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About WSLHD
WSLHD Safety & Quality Account
WE ACKNOWLEDGEWestern Sydney Local Health District acknowledges the first people of the land. The overarching Aboriginal nation in Western Sydney is the Darug nation.
We pay our respect to Elders past, present and emerging. We acknowledge the significance of land, water, spirit, kinship and culture, and the importance that these elements have to the health, well-being and future of the Aboriginal community.
Artwork by Leanne Tobin. Leanne’s artwork reflects the vibrancy and transitional motions of the dragon-flies as they move through their journey of life.
About WSLHD
WSLHD Safety & Quality Account
2
WSLHD is committed to continuously improving the quality and safety of its services, whilst creating an environment in which there is transparent responsibility and accountability for safeguarding high standards of safety and quality in the delivery of care.
National Safety and Quality Health Care
Standards Version 2, as at January 2019,
requires the provision of a signed Attestation
Statement by the Board. The purpose of this
statement is to ensure Board approval of
the accuracy and strategic alignment of the
account. The statement should confirm a
clear commitment to improving the safety
and quality of care across the district
or network.
Western Sydney Local Health District (WSLHD)
is privileged and entrusted with the care of
people living in the Cumberland, Blacktown,
Hills Shire and Parramatta Local Government
Areas (LGAs). WSLHD also provides tertiary
care to residents of the Greater Western
Region. With this comes the requirement
for accountability, transparency and
commitment to continuous safety
and quality improvement.
WSLHD works in partnership with community
members, consumers and key organisations
to plan, deliver and evaluate healthcare,
leading to better quality, safety and patient
outcomes. Strong established partnerships
with organisations such as the University of
Sydney, Western Sydney University, Western
Sydney Primary Health Network, Family and
Community Services and Sydney Children’s
Hospitals Network provide opportunities
for new approaches to multi-agency
service delivery, funding and governance
to improve outcomes for the community
of Western Sydney.
The purpose of this Account is to illustrate
our achievements for the 2019/2020
financial year and the future projects
planned for the 2020/2021 financial year.
This is our retrospective reflection of
performance against specific focus areas,
key performance indicators and most
importantly, meeting the expectations
of our community.
GRAEME LOY CHIEF EXECUTIVE WESTERN SYDNEY LOCAL HEALTH DISTRICT
OUR VISION
Western Sydney
Local Health District’s
vision is to be a trusted
partner with our
community, delivering
modern, cutting edge
health care to make
Western Sydney the
healthiest place to
live in NSW.
OUR MISSION
Equitable access
to safe, high quality
care underpinned by
NSW Health CORE
Values: Collaboration,
Openness, Respect
and Empowerment.
FORWORD
“As a Board we are
responsible to ensure
our clinical governance
frameworks are
effective to maintain
and improve our
standards of
patient care.”
3
Contents
WSLHD Safety & Quality Account
0102
0304
050607
08
Contents
SNAPSHOT OF ACHIEVEMENTS OVER THE PREVIOUS 12 MONTHS 10
Key Achievement 1: Responding to Emergencies 10
Bushfires 10
Mental health nurses shower support on NSW south coast: “the community is grieving” 10
Western Sydney medical heroes deployed to support bushfire crisis 10
Our response to the emerging COVID -19 Pandemic 11
Mental Health - Hotline for COVID 11
COVID-19 People & Culture Strategy: “Workplace Wellness Team” 11
Key Achievement 2: Community Engagement 12
Aboriginal partnerships Auburn/Mental Health Services 12
Key Achievement 3: Digital Program 12
Watchlist 12
FirstNet Launchpoint 12
Key Achievement 4: Responding to our growing communities 13
Auburn Baby Steps 13
Project Air 13
Blacktown Redevelopment 14
Westmead Redevelopment 14
Key Achievement 5: Exceptional People 15
WSLHD SAFETY AND QUALITY GOVERNANCE STRUCTURE 17
Hospital and Service Accreditation 19
Quality Awards Program 2019 19
WE SAID WE WOULD; THIS IS WHAT WE DID! REPORT CARD 2019/2020 22
Healthy People 24
Exceptional people 26
Integrated research, education and clinical care 27
Patient experience matters 30
Spending Wisely 31
Information underpins everything we do 33
ABOUT WESTERN SYDNEY LOCAL HEALTH DISTRICT 6
Demographics 6
Our Community 6
WSLHD Staff Composition 7
Our Health 7
Our Services 7
Children Fully Immunised 7
4
Contents
WSLHD Safety & Quality Account
050607
08
PATIENT AND CARER EXPERIENCE 36
How we measure and what we do 36
Recognise, Engage, Act, Call, Help is on its Way (R.E.A.C.H) 38
Patient Safety Video 38
Carer Program- caring for our carers 39
Compliments 40
Our Patient Stories 41
WSLHD Partnering with Consumers Standard 2 committee 42
PEOPLE AND CULTURE 44
Safety Symposium 2020 44
Cultural Change Strategic Framework 44
Workplace Wellness Drop-In Centres 44
Wellness Warriors support almost 5,000 staff through COVID-19 44
Department Visits 44
Manager Connect 44
FORMAL RESULTS 46
Strategy 1: Keep People Healthy 46
Strategy 2: Provide World-Class Clinical Care Where Patient Safety is First 47
Pressure Injury 48
Fall Related Injuries 48
Healthcare Associated Infections (HAI) 48
Respiratory Complications 49
Blood Clots 49
Medication Complications 49
Cardiac Complications 50
Vaginal Tears in Childbirth 50
Neonatal Birth Trauma. 50
Strategy 3: Integrate Systems to Deliver Truly Connected Care 51
Mental Health Services 52
Seclusion and restraint data 52
Access Block (Mental Health Presentation in ED >24hours) 53
Inpatient Absconding 54
Strategy 4: Develop and Support Our People and Culture 54
FUTURE PRIORITIES 56
Leadership 56
Culture 57
Research 57
Harm Minimisation 58
Vulnerable People 59
Patient Experience Matters 61
REFERENCES 65
5
About WSLHD
WSLHD Safety & Quality Account
182,240ED Presentations
164,645Admissions
35,257Surgeries
9,807Births
39,157Vaccines injections in High Schools
ABOUT WSLHD0101
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
6Left: Westmead Hospital emergency department director Dr Matthew Vukasovic.
WSLHD is responsible for delivering and managing $1.7 billion in public healthcare across more than 120 suburbs
Demographics
Western Sydney Local Health District
(WSLHD) provides a vast and complex
range of healthcare to around 1 million
residents and many more across the state
and internationally. WSLHD is responsible for
delivering and managing $1.7 billion in public
healthcare across more than 120 suburbs
spanning 780 square kilometres in the
Blacktown, The Hills Shire, Cumberland and
Parramatta local government areas (LGAs).
WSLHD employs more than 10,000 dedicated
individuals across 70 sites including Westmead,
Auburn, Cumberland, Blacktown and Mount
Druitt hospitals as well as a network of
comprehensive integrated care and
community-based services.
WSLHD incorporates
780 km2
four Local Government
Areas and sits on
traditional lands
of the Darug
Aboriginal nations.
WSLHD has a
population of about
1 Millionwhich is predicted
to increase by 2021,
with a 59% increase of
those aged 70 years
and older by 2026.
13,400people are Aboriginal
9,500live in Blacktown LGA
50.3%residents speak
a language other
than English
QUICK STATS
77,955Children up to
4 years old in WSLHD
135,077Young people
15 to 24 years old in WSLHD
138,097Children 5 to 14
years old in WSLHD
13,390People in WSLHD
identify as an Aboriginal person
1 in 4Australians aged over
16 will experience mental ill health each year
79,181People
aged 70+ in WSLHD
50.3%Speak a language
other than English at
home in WSLHD
25%Of Australians
have two or more chronic conditions
Our Community
We have the second largest population
in our catchment area of any LHD in NSW.
About half (46.8 per cent) of residents
were born overseas. A total of 50.3 per cent
of our community speak a language other
than English at home with 71.1 per cent of the
50.3 percent living in the Cumberland LGA.
Western Sydney is home to the largest
Aboriginal and Torres Strait Islander
population outside rural areas, with
many living in socioeconomically
disadvantaged areas.
The 2016 Census indicates about 13,400,
or 1.5 per cent of the population self-identifies
as being Aboriginal, with the majority (9500)
living in the Blacktown LGA.
There has been an increase of 59% in people
aged 70 years or over and a 54% increase
in people aged 85 years and over is forecast
from 2016-2026.
7
About WSLHD
WSLHD Safety & Quality Account
M2
M2
M5
See footnote*
3
4
67
8
11
12
10
9
21
5
CBD
r
M1
M7
M7M4
Rouse Hill
Maroota
Gosford >
Bondi >
Castle Hill
Macquarie Park
Liverpool
Parramatta
ProspectReservoir
The Hills Shire LGA
CumberlandLGA
ParramattaLGA
Blacktown LGA
Future WesternSydney Airport
SydneyOlympic Park
See footnote*
SydneyAirport
SydneyHarbour
Bridge
Penrith
Marsden Park
WESTERN SYDNEY
HOSPITALS
1. Mount Druitt Hospital
2. Blacktown Hospital
3. Westmead Hospital
4. Cumberland Hospital
5. Auburn Hospital
WESTERN SYDNEY
COMMUNITY
HEALTH CENTRES
6. Mount Druitt Community Health Centre
7. Doonside Community Health Centre
8. Blacktown Community Health Centre
9. The Hills Community Health Centre
10. Parramatta Community Health Centre
11. Merrylands Community Health Centre
12. Auburn Community Health Centre
N01 2 4km
* Hatched area of Parramatta LGA is outside
Western Sydney Local Health District
PHOTO: Westmead Hospital Emergency department deputy director Dr Kavita Varshney and Clinical Nurse Educator Emma Dixon.
Our Health
We face a growing burden of disease,
increasing complex chronic conditions
and a rising demand for health services.
Concerning community health trends include
childhood obesity, diabetes, rising mental
health issues and conditions associated
with aging.
Our Services
Our strategic priorities reflect our
commitment to delivering modern health
care in the areas that matter most to
Western Sydney.
We will influence better health and wellbeing
in our growing community. Achieving our
priorities requires a shift in our resource
investment and a redesign of our business.
Our collective work over the last five
years has stabilised our operations and
consolidated our services, positioning our
organisation to meet future health demands
with confidence. We will continue to grow
into a stronger, healthier business over
the next 5 – 10 years.
To meet future demand and to provide
excellence to the people of Sydney’s
west we have embarked on:
• Multimillion dollar capital redevelopments.
• Researching world’s best practice
and innovations.
• Partnering with key healthcare agencies
and organisations providing integrated and
seamless pathways across the system.
We are dedicated to meeting and exceeding
the performance expectations of our service
agreement with the New South Wales Ministry
of Health. We are investing in our business to
ensure alignment with consumer and provider
expectations and contemporary evidence for
a better healthcare experience.
Only by working together, connecting,
innovating and striving for excellence
can we continually deliver exceptional
patient experiences.
Children Fully Immunised
There has been 0.9% increase in the coverage
rate in the 1 year old and 1.5% in the 4 year old
categories for non-Aboriginal children.
The rate of fully immunised Aboriginal
children at age four (4) years was 96%, a
decrease from a previous 97.4% rate; whilst
in the corresponding 2019-2020 quarter,
full immunisation compliance for 1 year olds
dropped to 88.6% from 94.8%. A designated
nurse has been following up those children
who have delayed immunisation schedules,
with the GP.
