Quality of Care Report - Ballarat Health Services

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