Quality of Care Report - Ballarat Health Services

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