Bayside Health - Alfred Hospital

Bayside Health - Alfred Hospital

The Alfred

Caulfield Hospital

Sandringham Hospital

Bayside Health

Quality of Care Report 2007


Community Voices 2

Bayside Health 3

Quality of Care 4

Making a Better

Health Service 5

The Alfred Centre 6

Improvements in the

Emergency Department 7

Keeping You Safe 8-9

Making our Hospital Safe 10

The Old and New at

Sandringham Hospital 11

Community Care 12-13

Our Culturally

Diverse Community 14-16

Research supports

Quality Patient Care 17

Organ Donation Experiences 18

Your Feedback

makes a Difference 19


Patient Satisfaction 20

Get Involved 21

Community Participation

in Writing this Report 22

How to Find Us 23

Translation 24

Recycled paper and vegetable-based inks

were used in the production of this

environmentally friendly report.



Throughout this report, you will see

how Bayside Health is increasingly

involving the community and

consumers to inform and improve

our services.

The Community Advisory Committee is made up

of ten community members and two members

of the Board. The committee assists Bayside

Health to integrate consumer and community

views appropriately at all levels of the service.

The Community Advisory Committee provides

advice on strategies to enhance and promote

consumer and community participation,

including the development, implementation,

monitoring and evaluation of a Community

Participation Plan for Bayside Health.

The current plan (2007 – 2009) is available

on the internet:

It identifies a number of priorities and goals

which are:

• Consumers and the community have a role in

clinical governance (the system through which

organisations are accountable for continuously

improving the quality of their services and

safeguarding high standards of care) (See

Page 4)

• There is timely and effective communication

with our diverse community (See Page 14)

• Consumers and the community are actively

engaged in service planning and improvement

(See Page 6)

• The needs of the multicultural community are

considered in all services (See pages 14 – 16)

• There is an environment of partnership,

accountability and open communication with

patients and their carers and families (See

Page 15).

2 Bayside Health

Bayside Health

Bayside Health incorporates The Alfred, Caulfield General Medical Centre

and Sandringham and District Memorial Hospital and is the main provider of

health services to people living in the inner southeast suburbs of Melbourne.


is a 544-bed teaching hospital providing a

comprehensive range of specialist acute health

and mental health services. The Alfred provides

services to the residents of its local community

and is a designated state wide provider of Heart

and Lung replacement and transplantation, Adult

Cystic Fibrosis, Adult Major Trauma, Adult Burns,

HIV/AIDS, Haemophilia, Sexual Health, Hyperbaric

Medicine, Psychiatric Intensive Care and Elective

Surgical Services.


is a 348-bed major health service provider of

aged care, rehabilitation, aged psychiatry and

residential care. It provides an integrated range

of specialist assessment and treatment options

for older and younger people with complex

needs. Caulfield Community Health Service is also

located at CGMC and provides a range of primary

care services for residents in the local area.


is a 101-bed community hospital with a strong

focus on meeting the healthcare needs of its

local communities, and provides elective surgery,

general medical, dialysis, emergency, women’s

health and maternity services including a level

two (extra care) nursery.

Substantial improvements have been achieved

across Bayside Health with regard to the majority

of key indicators of performance that health

services report to the Department of Human

Services. There has been a significant drop in the

number of patients who wait in the Emergency

Department for more than 24 hours for a bed

in an appropriate ward to become available

from 1393 in 2004/05 to 416 in 2006/07 – with

no patients waiting more than 24 hours in the

Emergency Department in the last three months

(see Emergency Department story page 7).

All three hospitals work together to best meet

demand for services for our patients. For example,

changes have been made to the way some

services are provided at CGMC in the areas of

aged care and rehabilitation, transition care and

aged persons’ mental health. This has made more

beds available and contributed to improvements

in emergency access at The Alfred.

There has also been a reduction in surgery

cancellations at The Alfred from more than

30 per cent down to 22 per cent this year. Elective

surgery often has to be cancelled as patients who

require emergency surgery are given priority.

Focused effort in this area has included the

development of an Extended Short Stay Unit

and improved bed management at The Alfred.

A Short Stay Unit also opened at SDMH in July

2007 (see page 7).

From Jennifer Williams, Chief Executive

This, our seventh annual Quality of Care Report,

highlights some of the outstanding work in our

quest to realise our vision of ‘Excellence in Health

Care and Service’. This report demonstrates

our efforts to achieve our core values through

everyday practice, highlighted through the stories

of our patients and staff.

Bayside Health values:

• Caring and responding to our patients

• Encouraging and achieving excellence,

continual learning and improvement

• Working in partnership and cooperation

• Being responsible and accountable

for the services we provide

• Achievement through teamwork

• Treating people with integrity and

in a friendly, trusting and respectful

manner and environment.

We would like to thank everyone who

generously allowed us to share their

experiences and congratulate our staff for their

commitment to providing an excellent service

to our consumers and their families.

Quality of Care Report 2007 3

what is quality?

Quality of Care

Our consumers agree that our health service

demonstrates a commitment to safe and effective care.

This means that:

• Staff are aware how to report issues and feel safe to do so

• Systems are in place to identify adverse events

• Issues are followed up promptly and taken seriously

• Action is taken to prevent problems recurring

• Patients are informed about the outcomes of their care

• The Board monitors the quality of care and is kept informed

of any system failures and remedial actions taken.

