Annual Report - Northern Health

Our AchievementsDeliver quality health services strategic Goal 1At Northern Health we strive to deliver high quality health services that ensure optimal patient outcomes.By constantly monitoring and assessing our programs, improving efficiencies and reducing clinical risk we aimto provide the very best health care to the rapidly expanding northern community.National leader in overall length ofstay performanceNorthern Health’s ongoing improvement activities have ledto significant reductions in the average length of stay of ourpatients. By improving the way we plan, treat and communicatewith our patients, we have reduced the time patients needto stay in hospital. Getting patients back to their homes andfamilies as quickly as possible ensures that we can treat thenext patient waiting for our services, and our patients cancomplete their recovery in the safety and comfort of theirown homes.Data provided by the Health Roundtable, an independent nonprofitorganisation that helps health organisations to benchmarkperformance, shows Northern Health’s length of stay (LOS) isone of the best in the nation. The Health Roundtable uses arisk-adjusted length of stay known as the Relative Stay Index(RSI), and Northern Health’s current RSI of 78 per cent iswell ahead of the median performance of our peer hospitals,indicating Northern Health is maximising our limited resourceswhile reducing delays and duplication to ensure efficient healthservice delivery.Exceeding quality and safety keyperformance indicatorsNorthern Health’s key performance indicators for quality andsafety, such as hand hygiene compliance, are monitored byclinicians and managers, and are reported to the NorthernHealth Board Quality Committee. Data is audited threetimes each year in six inpatient units and the results aresubmitted to Hand Hygiene Australia. Effective hand hygieneis fundamental in ensuring quality and safety and 2011 resultsshow Northern Health’s overall compliance rate is 79 per cent,which is significantly higher than the 65 per cent target set bythe Department of Health and well above the overall nationalcompliance rate of 76.3 per cent.National Safety and Quality Health ServiceStandards accreditationNorthern Health actively participates in the Australian Councilon Health Care Standards (ACHS) accreditation program, whichassesses our commitment to providing high quality care, a safeenvironment and a culture of continuous improvement. This isone way the quality and safety of care we provide is measuredand indicates that industry wide, national standards are beingmet. In 2011, Northern Health enrolled in the National Safetyand Quality Health Service Standards Program with ACHS andsubmitted a self-assessment against the National Safety andQuality Health Service Standards in 2012. We are preparing toundergo an organisation-wide survey against the National Safetyand Quality Health Service Standards in 2013.Improving teamwork with Team STEPPS programImproving communication and team work is a priority atNorthern Health. In 2011 Bundoora Extended Centre was chosenas one of five Victorian sites to trial the Victorian Team STEPPS®Pilot Project (Team Strategies and Tools to Enhance Performanceand Patient Safety), sponsored by the Victorian Quality Council.The project uses effective, evidence-based tools and techniquesto improve teamwork, communication and patient safety. Staffhave enthusiastically adopted various elements of the programand continue to incorporate them into daily practice. The pilotproject has demonstrated improved communication throughdocumentation and reporting of clinical changes.Leading the way with a new Stroke Strategy PlanThe implementation of Northern Health’s Stroke StrategyPlan has proven to be very successful, with a national auditindicating Northern Health is outperforming peer sites. The newAcute Stroke Pathway aims to improve patient care by reducingvariation in clinical practice and promoting evidence-basedpractice and incorporating all medical, nursing and allied healthintervention together to ensure information is easily accessible.The Acute Stroke Pathway is used for patient documentationand includes a generic pre-morbid assessment that iscompleted by the team to reduce documentation duplicationand repetition of questions to the patient. It also includesprompts for medical, nursing and allied health staff onrecommended stroke management to ensure the team providescare using evidence based principles. The Acute StrokeTeam under take fortnightly education sessions and monthlymanagement and planning meetings to continue to improveacute stroke services. In April, The Northern Hospital introduceda new emergency code called, “CODE STROKE” that aims toimprove access to thrombolysis for patients by facilitating rapidassessment of stroke patients presenting within the 4.5 hourtime window. Currently, eligible patients are transferred to AustinHealth for thrombolysis, however The Northern Hospital plans tostart providing thrombolysis to stroke patients this year. Raisingawareness and improving support for patients with diabetes11/12 Northern Health annual report 23