Building for a brighter future - GHA Central

Review of Operations: Quality Report
West Gippsland Healthcare Group strongly supports a learning
environment that reviews systems and processes in the light of
errors, so that we can improve the care we provide to our
community.
Safe Quality Care
Healthcare organisations are large
complex places managing many
integrated processes and systems.
Research into what makes healthcare
organisations safer places is clear.
More often than not, mistakes happen
as a result of a sequence of events that
go astray. At WGHG, if a mistake
occurs, our learning culture allows
us to understand how we can prevent
similar mistakes from happening again.
To do this, we are building on our
safety culture; a culture where staff
feel comfortable to report things that
go wrong without feeling they will
be blamed, punished or ignored.
This culture supports an active
investigation learning environment.
What WGHG does to improve safety
➤ We encourage staff to report
incidents and close calls (near
misses). As a result, this year the
number of incident reports has
increased by 41% from an average
of 92 per month to an average of
130 per month, providing more
opportunities to learn
➤ We review and investigate all
incidents and near misses in a “no
blame, no shame” way to identify
contributing factors
➤ We use a comprehensive
investigation process that aims to
understand what happened and
why it happened, on all major or
serious incidents
➤ We involve all departments in safety
and quality improvement activities
➤ We involve experienced medical
and nursing staff in reviewing
patient records to confirm
appropriate care was given
and documented
➤ We have committees and working
parties linking medical, nursing,
allied health and support services
to monitor, review and recommend
quality and safety improvements
➤ These committees and working
parties report to the Clinical Quality
Committee who, in turn, reports to
the Board’s Standards Committee
to ensure that there is a high level
of responsibility for safe quality care
(Clinical Governance)
➤ We measure our safety and quality
performance and compare it to the
performance of other organisations
wherever possible
➤ We learn from incidents that occur
in other organisations
➤ We listen, investigate and learn
from complaints
➤ At WGHG, larger programs or
projects target key patient safety
risks such as infection control,
falls and pressure areas
➤ We develop and regularly review
policies, procedures and guidelines
to ensure they reflect current best
practice
➤ We provide ongoing education
and support to ensure our staff
are skilled and up to date
➤ Our equipment is regularly tested,
maintained and replaced to ensure
it meets our clinical needs
(continued on page 22)
Incident reporting
Incident reporting is a key component
of the clinical risk management
program.
In March 2006, WGHG introduced
a severity rating system for all
incidents. Incidents are rated
according to severity from 1 to 4,
most severe incidents being rated
1 and least severe rated 4. Most
incidents occurring at WGHG have
a low severity rating (3 or 4). A weekly
100
80
60
40
20
0
Types of Incidents Reported at WGHG
624
Falls
Medication/IV related 244
OH&S - Physical injury 237
Miscellaneous 227
107
Aggression related
incidents
29
Equipment or
instrument related
26
OH&S - Exposure
contaminated related
Clinical Risk and Evaluation (CARE)
meeting enables the Executive team to
look at all incident reports. Incidents
with a higher severity rating (1 or 2)
are investigated and reviewed. The
risks identified are directed to the
appropriate area to be addressed
and strategies are implemented to
minimise the chances of a similar
incident occurring. Incidents rated
3 and 4 are recorded and monitored
to look for trends that may indicate
a problem is emerging.
Property 22
Absconding 15
OH&S - Others 11
8
Related to consent and
patient identification
Communications disputes 7
Diagnostic incidents 7
Administrative/
contractual 5
In response to incidents we have:
➤ Implemented a critical instability call
process, improving the process for
nursing staff to call for specialist
medical support quickly
➤ Developed and implemented fluid
balance chart and medication
handover policy on all wards. This
provides an opportunity for staff
to double check for early changes
in patients fluid balance or where
medications may have been missed
➤ Standardised the times that
Warfarin (blood thinning
medication) is given, reducing
the likelihood of it not being given
and blood tests being missed
➤ Improved processes for staff and
information for families when the
death of a loved one is reported
to the Coroner
➤ Reviewed incident reporting systems,
educated and encouraged staff to
report incidents
➤ Reviewed Emergency department
pathology collection times ensuring
pathology requests are delivered at
appropriate times before pathology
staff leave in the evening.
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