Chair, Alfred Health Quality Committee

• Gayle Smith, Director, Strategy, Planning and Service Improvement

• Margaret Way, Director Clinical Governance

• The members of Alfred Health’s Community Advisory Committee, Executive Committee, Clinical

Governance Committee and Quality Committee


How to find us

The Alfred

Commercial Road

Melbourne VIC 3004

Phone: (03) 9076 2000

Fax: (03) 9076 2222

Website: www.alfred.org.au

Melway reference: 58 B5

Car parking:

The Alfred has a visitors’ car

park near the corner of Punt and

Commercial Roads.

The entrance is from

Commercial Road. An hourly

rate applies. Metered parking

at the front of The Alfred in

Commercial Road is also

available for up to two hours.

Public transport:

Trams - 3, 5, 6, 16, 64 and 67

travel along St Kilda Road.

Alight at the corner of St Kilda

and Commercial Roads. Tram

72 travels along Commercial

Road and there is a tram stop at

the main entrance of The Alfred.

Bus - Routes 216, 219 and 220

stop outside The Alfred.

Train – The Sandringham line

stops at Prahran train station, a

5–10 minute walk from

The Alfred.

Caulfield Hospital

260 Kooyong Road

Caulfi eld VIC 3162

Phone: (03) 9076 6000

Fax: (03) 9076 6434

Website: www.caulfi eldhospital.


Melway reference: 67 K3

Car parking:

Parking is available to visitors

in the hospital grounds for a $5


Public transport:

Tram - Route 67 runs from

Swanston Street, Melbourne,

to the corner of Glenhuntly

and Kooyong Roads, a short

distance from Caulfi eld Hospital.

Bus - Route 605 runs from

Flinders Street and stops in

Kooyong Road at Gates 1, 2

and 3.

Train – The Sandringham line

stops at Elsternwick station.

You can then catch a tram up

Glenhuntly Road to Kooyong


Taxis – A taxi phone is available

opposite Main Reception.



193 Bluff Road

Sandringham VIC 3191

Phone: (03) 9076 1000

Fax: (03) 9598 1539

Website: www.


Melway reference: 76 K12

Car parking:

Parking is available to visitors

in the hospital grounds for a $5

fee. Parking is also available in

the adjacent streets, however,

restrictions apply.

Public transport:

Train – The Sandringham line

stops at Sandringham train


Bus - Route 600 runs between

the train station and the

hospital. Alternatively, visitors

can catch a Frankston line

train to Moorabbin station and

Bus Route 825 runs between

Moorabbin station and the


Taxis – A taxi phone is located

inside Main Reception.


Taxis – A taxi rank is located

at the front of The Alfred on

Commercial Road. A taxi phone

is available inside the front door

near Main Reception.


The Alfred RED

Caulfi eld Hospital BLUE

Sandringham Hospital GREEN

This report has been printed on recycled paper



The Alfred Health Quality of Care Report is written for patients and community members to inform them

about how quality and safety is monitored and improved throughout the health service. If English is not

your fi rst language and you would like to find out about the information in this report please contact our

Interpreting and Multicultural Service on 9076 2000 and ask for extension 44026.


Η Αναφορά Ποιότητας Φροντίδας του Δικτύου Υγείας The Alfred γράφτηκε για ασθενείς και μέλη της

κοινότητας για να τους ενημερώσει πώς ελέγχεται και βελτιώνεται η ποιότητα και ασφάλεια σε ολόκληρη

την υπηρεσία υγείας. Αν τα αγγλικά δεν είναι η μητρική σας γλώσσα και θέλετε να ενημερωθείτε για τις

πληροφορίες που υπάρχουν στην αναφορά αυτή, μπορείτε να επικοινωνήσετε με την Υπηρεσία μας

Διερμηνέων και Πολυπολιτισμού στο 9076 2000 και ζητήστε να σας συνδέσουν με την εσωτερική γραμμή



Il Rapporto sulla qualità dell’assistenza di Alfred Health è stato scritto per i pazienti e i membri della

comunità per informarli su come la qualità e la sicurezza vengono monitorate e migliorate in tutto il

servizio sanitario. Se l’inglese non è la tua prima lingua e desideri saperne di più sulle informazioni contenute

in questo rapporto puoi contattare il nostro Servizio Interpreti e Multiculturale al numero 9076 2000

e chiedere dell’interno 44026.


Raport Alfred Health zatytułowany “Jakość Opieki” został napisany z myślą o pacjentach i członkach

społeczności w celu poinformowania ich na temat tego, jak monitorowane i udoskonalane są jakość i

bezpieczeństwo w usługach zdrowotnych. Jeżeli angielski nie jest Twoim pierwszym językiem, a chciałbyś

dowiedzieć się, jakie informacje zawarte są w tym raporcie, prosimy zadzwonić do naszej Wielokulturowej

Służby Tłumaczy pod numer 9076 2000 i poprosić o połączenie z numerem wewnętrznym 44026.


Отчет по качеству ухода за больными, подготовленный службой здоровья Альфред, написан для

пациентов и членов общественности для информирования их о том, как происходит контроль

и улучшение качества и безопасности службы здравоохранения. Если английский не является

Вашим родным языком, а Вы хотели бы познакомиться с информаций из этого отчета, пожалуйста,

свяжитесь с нашей международной службой переводчиков по телефону 9076 2000 и попросите

соединить Вас по номеру 44026.



9076 2000 44026

Quality of Care Report 2009

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