“Quality is something which is very important to every one who has ever been in a

hospital. The provision of quality service requires more than just having the best

available staff – it also requires constant attention to processes and systems. It is only

through a concerted effort that Bayside Health is able to ensure that the quality of its

services is at the ‘cutting edge’ of medicine and of consistently high quality. I am proud

to be a member of Bayside Health’s Clinical Governance Committee because I believe

the involvement of independent members helps to ‘keep the hospital on its toes’.”

Nigel Caswell, Clinical Governance Committee and Cultural Diversity Committee member

“During my time as a member of the Bayside Health Community Advisory Committee

(CAC) I have seen it develop into an enthusiastic group of people committed to the

provision of quality health care for all members of the community. Through a continuous

learning process, the CAC members have become more knowledgeable about health

issues and are better placed to inform the community about the current state of the

system and the progress being made in order to support further improvements.

CAC members bring community issues to the table, which enables Bayside Health

to better understand the concerns in the community and, where possible, to take

appropriate action to respond to such issues.”

Graham Ludecke, Community Advisory Committee member

4 Bayside Health

Making a Better

Health Service

Successful Accreditation Result

Bayside Health underwent a review by the Australian Council on Healthcare Standards (the

authority which accredits healthcare organisations in Australia) in June 2007. This was the first time

the health service had been reviewed as a single entity rather than on an individual hospital basis.

The interim report indicated that Bayside Health will maintain its full accreditation status for the

remaining two years prior to the next organisation wide survey. The feedback from the surveyors was

very positive, especially with respect to continuous quality improvement where we were awarded an

“outstanding achievement” rating.

Residential care services are reviewed by the Aged Care Standards & Accreditation Agency. Onsite

surveys, including unannounced follow-up visits, resulted in all three nursing homes being judged fully

compliant with the 44 required standards. An in-depth review of both infection control and continuous

improvement at the last visit also resulted in positive feedback, with no recommendations made.

Prof Ken Thomson

Australian First for Radiology Accreditation

The Alfred’s Radiology Department was given a “gold standard” rating

after it became the first public hospital radiology department in Australia

to achieve accreditation, ensuring it meets internationally recognised


The accreditation, awarded jointly by The Royal Australian and New

Zealand College of Radiologists (RANZCR) and The National Association

of Testing Authorities (NATA) was conducted under a voluntary scheme.

However, from July 2008 it will be a legislative requirement for all radiology

facilities in Australia to obtain this accreditation.

Do Patients Know their Rights and Responsibilities?

A survey of patients at Caulfield General Medical Centre found that many were unaware of their rights

and responsibilities and other important information related to their care. A working party, including

users of the service, was convened and developed a new patient information booklet which is:

• Available in larger print for people with reading difficulties

• Available in English, Italian, Greek, Polish and Russian – the key languages of the patient population

who use these services

• Able to be downloaded from the Bayside Health website by staff for patients who are being

transferred to CGMC from another site

• Presented in a folder to allow patients to keep all relevant information and brochures together

• Able to be updated easily to ensure that information remains accurate and relevant.

Quality of Care Report 2007 5


Bayside Health Falls and Serious Injuries

per 1,000 Bed Days


elective surgery

















The Alfred Centre


2001 2002 2003 2004 2005 2006

Victoria’s first dedicated statewide

elective surgery centre was officially


opened in March 2007 – marking

a new era for public healthcare in




Year “The Alfred Centre is the first surgical

serious injuries

centre of its kind in Victoria and will

have a major impact on the time

patients wait for elective surgery,”

said Mr Bracks, former Victorian


68% reduction in people waiting for elective surgery

The Premier said

2001 2002 2003 2004 2005 2006 2007

that patients

waiting for

elective surgery

were now less

likely to be

cancelled because

the new centre

had the added

benefit of being

quarantined from



the unpredictability of emergency

cases requiring immediate surgery.

The Alfred Centre has been a

significant addition to The Alfred and,

since the inception of the project in

2002, has generated interest from

healthcare providers around Australia

and internationally.

Bayside Health Chief Executive,

Jennifer Williams, said one of the

true highlights of the new centre was

that it would cater for all Victorians.

“As a statewide elective surgery centre

it will take patients from other hospital

waiting lists, in addition to The Alfred’s

waiting list,” Jennifer said.

“The 81-bed facility includes six

theatres, two procedure rooms and

extensive diagnostic services for The

Alfred and will greatly enhance the

hospital’s surgical and diagnostic







Increase Emergency Department presentation

The Alfred 18% and SDMH 35%

We were able to highlight prospective

user issues. We were supportive of

the forward planning which provided

for future building.


Anne O’Shea The Alfred SDMH

Community Participation Panel

– The Alfred Centre



6 Bayside 80 Health


Community Involvement in The Alfred Centre

2004 2005 2006 2007

Over 72% of patients are very satisfied with their

involvement in their treatment and care

As part of The Alfred Centre

Development, a Community

Participation Panel was established to

enable the community to have input

into the design and development of

the facility.

The Community Participation Panel

was made up of 12 people who

represented a number of groups from

the community. The panel included

representatives from the Ethnic

Communities’ Council of Victoria,

the Chinese Health Foundation of

Australia & the Chinese Community

Society of Victoria and a member of

the Jewish community.

The panel made a significant

contribution to The Alfred Centre’s

development, including:

• The location of car parking facilities

• Improved customer focus at

reception centres within The Alfred


• Input into the selection of key

pieces of equipment such as beds

and chairs

• Selection of the art work

• The naming of patient areas

• Appropriate signage

• Involvement in a range of focus

groups looking at issues such as

workforce recruitment and cultural

and linguistic issues.