WSLHD Staff Composition
4,711– 43.3%Nursing & Midwifery
1,577- 14.5%Medical (salaried)
1,059- 9.7%Allied Health
389- 3.6%Scientific and
Technical Clinical
Support
259- 2.4%Oral Health
Practitioners and
Support
1,859- 17.1%Corporate Services
475- 4.4%Hotel Services
52- 0.5%Maintenance and
Trades
463- 4.3%Other Professional &
Para Professionals &
Clinical Support Staff
43- 0.4%Other
TOTAL
10,891 - 100.00%
94.2%at 1 yr. old
Non-Aboriginal Children
95.5%at 4 yr. old
Non-Aboriginal Children
88.6%at 1 yr. old
Aboriginal Children
96%at 4 yr. old
Aboriginal Children
NSW Health Information Exchange and EDWARD NAP DataMart.
About WSLHD
WSLHD Safety & Quality Account
8
M2
M2
M5
See footnote*
3
4
67
8
11
12
10
9
21
5
CBD
r
M1
M7
M7M4
Rouse Hill
Maroota
Gosford >
Bondi >
Castle Hill
Macquarie Park
Liverpool
Parramatta
ProspectReservoir
The Hills Shire LGA
CumberlandLGA
ParramattaLGA
Blacktown LGA
Future WesternSydney Airport
SydneyOlympic Park
See footnote*
SydneyAirport
SydneyHarbour
Bridge
Penrith
Marsden Park
WESTERN SYDNEY
HOSPITALS
1. Mount Druitt Hospital
2. Blacktown Hospital
3. Westmead Hospital
4. Cumberland Hospital
5. Auburn Hospital
WESTERN SYDNEY
COMMUNITY
HEALTH CENTRES
6. Mount Druitt Community Health Centre
7. Doonside Community Health Centre
8. Blacktown Community Health Centre
9. The Hills Community Health Centre
10. Parramatta Community Health Centre
11. Merrylands Community Health Centre
12. Auburn Community Health Centre
N01 2 4km
* Hatched area of Parramatta LGA is outside
Western Sydney Local Health District
9
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
SNAPSHOT OF ACHIEVEMENTS0202
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
10Left: Drive through COVID-19 Testing Clinic Western Sydney University.
Key themes for WSLHD in 2019 and 2020 included an extraordinary and incredible response to the Bushfires and, global COVID-19 pandemic, together with unprecedented infrastructure growth, impactful research and incomparable focus on staff wellbeing.
Bushfires
WSLHD was part of a state-wide response
coordinated by the National Critical Care
and Trauma Response Centre and the
NSW Health Emergency Management Unit.
WSLHD heroic clinicians deployed included
three WSLHD emergency department
clinicians and six mental health nurses to
provide medical assistance and mental
health support to those personally affected
by the devastating bushfires.
The team worked in evacuation, recovery
and distribution centres across the south
coast communities where the reality of the
bushfire devastation was indescribable.
WLSHD is extremely proud of the volunteer
team for the provision of professional
expertise and care provided during this
devastating and traumatic time.
Key Achievement 1: Responding to Emergencies
WSLHD mental health staff Eliza Zhao, Rizvan Patel, Kathy Audley, Nick Dunne and Neralee Jeffrey in Batemans Bay.
WSLHD emergency department clinicians Dr Tracey Brown, Dr Kavita Varshney and Dr Evan Ferdous at Batemans Bay.
Mental health nurses shower support on NSW south coast: “the community is grieving”
Western Sydney medical heroes deployed to support bushfire crisis
SNAPSHOT OF ACHIEVEMENTS
11
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
Our response to the emerging COVID-19 Pandemic
Westmead Hospital is the designated home of the
NSW Infectious Diseases Unit and the first hospital in NSW
to provide care for a COVID-19 patient in January 2020.
Numerous mobile WSLHD COVID-19 clinics were set up
with testing exceeding 180,000 as at August 2020. Home
care for COVID-19 patients and mobile screening were
provided for our vulnerable and high-risk populations.
WSLHD also provided an additional 10,000 interpreting
sessions to facilitate understanding for returned travellers
spending their 14-day quarantine in Sydney hotels.
Mental Health - Hotline for COVID
NSW Government provided additional funding for mental
health workers to boost mental health services during the
COVID-19 pandemic with the aim to support the mental
health and wellbeing of people across the state.
As part of this initiative Western Sydney Mental Health
Services provided additional mental health staff and new
digital resources to ensure anyone who required support
was able to access it when they needed it through the
Hotline or online service.
COVID-19 People & Culture Strategy: “Workplace Wellness Team”
The People and Culture (P&C) team established
the Workplace Wellness Team to keep staff informed,
supported, focused and valued during the COVID-19
response. Numerous additional services were
implemented, including the following:
• Workplace Wellness Drop-In Centres at
Westmead and Blacktown hospitals
• Department Visits and information sharing
at Huddles across all facilities
• “Manager Connect”: information, consulting
and/or coaching support for managers
• Executive, General Manager and
Human Resource staff support
• A COVID-19 intranet portal with staff and
manager resources and information
• Wellbeing, mindfulness and meditation sessions
More than 5,100 staff interactions were delivered through
drop-in centres, coaching and ward visits. The wellness
support sessions provided staff with a safe space to talk
about concerns and have access to practical and realistic
advice on managing their feelings.
PHOTOS: Patient Antoine Kazzi getting tested for COVID-19 (left). Westmead Microbiology team (right).
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
12
Aboriginal partnerships Auburn/ Mental Health Services
To facilitate identification of and improve engagement
with our local Aboriginal and/or Torres Strait Islander
patients, families and community, a hospital wide
program was initiated at Auburn Hospital. The program
included an audit to obtain relevant information
of components needed to promote a ‘welcoming
environment’. In addition, a staff survey was conducted
to determine what the obstacles were to
“Asking the Question”.
Improvements made in response to the staff survey
and audit results included the installation of flags,
Aboriginal land maps and a Welcome to Country video
on all patient screens. Furthermore an educational
session was developed to train frontline staff on “asking
the question” to better identify Aboriginal and/or Torres
Strait Islander patients. An Aboriginal community walk
around was held to engage with the community and
identify further culturally appropriate improvement
opportunities. This led to the initiation of the Auburn
Hospital Multicultural Garden project.
To date there has been an increase of 62% from 2017-18 to
2019-20 (YTD) in Emergency Department presentations
who now identify as an Aboriginal and/or Torres Strait
Islander person. The welcoming environment audit
showed a 54% increase in compliance. Self-reporting for
staff “asking the question” also showed improvement
with more staff asking all new patients and those who
were readmitted.
Within the Western Sydney Mental Health district,
a project group consisting of the Aboriginal Liaison
Officer, Quality Improvement Officer and Redevelopment
Program Manager for Mental Health engaged with
Aboriginal communities for guidance and advice.
The project group met with the Men’s shed, Women’s
groups, Parramatta Koori interagency members and
other groups in South West Sydney at their respective
local meeting rooms. Discussions evolved around cultural
items and needs for the campus. All of these groups
attended a meeting on the Mental Health campus and
completed a tour of the facility. This enabled them to
identify needs and provide suggestions of changes
that could be implemented.
Recommendations from the collaborative project group
and the Aboriginal community were submitted to the
Mental Health Executive for approval. To date, current
works approved include the new pavilion which will
provide a shaded outdoor meeting place.
Continued engagement and collaboration with local
Aboriginal groups is being maintained to address the
emerging needs of our community.
Watchlist
The introduction of “Watch list,” to facilitate electronic
prescriptions for discharge at Blacktown Hospital,
enabled automated instantaneous notification of
electronic discharge prescriptions to pharmacy. This is
another “first” nationally in a public hospital. The program
has driven patient improvement benefits by reducing
discharge waiting time by 28% during the implementation
period. During this phase patients’ average waiting time
of 105 minutes was reduced to 76 minutes. A subsequent
sustainability review (period February - June 2020)
demonstrates further improvement with waiting times
decreased by 33% on average. Patients are now waiting
on average 74 minutes as opposed to 111 minutes for
discharge medications.
FirstNet Launchpoint
Auburn Hospital Emergency Department (ED) nurses
were the first in NSW to successfully implement the new
Cerner FirstNet tracking system known as LaunchPoint,
and use Dynamic Documentation templates to record
nursing assessments. The implementation aimed to
standardise best clinical practice and documentation
across the four (4) Emergency Departments across the
LHD. The implementation process has been extremely
smooth, with a 93% training completion rate from ED
nurses. ED nurses have felt supported and prepared for
the change due to the comprehensive eMR training.
Key Achievement 2: Community Engagement
Key Achievement 3: Digital Program
PHOTO: Westmead Hospital Aboriginal liaison officer Narelle Holden and Cumberland liaison officer Shai Grigg.
13
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
Auburn Baby Steps
The Auburn Baby Steps project used
My Experience Matters (MEM) data to
understand patient experience. Issues with
access to appointments and waiting times
were identified in the MEM survey.
Partnering with WSLHD’s Innovation &
Redesign Team, the Baby Steps Project
commenced in August 2019 as part of the
Agency for Clinical Innovation’s Centre for
Healthcare Redesign Graduate Certificate
Program. The aims of the project were to
provide timely access to specialised antenatal
care and improve patient experience at
Auburn Hospital.
The three key objectives/solutions include:
• Improving access and reducing risk
by increasing the number of women
commencing antenatal care by 14 weeks
gestation (currently 4%)
• Improving capacity through appropriate
care transfer and proactive appointment
cancellation when a woman gives birth
• Improving referral, bookings management
and notification processes including
referral entry into the hospital’s
patient administration system (iPM)
and implementation of robust referral
acceptance, attendance management
and prioritisation procedures
Key Achievement 4: Responding to our growing communities
Project Air
WSLHD Mental Health Services (MHS)
successfully implemented three Gold
Card Clinics in late January 2019, across
Blacktown, Parramatta and Cumberland
Hospitals in response to the NSW Project Air
Strategy for Personality Disorders framework.
These clinics work closely with the Mental
Health Acute Care Teams (MHAC Teams) to
ensure consumers and families affected by
personality disorder, are offered timely and
accessible psychological support. Consumers
are offered an appointment within 3 days
of presenting to Emergency Departments,
Admissions Units, and Acute Care Teams
across the District or following discharge
from inpatient services. A structured brief
intervention model, inclusive of individual
and family/carer components, is utilised.
As at December 2019, 185 patients
accessed this service.
The Gold Card Clinics partnered with
universities to facilitate an integrated training
program designed to equip clinicians
with contemporary best practice skills to
manage patients with personality disorder.
The program is offered to early-career
psychologists, with nine (9) provisional
psychologists trained in 2019.
The preliminary outcomes to date reflect the following:
15% of women
commence care at
<14 weeks gestation
(47% commencing
14-18 weeks
gestation-
baseline 39%)
94%
of referrals
were accurately
entered into iPM
(baseline 4%)
An average of
16% incomplete referrals
received (baseline
60%)
Greater than
3%
increase in
appointments
in 5 months
The Baby Steps project involves ongoing evaluation to inform efficient solutions.
PHOTOS: WSLHD Population Health Auburn Children Immunisation Clinic. Left to right: Mafi Fahina (Mother), Moriah Fahina (Baby girl), Hayley Carra (Reg Nurse). Blacktown Hospital Acute Services Building. Westmead Hospital Central Acute Services Building.
