Quality of Care Report - Ballarat Health Services

Welcome to the Ballarat HealthServices 2007-2008 Quality ofCare ReportThis report is for you, the consumer, patient/client/residentand carer to read about what Ballarat Health Services hasbeen doing over the past twelve months, 1 July 2007-30June 2008.This report is one of the ways we inform you how we meetyour health care needs at Ballarat Health Services, and aboutthe way we keep improving the quality of the care weprovide. The report does not cover every detail of all aspectsof our service, but rather focuses on areas deemed importantby the community and our staff. Mental illness; two simplewords but what they represent is a very complex and diverseillness that affects one in five Australians to varying degreesfrom short-term episodes of depression right through to themore severe psychotic illnesses such as schizophrenia andbipolar mood disorder. One of the major focus of this yearsreport is to help the community better understand mentalillness from the perspective of the client, their family andclinicians. Throughout this report, you will see how BallaratHealth Services is increasingly involving the community,consumers and staff to inform and improve our services.Our thanks are extended to the Ballarat Health ServicesCommunity Advisory Committee (CAC), former patients,carers, community and staff for their comments andcontributions to this year’s report. The Community AdvisoryCommittee is made up of six community members and twomembers of the Board. The committee assists Ballarat HealthServices to integrate consumer and community viewsappropriately at all levels of the service.We look forward to hearing your opinion on this year’sQuality of Care Report and the services Ballarat HealthServices provides. You are invited to complete and return thefeedback form at the back of this report. Your views are vitalin helping us plan future services and where we need toimprove.CONTENTSVision Mission and Valuesof Ballarat Health Services 1Contents and Welcome 2Planning and Developing our Report 4Serving our Community 5Community Advisory Committee 7Promoting the Benefitsof a Multicultural Service 9Your Experience 11What happens if you have a complaint 13Staff in the Community 14Psychiatric Services 15Accessible and Responsible Care 20What if you or your loved ones needto move into Residential Care 28Governance and Risk Management– Putting Patient Safety First 29What’s New 38Our Staff and Volunteers 39Ballarat Health Services adoptsimportant environmental statement 40Training staff to be preparedfor emergencies 41We Value Your Opinion 42Ms. Lynne McLennanPresidentBoard of ManagementMr. Andrew R. RoweChief Executive OfficerQuality of Care Report 2007-08 2

Community Advisory Committee Front row: From left Mark Patterson, Liz Sheedy, Jan Skewes, Maree Harris, Andrew Miller, back row WendyHubbard, Lois Abraham, Greg Haines (Chair), Simone Rosewall and Debra Tsilfidis.Planning andDeveloping the2007-2008 Qualityof Care ReportOur aim is to make this report relevantto the community includingpatients/clients/residents and our staff.To plan this report we:• Reviewed the guidelines andminimum reporting requirements for2007-2008 from the Department ofHuman Services (DHS)• Reviewed the DHS comments for the2006-2007 BHS report• Reviewed the feedback that you thepublic provided us by filling in andreturning the questionnaire in the2006-2007 report2006-2007 Quality of Care FeedbackBHS was pleased with the constructivefeedback provided to us by you thepublic. We went to great lengths toensure the most effective means ofdistribution. This meant that there wasan opportunity to distribute over19,000 copies particularly by circulatingthe report in The Courier newspaper.We reviewed each and every feedbackform sent in and incorporated many ofthe suggestions in this years report.A number of the feedback formsrequested additional information aboutPsychiatric Services and we haveresponded by making this service afeature of our report. We receivedconstructive feedback from DHS andhave reviewed this in line with thecriteria for the 2007-2008 report.Some of our staff wrote to us aboutthe report reminding us that the staffwho work at BHS are also part of thecommunity. We considered how wecould incorporate this in our2007-2008 report and have not onlyreported on staff and their qualityoutcomes but have included theirstories as part of the community. Dueto the number of department headsthat suggested we promote thevaluable services they provide to thecommunity, we have decided to offer acomprehensive listing of all SpecialtyServices available at BHS to keep youinformed.Distributing the reportHard copies of this report have beendistributed widely across thecommunity via health services, medicalservices, community services, localcouncil and public libraries. For peoplewith access to a computer we have putthe report on Ballarat Health Servicesinternet site at www.bhs.org.au it canalso be viewed by BHS staff on theintranet.A full page summary of this report hasalso been placed in our regionalnewspaper to ensure a widedistribution. A newsletter summary ofthe report will be sent to all patientsadmitted to BHS during the next sixmonths.If you would like this publication as a;• Large Print Version• On CD• Translation in a different languageplease contact Ms Helen Manning(03) 5320 4439We value your feedbackTo continue to improve our reporting, please let us know what you think sothat we can continue to meet your needs. Once you have read the report,please take the time to complete the freepost evaluation form in this reportand send it back to us. Alternatively you can email your feedback toqualityofcarereport@bhs.org.au or telephone us on (03) 5320 4014 or(03) 5320 4439 with your comments.Ballarat Health Services Quality of Care Report 2007-08 4

BHS theatre nurses Lauren Atkinson and Tiarni Platt kick off the super boot competition. The North Ballarat Football Club and the CIty of Ballaratteamed together to raise funds to support BHS in purchasing a new retroscope to assist in the treatment of the specific men’s health problem ofprostate disease.Servingour CommunityOur Campuses and ServicesBHS was established in 1997 throughthe amalgamation of three existingorganisations' resulting in anintegrated health service;• The Base Hospital which has220 acute beds;• The Queen Elizabeth sub acute siteof 70 beds and 525 residential bedshoused at 12 sites; and• Grampians Psychiatric Service with67 acute beds.BHS is the largest regional health careprovider and principle referral hospitalto the culturally and linguisticallydiverse Grampians region. BHSemploys over 3000 staff. The keyservices are based at two sites, theBase Hospital and the Queen ElizabethRehabilitation Centre. In addition,there are 13 off-site facilities includingresidential aged care and communitybased programs located throughoutBallarat. Community based psychiatricservices are located in Horsham,Stawell, Ararat and Bacchus Marsh.Demand continues to grow for BHSservices with increased patientnumbers treated, and more complexconditions as the population ages. In2007-2008 BHS:• admitted 31,799 acute inpatients,• performed 10,403 surgicaloperations,• delivered 1192 babies and,• treated 43,192 patients in theEmergency Department.Our CommunityWho are our consumers?As the major referral hospital in theGrampians region we are accessible toover 200,000 consumers who live in anarea covering 48,000 squarekilometers, from Bacchus Marsh to theSouth Australian border.BHS has a catchment area spreadingacross 12 local government areas andcovers 20 per cent of the state. Theprimary catchment for which BHS is thelocal health care provider is defined asthe City of Greater Ballarat.The secondary catchment is the areafor which BHS is the main referralhospital for acute health care, andincludes Greater Ballarat and theadjoining shires, plus the township ofMaryborough. The tertiary catchment isthe area for which BHS is thedesignated tertiary referral hospital andpsychiatric service provider. The tertiarycatchment includes all of theGrampians region, as well as thetownship of Maryborough.Knowing our community is essential ifwe are to provide services that meetthe needs of everyone within thatcommunity. A total of 64 per cent ofBHS clients live within the City ofBallarat, with a further 27 per centliving in the Grampians region. Nineper cent of BHS clients live outside theregion.5Ballarat Health Services Quality of Care Report 2007-08

DemographicsAlmost 40 per cent of the catchmentpopulation reside in the primarycatchment area of Greater Ballarat.Approximately 21 per cent of thepopulation reside in the secondarycatchment and 39 per cent reside inthe tertiary catchment.Key characteristics of the populationinclude:• a continuing decline in the numberof children in the catchmentpopulation. Each age group up to 10years of age is lower than for 2001(which is in turn lower than for theprevious five years);• a reduction in the population ofyounger adults, which is typical ofrural populations, as younger adultstend to move away from the ruralareas for tertiary study andemployment opportunities;• a decline in all age groups between25 and 40 years over the past fiveyears;• conversely, all age groups over 40years of age have increased;• increases in the population forgroups 10-24 years of age are due togrowth in Ballarat and BacchusMarsh; and• the proportion of the population 65years and over in 2001 was 14.8 percent. This is estimated to haveincreased to 15.9 per cent in 2006.Overall, the population is ageingconsistent with the ageing of thepopulation across rural Victoria moregenerally. The ageing of the catchmentpopulation is a significant factor in theincrease in demand for health services,particularly services that support andmaintain the health of the frail elderlyin the community.Nevertheless, there is strong growth inyounger families around the urbanfringe. The increased populationgrowth in this area represents overtwo-thirds of the total populationgrowth in the Grampians region.It is projected that the population in2016 will be 239,856 persons. Thisrepresents a projected increase of 7 percent, or 0.7 per cent per annum overthe next 10 years.Specialties at Ballarat HealthServicesAboriginal Hospital LiaisonAcquired Brain InjuryAllied Health Services:DieteticsExercise TherapyOccupational TherapyPhysiotherapyPodiatryProsthetics and OrthoticsPsychologySocial WorkSpeech TherapyBreast CareCardiologyCentre Against Sexual Assault (CASA)ChaplaincyCoronary Care Unit,Cognitive Dementia and Memory ServiceCommunity Health ServicesCommunity Nursing,Community Programs including:Adult Day Activity CentresAged Care Assessment Service (ACAS)Allied Health Domiciliary ServiceCommonwealth Carer Respite Centre –Carelink CentresDomiciliary CareHome and Community care ServicesHospital Admission Risk Program (HARP)Hospital in the Home,Linkages – Central Highlands CoordinatedCarePlanned Activity GroupsPost Acute CareRegional Continence ServiceRegional Palliative Care TeamRehabilitation in the HomeCritical Care UnitCSSDDentalDiabetes ClinicDiagnostic and Radiology (X-ray) Services:Ultrasound,CT ScanMRI,EEGECGBreast ScreenDialysisEar, Nose and Throat Surgery,Emergency Medicine,Endocrinology, including DiabetesManagementFalls and Balance,Gastroenterology,General Medicine,General Surgery,Gynaecology,Infection ControlIntensive Care Unit & Medical EmergencyResponse teamLymphoedema,Medical Oncology,Neonatal,Nephrology,Neurology,Maternity ServicesOperating SuiteOphthalmology,Orthopaedic Surgery,Otolaryngology,Outpatient ServicesPaediatric MedicinePain ManagementPalliative Care,Perioperative Day Procedure UnitPharmacyPlastic Surgery,Psychiatry including:Child and Adolescent Mental HealthServices,Acute Community and Inpatient Services,Aged Community and Inpatient ServicesRadiologyRehabilitation, (In-patient and Out-patient)Residential Aged Care,Respite Care,Safety LinkStroke Management,Stomal TherapyThoracic Medicine,Urological SurgeryWound ManagementBallarat Health Services Quality of Care Report 2007-08 6