68% reduction in people waiting for elective surgery

Improvements in the

Emergency Department

Victoria’s First Emergency Nurse Practitioner

The nurse practitioner role expands the scope of current practice, allowing nurses

in the role to prescribe medications, refer patients to specialists and write medical

certificates. This has

contributed to the reduction

in waiting times in the

Emergency Department. The

Alfred’s Tash Jennings has

been endorsed as Victoria’s

first Emergency Nurse


“I became involved in the

project when we were

Tash Jennings

looking at ways to alleviate

the pressure on the Emergency Department in the face of a

growing number of patient presentations,” Tash said. “And

so far, statistics show that waiting times and length of stay

go down when a nurse practitioner is working.”
















2001 2002 2003 2004 2005 2006 2007

Increase Emergency Department presentation

The Alfred 18% and SDMH 35%

2004 2005 2006 2007


The Alfred



Short Stay Unit at Sandringham Hospital

With funding from the Department of

Human Services (DHS), Sandringham

& District Memorial Hospital’s

Emergency Department has opened

a Short Stay Observation Unit.

Emergency Department Director, Dr

James Taylor, said the four-bed unit

would improve access and enhance

excellence of care for patients

presenting to the department.

“The unit will be a valuable addition

to the department as it will expand

the capacity of the department during

peak times and reduce congestion,”

James said. “This will, in turn, reduce

the length of time patients wait in the

Emergency Department and allow

more patients to be seen and also

reduce the amount of time the hospital


goes on ambulance bypass.’’ Patients

who may be treated in the Short

Stay Observation Unit include those

requiring observation or treatment











Over 72% of patients are very satisfied with their

involvement in their treatment and care


CGMC SDMH The Alfred

State Average

for less than 24 hours or patients

awaiting transfer to the ward or

another hospital or to be discharged


Quality of Care Report 2007 7

patient safety

Keeping About Bayside Health You Safe

Tips to Prevent Pressure Ulcers:

• The best thing you can do

is relieve the pressure by

keeping active and changing

your position frequently,

whether you are lying in bed

or sitting in a chair

• If you are unable to move

yourself, alert staff to help

change your position regularly

• Tell staff if you have any

tenderness or soreness over a

bony area or if you notice any

reddened, blistered or broken


• Avoid rubbing or massaging

your skin over bony parts of

your body.

1. Pressure Ulcer Prevention

Pressure ulcers or bed sores are unfortunately a common problem in hospitals

and are recognised internationally as one of the five most common causes of

harm to patients.

Patients at greatest risk of developing pressure ulcers are those who are frail,

elderly or immobile for long periods of time. This high risk group makes up a

large proportion of people treated at Bayside Health.

Bayside Health has achieved a decrease of 10 per cent in the incidence of

pressure ulcers during each of the past three years, which equates to 30 per

cent improvement.

2. Reducing the Risk of Infection

Multiple Resistant Staph Aureus (MRSA), which is commonly known as golden

staph, is an ongoing problem for all hospitals. A series of interventions has been

implemented at The Alfred since 2003 in the Intensive Care Unit (ICU) because

patients in this area are considered to be at particularly high risk. These include

the introduction of:

• A gel-based hand wash product in the ICU and the use of an “antibiotic

resistant organism” sign for anyone found to be harbouring MRSA.

• A hospital-wide staff feedback program using control charts. These charts

identify specific limits that demonstrate visually to staff to take action whenever

the limits are exceeded.

Mike Kennedy

Following these interventions, there was a statistically significant reduction in

MRSA both in ICU and throughout the hospital. During the past year, Bayside

Health has also participated in the Victorian Quality Council’s Hand Hygiene


Mike Kennedy is the Executive Director of the Victorian AIDS Council/Gay Men’s

Health Centre and has been a member of the Bayside Health Community Advisory

Committee (CAC) since its inception.

“The Infection Control Committee has benefited from having regular input from a

community and health consumer perspective. The CAC has had regular briefings

on key issues from infection control and infectious diseases staff, and has had the

opportunity to comment on patient fact sheets on infection control issues”, he said.

8 Bayside Health

3. Managing the Risk of Falls

Tips to Prevent Falls in Hospital

• Bring in and wear firm-fitting,

non-slip shoes or slippers

• Make sure pyjamas are fitted

and that the pants are not

too long

• Bring in the usual walking aid

(e.g. stick or frame) and keep

it within easy reach

• If your family member is

confused in new surroundings

they may need reminding to

use their walking aid or help to

locate the toilet or their room

• Spend time talking or reading

to your family member or

involve them in something


• Go for a walk around the

ward with your family

member (please ask the nurse

first or meet with the ward

physiotherapist). Safety always

comes first.

Falls pose one of the greatest risks to older patients. The increased risk of falls

in older persons is due to a number of factors including low blood pressure

when standing, lower muscle tone and poor balance, failing eyesight, poor

nutrition and vitamin deficiencies, dizziness, slower reflexes and medication.

As part of the governance responsibilities of the organisation, all falls across

Bayside Health are investigated and reported to identify strategies to reduce

the risk of other people falling.








Bayside Health Falls and Serious Injuries

per 1,000 Bed Days


2001 2002 2003 2004 2005 2006



serious injuries






While CGMC shows

one of the lowest

falls rates in similar

facilities in Victoria,

there has been an

increase noted over

the last two years.

There are currently

intensive sessions

being held with staff

to identify further

falls reduction


Melita Van de Vreede









68% reduction in people waiting for elective surgery

4. Addressing Medication Safety

Medication errors can occur at any point in the drug administration process.

Every year, these errors affect approximately 140,000 patients across Australia.