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
14
Blacktown Redevelopment
In response to the growing needs of our communities
in the Blacktown local government area, the opening
of the Acute Services Building at Blacktown Hospital
now facilitates access to new services for emergency,
birthing suites, centre for newborn care, women’s health,
hybrid and digital operating theatres and intensive care.
The expansion was part of the $700 million Blacktown
& Mount Druitt Hospitals expansion project.
Westmead Redevelopment
Westmead Hospital’s new Central Acute Services
Building (CASB) is now in the commissioning phase and
will be opening in February 2021. The 14-level building
includes two emergency departments and more than
300 patient rooms. This building is the centre part of
the $1 billion-plus Westmead Redevelopment project,
bringing world class infrastructure to the Westmead
Health Precinct.
15
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
In 2019/2020 numerous WSLHD staff were recognised for their exceptional contribution to healthcare. WSLHD is extremely proud of these staff achievements.
The Ralph Reader Award is the most
prestigious prize in cardiovascular research
to be awarded to investigators in Australia
and New Zealand. Two Westmead Hospital
cardiologist scientists, won this young
investigator prize at the 2018 Cardiac
Society of Australia and New Zealand
(CSANZ) Annual Scientific meeting.
The Basic Science prize and the Clinical
Research prize, 2 components of the Ralph
Reader award, were awarded to candidates
from the same hospital. This has never
occurred in the history of these awards.
The Basic Science prize was awarded to
Dr Sujitha Thavapalachandran and the
Clinical Research prize was awarded to
Dr Pierre Qian. Both are clinical fellows
at Westmead Hospital.
Key Achievement 5: Exceptional People
Ljubica Simic may be Westmead Hospital’s
happiest cleaner. Her uplifting personality
and kind-heartedness touched a family
so much that they nominated her for an
Australia Day Award.
The patient’s family said that “Ljubica used
to visit the family’s sick relative to say hello
and have a chat.” “She’d encourage the
patient to think positive thoughts … she is just
so happy and cheerful … she made us laugh
and made things so light-hearted when we
were in a horrible place.” “Her job is a cleaner
but she definitely has a much higher purpose
… she has an unbelievably golden heart.”
PHOTOS: Ljubica Simic Westmead Hospital’s happiest cleaner. Associate Professor Saurabh Kumar.
Snapshot of Achievements over the previous 12 months
WSLHD Safety & Quality Account
16
Member (AM)
Emeritus Professor Peter Zelas (left), has been
named a Member of the Order of Australia in
the 2020 Queen’s Birthday honours. He was
among distinguished people linked to Western
Sydney Local Health District (WSLHD),
to receive pre-eminent recognition for
achievements and service to Australia.
Medal (OAM) in the General Division
Auburn Clinical School head A/Prof Hadia
Haikal-Mukhtar (centre) was awarded the
Medal of the Order of Australia, for service
to medicine and to the Lebanese community.
A/Prof Haikal-Mukhtar is head of the Auburn
Clinical School, which is a partnership between
Auburn Hospital and the University of Notre
Dame Australia.
Officer (AO) in the General Division
Emeritus Professor Kim Oates, received the AO
for distinguished service to paediatric medicine,
as an advocate for child health and welfare, to
medical education and to professional societies.
Renowned renal physician Professor Jeremy
Chapman AC (right) has been announced as
the fifth person in history to receive the Asian
Pacific Society of Nephrology (APSN) Kenzo
Oshima Award. Prof Chapman is a world leader
in kidney transplantation. He has worked
at Westmead Hospital since 1987 and was
nominated in recognition of his outstanding
clinical, scientific and academic leadership,
particularly in the field of kidney transplantation.
PHOTOS: Emeritus Professor Peter Zelas (left). Auburn Clinical School head A/Prof Hadia Haikal-Mukhtar (centre). Renowned renal physician Professor Jeremy Chapman AC (right). Blacktown Cath Lab first procedure in Australia without using radiation. Richard Krawiarz (Patient in bed) and medical team.
17
WSLHD Safety and Quality Governance Structure
WSLHD Safety & Quality Account
The WSLHD Clinical Governance Framework and Western Sydney Local Health District Safety and Quality Improvement Strategy are keystone documents.
Providing a structure for the management
of safety and quality and the achievement
of strategic priorities in line with the
District’s goals and visions.
Clinical Governance plays a pivotal role in
ensuring the patient remains the key focus
in the delivery of care. A culture of safety,
quality and harm reduction is achieved through
building capacity, capability and enhancing
leadership across WSLHD. Patient and
Carer experience data is used to strengthen
organisational systems and inform
day-to-day service provision.
The Board has ultimate responsibility to
ensure corporate and clinical governance
processes are in place that guarantee safe,
reliable and high-quality health care provision
to our community. Clinical governance
assurance is provided to the Board via the
Health Care Quality Committee (HCQC),
a committee of the Board. HCQC ensures
that mechanisms, controls and monitoring
processes are in place to deliver safe care.
SAFETY AND QUALITY0303
WSLHD Safety and Quality Governance Structure
WSLHD Safety & Quality Account
18
SAFETY AND QUALITY
WSLHD Safety and Quality Governance Structure
Various measures including but not limited
to incident management, measuring patient
experience, the quality awards programs
and accreditation are utilised across the
LHD to ensure quality and safety focused
care is provided to our local communities.
WSLHD was the first site in NSW to
implement the new incident management
system, ims+, in partnership with eHealth and
the Clinical Excellence Commission (CEC).
As the pilot site, WSLHD has been integral
in informing ongoing improvement to the
ims+ system thus benefitting our other LHD
colleagues who transitioned to the system.
Numerous strategies were employed to
ensure the successful implementation of
the ims+ program. Over 8700 WSLHD
staff received training and information on
ims+ prior to its implementation. 90% of
staff surveyed, reported the ims+ system
to be an improvement from the IIMS
incident management system. 93% of staff
indicated that they felt supported and that
WSLHD was committed to the successful
implementation of ims+. WSLHD was able
to provide feedback to improve the flexible
delivery of education and training for future
ims+ implementation sites across NSW.
Standard 8Recognising and responding
to acute deterioration
Standard 7Blood Management
Standard 6Communicating for Safety
Standard 5Comprehensive Care
Standard 4Medication Safety
Standard 3Infection Prevention
and Control
Standard 2Partnering with Consumers
Standard 1Quality & Accreditation
Facility National Standards Committees
Facility Safety & QualityCommittee
Audit & Risk*
Nominations*
Finance, Performance & Assets*
Research & Development*
Professional Education*
* Subcommittees of the WSLHD Board
Health Care Quality Committee*
WSLHD BOARD
Standard 8Deteriorating Patient
Strategy
Standard 7Blood Safety
Standard 6Clinical Documentation &
Electronic Workflow
Standard 5LHD Individual Committees
Standard 4Drug and Therapeutic
Committees
Standard 3Infection Prevention
and Control
Standard 2Partnering with Consumers
WSLHD National Standards Committees
AntimicrobialStewardship (AMS)
Falls
Skin integrity &Pressure Injuries
End of Life
LHD Committees
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WSLHD Safety and Quality Governance Structure
WSLHD Safety & Quality Account
Hospital and Service Accreditation
All healthcare facilities in Australia are mandated to
undergo an accreditation review. Mental Health Services,
Drug Health Services and Auburn Hospital underwent
accreditation assessment against National Safety and
Quality Standards Version 2 and have retained their
accreditation status. Westmead, Blacktown and
Mount Druitt Hospitals are to be accredited against
National Standards Version 2 at the next phase of
their accreditation cycle.
Quality Awards Program 2019
Each year, WSLHD hosts the Quality Awards
as an opportunity to harness the creative and
innovative ideas of staff who are committed
to making a difference to patient care and
health outcomes.
Winners of 2019 WSLHD Quality Awards
The Physical Health Promotion Project
established a first time partnership between
Blacktown Hospital’s Women’s Health Clinics
and Riverstone Neighbourhood Centre, a
non-government organisation. Access to
antenatal services for women finding it
difficult to get to Blacktown Hospital due to a
lack of transport and/or personal or financial
difficulties, is now facilitated. Clinic attendance
has exceeded expectations.
Don’t Fall for It! A Falls Initiative sought to
reduce falls risk and hospital admissions for
falls-related injuries for all patients admitted
to Westmead Outpatient Physiotherapy.
Initiatives included implementation of the
first WSLHD outpatient falls risk screening
tool together with additional falls prevention
strategy meetings with staff, patients
and family. Outcomes for participants
During the COVID-19 pandemic, all accreditation
assessments were placed on hold by The Australian
Commission on Safety and Quality in Health Care,
with accreditation reviews rescheduled to commence
in the recovery phase of the pandemic in consultation
with stakeholders.
Integrated and Community Health have been accredited
under the Quality Standards - Aged Care.
included no falls-related hospitalisations,
a reduced average falls risk from moderate
to low, and 80% compliance with a home
exercise program.
The Emergency Care to the Sound of Music
program was developed in response to the
unexpected increase in drug-related deaths
and injuries at NSW music festivals. WSLHD
was the first local health district to apply
disaster management principles and deploy
a team to festivals using self-developed
equipment, resources and medication kits.
Early recognition and management of severe
drug toxicity at festivals led to reduced illness
and no further deaths after deployment.
Getting the basics right: Supplemental
oxygen is the first program implemented to
address supplemental oxygen compliance
in a non-respiratory service. The program
enabled staff to identify knowledge deficits
and generate and implement solutions based
on their own learning styles. Significant
improvements included increased prescribing
compliance from 0 to 100% and increased
target oxygen saturation range documentation
from 14% to 86%.
PHOTOS: Quality Awards 2019 set (left). Staff enjoy the 2019 Quality Awards (right).
WSLHD Safety and Quality Governance Structure
WSLHD Safety & Quality Account
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Streamlining Bowel Cancer Screening is a nurse-led
rapid access faecal occult blood test (FOBT) clinic.
It is an original and effective approach to the growing
clinical problem of bowel cancer. The nurse specialist
provides rapid triage, initial consultation, education on
diet and bowel preparation and liaises with GPs regarding
outcomes. The FOBT clinic has significantly reduced
the burden on gastroenterology clinics, providing a
streamlined, accessible, patient focused service for
FOBT-positive patients.
The “Food for thought: didn’t think we do healthy in
the West” project aimed to improve food outlet staff
engagement to promote healthy food and drink choices.
The stakeholder engagement model worked successfully
with engaging both small and large scale businesses.
At Mount Druitt Kiosk, compliance with the Healthy
Food and Drink framework rose from below 20% to
100% in one year.
Saving lives: Priorities in Action mental health model
of care in Westmead Hospital ED was revolutionised by
the implementation of a Child and Youth Mental Health
ED Navigator project aimed at reducing non-urgent
presentations by 50%. The navigator saw 71% of young
people who presented to Westmead ED during the
week, leading to a reduction in re-presentation rates
from 20% to 3%. Sustained evaluation demonstrates
decreasing wait times, effective links with GPs and
service providers after discharge and the potential
to improve outcomes for the youth.
Chief Executive Award - Supply, Storage and Administration of Medications (SSAM) project
introduced a basket storage system in the medication
room for non-imprest medications in Blacktown
Hospital’s surgical unit, as opposed to using bedside
drawers for each patient. Nurses saved an average
of almost 60 minutes to complete the round, which
improved overall productivity and morale. There is
now extra space available on benchtops to prepare
medications and patients are less susceptible to risks
as the ability to self-administer medications has
been removed.