Community AdvisoryCommitteeImproving ConsumerParticipationBallarat Health Services CommunityAdvisory Committee (CAC) wasestablished in 2005 to provide anadditional means forconsumer/patient/client and residentsto provide community input into theservice at a higher level of decisionmaking. This direct reporting allowsthe CAC to advocate to the Board ofour Health Services on decisions madein respect to quality of care, ensuringaccountability back to the community.Since its establishment in 2005, theCAC has developed a ConsumerParticipation Plan which outlines theapproach at Ballarat Health Services toconsumer and community involvementacross the organisation. The plan,which is reported annually to DHS,focuses on increasing organisationalcapacity for consumers, carers and thecommunity to become active partnersin decision making at all levelsthroughout BHS. A website has beendeveloped providing information to thecommunity about the role of the CAC.During the past year the committee hasprovided four service areas withcomprehensive reviews andrecommendations. Through the DHSVictorian Patient Satisfaction Monitor,consumers rated their satisfaction withBallarat Health Services higher than theaverage score of similar hospitals andhigher than the statewide benchmarkfor all public hospitals.Ballarat Health Services continues todemonstrate its accountability to thecommunity, encouraging members ofthe CAC to be actively involved inservice delivery and planning bymeeting the requirements set out inthe guide lines for consumerparticipation “Doing it with us not forus” policy (DHS, 2006).Community Participation PlanThe CAC has developed a consumer,carer and community participationregister.If you are interested in bringing acommunity perspective to decisionsthat are made at BHS, we are currentlyseeking consumers, carers andcommunity members interested inhealth issues to join the consumerregister. Being a member of theconsumer register creates opportunitiesfor those interested in health issues toparticipate on committees and becomeinvolved with projects. If you areinterested in joining the consumerregister, please contact the ConsumerLiaison Officer on 03 53204014 forfurther information about consumerparticipation at BHS.Community Review at Service LevelIn order to promote consumerparticipation in a meaningful way atBHS the Consumer Participation ServiceTool was developed. The tool wasbased on the National Resource CentreConsumer and CommunityParticipation Self Assessment (2004)and the principles of “Doing it with usnot for us” participation policy (DHS,2006).The aim of the review process is tosupport services within BHS to improvethe quality of care provided, byfacilitating the participation ofconsumers and the community in the86848280787674planning of services and care. Thereviews are conducted by the CAC inparticipation with the manager of theservice involved.The Consumer Participation ServiceReview (CPSR) involves the committeemembers receiving a package ofinformation about the service and itsplans or current activities prior to thereview. The manager and relevantteam members then attend the CACmeeting to present a brief overview ofthe service followed by a tour of thedepartment. This includes ongoingdiscussion with the CAC about specificconsumer participation strategies basedon the CPSR tool and answering anyquestions. The CAC then providewritten feedback andrecommendations to the managerutilising the CPSR tool.The CAC engaged in four servicereviews during the 2007-2008 yearrepresenting a cross section of theorganisation. Services reviewedincluded the Dialysis Unit, Cateringincluding a visit to the kitchen, the WBMesser Hostel at Queen ElizabethVillage and Gandarra Palliative CareUnit. The CAC believe that the reviewshave been an effective communicationvehicle for service managers thatpreviously may have a different level ofunderstanding and commitment toconsumer participation based more ondoing the “right thing” for patientsthan community participation.72Wave 9 Wave 10 Wave 11 Wave 12 Wave 13 Wave 14Ballarat Health Services 78 84 77 80 78 81Hospital Category B mean 80 80 79 80 78 79Statewide Mean 81 80 80 80 79 80Patient satisfaction measures achieved by BHS compared against other comparable hospitals andstate wide results.7Ballarat Health Services Quality of Care Report 2007-08

The department managers saw theinvolvement of the CAC as anopportunity to use the CAC as aresource to improve patientinformation and customer/consumerfeedback to benefit all consumers.One manager used it as an opportunityto gain a ‘consumer’ perspective on anewly proposed part of the service as itwas in the planning stage at the time.BHS has been invited to present theConsumer Participation Review atNational Forum in Adelaide in October2008.National Forum on Safetyand Quality in Health CareGreg Haines and Andrew Miller willattend the National Forum inAdelaide to present the BHS posteron Consumer Participation Review atService LevelBallarat Health Services Quality of Care Report 2007-08 8

Promoting theBenefits of aMulticultural ServiceCultural DiversityWhilst almost 87 per cent of thepopulation of the Grampians regionare born in Australia, we do have asignificant group of people who havechosen to make Australia and ourregion their home. Over the past 12months a number of families havesettled into Ballarat following theirarrival from Togo in West Africa. Thesefamilies have established themselves inthe community with children attendingboth primary and secondary schoolsand all families have become activelyinvolved with their school and churchcommunities as well as the BallaratAfrican Association.Community sectors responded well totheir arrival, with health professionalsand service providers working togetherto ensure a smooth transition for thesefamilies into our community. BallaratHealth Services is a partner in thisprogram and supports other localhealth providers by delivering acutehealth services as required.Cultural Diversity CommitteeThe Cultural Diversity Committee,established in June 2006, encouragescommunity representatives fromculturally diverse backgrounds. Theinvolvement of BHS on a number ofcommittees in the community hasenabled us to develop a betterunderstanding of the cultural needs ofall members of the community. As aresult we have implemented greateruse of interpreter services andtranslation cards across the healthservice. In June 2008 we took part in a‘Multicultural Conversation’ inpartnership with the City of Ballarat todiscuss what we do well and where wecan improve to ensure we are providingour services in a culturally appropriateway for all of our consumers.BHS and Ballarat and District AboriginalCooperative (BADAC) PartnershipAgreement continues to focus toimprove the health outcomes for theAboriginal community within theGrampians region.One of the major priorities of thePartnership Agreement has focused onreducing barriers to access forAboriginal and Torres Strait Islanderpeople living in the Grampians region.The 17 year life expectancy gapbetween Aborigines and otherAustralians can be attributed, at leastpartly, to their inability to access healthservices due to some or all of thesebarriers. In the 21st century we are stillseeing health conditions and healthoutcomes for Aboriginal people similarto those experienced by non-Aboriginalpeople in the 1920’s.The Partnership Agreement Taskforcehas implemented initiatives andstrategies to break down barriers toaccess, promote greater understandingof health priorities by key clinicians andimprove data collection. BHS, inconjunction with BADAC, hasconsidered the needs of the localAboriginal community and developed anumber of key roles within the healthservice to support and enhance accessto services.Key achievements include:• The Aboriginal flag was raised at thefront of the hospital during NationalAboriginal Islander Day ObservanceCommittee (NAIDOC) week 2007 tohighlight the awareness of thepartnership to improve Aboriginalhealth in the Grampians regiontogether with increasedunderstanding and communicationbetween BHS and BADAC;• improved community relationsbetween BHS and the Aboriginalcommunity;• joint planning of servicedevelopments;• Initiatives to ensure clients attendOutpatient Departmentappointments at BHS. Throughcollaboration between the BADAChealth clinic, BHS and the clients, thefail to attend rate has decreasedfrom around 40 per cent to 15-20per cent, which is in line with theaverage of all clients.• A weekly health clinic staffed by theBHS Aboriginal Midwife, locatedwithin BADAC, and run inconjunction with the Maternal andChild Health Nurse Programmanaged by the City of Ballarat,continues to be very well attended bynew mums and their children.• BHS staff participated in a PatientRegistration Training pilot program toimprove accuracy of data for allpatients on admission includingcomprehensively collectinginformation about the Aboriginalcommunity’s health needs.The Partnership Agreement and theTaskforce will continue planning toensure the identification andimplementation of strategies andinitiatives to improve access and reducebarriers for the Aboriginal communityto reduce the gap between healthoutcomes and life expectancycompared with all Australians.Job restores hope and pride for African refugee:Sudan’s Francis Laki has got his life back on track. The 48-year-old refugee has a job,he has his dreams and, most important, he has his pride. It is a wonderful change fora man who, just four months ago, had none of these things after coming to Ballaratin 2006. Determined to provide a better life for wife, Flora and their three children,Mr Laki reached out to Ballarat employment program, African BEAT.The initiative, designed to assist people from a refuge background, provides applicantswith training, work experience and job opportunities. With the co-operation ofBallarat Health Services, African BEAT employment support officer WilbertMapombere placed Mr Laki in its environmental services department in October lastyear. Mr Laki’s duties at Ballarat Health Services include cleaning and meal delivery.9 Ballarat Health Services Quality of Care Report 2007-08

'Underbank Stud’Two Day CampThis camp was run by Carol Trusler amidwife from Ballarat Health Services,Elspeth Rowe a maternal and childhealth nurse from the City of Ballaratand Lorraine Gittings a family therapistfrom the Ballarat and DistrictAboriginal Co-operative.The mum’s and bubs group from thehealth clinic located within BADACcame up with the idea and sourcedwhere to obtain the funding. The staffput in a submission to The BallaratFoundation requesting a grant whichoutlined the benefits of the project.The mum’s were looking for time awayfrom the issues they face daily. Thecamp gave the staff a uniqueopportunity to model parenting,discuss sensitive issues in a safeconfidential environment such asrelationships, time to connect with theother women in the group and buildon support, share ideas and for someenjoy peace and quiet. There was alsopractical time in the kitchen sharingcooking tips and recipes."Camp was a wonderful experience.The timing was perfect. It was nice tospend time with the other mothersfrom our "Mums and Bub's" group. Itwas also great to spend some one-toonetime with Sophie (12 month old).The early morning walks werewonderful and I felt so much peaceand tranquility while knowing Sophiewas being watched. The highlight forme was horse riding. I didn't think Icould still do it. It all came back like Iwas young again, I think I had to bedragged off the horse. I am so thankfulI was able to go and felt blessed tohave had this experience. Many thanksto all involved in making this trippossible." From a participant at thecamp.Sincere thanks to THE BALLARATFOUNDATION for their grant that madethis great opportunity a reality.I am so thankful I was able to go and felt blessed to have had thisexperience. Many thanks to all involved in making this trip possible.From a camp participantQuality of Care Report 2007-08 10

Your Experience Patient StoryJohn GaultJohn was busy doing some minorrepair work when he slipped froma ladder and as a result incurredwhat proved to be a very seriouscompound fracture to his rightleg and ankle. John wastransferred by ambulance to theEmergency Department of BHSand subsequently admitted for aperiod of nearly eight weeks. Thefollowing is John’s account of hisexperience of care; “Immediatelyupon arrival, I was attended to bya team of medical, surgical andnursing staff, and afterassessment I underwent astabilizing operation and wasadmitted to the orthopaedic wardfor further assessment andtreatment. I was an in-patient fora period of nearly eight weeks,and therefore had a somewhatextended opportunity toexperience first hand thetreatment at the hospital,including five visits to theoperating theatre. From thesurgeons and medical staff whomanaged my case, to the simplyexcellent nursing staff in theorthopaedic ward, to all of thetheatre staff, to physiotherapists,occupational therapists, dietitians,and orthotists, to the respiratorymedical team, to X-ray personnel,and to domestic and cleaningstaff, I can only say a huge thankyou. Without exception each andevery member of these varioushospital teams displayedprofessionalism and excellencewhich in my view would be theenvy of any organisationprivileged to have them in theirstaff team. I know I have a longway to go until my recovery isfully completed, but when it is, itwill have been the result of theprofessional skill of thesewonderful people. I want topublicly express my sincere thanksto each and every one of the staffat the Ballarat Health Services.They are all a marvelous credit tothe community which they sowonderfully serve.” John Gault11Quality of Care Report 2007-08

HELLO, the Hospitalhas New Doctors andNurses for a DayBHS recognises the importance ofhelping patients and families feelcomfortable being in hospital. Formalpreparation programs promotingpositive coping strategies for childrenare crucial to the provision of paediatricservices at BHS. The implementation ofthis program has led to improvedinformation sent to families withappointments and greatercommunication with generalpractitioners.Having a child treated at hospital canbe a harrowing time for the child andfamily. The Kindergarten Tour Programcalled Hello Hospital is designed to helpchildren familiarise with the hospitalsetting and medical procedures theymay encounter as a patient.Dressing up as doctors and nurses andtaking an X-ray of a favorite teddy bearis all part of the experience whileparticipating in the BHS Base Hospitaleducation program for kindergartenchildren.The Peadiatric and Adolescent Unitpiloted the program in 2006 as part ofthe organisation’s commitment toproviding a high quality and bestpractice service to the Ballarat anddistrict community.Amy Jones, Project Coordinator, said“Hello Hospital focused on providing apositive, visual and interactive tour ofthe hospital”.“It incorporates interactive activity andallows the children to experience thesights, sounds and smells of thehospital,” Ms Jones said.More than 700 children fromthroughout Ballarat and districtkindergartens will take part in theprogram which aims to:• Provide a positive educationalexperience for pre-school agedchildren;• Minimise anxiety and stressexperienced by children throughfamiliarisation of the hospital settingand medical equipment used;• Enhance understanding of medicalexperiences for children;• Prepare children for admission tohospital and medical procedures; aswell as• Foster a positive communitypartnership with other serviceproviders.The program includes visits to manykindergartens where the children havethe chance to learn about their bodyby looking at special dolls, and aregiven the chance to dress up and playwith some of the equipment, Thesecond part of the program includesvisits to the hospital and the childrenhave the opportunity to see theEmergency and RadiologyDepartments.Ballarat Health Services Quality of Care Report 2007-08 12

