Building for a brighter future - GHA Central

Review of Operations: Quality Report
➤ We check all our staff are
appropriately skilled and qualified for
the jobs they are doing. In 2005-06
we implemented a best practice
model for credentialling medical staff
and hope to extend this to allied
health and community services staff
next year.
Critical analysis of medical records
The review of patient medical histories
is another way to identify needs and
prevent incidents. Senior clinical staff
scan histories for potential adverse
events; histories are then scrutinised
by an appropriate member of staff or
a committee to identify areas for
improvement.
In response to critical analysis
of histories we have:
➤ Improved post operative pain
management and monitoring of
patients having urology surgery
➤ Reviewed guidelines, staff education
and documentation requirements
for monitoring of obstetric patients
➤ Reviewed anaesthetic charts to
include blood loss during surgery,
improving staff communication.
Infection control program
Hand hygiene and the
hand hygiene project
It has been known since the early 19th
century that hand washing is important
in preventing the spread of infection. In
2006 hand hygiene remains a key issue
Managing complaints
Complaints are an important method
of identifying patient quality and safety
issues. Formal complaints are referred
to, investigated and managed by a
member of the Executive team.
Complaints involving a clinical issue
are reviewed by the CARE meeting to
track the progress of improvement
recommendations. This year we have
reviewed our complaints record
management systems and identified
our software needs.
In response to complaints we have:
➤ Provided in-service education for
staff in the Emergency department
on pregnancy testing of women with
abdominal pain and psychological
support of women who have had
miscarriages
➤ Strengthened the role of the nursing
coordinators to inform the Director
but we are now changing the way we
do this. Structured observations of
actual hand hygiene practice against
opportunities for hand hygiene practice
revealed that even in a post-surgical
ward, hand hygiene practice fell below
the Victorian Quality Council target of
60% of hand hygiene opportunities
being taken. This finding was not
unusual across many hospitals.
The main hand hygiene practice
involved the decontamination of hands
by washing, using water and an antimicrobial
soap or solution. However
this method of hand hygiene had its
problems including skin irritation and
dryness, insufficient time to practice
hand hygiene, and in some cases the
perception that wearing gloves removed
the need for additional hand hygiene.
As a solution, the WGHG hand hygiene
project is promoting an alcoholchlorohexidine
hand rub, used before
and after every patient contact, and
after contact with objects, including
medical equipment, in the immediate
vicinity of the patient. The inclusion
of moisturising skin care products
minimise the risk of skin irritation
and dryness for users.
Staff education in the reasons for and
the use of alcohol hand-rub has now
commenced and a culture change is
under way at WGHG. The effectiveness
of Nursing and Director of
Medical Services if there is an
unusual delay in transferring
patients for ongoing care
➤ Reviewed Emergency department
protocols for the management
of paediatric patients
All complaints made to WGHG are
taken very seriously. Kathy Bailey,
Patient Services Manager, consults with a
complainant.
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of the hand hygiene project will
continue to be monitored using the
indicators suggested by the Victorian
Quality Council of rates of compliance,
the amounts of hand hygiene product
used, and the rates of nonsocomial
infection.
Cleaning standards
An essential component of the infection
control program is ensuring a clean
environment. To make sure WGHG
maintains a high standard of cleaning,
the Infection Control Nurse and the
Environmental Services Manager
conduct regular cleaning audits.
Each area of the hospital is weighted
according to the standard of cleanliness
required. For example, the Operating
room has a higher standard of
cleanliness required than the public
foyer. Each year, without notice
WGHG is audited to ensure it meets
a minimum standard by an external
surveyor. This year the minimum
cleaning standard score was raised
from80% to 85%. WGHG scored
92.4%, well above the target set.
To assist in improving cleaning
standards, Environmental services staff
had regular discussions on audit results
highlighting the areas that require more
attention to detail. They have also been
supplied with tooth brushes to remove
build up of soap around hand basins.
100
95
90
85
80
75
70
Cleaning Standards Score
91.77%
2002
93.50%
2003
93.50%
2004
SCORE SET BY DHS
91.40%
2005
92.40%
2006
Targeting high risk areas
is another way WGHG
improves the safety of our
patients and the quality
of care through ongoing
programs and projects.