At the Australian Health Ministers’ Conference in April 2004, Ministers agreed

that “to reduce the harm to patients from medication errors, all public hospitals

will use a common medication chart.” Prior to the adoption of a standard chart,

500 there were several hundred charts being used in hospitals across Australia.

Quality 0 Use of Medicines Pharmacist Melita Van de Vreede said, “Each time

2001 2002 2003 2004 2005 2006 2007

a member of staff changes hospital, they come across a new chart, which

increases the risk of error, so having a common medication chart is a good

safety principle”.

In January 2007 the new medication chart was implemented across Bayside

Health. Staff readily accepted the safety principle of a common medication chart.

Increase Emergency Department presentation

The Alfred 18% and SDMH 35%



Quality of Care Report 2007 9

patient safety

Making our Hospital Safe

Not all hospital care goes according to plan. Sometimes this is because the

patient has a very complicated condition or because there are associated risks.

However, things sometimes go wrong because of errors or because something

that should have happened did not happen, for example, test results were not

seen or the wrong drug was administered.

What do we do to make our hospitals safe?

Safety Culture

• We work to create a culture in which everyone is conscious of patient safety

• We promote reporting and review and analyse anything that goes wrong

including safety occurrences, sentinel events (very serious events) and

patient complaints

• We learn from things that go wrong in other hospitals.


• We have commitment from the Board and the Chief Executive and expect

senior clinical managers to help ensure and take responsibility for patient


• We report on patient safety to our Clinical Governance Committee, the

Quality Committee and the Bayside Health Board.

Review of clinical practice

• We review all major complications and deaths to see if anything could have

been prevented and finds ways to improve care

• We measure our clinical performance and compare it to other hospitals.

Clinical practice based on evidence

• We base treatment on research-based evidence

• Our policies and guidelines are based on research and provide guidance for staff

• We provide education, support and back up to all medical staff to support the

clinical care they provide.

10 Tips for Safer Health Care:

1. Be actively involved in your own healthcare

2. Speak up if you have any questions or


3. Learn more about your condition or treatments

by asking your doctor or nurse and by using

other reliable sources of information

4. Keep a list of all the medicines you are taking

5. Make sure you understand all the medicines

you are taking

6. Make sure you get the results of any test or


7. Talk to your doctor or healthcare professional

about your options if you have to go

to hospital

8. Make sure you understand what will happen

if you need surgery or a procedure

9. Make sure you, your doctor and your surgeon

all agree on exactly what will be done during

the operation

10. Before you leave hospital, ask your doctor

or healthcare professionals to explain the

treatment plan you will use at home.

10 Bayside Health

The Old and New at

Sandringham Hospital

Something Special for Babies

SDMH recently established a Special Care

Nursery containing three cots, which will

deliver additional care to newborn babies

who formerly would have required transfer

to another hospital.

This nursery, together with the recently

commenced breastfeeding support service,

have improved the hospital’s services

to cater for the growing demand from

families wanting to deliver their babies

in the local community.

“During Ruby’s stay in the Special Care

Nursery I was so impressed with the

care and attention given to Ruby by all

the staff. I always felt the nurses looked

after her as an individual, not just another

baby. My husband and I are very grateful

for all their efforts and education at such

an important time in our lives.”

– Ruby’s mum, Marie Neilsen.

sandringham hospital

Recognising a Long Term Volunteer

Bayside Health volunteers are recognised as partners with the organisation,

assisting paid staff in providing quality care for our clients, whether patients

or other associated members of the community. Volunteers perform roles that

complement and extend the services of Bayside Health.

Volunteers add to the quality of health care by helping patients, their families,

the staff, visitors and the community in a variety of ways, including friendly

visiting, assisting with group activities, kiosk support, concierge/guide duties,

Emergency Department duties and other activities that support individual units

and departments.

Betty Williams commenced her role as a volunteer at Sandringham & District

Memorial Hospital before it was opened to the public in 1964.

Betty enjoys volunteering at SDMH as it gives her a chance to give something

back to the community and the hospital. “I just love it.”

Betty Williams

During the past two years Betty has spent extra time at SDMH attending

the Haemodialysis Unit three times a week as a patient for dialysis. Despite

suffering health problems, Betty has continued in her role as a much-loved and

respected volunteer.

Quality of Care Report 2007 11

caulfield hospital

Community About Bayside Health Care

1. Improving Care for Older People

Caulfield FUTURES was launched in July 2006 and is a framework for change

which outlines a direction for delivering clinical services at CGMC into the future.

As a designated Centre Promoting Health Independence, CGMC promotes a

philosophy of person-centred care that underpins our service delivery.

Achievements include:

• The development of the Caulfield Access Unit to provide a ‘one stop shop’ for

clients needing community and ambulatory care. The unit provides a central

point of contact for both clients/carers and staff wanting to refer a patient for

community & ambulatory services.

• A range of projects and activities that focus on the implementation of the

Department of Human Services ‘Improving Care for Older People in Hospitals’

policy have commenced. These projects aim to ensure older people maintain

or improve their functioning while in hospital and focus on areas such as

nutrition, mobility, skin and continence.

• The introduction of new, interdisciplinary documentation in all subacute

inpatient wards. The new documentation is aimed at providing more

coordinated, efficient and safer health care for patients.

• An Ageing Well Expo and Community Information Open Day were held in

May 2007. The hospital was opened to the public to enable members of the

community to learn more about ways to maintain their health and wellbeing

as they become older.