What Happens if youhave a Complaint?Complaints are seen by Ballarat HealthService as an opportunity to improvethe health care we offer our patients.We encourage our consumers to let usknow if there is anything we could dobetter.We acknowledge that we don’t alwaysget it right in the delivery of our service;however, we are committed toaddressing patient concerns andimproving the way we deliver services.Having a complaints system that workswell is another means for you to haveinput into our service.BHS encourages anyone with concernsto raise them with the staff member incharge in the first instance, as concernscan often be addressed immediately, ina sensitive and confidential manner.For those not comfortable talking tostaff, or who are not happy with theway staff handled their complaint, theBHS Consumer Liaison Officer willfollow up the complaint. Eachcomplaint is assessed, investigatedaddressed, resolution attempted andquality improvement opportunitiesidentified.Complaints are managed under theguidelines of the Health ServicesCommissioner (HSC). The HSC criteriaare used to rate complaints andoutcomes in terms of the type of issue,the level of seriousness and the actiontaken in closure.All consumers who attend BHS havethe right to make a complaintinpatients,outpatients, residents’visitors, relatives and carers. Allcomplaints are treated as confidentialand not recorded in the medical file.The Consumer Liaison Officer also has arole in educating and consulting withstaff, helping them manage complexpatient and family interactions.In the past year considerable work hasbeen undertaken to try and improvecommunication with our consumers.The Emergency Department staff have80%70%60%50%40%30%20%10%attended a communication workshopfor frontline staff.We also know that timely resolution ofcomplaints is important to consumersand therefore we endeavor toacknowledge and open communicationlinks within three working days fromreceipt of a written complaint with theaim of early resolution.0%Strongly Disagree Disagree Agree Strongly AgreeStaff from feedback/complaints 18% 9% 9% 64%service were helpfulProcess was easy to follow 64% 36%and understandComplaint was acknowledged 27% 73%in a satisfactory timeStaff listened to what I had 10% 20% 70%to saySatisfaction with how the 45% 55%feedback/complaint was handledSatisfaction with the outcome 18% 36% 46%BHS provides a feedback mechanism so the process we use to facilitate complaint managementcan be evaluated by the consumers that use it. Results achieved are detailed above.“How does the Victorian Public Hospital Charter meet the challenges of thenew Victorian Charter for Human Rights and Responsibilities?”Fifteen senior staff members at BHS and fifteen members of the public were invitedto share in a unique learning and consultation workshop on this question in April thisyear. The forum was an opportunity for consumers and staff to learn from theVictorian Equal Opportunity and Human Rights Commission on the content andimplications of the Human Rights Charter for Ballarat Health and consumers andcommunity members. The Victorian Patient Charter is to be reviewed during 2008,the forum allowed for direct feedback on the review to the Victorian Public PatientCharter partly based on the new entitlements and responsibilities arising from theVictorian Charter for Human rights and responsibilities.13Ballarat Health Services Quality of Care Report 2007-08

Our Staff in theCommunityBallarat Health Services recognisestaff through monthly awardsprogramBallarat Health Services’ StaffRecognition Program was established torecognise and encourage outstandingcontribution or special achievement.It rewards and motivates teams andindividuals who in the course of theirwork put in extra effort. Each month acommittee considers all nominationsand agrees on one staff member orarea for the prestigious award.Dr Maurice EastonA very worthy recipient in 2008was paediatrician Dr MauriceEaston who was described onthe nomination form as “aprofessional role model whoother clinical staff should lookto”, the nomination formcontinued “he has workedextremely long hours, been oncontinuous call with a heavyafter hours load, even whenunwell and has done so alwayswith a smile, a gentle mannerand without complaint.”Kerryn OsborneBallarat Base Hospital nurse KerrynOsborne was driving down NormanStreet, Ballarat when she saw aman collapse on the footpath.Police officers David Hutchinsonand Richie Wynd were at theVictoria Police OSTT headquartersin the former Ballarat SecondaryCollege Midlands campus whenthey also saw the man collapse.Kerryn stopped the car with hertwo children on board, while thepolice officers rushed to RonWalker’s aid. The three heroesperformed CPR on the 80-year-oldafter he suffered a heart attack.Ron stopped breathing three times,only to be revived each time, andwas given only a one per centchance of survival when he arrivedat the BHS Emergency Department.Ron suffered a couple of smallstrokes as well but against all odds,he pulled through and was taken tothe intensive care unit before beingmoved to the cardiac stroke ward,where ironically Kerryn works.Although he has no memory of theincident Ron and his wife Claredescribed the trio as “absolutelywonderful”. “We are very relieved,very thankful and very grateful toall the people who helped saveRon’s life,” Clare said.Matt CambreyMatthew Cambrey is a great nurseand he is also an exceptional artist.Earlier this year, in his own time, hepainted a cartoon mural in one ofthe anaesthetic rooms in theoperating theatre to help calm thenerves of children going intosurgery. Matthew was presentedwith his employee of the monthaward for his outstanding workand contribution to the community.Ballarat Health Services Quality of Care Report 2007-08 14

Mental Health Clinician Leanne Scott discusses a treatment plan with a client.Psychiatric ServicesMental illness affects so many of us, yetthe condition is still stigmatised.But rather than coming to terms withthe fact that mental illness is very mucha part of everyday life, and a conditionthat can affect anyone at any time, it isstill something that is furtivelywhispered about and stigmatised tosuch a degree that the perception thata person suffering from mental illnesscould somehow be at fault remains.Mental illness just like heart disease,cancer or any other illness can affectanyone, anywhere, at any time – anddoes.Mental illness is a disease, like anyother disease, but still carries with it acertain stigma and that can be veryharmful. In fact, one in five Australiansduring their lives will experience amental health issue. This figureincludes everything from low levelanxiety and depressive disorders tosevere and enduring mental illnessessuch as depression, schizophrenia,bipolar, psychotic, personality andeating disorders.Ballarat Health Psychiatric Servicesincreased the number of directcommunity based contacts with clientsby 7961 to a record 100,409 contacts –up 44.33 per cent or 30,252 contactson five years ago.Psychiatric Services have been veryproactive in treating people earlier,which had lead to more people usingthe service.Ballarat Psychiatric Services has one ofthe lowest acute inpatient occupancyrates in the state. We are treating moreand more people in their ownenvironment, which lessons thelikelihood of clients needing acuteinpatient care.In an attempt to change the perceptionassociated with mental asylums fromVictorian days the following is a walkwith one family though the experienceof mental illness. Hopefully sharing thisjourney will help us all understand howthe different service providers and careareas ‘talk’ to each other.Being diagnosed with mental illness isnot the end of the world. There arevastly improved treatments and moresupport available today than there everhas been, any condition can besignificantly improved with medicationand the right social support.John’s journey shows how this occursand some of the processes we track tocheck how it is working.15Ballarat Health Services Quality of Care Report 2007-08

One Family’s Journeythrough ourPsychiatric ServicesJohn is a 22 year old man who lives athome on a farming property with hisparents, Colin and Jean(not their real names).He attended school at nearby Araratuntil he was 15 years old, then stayedat home, helping his dad out on thefarm.Colin and Jean state that John hasalways been a bit of a loner, mixingpoorly with other people and spendinga lot of time in his room, surfing theinternet and playing music. They say heis always talking to himself.Over the last few weeks, John’s parentshave noticed that he is not sleeping,spending all of his time locked in hisbedroom, always on the computer andplaying music very loudly. He hasbecome more and more withdrawn anduncommunicative.He has started eating and drinking verylittle, and seems very suspicious of hisparents.When Colin asks John to help out onthe farm, John becomes verballyaggressive towards his father, stating “Iknow what you are all trying to do toMental illness accounts forover 25 per cent of thedisability burden from allhealth problems across thepopulation as a whole.The economic impact ofmental illness in Victoria hasbeen estimated at $5.4billion annually.In 2006, mental illness was akey factor in 25 per cent ofall people on a DisabilitySupport Pension in Victoria.me!” He then storms out of the houseand runs off across the paddocks.When John doesn’t return home bydark, Colin and Jean go looking for himand find him in a pump station shed.He is curled up in the fetal position andhumming loudly. They take him homeand put him into bed.They contact their local generalpractitioner . in Ararat, who agrees todo a home visit.Following a lengthy consultation, thedoctor notes that John has beenhearing voices for a number of years,and believes that he is being controlledby people over the internet. He believesthat people wish to harm him becausehe has special powers.Psychiatric services provide24 hour 7 day a weekservices across the region.Experienced clinicians areavailable to provideassistance. (Telephone1300 66 13 23 local call)He is sleeping poorly and his dietaryintake is inadequate.The doctor recommends that John havea psychiatric assessment to provide adiagnosis and possible treatmentoptions. Whilst John is reluctant to dothis, his parents manage to get him toagree to the assessment. The doctorcontacts the Ararat Psychiatric Serviceto arrange the assessment.The details of John’s presentation areobtained from the doctor and theduty clinician arranges for anassessment to be done thefollowing morning at the farm.The doctor has given John asedative so that he cansleep overnight.All referrals forwarded bygeneral practitioners toPsychiatric Services lead to acomprehensive assessment.A recently developedprotocol “Working andCaring Together” outlinesthe collaboration betweenPsychiatric Services and theclient’s general practitionerin care and treatment.Following the assessment, anappointment is made for John to see aPsychiatrist in Ararat.John and his parents are given anoutline of the possible treatmentprogram and provided with strategiesto minimise the effects of the voicesand thoughts. They are given a 24 hourcontact telephone number and thefindings of the assessment arecommunicated to the generalpractitioner.John attends the appointment with thePsychiatrist in the company of hisparents.A comprehensive mental stateexamination and review of John’s lifehistory is taken.The Psychiatrist informs John that he issuffering from paranoid schizophreniaand outlines a treatment plan whichinvolves taking anti-psychoticmedications and undergoing a range ofpsycho-social treatment interventions,which will be provided by themultidisciplinary team.Mental Health Clinician Marice O’brien taking a triage callQuality of Care Report 2007-08 16

Victoria provides modern andsophisticated care for over60,000 mental healthpatients every year.Almost one million Victorianswill experience some type ofmental illness each year.Public Mental Health servicesare mainly directed at the 3per cent of the populationwho suffer from the mostsevere mental healthproblems, with around 40per cent of this groupreceiving a service from thepublic sector.Over the next few months, John and hisfamily receive regular visits at homefrom the Treating Clinician, whomonitors John’s progress, provideseducation, and delivers treatmentmodules aimed at improving John’slevel and functioning and minimiseunwanted disruptions to his daily lifeactivities.John is also reviewed on a regular basisby his Psychiatrist and treatmentplanning and progress reports are sentto General Practitioner. John’s mum andThe Psychiatric Service delivers evidencebasedbest practice treatments which areproven to be effective for people whosuffer from a mental illness. Treatment isdelivered in a family inclusive framework.Clinical staff undergo comprehensivetraining in the latest treatment methodsand education and training is provided byworld leaders who are recognised expertsin the field. Psychiatric Services have bothconsumer and carer consultants on staffto act as advocates for clients and theirfamilies. Jackie has been at the forefrontof actively involving carers and has set upcarer consultant groups across the region.dad remain involved and informed of allfacets of care delivery.John responds very well to thetreatments provided, and is able to getthrough most days without hearingvoices or having negative thoughts.He has never been employed, otherthan on the family farm, so the TreatingClinician arranges a referral andintroduction to the nearest EmploymentServices offices.He gains some casual work in a nearbyCamera shop and soon develops a keeninterest in photography.John enrolls for a photography courseat the TAFE College in Ararat and isdoing well.He also shows ability at webpagedevelopment and other computer skills.Colin and Jean are extremely pleasedwith his progress and are confident thatthey can assist John to remain well.The discharge planningprocess of psychiatricservices includes ensuringthat clients, their doctor andtheir families are aware ofearly warning signs whichmay indicate a relapse andhow and where to seek help.They know what early warning signs tolook for and how to seek help if it isneeded.Following a case closure review, Johnand his family are happy to receiveongoing care and monitoring from theirgeneral practitioner. The generalpractitioner is involved in the dischargeplanning process, the ongoingtreatment plan and how to obtain fromthe Psychiatric service should it beneeded.Other MentalHealth Statisticsfor Victoria:Around 30 per cent ofhomeless people have amental health problem.Some 28 per cent of newlyremanded offenders suffermental illness, with rates ofbipolar disorder andschizophrenia 10 timesthat of the generalpopulation.Almost one third of alcoholand drug treatment clientsneed access to public orprivate mental healthservices.Carer Consultant Jackie Crowe17Quality of Care Report 2007-08

