Quality of Care Report - Ballarat Health Services

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