Portland District Health Annual Report 2005 - South West Alliance of ...

findings in other organisations, development ofappropriate policies and procedures are just someof the areas that are examined in this clinical riskmanagement program.During the past year the clinical risk managementprogram has been further strengthened byimprovements in the following risk areas:• Credentialing & scope of practice• Participation in the Limited Adverse OccurrenceScreening’ (LAOS) Project• Clinical case reviews.• Root cause analysis of medication incidents.• Falls prevention• Wound management• Sharps incidents• Infection controlCredentials and Scope of Practice -Medical StaffIn order to provide good professional performanceand minimise clinical risk it is vital that our medicalofficers and staff are qualified to undertake theirduties.For example only suitably qualified medical staffare permitted to perform anaesthetics or undertakeobstetrics within the hospital.This process, known as credentialing, occurs beforea medical staff member is appointed. A specialistcommittee comprised only of medical staff undertakesthis. A representative of the appropriate College is inattendance to provide independent expert advice.The credentialing committee checks and advises thehospital’s Medical Appointments Advisory Committeeas to whether an applicant is suitably qualified forthe position they have applied for. This committeealso advises as to what limitations to practice shouldapply.During the year, a discussion document was preparedoutlining the Clinical Scope of Practice for alldisciplines of the Portland District Health medicalworkforce. This document was accepted by all VMOsand incorporated into the Credentialing policy. Thecredentialing process was conducted incorporatingthe guidelines from the Australian Council forSafety and Quality in Health Care. In all disciplinesrepresentatives of the relevant colleges were inattendance to comment on the college requirementsfor credentialing.Portland District Health has completed this processand all VMOs of the service, are fully credentialed towork within their limitations (scope of practice). Theprocess is ongoing and all VMOs will be credentialedevery 3 years, to ensure that all disciplines complywith the quality and safety standards of PDH.‘Limited Adverse Occurrence Screening’ (LAOS)ProjectPortland District Health has been participating inthe Otway Division of General Practice “LimitedAdverse Occurrence Screening” (LAOS) Projectfor approximately 2½ years. This Clinical RiskManagement Program is part of the Departmentof Human Services Strategy for “Improving PatientSafety in Victorian Hospitals”. The project has beenimplemented across the state (in Rural Victoria), andfrom this, we are starting to see state-wide trends inissues in patient safety.A selection of medical records are copied and sent offsite to a doctor in another area for review. Doctorsfrom other towns provide feedback on our care, toensure that we are doing our best. Your own doctormay also be involved. Educational issues arisingfrom the record may then be discussed confidentiallyby doctors at a quality improvement meeting. Thisallows clinical lessons to be learned and shared withother doctors, hospitals and services across the region.Your personal information is not collated, reproduced,published or used for any other purpose.Recommendations on clinical and systems issuesare discussed at hospital quality forums, theserecommendations are responded to by each individualhospital. The recommendations are forwarded to allthe General Practitioners and hospital Chief ExecutiveOfficers participating in the program.Since the last Quality of Care Report (12 months ago),603 records have been received from the 10 hospitalsparticipating. Of these 603 records, 38 cases wereregarded as potentially containing an adverse eventand 57 cases were regarded as presenting educationalopportunities.Some issues resulting in recommendations in this lastyear have included:• GP management of patients with unstableangina• Registrar training and supervision• Dealing with a poorly compliant patient• Home Medicines Review Program• Warfarin Guidelines• Training for patient decision making in PalliativeCare• Reviews of hospital narcotics and major traumaprotocols12