Dr Ram Singh with his familyPsychiatricServices StaffDr Ram Singh commenced employmentwith BHS as the Consultant Psychiatristof Horsham Psychiatric Services in2006.He has a strong commitment todelivering evidence-based psychosocialtreatments, within a family inclusiveframework.Ram completed his medical training atthe King George Medical College inLucknow, India and trained as apsychiatrist at the Post GraduateInstitute of Medical Education andResearch in Chandigra, India.He has published numerous researcharticles on Drug Abuse and DrugAddiction in medical and peer reviewjournals. He was awarded travelingscholarships in 1996 and 2000 from theNational Institute for Drug Abuse in theUSA and gave lectures during his visits.Ram was also a World HealthOrganisation consultant for theSoutheast Asian region and providedguidance and support for victims of thetsunami in the Maldives.Ram moved with his family from Delhi,India, where he had worked as anAssociate Professor in Psychiatry forsome 20 years. His wife, Sangeeta,worked full time in her own medicalpractice.Sangeeta has received a very goodassessment on her overseas practicefrom the Royal Australian college ofGeneral Practice since being in Victoria,and is currently awaiting herregistration.They have two children. Their daughter,Sakshi, is 17 years old and attended St.Brigit and Horsham College when theyfirst arrived. She now attends BallaratGrammar to further her interest inscience and mathematics.Sakshi was selected as a staterepresentative to attend the NationalYouth Science Forum in Canberra inJanuary 2008.Shrey is their 15 year old son andattends Horsham College. He does verywell at school and loves soccer.Ram says that the family has assimilatedwell into the local community, and theywere greatly supported on arrival byseveral Indian families who live andwork in the region.Ram attends the local Rotary clubmeetings and enjoys playing badmintonat the Horsham Indoor Sportingcomplex.The Singh family enjoys living in a ruralcommunity, however they admit thatcoming from Delhi with an estimatedpopulation of some 14 million peopleto Horsham with a population hoveringaround 20 thousand, took somegetting used to!Ram believes that the implementationof satellite clinics in the outlying townsof the region such as Nhill,Warracknabeal and Dimboola hassignificantly improved access to theservice for rural communities.Ram liaises closely with GP’s across theregion and provides education sessionsfor them as well as medical officers ofthe local hospital.Whilst this keeps him extremely busy,Ram is also considering an invitationfrom Kings College in the UnitedKingdom to undertake a MastersDegree in Drug Addiction Studies.Ballarat Health Services Quality of Care Report 2007-08 18

Psychiatric ServicesThe Future Working and CaringTogetherA new agreement between Ballarat’sdoctors and Psychiatric Services aims tostop people suffering a serious mentalillness from “slipping through thecracks”.The Working and Caring Togetherdocument is an alliance betweenBallarat Health Services PsychiatricServices and general practitioners tomake sure patients at highest riskreceive the right treatment whendischarged from hospital.The alliance was prompted aftergeneral practitioners were not aware ofwhat previous treatment patients hadreceived when being treated atPsychiatric Services.The Working and Caring Togetherdocument also involves the West VicDivision of General Practice and CentralHighlands Division of General Practicestretching from Bacchus Marsh to theSouth Australian border. It is estimatedgeneral practitioners help treatbetween 75 and 90 per cent of patientswith a mental illness who live in thecommunity.Accessible andResponsible CareIncreasing demand acrosshealth serviceThe ageing population and highburden of disease rates in theGrampians region have contributed toa significant increase in demand atBallarat Health Services. For the 2007-2008 financial year BHS hasexperienced unprecedented demand inthe emergency department, inpatientadmissions, operating theatre andoutpatients attendances. Births for the2007-2008 financial year were sevenless than the record figure of 1199 inthe 2006-2007 financial year, howeverin the past five years births haveincreased by 18.61 per cent or 187more babies.Reasons for the record increase include:• Ballarat’s general practitionershortage;• The ageing population across theregion;• Sicker patients;• Greater referrals from outsideBallarat;• A high burden of disease in theGrampians region, particularlydiabetes and cardiovascular disease;• The extension of Ballarat HealthServices; and• Regional centres no longer providingobstetric services.How long will it take to be seenif you come to the emergencydepartment at Ballarat HealthServices?Despite a record 43,192 peoplepresenting to our emergencydepartment people still need to beseen as soon as possible, this happensaccording to the severity of their illness:Category 1 – resuscitation- seenimmediately.Category 2 – emergency- seen within10 minutes.Category 3 – urgent-seen within 30minutes.Category 4 - semi urgent-seen withinan hour.Category 5 - non-urgent-seen withintwo hours.Waiting times for each category aremonitored and reported to theAustralian Council on HealthcareStandards every six months. BallaratHealth Services have managed tomaintain a constant level of servicedespite treating a record high numberof attendances with more complexpatients for the 2007-2008 financialyear.The Emergency Department hasachieved the targets set by theDepartment of Human Services, forpatient categories despite the increasesin patients presenting with morecomplex conditions.During this time the departmenttreated an additional 3,165 emergencypresentations, an increase of 7.94 percent on the previous year.19Ballarat Health Services Quality of Care Report 2007-08

The increases are being seen in allcategories compared to the same timelast year; Category 1-5 respectivelyreporting increase of 35, 276, 1260,and 540. During 2007-2008 financialyear all Category 1 patients were seenimmediately, therefore achievement ofstate-wide access performance targetwas met.With 43,192 attendances to thedepartment over the last year 38,706had a length of stay of less than sixhours. Total inpatient admissions alsoincreased to 31,804, which was 1495more than the previous year.Key measures included:- 80.8 per cent of patients whoneeded to stay in hospital wereadmitted to a ward within eight hoursof arrival.- 87.94 per cent of patients whodidn’t need to be admitted were in thedepartment four hours or less.- No patients stayed in the EmergencyDepartment longer than 24 hours.Improving Care in the EmergencyDepartmentThe Emergency Department incombination with the radiology andorthopaedic departments hascontinued research into the accuracy ofCT scaning for clinical scaphoidfractures. Two papers have beenpresented at international scientificmeetings, and subsequently submittedfor publication. Details of the researcharea can be found at:www.scaphoidfracture.com.au. Theseresearch projects involved informedwritten consent for all patients, andmeasurements of patient satisfaction.All resources are available for use byother organisations or individuals.The Emergency Department has alsoaudited several areas of clinicalpractice, with improvements in thepercentage of letters written to GPs ondischarge, and excellent compliancewith best practice treatments forchildren presenting with seizures, andalso the treatment of spontaneouspneumothorax.Length of Stay in the 2004/05 2005/06 2006/07 2007/08 TargetEmergency DepartmentNon-admitted patients 90% 90% 89% 87.94% 80%seen within 4 hoursAdmitted to ward 90% 85% 80% 80.8% 80%within 8 hoursLength of stay in ED of 5 0 0 0 80%more than 24 hoursNumber of ED attendances 35,835 40,062 40,027 43,192Data shows comparable length of stay inthe Emergency DepartmentBallarat Health Services Quality of Care Report 2007-08 20

Waiting for surgeryBallarat Health Services has sixoperating theatres and two procedurerooms, performed 10,443 operationsduring 2007-2008. Elective cases areperformed between 8am – 6pmMonday to Friday, with emergencycases performed as required, day ornight.As per DHS Elective Surgery GuidelinesBallarat Health Services endeavors totreat patients waiting for electivesurgery in a timely manner, Category 1patients within 30 days, Category 2patients within 90 days and Category 3within 365 days. This may not alwaysbe possible to achieve given thevolume and complexity of patientswaiting for elective surgery, particularlyin the specialties of orthopaedics andophthalmology.The number of complex Category 1elective patients waiting for surgery hasgrown significantly over the last fouryears, often resulting in those patientsin categories 2 or 3 experiencing delaysand sometimes cancellations. BHS hasmaintained the 100 per cent targetthat ensures that the most urgentpatients (Category 1) undergo surgerywithin the 30 days.BHS treats the most urgent emergencypatients first; sometimes this meansthat elective surgery is cancelled, andpeople with less serious conditionspresenting in the EmergencyDepartment must wait. BHS isconstantly reviewing the number andtypes of patients waiting for surgery toensure equitable access for all patientsand to this end conducts 6 monthlyaudits of the elective surgery waitinglist.Ballarat Health Services reported 84.30per cent category 3 patients waiting365 days or less for surgery, thereforenon-achievement of the Department ofHealth Services (DHS) waiting listtarget. The increased emergencypresentations put extreme pressure onelective surgery patients often resultingin cancellation of category 2 or 3surgery and impacting on hospitalresources and the management of thewaiting list. The DHS program, ElectiveSurgery Access Service (ESAS) a statewide program, to assist patients onlong waiting lists saw 28 of ourpatients receive their care earlier thanwould be possible at BHS to the end ofJune 2008. If you are a patientsaccepting treatment through ESAS youmust be willing and able to attendoutpatient, pre-admission and postoperativeappointments at thedesignated hospital. The initial referral2004/05 2005/06 2006/07 2007/08 TargetCategory 1: Urgent Admission 100.00% 100.00% 100.00% 100.00% 100%Within 30 days desirable for a conditionthat has the potential to deterioratequickly to the point it may becomean emergencyCategory 2: Semi-Urgent Admission 87% 78% 96% 88.54% 88%Within 90 days desirable for a conditioncausing some pain, dysfunction ordisability but is not likely to deterioratequickly or become an emergencyCategory 3: Non-Urgent AdmissionAt some stage in the future acceptable N/A 92% 83% 84.30% 93%for a condition causing minimal or nopain, dysfunction or disability that isunlikely to deteriorate quickly, and doesnot have the potential to becomean emergencyNumber of patients on the Elective 1009 1239 1140 1,017 1,046Surgery Waiting Listis arranged by the ESAS Coordinator atBallarat Health Services. The receivinghospital then communicates with bothyou and your General Practitionerregarding the surgery and care. Youwill also have access to a designatednurse at BHS regarding any enquiries orissues.For further information please contactthe elective surgery coordinator on(03) 5320 4775.Outpatient ServicesThe Ballarat Health Services OutpatientService is committed to the delivery ofa coordinated, flexible and high qualityOutpatients Service, responsive to youthe consumer.BHS has been investigating Outpatientwaiting times over the last year tomake sure the most urgentappointments are seen within anacceptable timeframe.The Outpatients Department hasimplemented an electronic waiting listwhich allows a current list of patientswaiting for an appointment.Each clinical specialty has an individualwaiting list with nursing staff assignedto contact long waiting patients bytelephone to provide assurance, clinicaladvice and if necessary anappointment. This phone call allowsthe staff to update demographicsdetails, remove the patient from the listif the appointment is no longerrequired and gives the patient anindication of waiting time.Outpatient visits exceeded 2007-2008target by 977 or 2.46 per cent.Ballarat Health Services had 36,694outpatients visits during the financialyear.Ballarat Health Services has asignificant number of outpatient’sappointments that are not kept – didnot attend (DNA). Significant resourcesare used in the management ofpatients that do not attend. A jointinitiative between BHS and the Ballaratand District Aboriginal Co-operative(BADAC) has been embraced by ourindigenous residents resulting in asubstantial decline in the failure rate ofAboriginals attending outpatientappointments.The proportion who now fail to attendtheir appointments has fallen to 21 percent, compared with a failure rate of40 per cent prior to the introduction ofthe program. Under the program BHSnow notifies BADAC, when makingoutpatient appointments forindigenous clients. BADAC staff arethen responsible for contacting theclient in the lead-up to theappointment and organizing transportand support if required.21Ballarat Health Services Quality of Care Report 2007-08

HARPThe Hospital Admission Risk Program(HARP) at Ballarat Health Services is aDHS funded program that usespreventative models of care in order toimprove the health of peopleexperiencing chronic and complexhealth conditions.HARP aims to achieve this throughtargeting clients who are identified asfrequent hospital attendees or at risk ofhospitalisation, and who would mostlikely benefit from integrated andcoordinated care provided by the HARPCare Coordinators.All of the HARP clients on the chronicdisease streams have care plans.Services include:• Providing better services, informationand advocacy to clients and theirfamilies.• Ensuring that clients are treatedquickly at the earliest signs of changein their condition.• Provision of ongoing support andmonitoring for clients betweenhospital admissions.• Improved communication betweenthe client, hospital, GP andcommunity agencies.• Referral and linking of clients withappropriate services.• Incorporating the principles of selfmanagement into the overall aims ofthe program.HARP currently offers services for thefollowing groups:• People with chronic heart disease;• People with chronic respiratorydisease;• People with Diabetes;• Older people with complex needs(Falls);• People with complex psychosocialneeds; and• Currently HARP has a total of115 clients.The following client story reflects thelevel of service coordination,integration and support required toassist consumers in navigating theirway to better health outcomes.Linda Govan (left), HARP Manager with HARP staff Diane Lawson, Carmel Cunnington,Karen Brodie and Nola PoulterYour ExperiencePatient StoryThe client is a 67 year old male, with a history of Type 2 diabetes and heartdisease, who presented to the Emergency Department at BHS, after collapsingdue to low blood sugar (hypoglycaemia). The client also struggled with anxiety,related to living alone on an isolated property outside Ballarat, had limitedfamily support, and a fear of experiencing further hypoglycaemic events.English is also a second language for the client.Assessment occurred at the client’s home by the HARP Care Coordinator andindicated that the client did not have a GP in Ballarat, was not monitoring hisblood glucose levels and required podiatry and ophthalmology reviews.Outcomes:The HARP Care Coordinator organised the following services for the client:• Linked in with GP services at Ballarat Community Health Centre,Sebastopol;• Referral to Podiatry, Dietetics and Ophthalmology;• Referral to the National Diabetes Service Scheme (NDSS);• Purchase of a glucometer, with support and education initially providedby Ballarat District Nursing and Healhcare, funded through Post Acute Careat BHS;• Other support services organised included home help, shoppingassistance and Safety Link; and• The client was reviewed by Dr Andrew Kemp for HARP, with follow upprovided at the Diabetes Clinic at the Queen Elizabeth Centre.Concurrently, the HARP Care Coordinator also provided support with selfmanagement strategies, related to blood glucose monitoring, development ofan Action Plan with the client to assist with “sick day” management,assistance with medication adherence through improving symptommanagement and understanding, and reinforcement of dietary advice.Through involvement with HARP, the client now has regular contact with hisgeneral practitioner, is gaining confidence in symptom recognition andmanagement, has shown improved medication adherence and is generallymore confident in navigating his way through the health care service system.Ballarat Health Services Quality of Care Report 2007-08 22