Chair of the Board Award –
It takes Two – A partnership approach between WSLHD and Blacktown City Council, the Munch &
Move NSW Health program is aimed to reduce childhood
obesity by 5% by 2025. By December 2018, 100% of
Blacktown City Council’s early learning childhood
services had adopted the program, an increase from
17% in July 2017. Outcomes of the program included
significant improvements to food menu compliance,
staff training, reduced food waste and colloquial
evidence that children were enjoying more vegetables.
Newslocal People’s Choice Joining the I and MI in IMI (Intramuscular Injection): Muscle Matters! Was a project
which addressed the need to choose correct sites for
injecting depots. Drug concentration is altered if depot
injections are administered at an unlicensed muscle
site. A baseline 12-month audit in June 2018 found only
83.6% of long-acting antipsychotic depot administrations
were being given correctly. After implementing all the
strategies, correct administration improved to 92.3%
by October 2018 and 100% by April 2019.
PHOTOS: The 2019 Quality Awards ceremony (left). The Quality Awards are WSLHD’s event of the year (below).
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Name of project Progress/outcome
Aboriginal Patient Dashboard
A component of the ED presentation dashboard for staff includes the discharge status of
patients identifying as Aboriginal, Aboriginal and Torres Strait Islander as well as Torres Strait
Islander communities. The dashboard is due for publishing in the near future. The intent of
the dashboard is to be able to facilitate the identification of needs.
Universal Delirium Precaution
The implementation has commenced with a rollout plan developed.
Health Literacy Hub in ICH – Implementation of Parenting Plus
Eight pilot programs were delivered to 86 culturally and linguistically diverse groups.
The new parents’ program content was modified using an intensive co-design process involving
frontline and managerial health staff and consumers. Version 2 of the Parenting Plus program
is now ready for wider roll-out.
Multicultural Health Committee
The first WSLHD Multicultural Health Committee meeting was held in May 2019. In 2019/2020
the Committee focused on identifying and collecting data to help establish the current level of
service delivery across the District that address the health needs of Culturally and Linguistically
Diverse (CALD) consumers and communities. Service self-assessment tools were used to map
how well the District is doing against NSW multicultural health policies.
A CALD Data Working Group was also established to identify and access data sources to
better understand the health of CALD populations in WSLHD. The group is working with
WSLHD Epidemiology and Health Analytics and Clinical Analytics and Performance Unit to
identify and access key patient data that can be used to identify priority groups and issues.
The collected data will be analysed to identify gaps, establish priority focus areas for
the District and will assist in the development of the WSLHD Multicultural Health
strategic framework.
Clozapine Peer group
The Clozapine Peer Group commenced April 2019 and continues to be held on a bi-monthly
basis with ongoing evaluation with its participants. It is a multidisciplinary group joining
consumers with pharmacy services, librarians, doctors, nurses, peer services, dieticians and
the carer and family liaison officer. Clients can share their lived experience with Clozapine,
as well as ask questions of staff and get support for any side effects endured.
So far the group has received positive feedback, clients have been relaxed and engaged in
different activities presented, and are keen to continue using the new initiative. The Clozapine
Peer Group scheduled presentations for 2020 include: pathways to community living; diet and
exercise; smoking cessation; oral health; sexual health; and mental health. Every event will also
have time for social activities, positive thinking, aspirational reflections and healthy snacks.
Patient Flow Collaborative
Mental Health Services and Westmead Hospital participated in the ‘Patient Flow Collaborative 2’
with the Ministry of Health. Key activities included the development of a comprehensive
‘Mental Health Patient Flow Demand Escalation Framework’ to effectively manage demand
and capacity across mental health services. This included the development of Short Term
Escalation Plans (STEP) to provide fast and efficient patient flow responses during periods
of unforeseen increased activity and demand.
STEP allows for accurate demand analysis, improved decision making, forward planning,
communication and collaboration with external partners. This collaborative has assisted in
streamlining mental health admission pathways from Westmead ED through to mental health
facilities across the District. The implementation of the NSW Health ‘Patient Flow Portal’ and
‘Electronic Patient Journey Boards’ in all mental health inpatient units has allowed for
improved patient flow processes and transparency of service capacity and flow.
We said we would; this is what we did!
Left: ENABLE graduate Hiro Kojo shows off one of her paintings to the Minister for Mental Health Bronnie Taylor.
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Name of project Progress/outcome
NSW Health Primary School Mobile Dental Program
Following funding as part of a NSW Premier’s priority, the NSW Health Primary School Mobile
Dental Program (PSMDP) was implemented in July 2019, targeting schools with the highest
levels of socio-economic disadvantage. Oral Health teams visit these schools and deliver a
preventive care package including dental examinations, oral hygiene instruction, diet advice
and topical fluoride application.
Ongoing dental care is provided by Oral Health teams in our fixed clinics. A total of 3,771
students accessed the program. The capacity of the program and participation by schools
have increased with the recruitment of 21 dedicated staff members in early 2020. Initial
findings have demonstrated an increase in identification of more serious dental disease
through the school assessments, allowing earlier interventional treatment for children.
Chronic Pain and Building pathways
A standardised pain assessment tool was developed and resources identified for use by consumers. The Pain assessment tool contains very comprehensive questioning to reveal patient pain improvements and outcomes measured before and after interventions. COVID-19 changed the way information and care were delivered to improve health outcomes for patients. The focus has now turned towards developing a self-paced booklet to promote patient engagement and provide clinicians with staged interventions.
The Westmead pain service clinicians and the Integrated Chronic Care Program (ICCP) identified several ways pain services can work collaboratively with consumers and provide timely interventions. Future plans include replicating other LHD pain service ways of working.
New Eye treatment using guide
Initial studies were very positive, with glue sealing corneal perforations and inducing healing with minimal inflammation, scarring or vascularization. Results were published in the Science Advances journal and aired on the Channel 9 News Australian media on 3 July 2020. Further trials were planned for earlier this year however due to COVID-19 trials have been delayed. Recommencement of the trial is planned after winter 2021.
National Gynae-Oncology Registry Pilot
The National Gynae-Oncology Registry (NGOR) pilot was one of eight research projects to be awarded a MRFF Ovarian Cancer Research Grant in 2020. The NGOR was awarded $3.5 million over 5 years to expand on the existing ovarian cancer module. The grant will enable the extent of variation in quality of care, its impact on outcomes and patient reported outcomes to be monitored. Thus far, 575 patients have been recruited to the ovarian cancer module (47 from Westmead).
The first Ovarian, Tubal and Peritoneal Cancer Module Quality Indicator Report was circulated to the Steering Committee in March 2020. The working group has revised the existing quality indicator set, following feedback from the steering committee.
In the meantime, several other gynaecological cancer modules are progressing. The endometrial cancer working group, chaired by A/Prof Alison Brand (Westmead), has finalised the endometrial module. A literature review of relevant quality indicators was circulated for review. In March, a teleconference was held to discuss and finalise the identified quality indicators. The cervical cancer module working group (Member Dr Michael Burling, Westmead) has been finalised and a literature review of relevant quality indicators was undertaken. In May, a working group teleconference was held to discuss quality indicators.
Obesity Clinic Over the last 12 months, the Blacktown Hospital Obesity Clinic focused on research and patient support. A current research study is exploring the impact of intensive weight loss on cardiac health, bone and body composition, medication use and cost and pituitary hormones. Group based models of care for psychological and dietetic intervention are being trialled in 2020.
Weekly peer support groups were established for patients to attend after metabolic surgery which has resulted in increased post-operative follow up, maintained lifestyle changes and reduced social isolation.
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Healthy PeopleWe are invested in keeping the people of Western Sydney healthy - now and in the future. Together with our partners, we are improving children’s health for current and future generations. We are addressing Western Sydney’s diabetes hotspot challenge. We are enhancing the understanding and management of mental health in our community.
WE WILL:
• Promote a good start for the
first five years of life
• Overcome diabetes together by
increasing prevention, screening and
enhancing community and hospital
management to slow the progression
of diabetes in our community
• Increase community awareness and
understanding of mental health issues
and breakdown stigmatism
Planned and Realised Actions 2019/2020
Saving Lives: Priorities in Action - Child and Youth, Mental Health, ED Navigation Service
Emergency Departments are the first point
of contact for many young people and their
families seeking mental health expertise in
times of crisis. WSLHD Perinatal, Child &
Youth Mental Health Services collaboratively
with Western Sydney Primary Health Network
(PHN), introduced a Child and Youth Mental
Health Emergency Department (ED) Navigation
pilot establishing a new Model of Care for young
people presenting to Westmead ED.
The risk lens was broadened to include
a comprehensive trauma-informed needs
assessment and short-term post-discharge
involvement, to reduce non-urgent
re-presentations.
The pilot exceeded expectations with the
Navigator service seeing 71% of young
people during the week. The re-presentation
rates reduced to 3% for young people
who attended the ED linked with the ED
Navigator, compared to 20% for those seen
only by pre-existing Consultation Liaison
Psychiatry services.
PHOTO: WSLHD Population Health Stepping On Program Greystanes Library. Left to right: Bharatkumar Joshi (Program participant), Yi Ming Wang (Program Participant), Lanying Rao (Program participant), Harsha Joshi (Client).
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Only 5% of young people who arrived in
the ED between 11:30am – 8.00pm waited
longer than 60 minutes for a Child & Youth
Mental Health assessment.
Migrant students say hello to health help
The Multicultural Health team joined forces
with TAFE NSW Blacktown for the latest
Hello Doctor event, which saw hundreds
of English-language students gain access
to important healthcare messages.
These messages were delivered in key
languages including Arabic, Persian, Dari
and Tamil. Doctors, nurses, oral health
and mental health experts were joined by
representatives from SafeWork NSW,
Energy & Water Ombudsman NSW and
other government and community agencies.
Students appreciated learning more about
topics ranging from dental hygiene, diabetes
testing, cervical cancer screening, to your
rights at work. Feedback from staff and
students indicated the day was excellent.
The success of the day has been attributed
to the strength of partnerships between
Multicultural Health, WSLHD and TAFE
NSW Blacktown.
Venous Thromboembolism (VTE) Prevention Program
In January 2020, WSLHD implemented
an electronic alert to remind clinicians to
complete the VTE risk assessment for their
patients. Early data indicates that there has
been an improvement in the number of
risk assessments undertaken. An upgraded
risk assessment tool and alert are due for
release by eHealth later this year. In addition,
the maternity electronic VTE risk assessment
tool has been implemented at Westmead,
PHOTO: Ping has her blood pressure checked by WSLHD supportive care clinical nurse specialist Alex Rudnitsky.
Auburn and Blacktown. Data indicates
that there has been a good uptake, with
an average of 91% of women risk assessed
at Westmead.
Sepsis
WSLHD developed and implemented
an Emergency Department alert to aid
sepsis recognition on presentation. The
alert algorithm has now been adopted by
NSW eHealth and has been incorporated
into a suite of tools for the recognition and
management of sepsis. WSLHD is currently
working on an electronic dashboard to
present the clinical elements of patients
who are placed on the Sepsis Pathway, with
planned implementation for later this year.
