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

AccreditationMonitoring Patient CareAccreditation is a measure of accountability. It is the formal process that is used to determine how well we are performingagainst standards that are set by governing agencies to ensure healthcare services such as Wimmera Health Care Groupdeliver quality care that is safe and appropriate to the needs of the individual. The accreditation process involves a writtensubmission of achievements against the standards and independent assessors from the accreditation body visiting ourhospital and conducting a thorough assessment. The thorough assessment can include: talking with patients, residents,clients and their relatives; interviewing staff and checking documentation and observing care, service delivery and theenvironment.Because Wimmera Health Care Group provides acute, aged care and community services, the organisation has beensuccessfully accredited under a number of accreditation agencies.AGENCY HOSPITAL AREA STATUSThis section presents a snapshot of how the principles of quality and safety are used to continuously monitorpatient care. We collect and monitor our care delivery as part of our strategic goal to pursue excellence in care.We also collect and report data to external organisations, including the Department of Health.Infection ControlInfection prevention remains a constant goal for Wimmera Health Care Group. Many strategies are used to minimisethe risk of infection: careful placement of patients at risk of infecting others or who are at increased risk of an infectionthemselves, auditing of processes, staff immunisation, and good hand hygiene, to name a few.Australian Council on HealthcareStandards (ACHS)Wimmera Health Care Group(excluding residential / aged carefacilities)Full four-year accreditation July 2009,successful self-assessment 2010.Periodic Review due July 2011.Infection control is a mandatory standard to be achieved in both Aged Care and Acute accreditations. Our Horsham andDimboola sites were assessed and accredited in 2009, with reassessment and accreditation to occur in 2011.Aged Care Standards AccreditationAgency (ACAA)Wimmera Nursing HomeKurrajong LodgeDimboola Residential ServicesWimmera Nursing Home and Kurrajong Lodgeachieved compliance May 2010, and thereforegranted full three year accreditation status.Two year accreditation for Residential Servicesat Dimboola granted in 2009.Wimmera Health Care Group staff are educated in the Five Moments of Hand Hygiene. Audits of hand hygiene complianceare regularly conducted with the results forwarded to the Department of Health. The latest audit showed an overallcompliance rate of 72.4% compared to the National compliance rate of 71.3%.Home and Community Care (HACC)Home and Community Care AlliedHealth Services - WimmeraCommunity Options and DistrictNursingFull four-year accreditation granted inAugust 2009.OVERALL COMPLIANCE RATE JUNE AUDIT 2011Correct HHMomentsMomentsObservedComplianceRateLower 95%CIUpper 95%CINational 214,685 301,175 71.3% 71.1% 71.4%Victoria 32,912 45,142 72.9% 72.5% 73.3%“Wimmera Health Care Group hasreceived continuous accreditation bythe Australian Council on HealthcareStandards since 1975, a track recordwe are very proud of.Our accreditation outcomes send amessage to the community thatWimmera Health Care Group, itsmanagement and staff, are committedto excellence in healthcare with a strongand continuing focus on safety, qualityand performance.”Mr Chris Scott, Chief ExecutiveWimmeraHealth CareGroup147 203 72.4% 65.9% 78.1%Mr Chris Scott, Chief Executive, shows off the hospital accreditation plaque.32Pursuing excellence in careWimmera Health Care Group Quality of Care Report 2010/201133