Oncology ServicesFour years ago when Dr Kate Hamiltonstarted working at Ballarat HealthServices as the full-time oncologist, sheinherited a “minimal public service”.Dr Hamilton set about building aservice to meet the needs of thepatients, including an inpatient serviceand a day oncology unit, both at theBase Hospital. When she first beganher clinics - she holds four each week -in 2004, Dr Hamilton was seeing oneor two patients each time. Now, shesees 20 patients each clinic, or 80patients a week. Dr Hamilton explainsthe reasons for the increase in demandin Ballarat;• Ageing population, the incidence ofcancer is rising across Australia,mainly linked to our ageingpopulation. The National CancerPrevention Policy 2007-2009estimates cancer cases will rise by 30per cent in the next five years.“People are living longer andthe diseases that used to kill them,such as heart attacks, strokes anddiabetes, we are better able tocontrol, allowing them to get cancersthey may have never lived longenough to develop before”.• BHS also has the only publiconcology service between Meltonand the South Australian border,with a growth of 20 per cent a yearover the last four year. The pressureon the service is enormous as DrHamilton is the only full-timeoncologist with one part-time cancerspecialist and an advanced trainee.The oncology nursing staff are alsokept extremely busy. A second fulltimeoncologist has been recruitedand is due to commence in late2008.• Improved treatments for manycancers now means patients whopreviously wouldn’t have benefitedfrom treatment can access theservice. There is a wider range ofoptions, for example, there are nowa few different chemotherapytreatments for lung cancer. Our aimis to provide the best quality of carefor people who come through thedoor.Ballarat Health Services medical oncologist Kate Hamilton with breast cancer survivor ChristineGlare. BHS currently has 29 patients enrolled in clinical trials, with eight studies open in oncology.• Clinical research results have shownthat adjuvant chemotherapy, whichmops up an rogue cancer cells leftbehind from initial cancer operations,can help prevent the diseaserecurring, especially in breast, boweland lung cancers. This means morepatients are now getting preventativetreatment.• The oncology program is a jointeffort involving doctors, nursingstaff, social workers and pharmacy.The only patients referred toMelbourne are acute leukaemia andsarcoma cases, which need highlyspecialised treatment. BHS offer acomprehensive service for ourpatients, we also have a palliativecare service and an excellentradiotherapy service.23Ballarat Health Services Quality of Care Report 2007-08

Diagnostic ServicesThe Diagnostic Services Department islocated in the newly refurbished EildonHouse. The entrance is off DrummondSreet North. The phone number for allbookings and enquiries is (03) 53204201.The Diagnostic Services Departmentoffers a one stop shop for lungfunction testing, EEG, holtermonitoring (both 24 hour and 96hour), ECG's and echocardiography,These procedures can be co-ordinatedto decrease the number of visitsneeded to the hospital to complete theinvestigations requested by yourdoctor.They can also be co-ordinated withyour radiology appointments for CTscan or ultrasound or MRIappointments so decreasing thenumber of visits you have to make toBallarat Health Services forinvestigations.Diagnostic Services client undergoing lung function test.The Diagnostic Services Departmentalso offers a Chest Pain Clinic for theassessment of chest pain by acardiologist, if requested by yourgeneral practitioner.Our friendly staff look forward tohelping to organise your appointments.Transit LoungeThe Transit Lounge was set up in 2006and operates out of the Base HospitalMedical Services building on level one.It can cater for up to 13 Transit Loungeclients in recliner chairs. The TransitLounge also encompasses The SameDay Unit and the management of theMedi Hotel.The purpose of the Transit Lounge is abed substitution model for patientsexperiencing delays in discharge. Theseclients do not need to occupy aninpatient bed and are awaitingdischarge arrangements to be finalized,for transport to collect them or theymay require administration of a finaldose of medication prior to discharge.Following in-service training providedto the ward staff, the frequency of usehas increased, as they are now moreaware of the benefits it provides to thebed management on the wards. Theincorporation of the Same Day Unit hasalso assisted the wards in being able tomove clients that require intravenousantibiotics or other therapies. Therecent appointment of a full timePersonal Services Assistant to theTransit Lounge has made thetransportation of clients from the wardquicker and easier and means thatCustomer Services is not required forthis purpose.Open hours are from 8:30 am to 5:00pm Monday to Friday.General feed back from clientswho have used the Transit Lounge;It is comfortable.Staff members are friendly.What a great idea lettingsomeone have the bed who needs it!The television and papersmake the stay more comfortable.It is great that our lunch from the ward isstill provided while we are in the Transit Lounge.Ballarat Health Services Quality of Care Report 2007-08 24

suitability for transplantation, or theoption of peritoneal dialysis.During 2007-2008 the dialysis unitprovided 5374 episodes of treatment.To improve the service to you we haveestablished a pre-dialysis nursecoordinator for a 12 month trial periodin January 2008 to develop andsupport pre-dialysis education to betterprepare patients for the progression todialysis with a matured vascular accessand knowledge about dialysis options.Aids and EquipmentDialysis Nurse Andrew Hull with dialysis client Judith BartlettDialysisWhat happens if you need to havedialysis?Ballarat Health Services Dialysis is asatellite unit of the North West DialysisService of the Royal MelbourneHospital.It provides optimal care to patients inthe Grampians region with end stagerenal disease (ESRD), as well as acuterenal failure. The service strives forreliable efficient haemodialysistreatment and making a positivedifference to the quality of patient6000500040003000200010000lives.A support service is provided for othersatellite units, including Donald, Ararat,Maryborough, Horsham, Daylesfordand Bacchus Marsh.Haemodialysis is also provided forpatients (including interstate andinternational), wishing to holiday in theregion, when spaces are available.Renal replacement therapy is providedin the form of haemodialysis, involvingthe use of a machine to pump bloodthrough an extra circuit and filter. Thistreatment may be permanent ortemporary, depending on the patient’sDialysis Unit statistics - Number of treatments1991 1993 1995 1997 2000 2002 2004 2006 2008Number of treatmentsBallarat Health Services toadminister $2.5 million programBallarat Health Services’ Aids andEquipment Program is set to play amajor role in the State Government’s$2.5 million vehicle modificationsubsidy scheme.The Ballarat Health Services program,led by Jeni Burton Manager, won thecontract ahead of 29 other similarschemes from across the state. Thefunding will see more than 220Victorians with a disability and theirfamilies benefit from easier vehicletransport. Under the scheme, financialassistance will be available for the firsttime for private vehicle modifications.The subsidy will assist people with adisability who require modifications todrive or travel as a passenger in theirvehicle. A maximum subsidy of up to$10,000 will be available to assistpeople with a disability to convert theircar for wheelchair access.The subsidy can provide assistance withspecialised lifters, carriers and trailersfor wheelchairs, ramps fixed to avehicle and modified driving controls toenable a person with a disability todrive. Ballarat Health Services is excitedto be playing such an integral role inthe delivery of the program as wecontinually work to improve the healthand wellbeing of our clients, theirfamilies and the community. If yourequire any further information onapplying for the subsidy you cancontact the program officer on(03) 5320 3715.25Ballarat Health Services Quality of Care Report 2007-08

BHS CateringCatering for your needsBHS Catering is a business unit ofBallarat Health Services, established inlate 1997 following the merger of theformer Queen Elizabeth Centre and theBallarat Base Hospital food servicesdepartments.BHS Catering provides food services fora range of clients and staff at BallaratHealth Services as well as externalprivate customers, which includes LocalGovernment meals on wheels providersin Ballarat and more broadly acrossVictoria, prisoner meals for theVictorian Police, meals for child carecentres and private function catering asrequired.BHS Catering is the only public hospitalkitchen in Victoria which has beenaccredited under the HACCPcertification (international food safetymanagement system).The volume of meals prepared on adaily basis ranges from 3070 to 5200depending on the day of productionand number of meals required.BHS Catering delivers approximately1780 meals for Ballarat Health Servicepatients and aged care residents on adaily basis with a further 1500 to 3500meals to private clients depending onvolume required.All food is cooked and packaged at theQueen Elizabeth Centre kitchen locatedin Ascot Street South, Ballarat, anddistributed via a fleet of BHS Cateringowned vehicles to various locations inBallarat and across Victoria.Patients and aged care residents ofBallarat Health Services are offered awide choice of meals on a daily basiswith selections ranging from acontinental breakfast through a lunchand dinner menu consisting of fourdifferent soups, eight different hotdishes, (cold meals if preferred) and aselection of lighter meals such assalads, sandwiches and desserts.New menus are introduced by BHSCatering every six months to reflectseasonal change, customer choice and40.0%30.0%20.0%10.0%the growing need to cater for culturaldifferences. All meals prepared by BHSCatering meet Australian DietaryStandards and address the nutritionalneeds of the clients. To achieve this,menu development is a jointresponsibility of BHS Catering, theDietetics Department and clinical staff,where input on meal modification andconsistency is critical to the patientsnutritional intake and wellbeing.Menu Monitors discuss mealpreferences with patients on a dailybasis and assist with meal selection inaccordance with dietary requirements.0.0%Poor Fair Satisfactory Good Excellent No ResponseQuantity of food 3.2% 3.7% 31.4% 31.4% 33.5% 5.9%Variety of food 2.7% 6.4% 35.6% 35.6% 33.0% 6.4%Quality of food 2.1% 8.5% 35.6% 35.6% 30.3% 6.4%Temp of hot food 2.7% 7.4% 34.6% 34.6% 37.2% 6.4%Client/patient feedback of inpatient meals from November 2007 - January 2008Ballarat Health Services Quality of Care Report 2007-08 26

“I never expected to make this decision for many yearsbut because of what happened to me I am so pleasedto be able to call Messer Hostel my home.”27Quality of Care Report 2007-08

What Happens if youNeed to Move into aResidential CareFacilityHelping Our Aged ResidentsFeel At HomeEveryday, patients and their families arefaced with the sometimes unfortunatefact that returning to their own homesis just not an option at their stage inlife. The quality of care for our agedcare residents is important to us. Thesocial and emotional needs of theelderly are just as critical as physicalhealth in ensuring wellbeing.The standard of care provided at allBallarat Health Services residential carefacilities is of an extremely highstandard. All staff work tirelessly toachieve total compliance in all 44expected outcomes of the Aged Careand Accreditation Standards.WB MesserIs a 45 bed low-level care facilitysituated on the Queen Elizabeth Villagesite in Gillies Street, Wendouree. Thefacility is comprised of four joinedhouses, each featuring their ownkitchen, dining room and privatelounge, while the 45 bedrooms all haveensuites. The Queen Elizabeth Villageis located beside one of Ballarat’s majorshopping centres and features directpedestrian access.Public transport is also readilyaccessible. The facility is located on alarge well-manicured site with apeaceful rear garden area. Residentshave access to a visiting Podiatrist andhairdresser, telephone, television andVCR, CD and tape player, librarybooks, newspaper, postal services anda small shop on site. There is anactivity room, dry cleaning service, anddirect access to a major shoppingcentre, courtyard access from eachhouse, single rooms with ensuite,activities programs, and furnishedrooms.To address the care needs of residentsthere are 24 hour care staff, 24 houraccess to nursing staff, manager on siteas well as the Director of Nursing.Your Experience Residents StoryNoel EdwardsNoel Edwards a resident at WBMesser shares his experience ofhaving to make this unexpecteddecision; “After a very quick rideto Epworth with the lights andsirens blazing, I was not aware ofanything for several days, buteventually awoke to find that inthe process of operating on amassive aortic aneurism it wasnecessary to close off the bloodsupply to my spine for 30minutes. Result, still alive butnow a paraplegic. I then spentsome time at CaulfieldRehabilitation Hospital and thensome months at the QueenElizabeth Rehabilitation Centre.It was during this time I realized Iwas unable to care for myselfeasily or even properly in awheelchair. It is difficult to makea bed, handle a stove, get closeto a sink, use top or bottomcupboards as well as vacuumcleaner, lawn mower and all theother tasks I took for granted.I was offered a room at MesserHostel and took it although alittle apprehensive about living ina home, soon got over thatfeeling. However, my room is bigand I have filled it with books,music computer, personalrefrigerator favorite paintings andpictures, writing desk and otherpersonal things.In looking for some of theindependence I had lost, my carwas fitted with hand controls anda hoist on the roof to lift mywheelchair up to transport it. Ipassed a new license test and cannow drive myself tophysiotherapy mostly, but really toany other place I choose providedit does not have steps.My new home is warm andfriendly and as I often go out dayor night, a nice greeting is therewhen I come home even at 1.20am as has happened on twooccasions with another late nightevent on my calendar planned fornext month.”Noel enjoys an evening of entertainment with friendsBallarat Health Services Quality of Care Report 2007-08 28