Middle Years Project (MYP)
The Middle Years Project (MYP) a
partnership project with NSW Department
of Education, WSLHD, Sydney Children’s
Hospitals Network (SCHN), Family and
Community Services (FACS), Police, Juvenile
Justice and Western Sydney PHN was
implemented during 2019/2020. This group
provides multi-agency support for vulnerable
students in years 5 & 6 with behavioural
disorders, to help improve their transition
to high school. This program is supported
by a Service Level Agreement with NSW
Department of Education. During 2019/2020,
104 screens were conducted with 21 full
assessments; 79 group sessions and 53
individual sessions were held. MYP continues
to follow and support young people in the
transition from primary to high school. The
project has had a positive impact on the
engagement of young people in high school
during the transitionary time.
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Exceptional PeopleOur people are the heart of our organisation. We want to support, nurture and recognise them. We are committed to supporting our people to work with confidence through robust education programs to ensure they maintain their ability to deliver world-class healthcare into the future.
WE WILL:
• Invest in our staff and support systems
to attract, retain and develop people of
the highest calibre; strengthen our
recruitment practices and invest in
optimising the performance of
our people
• Reinforce clinician leadership and invest
in leadership skill development, roles
and responsibilities to promote effective
decision making
• Cultivate collaborative and cohesive
behaviours for working together
‘The Knock on Effect’ – Pressure Injury Forum
‘The Knock on Effect’ Forum was
developed in response to an increase in
hospital acquired pressure injuries across
the district in 2019. The Clinical Practice
and Innovation team created an innovative and
thought provoking video depicting the true
story of a patient who developed a pressure
injury whilst receiving treatment in WSLHD.
It highlights the devastating “knock on”
effects on the lives of patients and families,
even years after the initial injury.
Clinicians were challenged at the forums,
hosted at all facilities across the LHD, to
reflect on current practice and develop
innovative solutions to prevent patients
developing pressure injuries. An evaluation
of the impact on practice is scheduled
to be undertaken.
Chronic & Complex (CAC) Allied Health Minimum Documentation Standards
Minimum documentation standards were
developed and endorsed for all allied health
disciplines across chronic and complex
(CAC) allied health outlining accreditation
requirements, compliance with policy
directives and clinical requirements.
Minimum documentations standards and
the introduction of templates aim to provide
equity and consistency in the service
provided to the clients receiving CAC Allied
Health services. Clinical documentation
compliance improved from 10% to 92% and
changed from being task to patient focused.
General assessments improved by 57% and
responsiveness to clinical concern improved
by 28%. Documented plans and handovers
also dramatically improved by 41%, enabling
continuity of care for clients.
Initiative of the Month
WSLHD Nursing & Midwifery Clinical Practice
and Innovation Team commenced a program
in March 2019 acknowledging and celebrating
nursing and midwifery practice development
and quality improvement activities across
WSLHD. This activity aims to support teams
to continue with the valuable work they are
undertaking and encourage other teams to
commence their own improvement activities.
Each month a nursing and midwifery team
engaged in a practice development or
quality improvement initiative is awarded
the title ‘WSLHD Nursing & Midwifery
Initiative of the Month’.
Westmead Hospital plastic surgeon develops new tool to fight deadly melanoma.
A team led by Dr Varey and Associate Professor Serigne Lo from the Melanoma Institute Australia developed an online calculator to predict the risk that a patient’s primary melanoma has spread to nearby lymph nodes. The tool calculates risk based on a range of factors entered by the treating doctor and has the potential to better identify melanoma patients who are most likely to benefit from a sentinel node biopsy, as well as those least likely to benefit.
The main benefit of the calculator is likely to be for those deemed to be at low risk of disease spread, who can safely forgo a sentinel node biopsy. Avoiding unnecessary procedures is good for patients, clinicians and health services.
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In FY2019/20 seven teams were
acknowledged, with their work being
celebrated at a local level to recognise staff
effort. At a district level, achievements
were celebrated via the intranet and pulse
articles were published to share the quality
improvement initiatives.
Research grants awarded to Western Sydney Local Health District
Grants have been awarded to researchers
within Western Sydney Local Health District
(WSLHD) in the 2020 National Health
and Medical Research Council (NHMRC)
Investigator Grants scheme, covering a
diverse range of health projects including
kidney transplantation, liver disease, heart
health and tuberculosis.
The WSLHD recipients are as follows:
Dr Caleb Ferguson. A trial to assess the
effectiveness of a digital education program
to improve quality of life for people living
with the most common heart rhythm
disorder, atrial fibrillation.
Prof Clara Chow. Exploring low-cost,
innovative health service provision and
clinical management of heart disease, the
leading cause of illness and death worldwide.
Prof Jacob George. Using mathematical
modelling and genetics to improving
treatment of fatty liver disease, which
affects one in three Australians.
Dr Justin Beardsley. Determining the size of
the problem of lung infection problems due
to the mould Aspergillus in Vietnam, where
the issue is often wrongly labelled as failed
tuberculosis treatment, and how best to
address it.
A/Prof James Chong. Developing innovative
heart regenerative therapies that could be at
the clinical trials stage in the near future. This
would mean that new heart muscle, grown
from stem cells, could help repair damage
caused by a heart attack.
Prof David Harris. Using genetically-
engineered immune cells to prevent organ
damage in end-stage kidney disease.PHOTOS: Prof Clara Chow (left). Prof Jacob George (right).
Integrated research, education and clinical careIntegral to providing excellence in clinical care we will evaluate and act on the needs of our priorities to drive continuous improvement. Research will be translated into effective clinical service models that deliver positive health outcomes.
WE WILL:
• Take an integrated whole of hospital
approach to ensure care is delivered in
the best way, applying best practice,
for the best value
• Clearly delineate our services, coordinating
our surgical and interventional programs
to improve clinical and cost outcomes
• Reform our mental health services so that
people with mental illness are supported
to live well in the community and access
treatment as required
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Prof Jonathan Iredell. Bringing together
modern genomics and the promise of novel
positive therapies to eradicate antibiotic-
resistant organisms and genes from people
at risk from severe infection.
A/Prof Germaine Wong. Using big data
science to predict complications in kidney
transplantation, and find new and better
ways to identify and treat at-risk individuals.
New outpatient clozapine handling procedure during COVID-19 pandemic
During the COVID-19 pandemic, Blacktown
Mental Health Services developed strategies
to keep both patients and staff safe. In order
to minimise close contact and practise social
distancing, most clozapine patients were
offered telehealth consultation with Medical
Officers. Clozapine outpatient prescriptions
are written, dispensed and delivered to
patients at home. Procedures have been
implemented to ensure medication delivery
is carried out in a safe and secure manner,
without any physical contact between
staff and patients. There is an escalation
process to prevent relapse should nursing
staff during delivery notice any change in
the patient’s mental state. This process has
enabled patients to continue to be reviewed,
monitored and receive their prescriptions
in a timely fashion.
Innovative Education Delivery - Cumberland Education Department and Yaralla
Yaralla Mental Health Unit created a
dedicated education space to facilitate
learning in a relevant and time efficient
manner. Relevant equipment was purchased
together with adaptation of presentations.
Nursing staff learning opportunities have
increased and less time is spent away
from the unit. Ongoing updated education
material is displayed via a slide show on
a large television screen located in the
nurse’s station. Mandatory in-service
education, traditionally held in the
Education Centre, has been successfully
adapted to fit into appropriate time slots
and presented on the ward. The response
from staff is positive – stating that
“we have been able to attend more in-service education than before.”
Evaluating the effectiveness of the Chronic Disease Management Program (CDMP)
In 2019, the Hub partnered with Integrated
and Community Health to supervise a group
of University of Sydney School of Public
Health Capstone students to analyse project
data to assess the impact of the CDMP on
different domains of health literacy.
The data analysis identified statistically
significant improvements and provided
the first evidence of the potential impact of
the CDMP on improving different domains
of health literacy amongst a diverse sample
of participants with chronic diseases using a
multi-dimensional instrument. A manuscript
reporting the results was published in the
International Journal of Environmental
Research and Public Health as part of
the special issue on Health Literacy and
Equity – Interdisciplinary Perspectives
and Recent Trends in Health Literacy
Research and Action around the World.
Co-authors included the University of
Sydney and WSLHD staff and students.
PHOTO: Technology
enhances working with colleagues
across the district.
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Building WSLHD staff capacity through the Health Literacy Seminar Series
The Health Literacy Hub offers a bi-monthly
health literacy research seminar series for
healthcare professionals in Western Sydney.
The series covers best practices and research
innovations in the area of health literacy with
the aim to build capacity within WSLHD to
improve health literacy and outcomes for
our patients and consumers.
Eight seminars have been delivered since
2018, with an additional three scheduled for
2020. Up to 178 healthcare professionals
registered for individual seminars, with over
700 professionals registered across the series.
The seminars will continue to be conducted
bi-monthly across 2020/2021.
The Speech Pathology
The Speech Pathology (SP) team was
successful in the Paediatric Innovation
Funding Scheme (PIFS) grant application
for the “Growing Little Language Learners:
An Integrated and Community Health
(ICH) and Early Childhood Education and
Care (ECEC) partnership to improve health
and developmental outcomes for children
in Western Sydney” research project.
The project started as a partnership with
Cumberland council. Through a successful
grant application and partnership with
University of Sydney and council, the
acceptability of this program has now been
evaluated. Clinician researchers have been
invited to attend a writing for publication
workshop with two abstracts accepted for
presentation at national conferences.
The SP team’s learning has been shared
across other Allied Health services and
has informed new Child and Family
Health research project thinking.
Targeted Early intervention and place based care:
Seventy two percent (72%) of enrolled
children who had not previously accessed
child and family services were screened for
delays in language and communications.
Children with identified communication
delays are now provided clinical intervention
in the preschool era, using a whole of
preschool care model approach to support
the child’s development. The program has
been evaluated using environmental and
educator assessments. Where educator
participation in professional development and
mentoring was high, project outcomes show
significant improvement in all subscales.
These early results indicate the program
is effective in addressing social inequities
in children’s health and development.
PHOTO: Western Sydney speech pathologists to support little language learners.
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Patient experience mattersWe will improve our communications, be transparent and accountable. We will deliver safe, quality care whilst promoting dignity and respect. We will strengthen our systems, our processes and our care interactions. We will ensure the voice of the people of Western Sydney is heard in all aspects of care - health care policy, planning, design, delivery and evaluation.
At Cumberland Hospital, peer workers,
carers and staff collaborated to maximise the
benefits associated with service relocations
in preparation for the Parramatta Light Rail.
In 2019, five cottages were refurbished.
A new Pavilion and new 20-bed subacute
mental health inpatient unit will become
available later in 2020 to replace Boronia.
Peer workers consulted with two large
consumer groups in July 2019 and small
consumer group consultations in 2020
to inform the overall design and layout.
WE WILL:
• Learn from the experiences of our
patients, carers and families, with a focus
on collaborating with people from our
community to improve our services
• Strengthen our care teams working
collaboratively with patients, carers
and families to provide holistic
coordinated care
• Help people to better understand
their health and manage their care
Mental Health Building works - consumers co-design
Elements of co-design have been
incorporated into a variety of major capital
works projects in Mental Health Services (MHS)
across WSLHD. At Blacktown Hospital, a
Project User Group (PUG) consisting of
peer workers, carer representatives and
staff collaborated with the project team to
work from schematic to detailed design for
a new acute mental health inpatient unit at
Blacktown Hospital. A transition room and a
Keith’s Closet have been incorporated into
the facility design and will be included in
the revised models of care based on PUG
member recommendations.
PHOTO: Westmead patient Melvern Beyers with Westmead Hospital interns Dr Hayden Andrerson (right), Dr James Grogin (left) and Dr Vlad Danaila (dark blue shirt), who helped Melvern when he fell from his wheelchair in Westmead Hospital’s busy food court.