2. Ensuring a Safe Return Home

The Transition Care Program (TCP) provides client-centred care and restorative

services for up to 12 weeks for older people who have been in hospital. The

program is goal orientated and utilises low level intensity therapy and case

management. This provides a mechanism for quicker discharges from hospital

either to the client’s home or to a residential care setting.

June Whitehead

June Whitehead has been one of the many successes of this dedicated program.

Prior to her involvement, June had four lengthy hospital admissions in less than

a year. She felt exhausted and was uncertain if she could manage at home once

discharged from hospital again. The program assisted June to achieve her goal

of returning home by providing daily care. “I have learnt for once in my life

that I have to work in with others in maintaining my health and I could not have

done this without the Transition Care Program,” June said. June has now been

discharged and a community care package of services will continue to look after

her care needs on a permanent basis.

12 Bayside Health

3. Psychiatric Services Reach the Homeless

A move by The Alfred’s Homeless Outreach Psychiatric Service (HOPS) to

reach more homeless clients by linking up with other homeless agencies has

been a great success.

HOPS Nurse Manager, Anthony Kennedy, said HOPS now provided secondary

consultation outreach services by being onsite at Sacred Heart Mission’s drop

in centre in St Kilda and also at Hanover welfare mission, which provides

crisis accommodation.

“Two years ago we couldn’t reach those people who wouldn’t come anywhere

near our psychiatric facility at the Junction Clinic – now we see and treat huge

numbers of people at sites where they traditionally seek support and refuge.

“Other psychiatric services are now looking at using this model because it has

been demonstrated that it actually works,” Anthony said.

“Most people we see have a multitude of problems, like drug and alcohol

dependence, depression, personality disorders, intellectual disability and

mental illness. Homelessness adds another layer of complexity on top of these

issues, which makes their care quite intricate.”

4. Helping People Maintain Independence

Caulfield Community Health Service (CCHS) and the Mobile Aged Psychiatry

Service (MAPS) team provide direct care and health promotion to adults in

need, particularly those living in Supported Residential Services.

Research indicates that older people with a mental illness are at greater risk of

falls. In response to this evidence as well as feedback from consumer forums,

it was decided to provide a regular program to address this decline with the

aim of maintaining independence for this client group in the community.

A program was developed which includes strength training exercises and

games, as well as structured creative activities that promote social connection

within the group. Free transport and lunch for all involved was also valuable

in supporting the program. The outcomes of this program have been very

positive – orientation to days of the week has improved as well as the

communication skills of this client group.

Quality of Care Report 2007 13

cultural diversity

Our Culturally

Diverse About Bayside Community


1. Work of Cultural Diversity Committee

The Cultural Diversity Committee at Bayside Health provides advice to staff to

ensure that systems are in place across the organisation to respond effectively

to issues of cultural, religious or linguistic diversity. The Committee is also

involved in the development of a Cultural Diversity Plan to address the following


• Understanding the patients / carers and their needs

• Fostering relationships and partnerships with multicultural and

ethno-specific agencies

• Developing and maintaining a culturally diverse and aware workforce

• Using translation and interpreting services effectively

• Encouraging participation in decision making about treatment and care.

The Committee is also committed to increasing the level of awareness of cultural,

religious and linguistic diversity and cross-cultural issues across the service.

Through the acknowledgement and celebration of ‘Celebrate our Cultural

Diversity Week’ staff at Bayside Health are given the opportunity to celebrate

Victoria’s cultural, linguistic and religious diversity.

Celebrations this year involved the display of promotional posters in prominent

areas across all hospital sites, and orange ribbons were available for staff to

wear as a symbol of respect for diversity and support for community harmony.

2. Cardiac Rehabilitation for our Community

The Caulfield Cardiac Rehabilitation Unit provides education and exercise

programs for people with Coronary Artery Disease and Heart Failure.

Whilst the service has always used interpreters at key points of the program

(for example, orientation to the program and discharge planning), patients

of the service who had limited English were only able to be involved in the

exercise program and missed out on the education component. The team

wanted to provide individuals from Culturally and Linguistically Diverse (CALD)

backgrounds with a similar program to that offered to people who speak English

– so a new program was developed!

With the assistance of Russian, Greek and Italian interpreters the new program

includes six education sessions addressing issues such as understanding heart

disease and risk factors, medication management, principles of exercise, activity

guidelines, nutrition and stress management. The education sessions have a

maximum of five patients and two different languages.

14 Bayside Health

3. Meeting the Needs of HIV Communities

Individuals from Culturally and Linguistically Diverse

(CALD) backgrounds who are diagnosed with HIV

frequently face a range of complex health and social

issues not experienced by other individuals with HIV.

These issues include:

• immigration;

• resettlement (housing, financial issues, employment);

• mental health issues (particularly related to trauma);

• family relationships both here and in their own

country; and

• stigma, discrimination and isolation.

The HIV CALD Service at The Alfred provides support

to clients via a bi-lingual worker and aims to provide

emotional and practical support to reduce isolation

and improve access to healthcare services and relevant

support services in the community. Patients are actively

supported and encouraged to have input into their

treatment and care.

4. Koori Play Time

Aboriginal and Torres Strait Islander children experience

significantly worse health outcomes than non-Indigenous

Australian children. There are multiple health risk

factors confronting Indigenous children which include:

• Low socio-economic status

• Changes to social structure and isolation

• Discrimination and alienation

• Parental unemployment.

In an attempt to address some of these issues, Caulfield

Community Health Service, in partnership with the

local Indigenous community, Inner South Community

Health Service and the Department of Human Services,

established a playgroup for Indigenous children in

the local area. Koori Play Time aims to create an

appropriate, safe and welcoming environment for

Indigenous families to access a local play group for

children 0-5 years old.