Governance and RiskManagementPutting Patient Safety FirstBHS has many systems in place tomonitor, evaluate and improve thequality of care you receive when youhave need to access our services.Collectively these systems and process’smake up our Clinical GovernanceFramework, the major components ofwhich are described in the followingsection. The staff of the Governanceand Risk Management Unit play anintegral role in supporting theGovernance Framework across ourhealth service.Improving care.Our staff are actively involved in projects aimed at improving care for our patients, clients and residents. To supportand recognise their contribution we presented three quality awards for 2007. These awards which are described belowwere in recognition of outstanding work in improving services and were for both the clinical and non- clinical areas ofthe organisation.1.Nursing interventions to improve bowel management in residential careThis project involved the introduction of evidence based principles in relation to bowel management into a high careresidential facility. The results showed an 85 per cent reduction in the use of suppositories and restoration of residentdignity in relation to bowel management.2.Improving follow-up of patients with mild traumatic brain injuryPatients with a traumatic brain injury often need interventions for up to three months post their injury. Despite thisneed for support, only a small number of referrals to the Acquired Brain Injury (ABI) clinic were received from theEmergency Department (ED) in 2006. This prompted an evaluation of the referral system that was being used.Collaboration between the ED, speech pathology and the Acquired Brain Injury (ABI) resulted in a new and streamlinedreferrals system, increasing referrals by over 80 per cent in the first two months of operation.3.Improving Access to Electronic JournalsIn 2006 the library staff noted frequent requests for assistance in locating clinical journals and evidence of confusionwith staff knowing how to efficiently do this. A new journal catalogue was implemented which included a list of alljournals and a link to electronic journals. After implementation the journal usage increased by 63 per cent.AccreditationAccreditation is a process that healthservices use to ensure that they deliverhigh quality, evidence based and safecare to their patients.The Australian Council on HealthcareStandards (ACHS) is the externalorganisation that conducts theaccreditation process, and sets out theEvaluation and Quality ImprovementProgram (EQuIP) which Ballarat HealthService utilises to assist it in its qualityimprovement programs.BHS underwent a full accreditationsurvey in October 2006, with full fouryear status achieved. Between eachfull assessment there is a process of selfassessment, ongoing reporting andevaluation of progress on therecommendations received from theprevious survey.The table below outlines all of theaccreditation processes that we have inplace across the health service and thecurrent status of each.Type of AccreditationStatusAustralian Council on Full 4 year accreditation achieved October 2006Healthcare Standards(incorporating the entire health service)(ACHS)** 43 criterion assessed = 23 EA’s and 20 MA’sDue for Periodic Review in February 2009Aged CareFull accreditation achieved 2006 for11 of the 12 residential sitesStandardsIncorporating all of the 44 aged care standards.Accreditation The 12th site achieved full accreditation in 2007.Agency (ACAA) Due for reaccreditation in 2009National Mental Health Full 4 year accreditation achieved in 2006Due for review in 2010Home and CommunitySuccessful review in 2004. Review in conjunction withCare (HACC) ACHS periodic Review February 2009DHS Disability Successful review July 2008.Radiology Successful stage 1 review July 2008New accreditation process with ACHS in 2009Baby Friendly Currently preparing for accreditation process in 2009.Hospital Initiative**EA = Extensive achievement requiring evidence of benchmarkingMA = Moderate achievement requiring evidence of evaluation29Ballarat Health Services Quality of Care Report 2007-08

A total of 11 recommendations weremade from the accreditation process in2006 to guide specific improvementprograms. These included:• Improvements to the management ofthe health record across BHS toimprove access, tracking, securityand storage of records to bettersupport care.Progress on this recommendationto date includes:• Successful submission for anelectronic filing system – scannedclinical record project due forimplementation June 2009.• Increase and improvements inthe storage space for paper medicalrecords.Checking we are getting things right - Internal AuditsInternal audits are carried out across the organisation to ensure that the treatment/ service the patient/ client receivesis the best that we can possibly give and identify areas where improvements can be made.Medical Record Documentation AuditThe medical record is an integral component in the successful communication between health care professionals andthe patient. A compliance audit was conducted that gauged staff compliance with the policy. Further work isalready underway which reinforces the importance of sound clinical documentation.Correct patient, correct procedure, correct siteDHS identified that one of the main areas where errors could occur, and thus the patient could be put at risk, is atthe time of a procedure. BHS recognised this and implemented a policy to minimise this risk to our clients.Ward Pre-Operative Audit ChecklistOperating Theatre Pre-Operative Audit Checklist100%100%90%80%70%60%93%93%83%82%90%80%70%60%72%72%65%82%50%59%50%40%40%30%43%30%20%20%27%28%10%0%7%0%7%0%17%0%ID label Allergies Consent Site & side Images, ifdocument noted & form notated applicable,as present documented completed are present& checked0%17%1%10%0%1%1%17%1%17%1%ID label Allergies Consent Images, ifdocument noted & form applicable,as present documented completed are present& checked% YES % NO % BLANK% YES % NO % BLANKThis audit gauged the level of compliance to the policy. As an organisation, striving for best practice and optimaloutcomes for our patients, BHS must aim for 100 per cent compliance with all aspects of the policy. The above auditdemonstrates that effort needs to be put in to achieve the goal of 100 per cent compliance.Monitoring our performanceAll departments have developed a set of performance indicators that are relevant to their systems and patient/ clientcare models. They are used to check progress and identify areas where improvements can be made. Some of theindicators are sent into DHS and benchmarked against other organisations.Ballarat Health Services Quality of Care Report 2007-08 30

Committed to SafetyBHS is committed to providing thesafest possible care and environmentfor our patients, their visitors and ourstaff. A safe environment is one inwhich risk has been reduced to anacceptable level. A risk is anythingwhich could prevent the delivery ofusual business, in this case, health care.Risk management therefore is puttingprocesses and strategies in place thattry to anticipate and prevent these risksfrom occurring.Ballarat’s risk management frameworkhas expanded significantly in the pastyear as a result of the high level ofcommitment by the managementteam. Initiatives include:• A full time Risk Manager wasappointed in May 2008 to coordinateand oversee thedevelopment of risk managementstrategies across all the clinical andcorporate areas of the health service.• The Risk Manager is a member of theGovernance and Risk ManagementUnit to ensure that it is part of theculture and processes of qualityimprovement built up at BHS overrecent years.• A comprehensive and dynamic riskregister across all areas of the healthservice has been completed and isregularly reviewed. Staff at all levelsare able to feed into this when theyidentify risks in their local areas. Theelectronic risk register is linked to theincident reporting system to assist usto use incidents to identify risks.• The Occupational Health and Safetyteam visit all sites and units toconduct and assist staff inundertaking safety audits of theenvironment and equipment.• Executive and senior staff havereceived training from the VictorianManaged Insurance Association(VMIA) to assist them to be part ofthe risk management process andculture at BHS.• Training in using the Riskman database effectively is provided regularlythrough the ongoing ProfessionalDevelopment Program.• Special training events on patientsafety and monitoring performanceare offered to staff throughout theyear by the Governance and RiskManagement Unit.• The key clinical risk areas continue tohave active and effective HarmMinimisation Working groupsleading our improvement in the areasof infection control, falls, pressureulcers, medication errors, chokingand swallowing hazards and violenceand aggression.• We use a large range of sources tohelp us comprehensively identify ourrisks including:o Incident reports;o Clinical and operational audits;o Responding to alerts andrecommendations from otherorganisations, and the Departmentof Human Services, nationally andinternationally; ando Patient feedback.Managing and learning from thingsthat go wrongIncident reporting system andprocesses for ensuring the properfollow up and management of adverseevents (unplanned harm to patients orstaff) in a health service is essential togood clinical governance and riskmanagement.We do this by investigating events thathave gone wrong in order to ensure welearn the lessons and try and avoidthem happening again in the future.Integral to this is a culture of no blamewhere staff feel able to report allevents and mistakes and not cover itup.No risk of delay in emergenciesThe investigation of some incidents involving liftdelays in 2006-2007 during patient emergenciesidentified significant risks.There was a problem with a centrally locatedresuscitation trolley in the Intensive Care Unit in alarge multi-story hospital. Difficulties with the priorityaccess to the lifts to get the resuscitation equipmentand team to the patient requiring emergency care asquickly as possible was also identified.To reduce that risk in the past year there has been anupgrade of the lifts allowing the emergency team toaccess it immediately. Extra resuscitation trolleys havealso been positioned on every floor of the hospitalmaking our response time quicker in an emergencysituation. Extensive staff training has also beenundertaken.31Ballarat Health Services Quality of Care Report 2007-08

Infection ControlMonitoring our Infection RatesWe track our Infection rates to checkour progress in the fight againstinfection.Data is submitted on wound infectionsand antibiotic use to the VictorianNosocomial Infection SurveillanceSystem (VICNISS). These reports enableus to compare our performance withother hospitals in the state. During theyear BHS achieved excellent results inthe VICNISS review. However, we stillhave room for improvement withantibiotic choice and timing withsurgery. Strategies to improve thisinclude dissemination of antibioticguidelines to all doctors, education andtabling of reports at surgical forums.The VICNISS Type 1 indicatorsmonitored at BHS include:• Surgical site infections followingbowel surgery;• Surgical site infections following hipand knee surgery;• Blood stream infections associatedwith the use of central lines in theIntensive Care Unit; and• Haemodialysis surveillance.The results for these indicators werewithin the expected limits for ourhealth service.Achievements• A consistent zero infection rate in theICU in relation to central lineassociated blood stream infections(CLABSI) over the last four years sincethe commencement of the VICNISSsurveillance.• Multi-Resistant Organism surveillance(Golden Staph). The incidence ofMRSA (‘Golden Staph’) infection rateis kept very low by:• hand hygiene practices;• adhering to precautions such aswearing gloves and gowns;• nursing patients with a resistantorganism separate to other patients;• screening patients for MRSAroutinely when transfered frommetropolitan hospitals;• maintaining currentpolicies/guidelines for managementof MRSA; and• educating staff and visitors.These routine procedures limitinfections moving from patient topatient. Most of the MRSA (’goldenstaph’) infections seen at BHS havebeen acquired either in the communityor at other hospitals and there hasbeen no transmission of infectionwithin our hospital.Clean hands at Ballarat Health ServicesResearch shows compliance with hand hygiene is poor.Common reasons include lack of time, lack of sinks, skin irritationand dryness and inadequate knowledge of guidelines or protocolsfor hand hygiene.As part of a DHS funded state wide project to address thisissue, we have introduced the Hand Hygiene Project.Don’t Get Caught Dirty Handed• Aiming to provide staff with a computerbased credentialing program.• Providing hand care and dermatological support.• A major focus this year will be to encourage patientsand visitors to clean their hands before touching patients by:Having hand rub readily available at all public entrancesand wards;Having clear signage regarding appropriate use ofthe hand rub; andProviding hand hygiene pamphlets throughout the facility.Ballarat Health Services Quality of Care Report 2007-08 32

