Quality of Care Report 2010 - 2011 - Wimmera Health Care Group

MONITORING QUALITY AND SAFETYClinical Risk ManagementCare provided at Wimmera Health Care Group is underpinned by a strong and effective clinical governance framework.It is through this framework that we are accountable for monitoring and continually improving the quality and safety ofour service. The Clinical Governance Committee which consists of Board members, the Executive and key members of theQuality and Safety team, is responsible for ensuring implementation of the framework. The Clinical Governance Committeehas also developed a Quality and Safety Strategic Plan to assist in the process and monitor a number of key performanceindicators which provide a view of the whole health system and measure all dimensions of quality.View of Health System using Whole System MeasuresDimensions of QualitySafeEffectiveAppropriatePatient with HealthNeedsPatient-CentredEfficientAccessibleProcess of ProvidingServicesPatient with HealthNeed MetNumber of fallsresulting infractureNumber ofpressure ulcers bygrade% of patients aged ≥65 years readmittedwithin 28 daysIncidence of nonfataloccupational injuriesand illnessesClinicalOutcomesDaily improvement infunctional activity rate(GEM patients)Averageimprovement inBarthel Score(GEM patients)FunctionalOutcomesNumber ofclinicians attendededucationsessionsNumber of opendisclosureoccurrencesSatisfactionAll Wimmera Health Care Group staff aim to provide thebest possible care to our patients, residents and clients,however, healthcare in the 21st Century is very complexand even with the best intentions, there are times whensomething goes wrong resulting in an adverse event.An adverse event is an incident which results in harm to aperson receiving health care. Examples of adverse eventsare a wound infection after surgery, an allergic reactionto a medication and the development of a pressureulcer. Not all adverse events are preventable, but a largenumber are.Clinical Pathways AwardWimmera Health Care Group’s Clinical Risk ManagementProgram aims to reduce the chance of individuals in ourcare experiencing an adverse event.There are currently a number of individual projects beingundertaken as part of Wimmera Health Care Group’sClinical Risk Management Program. You can read aboutsome of our projects in the following articles in thisreport:• Medication Safety• Falls Prevention• Pressure Ulcer Prevention• Blood TransfusionsAccessTime betweenreferral &assessment forACAS clientsDays to third nextavailable PodiatryappointmentEnd of LifeTime spent in hospitalin last 6 months of life(palliative care only)% residents withweight loss ≥ 3kg% residents withunplanned weight lossover 3 consecutivemonthsOur staff understand that everyone, not just the ClinicalGovernance Committee, is responsible for quality andsafety within the health service. This means that staffact in the right way as part of a safe quality program withappropriate accountability to patients, management andthe community.Adverse eventrate (LAOSScreening)% STEMI patientscompliance with4 processes% Stroke patientscompliance with4 processes% with fallsassessment &appropriateintervention% with pressureulcer assessment& appropriateinterventionCostsWIES per bed day≥ 65 year oldpatients with LOS> 5 daysPatientSatisfaction withCare ScorePatientExperience Scoreis given to the right patient, at the right time, in theright way, by the right clinician. We have many waysof monitoring that this occurs from the accreditationprocess to monitoring clinical indicators and undertakingclinical audits. Some of these activities are presentedthroughout this report.Our clinical pathways program received one of theState’s highest healthcare awards, being jointly awardedthe Minister for Health’s Award for Improving QualityPerformance at the annual Victorian Public HealthcareAwards, held in October 2010.The Improving Quality Performance Award recognisesoutstanding initiatives using evidence-based treatmentoptions that result in the best clinical outcomes, improvedconfidence and patient experience. Wimmera HealthCare Group was recognised for using clinical pathways toimprove and sustain quality patient care.Clinical Pathways act as the patients’ medical record,with all health professionals involved in the patientscare having agreed actions to be checked off each day oftheir stay in hospital. Clinical Pathways have key processindicators, documentation and are multidisciplinary,meaning the Doctor, Pharmacist, Physiotherapist,Speech Pathology, Nurse and all other relevant healthprofessionals use the same Clinical Pathway for thediagnosed problem.In summary, clinical pathways work to:• achieve quality standards of care;• improve communication between healthcaredisciplines;• improve patient involvement in plan of care;• reduce practice variation;• allow auditing of clinical practice;• enhance documentations; and• allow implementation of local pathways based onevidence based clinical guidelines and facilitiesavailable at our health service thereby providing“optimal care” for the patient.At Wimmera Health Care Group we also achieve thisby working with our staff and patients in key areas thatassist to enhance the delivery of clinical care.Consumer ParticipationConsumers are involved and engaged with WimmeraHealth Care Group through the Community AdvisoryCommittee and the Cultural and Linguistically Diverse(CALD) Committee. Consumer complaints, compliments,suggestions and surveys are used to enhance the qualityof care we provide.Clinical EffectivenessClinical effectiveness is ensuring that the right careEffective WorkforceWe have systems in place to ensure that staff employedat Wimmera Health Care Group have appropriate skills,qualifications and experience to provide safe high qualitycare. These include: credentialing and scope of practice;clinical practice and education programs; and mandatorycompetencies.Risk ManagementWimmera Health Care Group has a robust riskmanagement system which involves managing clinicalrisk to patients as part of the broader organisationalrisk management system which includes corporate andoccupational health and safety risks.Alan Wolff, Janette McCabe, Sally Taylor, Alicia McGrath, Sammy Sordello and Ian Campbell accept the Victorian Public Healthcare Award.30Pursuing excellence in careWimmera Health Care Group Quality of Care Report 2010/201131