Whilst the program provides an environment for the

children to socialise, learn new skills and develop self

esteem, it also provides an opportunity for Indigenous

parents to support each other and learn parenting skills.

The program also promotes healthy eating and lifestyle

through nutrition activities including healthy morning

tea and lunches.

When evaluating the program, the participants

expressed a desire to have a “yarn” rather than complete

a questionnaire. The yarn highlighted the benefits of

the informal parental support and advice from program

workers and maternal and child health nurses, as well

as education on topics such as nutrition, speech and


Quality of Care Report 2007 15

5. Linking with our Indigenous Community

The expansion of the role of the Aboriginal Liaison Officer at Caulfield

Community Health Service (CCHS) to include The Alfred has opened up a whole

new area of work for Sharon Bolger. During her 10 months at Bayside Health

she has established a close working relationship with the local Aboriginal

communities through a number of outreach programs offered by CCHS and the

Inner South Community Health Service. This is obviously a critical step on our

journey to better meeting the needs of the Aboriginal and Torres Strait Islander

(ATSI) communities.

A small but significant part of the process of establishing effective relationships

was the recognition and promotion of NAIDOC week across the three hospital

sites. Staff were made aware of NAIDOC week via promotional posters, emails

to all staff and the display of the Aboriginal and Torres Strait Islander flags in

prominent locations.

Sharon Bolger

Whilst there is a lot of work still to do, Sharon has been focussing on:

• Establishing links with Aboriginal services to inform them of her role and

to facilitate support for Aboriginal patients who attend Bayside Health

• Identifying the training needs of Bayside Health staff and focussing initial

education sessions on the needs of the staff in the Emergency Department

at The Alfred

• Reviewing and establishing procedures to ensure that individuals from the

ATSI communities are correctly identified to ensure their individual needs

are addressed whilst in hospital, and that appropriate services are involved

during discharge planning.

Bayside Health is in the process of establishing an Aboriginal Working Party

to include staff from the three hospital sites.

Work with our GPs

The focus of current efforts being made by Bayside Health’s GP Liaison team

is to improve patient care through better communication between GPs and the


Referral management guidelines have been developed so that GPs have

a clearer idea of the information they need to include, thus assisting with

appropriate triaging of referrals.

Dr Josie Samers and Judith Bushell

A part of Bayside Health’s website was developed “For GPs” by the GP Liaison

team. This gives GPs quick access to information, forms, and contact numbers.

The GP Liaison team also assisted in establishing a 1-800 number for The Alfred

Emergency & Trauma Centre.

16 Bayside Health

Research supports

Quality Patient Care

Sustainable improvements in clinical practice and patient outcomes

are underpinned by excellence in clinical research. Bayside Health

is a partner in one of Australia’s leading centres of clinical research

– the Alfred Medical Research and Education Precinct (AMREP).


Kimberly Finds Strength in her Heart

Kimberly Cowcher, centre,

with family

Kimberly Cowcher may not be used to wearing her heart on her sleeve –

but she is used to carrying it around in her backpack. The Cobram teenager

had experienced much sickness in her short life. She was diagnosed with

non-Hodgkin’s lymphoma, a paralysing auto-immune disease, and then

suffered heart failure from her chemotherapy. In July 2006 she fell into a

coma and her family was told her only hope of survival was an artificial

heart designed for adults. Kimberley became the youngest Australian

recipient of the VentrAssist. The artificial heart assist device is connected

to the heart and an external power source. The VentrAssist helps the

heart’s pumping function, enabling significantly improved quality of life.

The artificial heart allowed Kimberly to enjoy time out with her family

and continue her schooling. “It’s given me a lot to live for,” Kimberly said.

“I can breathe. I don’t get short of breath. I’m grateful I’m here.”

While most people were expected to go on the waiting list for a heart

transplant once they had recovered physically and mentally, Kimberly

and her family were delighted when her own heart made a full – and

unexpected – recovery. Head of The Alfred’s Heart and Lung Transplant

Unit, Professor Don Esmore, said that the number of people whose own

hearts actually recover as a result of having an artificial heart implanted

was about five per cent. “Kimberley’s case is unique, as the cause of the

problem was rare and the time she spent with the heart implanted was

considerable,” Don said. “But she is doing very well, which is incredibly

gratifying. This is absolutely the best possible result for her.”

An Innovative Approach to Trauma Care

Traumatic injury is a leading cause of death and disability for Victorians.

The resuscitation of severely injured patients is rapid, complex and requires

multiple decisions in a short space of time.

The team behind the Trauma Reception and Resuscitation Project have

developed an innovative software program to guide the critical first thirty

minutes of trauma care.

Associate Professor Mark Fitzgerald, Director of The Alfred Emergency and

Trauma Centre, believes that this is a world first and has the potential to

transform approaches to treating severely injured trauma patients. “The

Victorian State Trauma System is a world leader in trauma innovations and

research,“ he said. “The Alfred has one of the busiest and most experienced

Trauma Centres in Australia. This project means that the Victorian community

can expect to receive state of the art trauma care and that we are doing the

research necessary to measure its success.”

Quality of Care Report 2007 17

organ donation

Organ Donation


Encouraging Organ Donation

For some families, the only positive to come out of a loved one dying

is being able to give another person life by donating their organs.

Despite this, Australia has one of the lowest donation rates in the

developed world.