Achievements• The use of alcohol/chlorhexidinebased rub has more than doubledover the last 18 months• Improved staff compliance with handhygiene from 74 per cent in 2006 to91 per cent in 2008.Sharps injuries and blood and bodyfluid exposures at BHSTo protect themselves and otherpatients, we have measures in place toprevent and treat injuries to staff suchas needle stick injuries as well as bloodand body fluid splashes, where staffmay be exposed to blood borneinfections.A total of 17 blood exposures fromneedlesticks were reported in 2006 and24 in 2007. From January to June2008, 14 needle stick injuries havebeen reported. Exposure managementis an identified risk and one in whichBHS is constantly striving to ensure thatexposures are kept to a minimum.Safety needles and syringes are beingtrialed in the hospital to add to ourextensive number of safety devicesalready in use.100%80%60%40%20%0%74%2006 2007 2008Staff vaccination program includingannual influenza vaccinationVaccinating staff helps to preventinfections such as ‘the flu’ movingbetween staff and patients and reducesstaff sick leave, particularly during thewinter months. Influenza vaccination isoffered to all staff from March eachyear. In 2007, 1095 out of 2553 (42.9per cent) of all staff were vaccinated,up from 787 in 2006. This rate has83.90%Series 1 Linear (Series 1)Percentage of staff compliance with the Hand Hygiene Project91.47%increased again in 2008 and all data issent to VICNISS for comparison withother hospital rates.BHS have a staff health clinicincorporating vaccinations for staff.This clinic operates twice per week andis available for all staff. Vaccinationsoffered in this clinic comply withcurrent vaccination recommendationsmade by DHS in 2007.100%95%90%85%80%75%70%92.3%91.6%93.3%89.2%2001 2002 2003 2004 2005 2006 2007 2008Weighted Score91.9%DHS AQL93.5%94.9%92.2%During the eight years of audits the Ballarat Base Hospital has consistantly (seven out of eight)rated well over the 90 per cent. This places BHS in the high achievement group. This years scoreof 92.2 per cent was slightly down on the previous two years.Clean Hospital-Clean-Departments-Clean RoomsWe carry out internal audits and anannual external audit to ensure ourclean hospital lowers the risk ofinfection to you.Cleaning standards are a performancerequirement of the Department ofHuman Services and are applicable toall relevant acute and sub acuteVictorian Public Hospitals.From 2001 to 2008 the Base Hospitalexternal cleaning scores have averagedfrom 94.5 per cent in 2007 down to89.2 per cent in 2004. Between 2001and 2005 the minimum requiredstandard was 80 per cent and from2006 onwards it was lifted to 85 percent33Ballarat Health Services Quality of Care Report 2007-08

Preventing Fallsin HospitalPatient falls are a challenging safetyand quality of care issue in the hospitaland residential setting where an ageingpatient population and persons withphysical and thinking limitations areexposed to unfamiliar and potentiallyhazardous surroundings (Tzeng, 2008).Falls prevention strategies at BHScentre on timely assessment, referralsfor intervention where needed andreassessment to evaluate improvement.National ComparisonFalls data is submitted to the AustralianCouncil on Healthcare Standards(ACHS) biannually and is thenbenchmarked against otherorganisations. At Ballarat HealthServices, the sub-acute and residentialservices areas were identified in 2007as being of most concern regardingfalls prevention.The Falls Minimisation Working Grouphas considered a number of strategiesto address the falls risk in these areas.These include:• A trial of hip protectors;• Investigation of medication relatedfalls; and• Individual resident and client falls riskprofiles.Funding was also sought and approvedto commence a project in the subacutesetting to explore intrinsic andextrinsic risk factors for falls.Researchsub-acuteA study was commenced in July 2008to explore current practices around fallsassessment and prevention in the subacutesetting. This study which isscheduled to be completed at the endof 2009 should assist the organisationto reduce the incidence of falls in thisarea.ResidentialBallarat Health Services is part of amulti-centre trial run by the NationalAgeing and Research Institute (NARI).This trial is funded through theCommonwealth Department of Healthand Ageing and will be exploring therelationship between dementia andfalls. It will run from January 2008 toDecember 2009.Ballarat Health Services records all fallsinto a centralised management system,to enable analysis of falls across theorganisation. This contributes to theimplementation of strategies needed toaddress any issues.ReferencesTzeng Huey-Ming, Chang-Yi YinNurses’ solutions to prevent inpatientfalls in Hospital patient roomsNurse Econ. 2008: 26(3): 179-187Janetti Publications, Inc.Preventing PressureUlcersPressure Ulcers or bed sores are acommon problem in hospitals, and arerecognised internationally as one of thefive most common causes of harm topatients. Patients at greatest risk ofdeveloping pressure ulcers are thosewho are frail, elderly or immobile forlong periods of time. These are criteriathat fit many of the patients who aretreated at Ballarat Health Services andalmost all of those who live in ourresidential facilities.From 2003-2006, BHS participated in asurveillance program run by theVictorian Quality Council, collectinginformation on the incidence of skinbreakdown. This was the Pressure UlcerPoint Prevalence Survey (PUPPS). Theinformation was used to planprevention strategies and trackimprovement. In March 2008, the SkinIntegrity Harm Minimisation Grouprepeated the surveillance programlocally.The March study showed a 7.5 percent decrease in pressure ulcerprevalence from 2006. The statewidemean pressure ulcer prevalence in 2006was 17.6 per cent.Patients who are unable to movethemselves independently (immobility)were found to be most at risk ofdeveloping a pressure ulcer.Ballarat Health Services has introduceda number of systems and assessmentsto reduce pressure ulcers. A majorfactor in reducing pressure ulcerincidence is having a pressure ulcer riskassessment done as this then promptsstaff to put pressure relieving devices inplace if needed. Since the PUPPSsurveys began BHS risk assessment hasimproved significantly from 52 per centto 74 per cent in the most recentsurveys.Future DirectionsRecommendations arising from thelatest survey include:• Local ward initiatives to improveresults;• Consideration of need to purchasemore pressure relieving devices;• Increasing risk assessment education;The Department of Human Services hasnow mandated that organisationsreport pressure ulcer incidence and therate of risk assessment completion.Ballarat Health Services report theseseparately for the Base Hospital andQueen Elizabeth Centre sub-acute siteswhere they will be compared to similarorganisations.Key Findings PUPPS 3 PUPPS 32006 2008Summary DataPrevalence of patients with pressure ulcers 19.90% 12.40%Proportion of patients with pressureulcers present on admission (only) 42% 40%Primary associative risk factor Immobility ImmobilityPrevention and ManagementPressure ulcer assessment tool completed 52.60% 74%Use of pressure relieving devices 60.50% 85%Ballarat Health Services Quality of Care Report 2007-08 34

Dr Luke Mitchell and Michelle Hamrosi (medical student) - Medical staff at BHS are trained in the correct use of the National Inpatient MedicationChart (NIMC) to reduce patient medication errorsUsing MedicationsSafelyBallarat Health Services monitors andaddresses medication safety in anumber of ways. With our centralisedreporting management system, we areable to identify ways that our systemscan be improved so that we can reduceerrors in this area.Staff have been encouraged to becomfortable reporting errors, so thatanalysis of incidents can be undertakenand steps taken to prevent moreNumber of incidents6005004003002001000serious errors.Since 2005, the Base Hospital,Psychiatry and sub-acute sites haveconsistently improved reporting ofmedication incidents. The residentialfacilities have shown significantimprovement in reporting over the past12 months, with the six months toJune 2008 being now almost twice the2005 reporting rate.Some of our achievements in safemedication practiceIn 2008, BHS participated in the QualityUse of Medicines initiative – a webMedication Incident Reporting2005 2006 2007based program developed by theClinical Excellence Commission to assisthospitals in developing safermedication systems. The programconsists of a self-assessment that thehospital completes and a set ofmedication safety indicators. At thispoint, the program is a tool forhospitals to use to plan improvementlocally, however in the future, we maybe able to compare our performanceagainst other similar organisations.A Thromboprophylaxis (clot prevention)working group was established toreview and update treatmentguidelines for those patients whorequire blood thinning medicines suchas Warfarin. Because of the work ofthis group, there is a closer workingrelationship with General Practitionersin managing Warfarin in patients whohave recently been discharged fromhospital.The Australian Pharmaceutical AdvisoryCouncil has developed guidelines formedication management in residentialaged care facilities. Ballarat HealthServices Residential Service hasundertaken a large body of work inrecent years in order to be compliantwith these standards.Hospital, Psychiatry and sub acuteResidential35Ballarat Health Services Quality of Care Report 2007-08

What Happens If YouNeed a BloodTransfusionMaximising SafetyThe risks associated with bloodtransfusion are recognisedinternationally, and attention hasfocused on programs to improve thequality and safety of hospitaltransfusion practices. Ballarat HealthServices participates in the BloodMatters, Better Safer TransfusionProgram run by the Department ofHuman Services and employs aTransfusion Nurse to overseetransfusion practices and education ofstaff.One area of transfusion risk that ismonitored regularly is adherence to thepre-transfusion blood sample policy.The collection of the pre-transfusionblood sample for compatibility testingis the beginning of a complex chain ofImproving Care forOlder People (IC4OP)Council of Australian GovernmentsLong Stay Older Patients (COAG LSOP)is a four year statewide initiative thatfocuses on improving care for olderpeople, particularly in rural areas. Theinitiative aims to prevent avoidablehospital admissions; the focus is onimproving the care older people receiveand to minimise their risk of leavinghospital with a lower level offunctioning than they had prior to theirhospitalization. Together theseinitiatives aim to prevent older peoplestaying in hospital longer thannecessary and avoid the potential forresidential care. The project will addressall areas of caring for the older patientthrough the acute hospital stay and isfunded until June 2010.Ballarat Health Services has been theDementia lead in a Victorian Dementiaproject and has developed a Dementiacare in hospital support pack thathighlights the importance of involvingthe carer/s in the care planning. The1614121086420Number of Pre-Transfusion Blood Samples Rejected by LaboratoryJan-Jul 2008January February March April May June Julyevents in the process of clinicaltransfusion. If an error in patientidentification is made at this step it canlead on to the patient receivingincompatible blood or blood meant foranother patient. BHS and DorevitchPathology have policies in place thatmeet national and internationalguidelines to ensure that patient /sample errors do not occur. Anypackage includes an “Information forCarers of Patients with Memory andThinking Difficulties – a guide tohospital” brochure and an informationabout” ME “ form for the carer to fillin that gives hospital staff informationand an understanding of the patient’susual dementia behaviours, which willassist with their in hospital careplanning.Over the next two years the IC4OPproject at Ballarat Health Services willbe concentrating on better assessmentof people over 65 while in hospital andsample received in the laboratory thatdoes not meet these requirements isdiscarded and a repeat sample isrequested. Although the number ofrepeat blood samples requested aresmall (varying from 4 in January 2008to a high of 14 in March 2008), theZero Tolerance Policy that is in placeensures that the patient is not put atrisk.making the hospital journey morepatient centred allowing patients andtheir carers to be more involved in theirown care pathway.The IC4OP project will emphasise theimportance of involving ‘carers’ in allaspects of care planning for thepatient while in an acute hospital caresetting and will lead to a reduction ofstress for the older patient, carers andhospital staff. Carers can have peace ofmind when leaving their loved one inthe care of Ballararat Health Services.The dementia care package includes information for carers of patients with memory loss andthinking difficultiesBallarat Health Services Quality of Care Report 2007-08 36

“Having to travel to Ballarat for treatment has becomeso much easier having somewhere wonderful to stay.”Judith Moss - on the new Medihotel37Ballarat Health Services Quality of Care Report 2007-08