31
We said we would; this is what we did! Report Card 2019/2020
WSLHD Safety & Quality Account
Spending WiselyWe will achieve real results from our investment. We will ensure we are efficient, productive and innovative in business design and delivery. Building on our strong foundation in health economics to make Western Sydney healthier in the face of finite resources and growing demands.
WE WILL:
• Accurately evaluate and assign our
activities to attract appropriate funding
• Analyse high quality data and information
to maximise our use of resources, improve
our operational efficiencies and reduce
variations in care
• Pursue broader opportunities to attract
additional resources
Patient Reported Measures - Integrated & Community Health
WSLHD is working collaboratively with the Agency for Clinical
Innovation to improve the recording of the Ministry of Health’s
Patient Reported Measures (PRM) Program. The Health Outcomes
Patient Experience (HOPE) will be the IT solution, capturing both
experience and outcome measures. Patient Reported Experience
Matters (PREMs) Data is being collected from a range of various
services including:
WSLHD Health Care Interpreter Service Video Interpreting Project
In February 2019, eHealth together with
ACI started the development of a future
single state-wide Telehealth platform
myVirtualCare (mVC). WSLHD HCIS was
invited, as an early adopter of this platform,
to participate in the creation of a designated
Virtual Waiting Room for Interpreters.
Testing of the platform commenced in
Blacktown Women’s Health Clinic (WHC)
in November 2019 and moved to a trial
involving patients in February 2020. Since
3 April 2020, as a consequence of the
social distancing rules, phone interpreting
has become the HCIS’ predominant mode
of interpreting, while the interest in video
interpreting has grown exponentially.
90.3% of services are now delivered via
the phone, 8% onsite and 1.7% via video.
The uptake of video interpreting is a
significant achievement and something
HCIS will further develop. A total of 110
video sessions were provided over the last
2 months (17 in March and 93 in April 2020).
Out of those 110 sessions, 65 were done in
WSLHD and 45 were provided to other users.
The Leading Better Values Care (LBVC)
PREM has been translated into 9 languages
for use across WSLHD. In addition, the
following activities are underway:
• Translation of LBVC Telehealth PREM
into 9 languages- in progress
• Mapping of Referral Pathways for
PROMIS29 using WSLHD Health Pathways
• LBVC Dashboard build
An Integrated Care Clinical Reference
Group including representatives from
LHDs/SHNs has been established.
The group will facilitate the embedding
and sustaining of the PRM program and
to improve the culture of WSLHD, an
investment in change management
training has been developed.
• High Risk Foot Service
(HRFS)- Blacktown
• Telehealth and Osteo- refracture
Prevention- Blacktown
and Westmead
• Telehealth and Osteoarthritis
Chronic Care Program- Auburn
• Bronchiolitis PREMS 2019
season – Mount Druitt
Paediatric Team
• Direct Access Colonoscopy
Baseline PREMS across
Westmead and Auburn
• COVID-19 In-home
telephone support service
PREM using MEM
• Co-ordinated use of Redcap
to rollout PROMs in the LBVC
space while we await HOPE
We said we would; this is what we did! Report Card 2019/2020
WSLHD Safety & Quality Account
32
The District’s savings in terms of travel
associated costs are shown below.
In summary, the initial results from the video
pilot project are positive. Future work entails
further development of video interpreting
capacity by:
• Training interpreters (both staff and
some Sessionals) on how to use the
Telehealth platforms in order to
provide video interpreting
• Redesigning the current workplace to
increase suitability for video interpreting.
Violence, Abuse & Neglect (VAN) Services Redesign Project
The District is on track in the implementation
of the VAN Framework. There are strong
levels of integration across current VAN
services including a newly refreshed VAN
Committee; consistent levels of supervision
and support for staff; effective interagency
relationships and robust capacity building
across the LHD. Areas for improvement
identified include involving consumers in
VAN service planning, ensuring VAN
information is reflected in LHD strategic
planning and refining data collection to
allow development of expansion strategies
for VAN services. The VAN service has been
enhanced by the addition of permanent
clinical positions including Domestic
Violence, Adult Survivor, Integration and
Community Development Counsellors.
6S Lean Thinking Storeroom Project
The aim of this project was to Minimise wastage (out
of date stock); maximise staff time (less time spent by
clinicians looking for stock) and maximise space. New
storage solutions were purchased making accessibility
and visibility to products easier; reduced time spent
collecting and ordering supplies and also reduced
cleaning. Re-location of stores to one specific area
made ordering of supplies seamless, reducing over
ordering, minimising wastage and therefore cost.
This has also facilitated keeping the area clean and
clutter free. The introduction of the communication
board in the store room improved communication
helping to reduce delays when ordering priority
products. This successful project has been rolled
out across the five Community Nursing teams.
PHOTOS: WSLHD Interpreter Services health care interpreter Yulita Luck in one of the WSLHD Interpreter Services new accoustic booths. Westmead Hospital staff threw on their pyjamas to encourage patients like Elias Mardini (left) to get up, get dressed and get moving.
Information underpins everything we doWe understand that health strategy and digital health are now one and the same. Fit-for purpose health service delivery depends on access to high quality information. Information management and digital technologies will transform the way we work, where and how we provide services, how patients interact with us and how we integrate clinical care with research and education.
WE WILL:
• In collaboration with our partners,
implement our eHealth strategies
and investment plans so we have the
information systems and services we need
• In collaboration with our University
partners, data sciences will be a core
component of healthcare planning,
design and delivery
• Build our health informatics capability
by establishing clinical information
leadership roles and embedding health
informatics in our management training
and leadership development
The e-Patient Communication Portal (ePCP)
The e-Patient Communication Portal
(ePCP) is an online system that guides
staff through a five-step process (refer
to below diagram) so they can download
pre-defined templates and tools and check
the readability, understandability and
actionability of content.
A range of accessible health literacy
resources are provided as part of the system
to assist in the development or revision of
patient communication material.
SUBMITyour resource to HLH
for approval to publish
5REVIEW
your resource withconsumers for feedback
4DEVELOP
your content usingsoftware on your PC
3DOWNLOADa template from our
template design library
2
ePCP 5 STEPdocument builder
REGISTERyour resource using
our online form
1
The automated process is linked to the
consumer review processes so that staff
can develop and modify resources based on
consumer co-design and feedback from a
range of end-users, prior to submission for
final approval. The e-PCP has the ability to
connect staff to the LHD STREAM printing
service. User acceptance testing (UAT) will
commence in late May/June 2020 and will be
modified according to testers' feedback. The
Hub is planning an evaluation of the system
across 2020/21 following its implementation.
Clinical Emergency Response System (CERS)
Following the implementation of the
standardised WSLHD CERS for all adult
inpatients in February 2019, significant
improvements have been demonstrated
in the notification of red zone breaches.
Visibility and accessibility of data continues
to be an ongoing challenge for the
monitoring of patient observations and
staff adherence to clinical practice
guidelines for deteriorating patients.
As part of the Digital Health Program, a
Watchlist for the Between the Flags (BTF)
program has been implemented for adult
inpatients on a standard observation chart.
The Watchlist is set at a ward level and is a
real time visualisation of all patients on that
ward and their observations. It is currently
only available to those clinicians that have
a digital health profile (DHP), however the
majority of nursing staff will be transitioning
to a DHP by the end of 2020.
Work is now underway to standardise
speciality services and specific population
groups, such as paediatrics and community
services. In addition eHealth has released
BTF version 4.1 which includes the electronic
medical record (eMR) version of the maternity
and neonatal standard observation charts.
Planned implementation is October/
November 2020.
We said we would; this is what we did! Report Card 2019/2020
WSLHD Safety & Quality Account
34
Free tech talk
A forum facilitated by chief medical
information officer A/Professor Naren
Gunja to discuss the ways Western Sydney
Local Health District (WSLHD) is embracing
digital and technology advancements.
All WSLHD hospitals have now transferred
over to electronic medication management
(eMeds) which replaces paper records.
Integrated Chronic Care Program (ICCP)
Short Message Service (SMS) a new tool
for ICCP, is currently being trialled by
Health Coach Staff. The in-house SMS
system was successfully set up to send
appointment reminders from Health Coach
Staff to their clients. The rationale for this
tool is to remind clients of their telehealth
appointment, to encourage better client
preparation for the calls and to reinforce
the time-sensitivity of their goals/actions.
At this point, data and patient feedback
are currently being collected to determine
its uptake amongst Health Coach Clients.
The intention is to expand its use by the Care
Facilitators looking after the Aboriginal/
Torres Strait Islander cohort and then
to all care facilitators.
Got Ya Back Midiga
The “Got Ya Back Midiga” was a project
initially developed in 2011 by the WSLHD
Integrated Violence Prevention & Response
Service (IVPRS) in partnership with the
community and the Aboriginal Affairs
and Yarramundi Kids Company. The
program aimed to close the gap for the
Aboriginal community by raising awareness
and preventing child sexual assault. The
Aboriginal Affairs and Yarramundi Kids
puppet show was delivered to over 500
children across five schools in the Mount
Druitt area, along with education and
training to school staff, parents and carers.
The project led to many disclosures of
current and past child sexual assault by
school staff, parents, carers and children.
The project was structured to ensure
that there were immediate multi-agency
responses including reporting, investigations,
support and counselling. The Got Ya Back
Midiga project was evaluated successfully.
However to ensure long term project
sustainability, a culturally specific script has
been developed so that an alternative video
resource option could be created for use
across numerous community settings.
The script is ready for production, through an Indigenous Production
Company, who have proposed a flat animation story. In 2020, IVPRS
received funding from MoH and Education Centre Against Violence
(ECAV) to develop the animated video resource and associated
materials for implementation.
Device Integration – Recovery
The Device Integration project was introduced into a Recovery
Unit in March 2020 and involves the use of existing eAnaesthesia
GE Gateway infrastructure. The device retrieves specific vital sign
values from the GE Patient Bedside Monitor and transmits this into
the patient’s electronic medical record (eMR). Device Integration has
improved patient safety and quality of care provided by recovery
nursing staff through providing reliable, accurate and complete vital
sign data, and enabling real time access to vital sign information.
Transcription errors and data omissions have reduced, facilitating
more time on patient care and improving workload efficiency.
Staff are now able to dedicate more time to focus on interacting
with the patient to ensure patients have a better experience in the
postoperative care unit. Device Integration is easy to use and has
been readily taken up by the recovery team.
Ultrasonic Induced Sputum
As of March 2020, patients with respiratory conditions at Blacktown
and Mount Druitt Hospitals are now receiving validated evidence-
based practice testing for Tuberculosis and Pneumocystis jiroveci
fungus (PJP) pneumonia. This project required procurement of
2 ultrasonic nebuliser machines, training of staff using validated
competency checklists, infection control approval and CSD (Central
Sterilisation Department) processes. The likelihood of obtaining false
negative test results is reduced compared to the previous system
used to obtain induced sputum specimens.
PHOTO: Westmead Hospital emergency department staff specialist Dr Amith Shetty.
Patient and Carer Experience
WSLHD Safety & Quality Account
36Left: Westmead patient Mamoud El Massiny with registered nurse Aileen Dalay.
It is very important for us to understand our patient experience, celebrate what works well and identify where we can improve.
How we measure and what we do
We have various measurement tools
including the State level Bureau of Health
Information (BHI) patient experience surveys
measuring patient experience across all
NSW hospitals and our local real time
My Experience Matters (MEM) Survey.