Clinical Ethicist Associate Professor Paul Komesaroff said the reasons for Australia’s comparatively

low donation rates were complex. “They probably reflect limited awareness of the benefits of organ

transplantation in the community,” Paul said.

To help improve the availability of organs and tissues for transplantation, The Alfred, along with

20 other hospitals across Australia, is participating in the Australian Organ Donation Breakthrough

Collaborative. “The project involves talking with health professionals and families who have been

approached about organ donation to discuss the nature of their experiences, including both difficult

and positive elements, and the role of religious, cultural and other factors in decisions they may make,”

Paul said.

Successful Lung Transplant for Children

Tamara, Will and Alysha are the first three recipients

under the Victorian Paediatric Lung Transplant Program

at The Alfred, which was officially established in June

2005. The program has been developed through strong

collaboration utilising the expertise of staff from The

Alfred and the Royal Children’s Hospital. Teamwork has

been the key to the initial success of this program, with

lung specialists, cardiothoracic surgeons, allied health

and nursing staff all joining forces and being rewarded

with three happy smiling children. Critically ill children

who were stuck in hospital in the final stages of severe

lung disease are now running, laughing and playing.

18 Bayside Health


The Alfred 18% and SDMH 35%

Your Feedback

Makes a Difference

Committed to listening

to your hospital experiences,

Greg Hann & Libby Apps

(Patient Representatives)





Our aim


is for patients to feel they have received appropriate care in a

2004 2005 2006 2007

comfortable, supportive and Year safe environment. If patients or their families

have any The concerns, Alfred they SDMHare actively encouraged to raise them in the first

instance with the staff member in charge of the department.

If the problem remains unresolved or the patient / family member is

dissatisfied, the concern is referred to one of our Patient Representatives.

The Patient Representative provides an independent point of contact for

patients requiring help with the progress of their complaint, as well as

offering education for hospital staff and managers on responding to

consumers Over 72% and of conflict patients resolution. are very satisfied with their

involvement in their treatment and care

The 100 number of complaints received has increased marginally over recent

years. This trend is seen as positive as it provides another avenue to identify


opportunities for improvement to our services.


Some examples of improvements made as a result of consumer feedback


this year include:


• Additional seating being installed in high traffic areas

• 50 New protocols for patients fasting for surgery

• 40 New flooring to reduce hazards

• 30 Employment of two new case managers

• Review of the process for patients who require Aged Care Assessment


• 10 Continuing education on correct procedures

• On


going education for staff on the importance of good communication

CGMC SDMH The Alfred



State Average

We are also addressing concerns registered about waiting times, access and

delay in elective surgery, access to outpatient appointments, and the impact

of noise disruption caused by major building works.

If Bayside Health consumers remain dissatisfied with the outcome of their

complaint, they are encouraged to contact the office of the Health Services

Commissioner. This is an independent, impartial statutory authority designed

to assist consumers in their dealings with all health services providers.

To contact the Health Services Commissioner telephone: (03) 8601 5200.





27% increase in Complaints across Bayside Health










Quality of Care Report 2007 19


patient satisfaction
















Patient About Bayside Satisfaction


2001 2002 2003 2004 2005 2006 2007

The Department of Human Services Victorian Patient Satisfaction Survey

provides another opportunity for Bayside Health to receive feedback from

people who access our services.

Some improvements which have been made as a result of the Patient

Increase Emergency Department Satisfaction presentationSurvey across the three sites include:

The Alfred 18% and SDMH 35%

• Refurbishment of the waiting rooms

2004 2005 2006 2007


The Alfred SDMH

• Provision of a children’s play area at Sandringham & District Memorial

Hospital (pictured)

• Revision of the means of providing information to patients regarding


• Revision of the visiting hours for patients

• Review of the cleaning schedule for toilet amenities

• Purchase of a television for the waiting rooms

• Review of the processes for ensuring food reaches patients at the

appropriate temperature.

Consumer Feedback Survey










Over 72% of patients are very satisfied with their

involvement in their treatment and care

Another aspect of patient satisfaction that we take very

seriously at Bayside Health involves the extent to which

patients feel they are involved in decisions about their

own treatment and care.

In March 2005, additional questions were added to

the Department of Human Services Victorian Patient

Satisfaction Survey to enable this information to be

gathered. The results depicted in the graph show that the

percentage of patients satisfied with their involvement in

their treatment and care (March 2005 – February 2006) is

the same as for peer hospitals across the State.



CGMC SDMH The Alfred


State Average

27% increase in Complaints across Bayside Health

20 Bayside Health


Get Involved!

The Quality of Care Report is a report for the community. It is our

opportunity to inform you of the services we offer and the strategies

in place to continually improve the quality of these services.

Your comments and feedback enable us to develop a report that meets

your needs and answers the questions that you want answered.


I am a: (please tick)

Patient Relative / Carer Health Professional

Other .............................................................................................................................................................................. .

From where did you obtain the report?


Are you satisfied with the presentation of the report?



Comment: ............................................................................................................................................................................

Are you satisfied with the content of the report?



Comment: ............................................................................................................................................................................

Was the content easy to understand?



Comment: ............................................................................................................................................................................

Did you find the report informative?



Comment: ............................................................................................................................................................................

How could this report be more meaningful to you?






Please post to:

Clinical Governance Unit

Bayside Health

Commercial Road

Melbourne VIC 3004

Quality of Care Report 2007 21

Community Participation

in Writing this Report

In our last Quality of Care Report, we requested feedback from the community via an

on-line survey or by making direct contact with staff by telephone. Neither of these

strategies achieved much response from the community. The lack of response has

resulted in alternative strategies being used for this report.