What’s New atBallarat HealthServices?Dental Clinic ManagementTransfers to BHSIn May 2008 the management of thepublic dental clinic located within thegrounds of Ballarat Health Services(BHS) transferred from Dental HealthServices Victoria (DHSV) to BHS. DHSVhad managed the clinic for the past tenyears in this location and were keen forthe management to transfer to BHS toenable a local focus on dental services.When BHS assumed the managementof the clinic it had a significantly longwaiting time for general care, with thecurrent waiting times of 56 months (asreported on Department of HumanServices website) well outside theminimum standards adapted from theNational Oral Health Plan for access tocare for adults.Ballarat Health Services intends toimplement a number of strategies andinitiatives to improve access for thecommunity and to reduce the currentwaiting time for general dental anddenture care. Since assuming themanagement of the clinic a number ofthese initiatives have beenimplemented including:• Extending the operating hours toincrease the access for thecommunity to dental care.• Increasing links with teaching andclinical placements to encouragedental graduates to chooseBallarat when seekingemployment.• Improved links with privatesector to enhance recruitmentopportunities and to provideaccess for some clients throughthe private sector.• Traineeships for dentalassistants to provideemployment opportunitiesfor young people in Ballarat.Ballarat Health Services acknowledgesthat there is a significant amount ofeffort required to reduce the currentwaiting times for care and we arecommitted to improving access todental care for our community. Thesupport of DHS will be essential ifimprovements are to be achieved.Medi HotelThe Medi Hotel opened on the 11 May2008. It has 17 rooms, three beingsingle rooms and the others attachedto lounge rooms containing double pullout sofas. These have a sharedbathroom in between.The purpose of the Medi Hotel is toprovide overnight accommodation toguests who may not have transport ora carer post procedure, or may need totravel a distance and/or are required tobe admitted early for their procedure.The aim of this is to provideaccommodation for clients that mayotherwise take an inpatient bed butnot require the acute care.There is also the capacity forcarers/family members of currentinpatients to stay in the Medi Hotel ifthey live a distance from BHS. This is ata cost per night to each carer whostays.The Medi Hotel is staffed by PersonalCare Workers whose shift commenceat 4:30 pm and finish at 8:00am.Guests and Carers are asked to vacateat 10:00am and check in at 2:00pm.The Staff of the Transit Lounge manageany calls and registrations duringbusiness hours. Out of business hoursthe Patient flow Coordinator takesreferrals and supervises the PersonalCare Workers.Hours of operation are 5pm Sunday to10am Friday.Ballarat Health Services Quality of Care Report 2007-08 38

Our Staff andVolunteersHow can you be sure that our staffare suitably qualified andexperienced to care for you?Ballarat Health Services complies withguidelines established by theDepartment of Human Services. Weensure that all our staff areappropriately qualified, have up-todateskills and the necessary experienceto provide the best quality care. Wehave reviewed and updated ourchecking systems over the last twoyears including police checks for allstaff.All new applicants had theirregistration, qualifications, referencesand skills checked and documentedprior to employment. Clinical staffmust provide evidence each year thatthey are registered to practice by theirrelevant, recognised, registrationboards. In addition, each member ofstaff is involved in a performanceappraisal. This involves a yearly review,of individual performance against predeterminedperformance indicatorswith the relevant manager.How do we ensure our medicalstaff deliver safe, quality care?A subcommittee of the Board ofManagement has the responsibility tooversee the credentialing, privilegingand appointment of the medical staffwithin Ballarat Health Services.Credentialing procedures are used toverify the qualifications of all medicalstaff practicing at Ballarat HealthServices. This means the health serviceemploys a formal process, based onnational standards, to verify thequalifications, experience, professionalstanding and other relevant attributesof our medical practitioners to ensurethey are competent and suitable toprovide safe quality health care. Formedical staff once their qualificationsand registration has been verified, thescope of the clinical practice that theyare to be granted to perform iscarefully defined based on theircredentials, competence, performanceand professional suitability and isknown as privileging.Volunteers Supporting BallaratHealth ServicesBHS auxiliaries, support groups andvolunteers have again givenunprecedented service to ourorganisation. BHS has approximately350 volunteers they range from 18 to80 years and come from all walks oflife. Our volunteers work in variedareas throughout the organisation andhelp to maintain a high standard ofservice to our patients, clients and thecommunity. Volunteers do notparticipate in the clinical care of apatient. Rather, they assist insupervision by sitting with patients andreducing anxiety through distractionand diversion, opening food packages,encouraging self feeding and providingsocial interaction.BHS is looking forward to leading theway in training for volunteers withinthe health sector, by offering acertificated course which will enhancethe skills volunteers already have andgive them an opportunity to gain newskills to enable them to claim priorlearning if they choose to seekemployment or move into another areawithin the Health Service.Dr Johan Le RouxDr Johan Le Roux and his familymoved from Cape Town in SouthAfrica to Ballarat to work as anorthopedic surgeon. Before Johancame to Ballarat he worked at theTygerberg Academic Hospital from2002 in a public capacity andsince 2007 in a part time privatecapacity; Johan pictured with hispatient Wade Duffy, also did histraining there. Johan’s wife isMartjie and she is a qualifiedphysiotherapist who had beenrunning her own practice for thelast 8 years in Cape Town.Another volunteer initiative is to involvevolunteers in some of the committeeswithin the health service. In 2009 wewill have our first volunteerOccupational Health and Safetyrepresentative who will attend ourservices committee to report on anysafety issues that relate to volunteers.We also plan to have a volunteerrepresentative on our Cultural DiversityCommittee with a view to implement amentoring program for our culturallyand linguistically diverse volunteersBHS Foundation committed tosupporting roleThe Ballarat Health Services Foundationis proud to support vital medicalequipment acquisition and facilitydevelopment. It is able to do this onlywith the generous support that hasbeen given by its members and by thecommunity.The recent purchase of patienttreatment chairs for the Oncology Unithas been a great benefit for patientsafety and comfort and we thank youthe community for your generoussupport. August 2008 also marks thecompletion of the BHS Foundation’s$100,000 commitment to the sixthoperating theatre appeal which wasgenerated from interest received fromthe Foundation’s investments.39Ballarat Health Services Quality of Care Report 2007-08

The Foundation has been impressed bythe record number of patients thathave been treated this year, especiallyin maternity and paediatrics. Last year1200 babies were born at the BaseHospital, and a further 1192 during the2007-2008 financial year. TheFoundation is very aware of theequipment needed to care for so manybabies, to nurse increasing numbers ofchildren admitted to our children’sward and to treat children andadolescents in the emergencydepartment. The BHS Foundation isinviting you to support our quest toraise $50,000 for children’s careequipment with the priority being a$21,000 incubator for the Special CareNursery. The foundation invites you tosupport this appeal and in turn theexcellent care and skills of our nursesand doctors. To make a gift please callGeoff Millar on (03) 53204093 or emailfoundation@bhs.org.auBallarat HealthServices AdoptsImportantEnvironmentalStatementAn important environmental statementwas endorsed by the BHS Board ofManagement in 2008. Ballarat HealthServices is dedicated to improving thehealth of its clients and thecommunities it serves and protection ofthe environment is essential to the longterm health of our communities.Ballarat health Services will;• Manage its operations in a mannerthat is protective of the environmentand human health.• Seek new and innovative ways tomeet environmental goals throughconservation, reduction, reuse andrecycling programs and throughpartnering with others in thecommunity to safeguard theenvironment.• Apply these principles to achieveoptimal environmental practicesconsistent with clinical excellence,organisational goals and financialconsiderations.In meeting these safe practice andenvironment standards, Ballarat HealthServices must demonstrate to theAustralian Council on HealthcareStandards accreditation agencyresponsible and accountableenvironmental management,continuous improvement,benchmarking best practice and thepromotion of organisation-wideawareness and education of itsenvironmental responsibility andpractices. It will be the responsibility ofall staff at Ballarat Health Services topromote practices and apply standardsthat are consistent with thisenvironmental statement.State-of-the-art water recyclesystem launched at Eureka LinenBallarat Health’s Eureka Linen Serviceflicked a switch on a state of the artwater recyle system to slash waterBHS Paediatrician Dr David Tickell checks in on one of his patientsusage by 70 per cent. The ongoingdrought is causing businesses tochange their practices and invest inwater saving initiatives and EurekaLinen is leading the charge.Through a joint initiative by BHS,Central Highlands Water andDepartment of Sustainability andEnvironment a water recycling unit hasbeen installed at the linen service tosave up to 40 million litres of water ayear. The recycling unit ismanufactured in Australia by EcoNovaand can recycle up to 30,000 litres ofwater per hour through an ultrafiltration unit.The linen service processes an averageof 50 tonnes of laundry each week.At present the laundry uses about 55million litres of water a year which,following the washing process, ismoved to a settling pit before filtrationand re-use.Ballarat Health Services is doingeverything it can to adopt water savingpractices to reduce overall consumption.Ballarat Health Services Quality of Care Report 2007-08 40

Ballarat HealthServices MassCasualty TraumaExerciseIn the event of human influenceddisasters such as the London andMadrid Bombings, incidents such asthe Kerang or Trawalla Train crashes ornatural disasters such as HurricaneKatrina or the Ash Wednesdaybushfires the community has anexpectation that hospitals will be ableto deal with the large numbers ofinjuries that would result. This type ofmass casualty incident is known withinhospitals as a Code Brown andrepresents a significant alteration in thenormal operations of an impactedhospital.Planning for these events representunique challenges in the setting oflimited budgets and increasing patientthroughputs. Undertaking masscasualty Incident plans, procedures andprocesses is made even more difficultas simulating a large number of“casualties” cannot be achievedwithout closing down vital facilities,removing staff from areas such as theEmergency Department, OperatingSuite and Critical Care Unit and even ifthat could be achieved the cost toconduct this type of “real” exercise isprohibitive.Despite this exercising remains a criticalendeavor, capable of validating plans,procedures and equipment as well ashighlighting areas for improvement.DHS recently introduced theEmergoTrain System (ETS), a real time,real resources, disaster simulation toolthat uses magnets known as “Gubas”to represent staff, casualties andresources. ETS has been internationallyaccepted in Sweden, UK, Netherlands,Germany and Japan and by the WorldHealth Organisation. Using ETS allowsboth pre hospital and hospitalorganisations to simulate a masscasualty incident without impacting onnormal operations and at a minimalcost.Exercise Glass House: August 2008For Exercise Glasshouse the participantsranging from Ambulance Victoriaparamedics to hospital staff and up todivisional level EmergencyManagement staff had to respond to aincident where a truck carryingexplosives rolled over and crashed intothe State Government offices on MairSt resulting in a significant explosion.The resultant impact affected over 130“Gubas”. A total of 95 were taken toBallarat Base Hospital Emergencydepartment, including 22 selfpresenters and 20 were seen by StJohn of God Hospital (Ballarat) ED staffwho formed part of the exercise. Afurther 13 were transported to variousMelbourne hospitals. A total of 24succumbed to their injuries at thescene.The event involving 130 BHS staff andexternal emergency services personnelwas hailed by the exercise coordinatorsfrom the Department of HumanServices and by observers as one of thebest run simulations ever.This exercise was unique in Victorianhealth in that it brought Ballarat HealthServices together with agencies such asCFA, Victorian Police, AmbulanceVictoria, SES and the MunicipalEmergency Coordination Centre. In thepast this type of exercise has onlyinvolved the health service andAmbulance service. However thisexercise showed that not only couldmultiple agencies be involved but thatthe notion of an “all agenciesapproach” to disaster managementcan be achieved successfully. As aconsequence of this exercise BHS isbeing held up as an example to otherVictorian Health Services in how tointegrate disaster responses acrossmultiple agencies.Don Garlick, Emergency ManagementCoordinator, said the Emergo TrainSystem was an educational tool fortraining and testing preparedness formajor accidents and disasters, usingthe principle of ‘learning by doing’.The exercise was conducted as thoughit was a normal day at Ballarat HealthServices where the organisation wasclose to 100 per cent capacity. “Theexercise is designed to put emergencyservices under pressure. It was basedon real time and real resources.” Donsaid. “So, for example, if a patientneeds to be transported to Melbourneby road ambulance that ambulance cannot be put back into use until thethree-hour turn around time iscompleted.” One of the most pleasingaspects of the exercise was theleadership demonstrated by the BHSHealth Service Incident ManagementTeam. “There were particular positivereferences by outside agencies andstaff well experienced in emergencymanagement to the way that the BHSIncident Management Team conductedthe response.”There was some great work carried outby all those involved and it allowedstaff to deal with all variables that mayoccur in a major incident or disaster.BHS will not rest on its laurels howeverwith close examination of the exercise,feedback and evaluation to becollected and collated with a report tobe generated on any improvementsthat can be implemented.41Ballarat Health Services Quality of Care Report 2007-08

Clean Hospital - Clean Departments - Clean RoomsQuality of Care Report 2007-08 43

Tell us what you think….We invite you to comment on this Quality of Care Reportso that we can continue to improve.What did you think of the information in this report? (please circle)PoorExcellent1 2 3 4 5What did you think of the presentation of this report?PoorExcellent1 2 3 4 5Do you think this report is (please circle)Too Long Too Short Just RightDo you think it was? (please circle)Easy to About Difficult tounderstand right understandIs there other information or comments you would like us to consider in future reports?If you would like specific information on any services provided by Ballarat Health Services,please complete this section;Contact DetailsArea of InterestThank you for taking the time to complete this form.Your views are very important to BHS and your comments are appreciated.Please fold this completed form and post or give it to a member of staff who willforward it to the Consumer Liason Officer

Delivery Address:PO Box 577BALLARATNo stamp requiredif posted in AustraliaBallarat Health ServicesReply Paid 577BALLARAT VIC 3353