To date, MEM has collected over 11,500
local survey responses since 2017 covering
inpatient, outpatient and community settings.
Our benchmark for patient experience is 85%
and we are currently above the benchmark.
Our data has shown us the following:
• Last year 2% of patients identified
as Aboriginal.
• Cost of parking and availability of
spaces has been an issue for patients.
Some changes made in response to
MEM data include:
• Updated information about how to
claim concessional parking available
on our WSLHD Internet site.
• As waiting times in clinics are an issue,
several clinics have undertaken reviews and
system improvements to their bookings.
One of the key positive themes identified
from the survey was staff compassion. Staff
compassion was iterated 271 times in the
comments and/or free text section within
the 2019 surveys.
Mapping My Experience Matters (MEM)
Experience and engagement data sets show
a slow consistent improvement trend from
January 2019 to the present time. The MEM
data is reported at a facility and unit level to
identify and inform improvement strategies.
The MEM survey tool is used to create
tailored patient experience surveys for
over 25 special projects. The recent MEM
COVID-19 community results informed us of
how much our patients valued the support
from clinicians calling them daily to provide
health or psychological support.
To date, MEM has
collected over
11,500local survey
responses since
2017
Our benchmark
for patient
experience is
85%and we are
currently above
the benchmark
Last Year
2%of patients
identified as
Aboriginal
JAN
-18
FE
B-1
8
MA
R-1
8
AP
R-1
8
MA
Y-1
8
JUN
-18
JULY
-18
AU
G-1
8
SE
P-1
8
OC
T-18
NO
V-1
8
DE
C-1
8
JAN
-19
FE
B-1
9
MA
R-1
9
AP
R-1
9
MA
Y-1
9
JUN
-19
JAN
-20
FE
B-2
0
MA
R-2
0
AP
R-2
0
MA
Y-2
0
JUN
-20
JULY
-19
AU
G-1
9
SE
P-1
9
OC
T-19
NO
V-1
9
DE
C-1
9
COMPARISON OF WSLHD MY EXPERIENCE MATTERS & BHI DATA FOR PATIENT EXPERIENCE 2018 - 2020
70
75
80
85
90
95
Under Performing
WSLHD Experience Score Linear (WSLHD Experience Score)BHI Experience Score
Performing
37
Patient and Carer Experience
WSLHD Safety & Quality Account
JULY
-18
AU
G-1
8
SE
P-1
8
OC
T-18
NO
V-1
8
DE
C-1
8
JAN
-19
FE
B-1
9
MA
R-1
9
AP
R-1
9
MA
Y-1
9
JUN
-19
JAN
-20
FE
B-2
0
MA
R-2
0
AP
R-2
0
MA
Y-2
0
JUN
-20
JULY
-19
AU
G-1
9
SE
P-1
9
OC
T-19
NO
V-1
9
DE
C-1
9
COMPARISON OF WSLHD MY EXPERIENCE MATTERS & BHI DATA FOR PATIENT ENGAGEMENT 2018 - 2020
60
70
80
85
90
95
75
65
Under Performing
WSLHD MEM Engagement Score Linear (WSLHD Engagement Score)BHI Engagement Score
Performing
JULY-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20
MENTAL HEALTH SERVICE - YOUR EXPERIENCE OF SERVICE (YES) RETURN RATES
100
200
300
400
0
285 274 265180
264325 323
188
352
163254
187
The MEM surveys facilitate early
identification and escalation of issues and
inform project or service improvements.
MEM surveys are translated into the
16 most commonly spoken languages,
including languages of our most vulnerable
newly arrived populations.
As health adapts and develops new
telehealth models of care delivery as a
result of COVID-19, MEM surveys will be
developed in collaboration with teams to
monitor and respond to patient experience.
WSLHD Mental Health Service YES (Your Experience of Service) return rates 2019-2020 for the Safety and Quality Account
In the 2019/20 financial year, there has
been 1791 Your Experience of Service (YES)
consumer satisfaction surveys returned from
Inpatient Services and 1269 returned from
Ambulatory (Community) Services.
“In the first 3 months of our trial we had a big win. Through identifying upcoming appointments for women who had already given birth, we were able to reschedule 109 appointments for other women needing an appointment”.
Julianne Harvey
Innovation and Redesign
Project Lead Western
Sydney health District.
Patient and Carer Experience
WSLHD Safety & Quality Account
38
JULY-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20
INPATIENT - YOUR EXPERIENCE OF SERVICE (YES) RETURN RATES
50
100
150
200
250
0
190
140
158
95126
198209
101
172
101
181
120
The District’s return rate of YES surveys for inpatient services over the last 2 financial years is 36%, which is above the 33% state average.
JULY-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20
AMBULATORY (COMMUNITY) - YOUR EXPERIENCE OF SERVICE (YES) RETURN RATES
50
100
150
200
0
95
134107
85
138 127114
87
180
62
73 67
The District’s return rate of YES surveys for Ambulatory (Community) services over the last 2 financial years is 5%, which is above the 2% state average.
Feedback Friday
Feedback Friday was initiated at Auburn
Hospital to better understand patient
and carer experience, and make informed
improvements as a result of the experience
feedback. Feedback Friday occurs on one
scheduled Friday each month, to obtain
patient and carer feedback from patients
and carers, within the hospital. Responses
are reviewed and distributed to wards and
departments, who are required to develop
improvements and solutions to address
feedback themes and issues.
To promote ward and unit participation, a
competition is being run which will reward
individuals and wards for promoting and
obtaining surveys and making improvements
in response to feedback.
Recognise, Engage, Act, Call, Help is on its Way (R.E.A.C.H)
R.E.A.C.H is a system developed by the
Clinical Excellence Commission (CEC) that
helps patients, their family and carer/s
escalate their concerns with staff about
changes in a patient’s clinical condition.
R.E.A.C.H has been implemented in
all WSLHD facilities including
Cumberland Hospital.
In 2019, we worked collaboratively with
the Clinical Excellence Commission and
our Aboriginal Community to develop
R.E.A.C.H information for Aboriginal Patients.
This brochure is now available across NSW
and all WSLHD facilities. Between January
2019 and April 2020 there have been
62 REACH calls across WSLHD.
Patient Safety Video
The patient safety video ‘What matters to
you matters to us– how to stay safe during
your hospital stay’ was created by WSLHD
to provide information to patients about
the hospital experience. The concept is the
same as airline flight safety videos. The aim
of the patient safety video is to encourage
patient involvement in their own care
and ensure safety during their stay. The
video is displayed on the bedside Patient
Entertainment Systems (PES).
Working collaboratively with the Health
Care Interpreter Services (HCIS), translated
videos in the eight most commonly spoken
languages in Western Sydney were created
and are available on the PES. A transcript of
the patient safety video is also available in
English and six languages including Persian,
Vietnamese, Turkish, Korean, simplified
Chinese and traditional Chinese. Translated
information on pressure injuries, falls and
blood clot prevention is also available
on the PES.
Overall
79%of mental health
consumers who
completed the
survey were reporting an
excellent or very
good overall
experience in
quarter 4 of the
Financial Year
2019-20
Similarly,
90%of the Ambulatory
(Community) service
consumers who
completed the
survey were reporting
an overall score
of excellent or
very good overall
experience.
MENTAL HEALTH
SERVICES YES SURVEY
Percentage
of consumers
reporting an
excellent
or very good
experience.
39
Patient and Carer Experience
WSLHD Safety & Quality Account
Carer Program- caring for our carers
Western Sydney Health understands and values the contribution carers make to the people they care for. Our staff recognise that a carer constantly provides support when patients are in or out of our care.
Key initiatives of the Carer Program include:
• Carer Zones have now been built into
Westmead’s new Central Acute Services
Building (CASB)
• Visiting Hours and Staying Overnight
Procedure has been amended to facilitate
carers staying overnight with patients.
This has resulted in better and safer
outcomes for our patients
• We are working collaboratively as part of a
research project to examine the effects of
having a carer stay overnight and how this
could decrease the falls risk for a patient
• The patient contact information
components of information patient
manager (iPM) has been upgraded to now
record a patient’s carer’s contact details
or to record if the patient themselves is
a carer. Administration staff have been
educated about the importance of
collecting this information. The upgrade
went live in April 2020 and by mid-May
we had nearly 1000 carers registered
on the iPM system
• The iPM upgrade has allowed us to identify
how many young carers are engaging
with our services which informs our
Young Carers Program information and
resources availability
The PES has been updated with specific
information for carers such as visiting hours
and information on how to organise an
overnight stay within our Carer Zones.
A district wide Carer Survey helps us monitor
issues that are important to our carers.
By the end of 2020 we aim to increase the
number of carer surveys by 25%, to improve
Carer Experience.
PHOTO: Westmead patient Paul Molly and his wife Betty Molly.
40
Patient and Carer Experience
WSLHD Safety & Quality Account
“Our little man arrived a few weeks early & I just wanted to say a HUGE thank you, to you and your amazing team of midwives and doctors. After a very long labour in the end, I can’t thank everyone enough for being so patient, informative, kind and just overall wonderful throughout the birth of baby. Special mention to both the staff, who were by my side most of the birth & an amazing calming presence to have with me. Thank you all again. Looking forward to the next time with you and your amazing team.”
“I would just like to say a big thank you for giving me such a wonderful experience
with my second pregnancy and birth of my son. My first experience of labour and
breastfeeding was extremely overwhelming and stressful due to several factors.
I was so worried that I would have the same experience with my second baby.
Not only did the midwife help me to remain calm throughout the pregnancy but
during labour she really supported and coached me mentally and physically to be
able to successfully deliver and breastfeed my son.
I am absolutely sure that I would not have been able to do it without her continued support throughout my pregnancy and post birth visits. Without those visits from her, I am sure that my anxiety would have produced a very different result. I could not have had such a positive experience without her. I am eternally thankful that the Midwifery Group Practice was available to me.”
“My mother arrived to Blacktown Hospital Emergency via Ambulance on 27 January 2020 after she collapsed at home. She was later admitted to Ward for a total of five nights. I could not be happier with the treatment she received and the attention we were given. I would phone in at 8am, 10am then the last call at 8pm, and every time I was greeted with compassion and empathy for what we, as a family were going through. At one point my father and I were so distraught that when I phoned in, our nurse could hear it in my voice and insisted that I speak to mum, so very thankful. I want to thank your dedicated nurses for the AMAZING job they did in looking after, caring and helping my mum throughout her stay.”
WSLHD values all compliments received about patient experience and the care provided by our staff.
Compliments
41
Patient and Carer Experience
WSLHD Safety & Quality Account
Thumb print celebrates cancer patients’ final day of treatment
Blacktown Hospital patient Maryam
Shahrestani leaves her mark as she
completed her cancer treatment.
It was a special moment when breast
cancer survivor Maryam Shahrestani
painted her thumb green and pressed
it to the wall in Blacktown Hospital.
Each thumb print forms a new leaf on
a beautiful, evolving artwork created
by patients on the day they complete
their treatment. The visual concept
was inspired by the hospital staff
and patients of the Cancer and
Haematology Centre at
Blacktown Hospital.
Maryam made the latest addition to the
wall when she completed her last day
of cancer treatment this week, having
been diagnosed with early-stage breast
cancer after a routine mammogram in
June last year. “It was a huge surprise
when they told me I had cancer – I just
cried,” Maryam said. “I lost my sister
a few years ago to breast cancer so it
brought back some sad memories.