The lack of feedback also prompted us to conduct a focus group with a mix of consumers

and staff to gain feedback.

The Quality of Care Report for 2007 has been compiled with this feedback in mind and,

as in previous years, with active input from Community Advisory Committee members

in relation to content and format.


This report was compiled by:

• Libby Apps, Quality Improvement and Consumer Coordinator, Sandringham & District

Memorial Hospital

• Jane Blaxland, Community Advisory Committee member, Bayside Health

• Jill Exton, Quality Improvement and Accreditation Coordinator, Caulfield General

Medical Centre

• Jo Gatehouse, Community Participation Coordinator, Bayside Health

• Alexandra Hanton, Administrator & Data Coordinator, Clinical Governance Unit,

Bayside Health

• Caroline Hedt, Clinical Photographer/Visual Communications Manager, Bayside Health

• Nicole Rasmussen, Clinical Governance Improvement Manager, Bayside Health

• Rimma Sverdlin, Community Advisory Committee and Cultural Diversity Committee

member, Bayside Health

• Emma Watts, Public Affairs Officer, Bayside Health

• Margaret Way, Director Clinical Governance, Bayside Health

Bayside Health Quality of Care Report editors would also like to acknowledge the

contributions from many patients, carers and staff across the health service, and input

from members of Bayside Health’s Community Advisory Committee, Executive Committee,

Clinical Governance Committee, Board Quality Committee and Board of Directors.

Distribution of the Report

The Bayside Health Quality of Care Report is distributed to key community and consumer

groups as well as to community health centres, local councils and GPs in the catchment

area. It is made available in waiting rooms and outpatient areas of the hospitals. We also

make the report available to our staff. It is sent to media outlets and published on the

Bayside Health website

The report is not translated but it is distributed to key ethnic organisations in touch with

ethnic communities in an attempt to make it accessible. Consumers who do not read

English can contact the Multicultural Adviser, Renee Leighton, on (03) 9076 3026 who

will arrange an interpreter if required to discuss the report.

Additional copies can be obtained by phoning (03) 9076 2804.

22 Bayside Health

How to Find Us

The Alfred

Commercial Road,

Melbourne VIC 3004

Phone: (03) 9076 2000

Fax: (03) 9076 2222


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 & 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.

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.

Caulfield General

Medical Centre

260 Kooyong Road,

Caulfield VIC 3162

Phone: (03) 9076 6000

Fax: (03) 9076 6434


Melway reference: 67 K3

Car parking: Parking is available to

visitors in the hospital grounds for a $4

fee (current at time of publication but

subject to change).

Public transport:

Tram – Route 67 runs from Swanston

Street, Melbourne, to the corner of

Glenhuntly and Kooyong Roads, a

short distance from Caulfield General

Medical Centre.

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 Road.

Taxis: A taxi phone is available

opposite Main Reception.

Sandringham &

District Memorial


193 Bluff Road,

Sandringham VIC 3191

Phone: (03) 9076 1000

Fax: (03) 9598 1539


Melway reference: 76 K12

Car parking: Parking is available

to visitors in the hospital grounds for

a $4 fee (current at time of publication

but subject to change). Parking is

also available in the adjacent streets,

however, restrictions apply.

Public transport:

Train – The Sandringham line

stops at Sandringham train station.

Bus – Route No. 600 runs between the

train station and hospital. Alternatively,

visitors can catch a Frankston line train

to Moorabbin station and Bus Route:

No 825 runs between Moorabbin station

and the hospital.

Taxis: A taxi phone is located

inside Main Reception.

Quality of Care Report 2007 23


The Bayside Health Quality of Care Report aims to inform our communities about processes for

monitoring and improving the quality of care and services provided by Bayside Health. If you would

like any information in this report translated, please contact Renée Leighton, Multicultural Adviser,

by telephoning (03) 9076 3026.


QC Report mira a informare le nostre comunità sui processi per monitorare e migliorare

la qualità dell’assistenza e dei servizi forniti da Bayside Health. Se vuoi che qualsiasi

informazione contenuta nel rapporto venga tradotta, telefona a Renée Leighton,

coordinatore per i servizi transculturali, al 9076 3026.


Στόχος της αναφοράς QC Report (Έλεγχος Ποιότητας) είναι η ενηµέρωση των κοινοτήτων

µας για τις διαδικασίες ελέγχου και βελτίωσης της ποιότητας της φροντίδας και υπηρεσιών

που παρέχονται από το ∆ίκτυο Υγείας Bayside Health. Αν θέλετε µεταφρασµένες

οποιεσδήποτε πληροφορίες αυτής της αναφοράς, µπορείτε να τηλεφωνήσετε στην

Renée Leighton, Συντονιστής ∆ιαπολιτισµικής Υπηρεσίας στο 9076 3026.


QC Report ma za zadanie poinformowanie naszych społeczności o procedurach kontroli

i poprawy jakości stosowanych w odniesieniu do świadczonych przez Bayside Health

usług opieki zdrowotnej. Jeśli chcieliby Państwo otrzymać którekolwiek z zawartych w

tym raporcie informacji w tłumaczeniu na inny język, prosimy zadzwonić do Koordynatora

Usług Wielokulturowych, Renée Leighton, pod nr. tel. 9076 3026.


QC Report стремится информировать население о контроле и повышении качества

ухода и услуг, предоставляемых Bayside Health. Если вы хотели бы получить перевод

информации из этого отчета, то позвоните координатору Этнической службы

Renée Leighton по номеру 9076 3026.

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