Our Patient Stories
COVID-19 survivor encourages testing: “I’m glad I played it safe”
Mohammed Zelka was supposed to be enjoying life as a student
in Poland this year. But while COVID-19 interrupted his plans and
even hit him personally, the 25-year-old considers himself one
of the lucky ones. Mohammed self-isolated from the moment he
re-entered the country in March, was diagnosed early, and received
expert advice and care throughout his journey from the Western
Sydney Local Health District (WSLHD) Public Health Unit and
COVID-19 Community Monitoring Clinic.
“I only ever got mild symptoms of the disease. A dry cough,
discomfort in my chest and some difficulty breathing, that was
pretty much it,” he said. “If this was any other year then I probably
would’ve kept going about my life with something like that.”
“I encourage everyone including my friends, family and colleagues that it’s very important to have regular check-ups with your GP and mammograms.”
“I’m glad I played it safe and got tested straight away.”
Patient and Carer Experience
WSLHD Safety & Quality Account
42
Consumer Councils
WSLHD has a number of councils initiated
over the last six years to better understand
the needs of our consumers and community.
The WSLHD Consumer Council has a large
membership, with 20 to 60 members in
attendance at monthly meetings. The co-
chairs of the WSLHD Consumer Council meet
with the Chief Executive on a monthly basis.
More recently we set up two new councils to
better understand the needs and experiences
of our community and create a channel
for two way information flow. The Auburn
Hospital Community Council was set up
in mid-2019 and meets monthly, whilst
Westmead Hospital Community Council,
set up in February 2020, has met twice. The
council membership consists of cross-sector
community leaders from education, health,
local council, police and other community
organisations along with representatives
from the WSLHD Consumer Council.
The Councils have been particularly useful
during COVID-19 to enable us to understand
the communication challenges being
experienced in parts of our community.
These challenges are communicated internally
through our WSLHD communication channels
and escalated externally to organisations and
agencies, including the Ministry of Health.
WSLHD continue to collect and analyse data
to measure the impact of the Community
and Consumer Partnerships program
across Western Sydney. We have found that
over a three year period (2016-2018) the
program appears to have built a culture for
partnership across the LHD. We are currently
assessing a number of activities that involve
Consumer Representative engagement,
with outcomes to be published in 2020.
WSLHD Partnering with Consumers Standard 2 committee
A partnering with Consumers Standard 2
committee was formed in 2019 The objective
of the partnership committee is to support
the LHD to identify, develop and implement
systems that build partnership with patients,
carers and other consumers in order to
improve the safety and quality of care.
The committee membership is comprised
of 50% consumers and 50% WSLHD staff.
CONSUMER COUNCILS
The WSLHD Consumer
Council has a large
membership, with
20 to 60
members in
attendance at
monthly meetings.
CONSUMERS STANDARD 2 COMMITTEE
The committee
membership
is comprised of
50%
consumers and
50%
WSLHD staff.
PHOTO: Free training is provided to new consumer representatives and they are supported by other experienced peers.
PEOPLE AND CULTURE0606
OVERARCHING PRIORITIES
Wellbeing, Bullying & WHS
Improve staff wellbeing and
empowerment, strengthen
processes, training and support
to effectively deal with bullying,
harassment and discrimination
to keep our workplace safe.
Job Satisfaction
Focus on listening to our staff as
well as improving skills, satisfaction
and empowerment through
fostering mentoring, training, talent
growth and building capability
to enhance purpose, mastery
and autonomy.
Keeping People Informed & Celebrating Success
Improve all aspects of communication
and collaboration as well as
recognising, acknowledging and
celebrating the success of our staff.
SPECIFIC PRIORITIES
Strategic Planning
Improve strategic, tactical and operational
planning – all levels of the organisation.
Staffing Numbers, Workload & Overtime
Improve focus on staffing levels, workload
priorities, skill mix and supports available to
prevent burnout and frustration.
Recruitment Confidence
Improve local and district recruitment practice
and processes, supports and training, attraction
and retention, decision making and review the
current Recruitment Supportive Model.
High Performance
Focus on training, improving skills, performance,
talent strategies and understanding motivators
to performance.
Diversity & Inclusion
Enhance the cultural competency framework
and related diversity programs across
the district.
Cultural Priorities
People and Culture
WSLHD Safety & Quality Account
44
People and Culture
WSLHD Safety & Quality Account
Left: Organisational development consultant and Workplace Wellness team co-leader Shari Hendricks.
PHOTOS: Hundreds of staff share ideas at first Safety Symposium. People & Culture team, dressed in purple vests, are supporting staff through the COVID-19 pandemic.
Safety Symposium 2020
We hosted the WSLHD Safety Symposium
event this year, with nearly 400 staff and
guests in attendance. We received over
1000 ideas on how to improve our safety
culture, separated into four categories of
“continue”, “start”, “stop” and “change”.
All of the feedback related to:
• Safety Processes
• Safety & the People Who Use
Our Services
• Safety & Leadership
• Training, Education and Support
Cultural Change Strategic Framework
In recent years, WSLHD has reported
consistently less than desirable results in
People Matter Experience Surveys. These
results, as well as results gathered from
the World Cafés sessions have informed
the development of the cultural strategic
framework. Its purpose is to improve our
organisational culture. The framework
utilises an evidence based organisational
development methodology to strategically
develop teams and individuals across
the LHD to enhance a culture of
psychological safety.
Workplace Wellness Drop-In Centres
Established locations have been set up in
Westmead and Blacktown Hospitals for
staff to come visit, chat with one of our
Workplace Wellbeing Team and get the
latest information about COVID-19.
Numerous resources are available to our
staff ranging from Access EAP (Employee
Assistance Program) through to websites,
hotlines and community services. We are
checking in with all staff on what they
need to feel more informed, supported,
focused and valued.
Wellness Warriors support almost 5,000 staff through COVID-19
People and Culture team are visiting all areas of the LHD in
purple vests providing support to staff that may be feeling
overwhelmed by COVID-19 changes to the workplace.
Department Visits
Our team members are visiting departments (where safe to
do so and invited) to speak with managers and their teams,
providing the same support as in the Drop-In Centres.
Separate Manager Connect conversations can also be had
with managers in these areas. As we do not have wellbeing
centres at Auburn, Mount Druitt and Cumberland facilities,
days are arranged to visit to different areas.
Manager Connect
We have approximately 800 managers across the district.
This service is delivered in a number of ways, including via
email and phone calls to managers in specific areas as directed
by Human Resources (HR) and the Executive. Check-in topics
are based on ensuring our managers are informed, supported,
focused and valued. Coaching and consulting is provided in
addition to referrals to other resources and support.
Formal Results
WSLHD Safety & Quality Account
46Left: Surgeon cleaning hands before going into theatre.
7.2%of Non-Aboriginal
women who smoked
during pregnancy
892Number of
Get Healthy
in Pregnancy
Referrals
7902Number of
Hospital Drug
and Alcohol
Consultations
Strategy 1: Keeping People Healthy
The domains of effectiveness, efficiency and equity are focused on in Strategy 1.
Measure WSLHD target
WSLHD result
Have we improved since last report?
Data period
Equity
Percentage of Aboriginal women who smoked during pregnancy
49% 45% No Apr -Jun 2020
Percentage of Non-aboriginal women who smoked during pregnancy
7.0% 7.2% Yes Apr- Jun 2020
Effectiveness
Percentage of women quit smoking by the 2nd half of pregnancy > 27% 21.6% No 2020
Number of Get Healthy in Pregnancy Referrals > 772 829 Yes FYTD Mar-20
Percentage of children with height & weight recorded – childhood obesity > 70% 50.6% No FYTD Mar-20
Number of LHD residents who initiated Hepatitis C Antiviral Treatment > 350 134 No FYTD Dec-19
Efficiency
Number of Hospital Drug and Alcohol Consultations
> 7285 7902 Yes FYTD Mar-20
Data availability for these measures varies depending on the current programs reporting process.
Abbreviations
FY Financial year
FYTD Financial year to date
< Less than or equal to
< Less than
> Greater than
> Greater than or equal to
Key
Performing
Underperforming
Not Performing
Data extracted from NSW Health Monthly Performance Report June 2020.
It is well recognised that a healthy baby at
birth is really important for determining
future health and wellbeing. To help achieve
this outcome, it is important for mothers to
have a healthy lifestyle during pregnancy.
A key focus is helping women achieve a
healthy pregnancy with a strong emphasis
on quitting smoking. A project addressing
Women smoking in pregnancy, in Blacktown
hospital, demonstrated a 25% decrease
following an intervention. There has been an
increased percentage of Aboriginal women
who smoke during pregnancy since the
previous reporting period.
WSLHD developed and implemented
multiple strategies which includes opt-out
Quit line referrals, commencement of using
carbon monoxide monitors, introduction
of Safer Baby Bundle, development of
Aboriginal smoke-free home/no smoking
around children animations and delivery
of a social marketing campaign.
Childhood obesity is a growing issue. It is
important to recognise children who are
overweight or obese, as these children are at
greater risk for type 2 diabetes, cardiovascular
conditions and certain cancers in adulthood.
At WSLHD, staff training, an improved
communication strategy, identified champions
and a pathway to assist measurements have
been developed and implemented.
Hepatitis C is a blood borne virus that causes
damage to the liver which can have long-
term health consequences. Treatment with
direct-acting antivirals is now 95% effective
in curing patients with Hepatitis C. WSLHD
percentage of treatment initiations is 41.5%,
which is significantly below the target of
64.6%. Actions are being implemented to
improve treatment initiation.
Drug and alcohol misuse has both social
impacts through violence, crime and trauma,
and individual health impacts through
increased rates of morbidity and mortality.
Providing access to treatment is a key
component to improving outcomes
for patients.
47
Formal Results
WSLHD Safety & Quality Account
The domains of safety, effectiveness, human centred culture and timeliness & accessibility are focused on in Strategy 2.
Strategy 2: Provide World-Class Clinical Care Where Patient Safety is First
Measure WSLHD target
WSLHD result
Have we improved since last report?
Data period
Safety
Hospital Acquired Renal Failure (Rate per 10,000 episodes of care)
< 2.3 0.5 Yes FY2019/20
Hospital Acquired Gastrointestinal Bleeding (Rate per 10,000 episodes of care
< 11 7.4 No FY2019/20
Hospital Acquired Delirium (Rate per 10,000 episodes of care)
< 39.4 27.8 Yes FY2019/20
Hospital Acquired Persistent Incontinence (Rate per 10,000 episodes of care)
< 5 1.9 Yes FY2019/20
Hospital Acquired Malnutrition (Rate per 10,000 episodes of care)
< 4.7 0.2 Yes FY2019/20
Discharged Against Medical Advice for Aboriginal Inpatients (%)
< 3.9% 2.9% NAFYTD
May-20
Effectiveness
Percentage of women quit smoking by the 2nd half of pregnancy
> 5.7% 4.7% YesFYTD
May-20
Percentage of children with height & weight recorded – childhood obesity
> 6.2% 6.3% YesFYTD
May-20
Human centred culture
Overall Patient Experience Index for adult admitted patients
≥ 8.5 8.16 NoOct-Dec
2019
Overall Patient Experience Index for emergency department patients
≥ 8.5 7.44 NoOct-Dec
2019
Patient Experience Index for admitted adult patients
≥ 8.5 8.09 NAOct-Dec
2019
Patient Experience Index for emergency department patients
≥ 8.5 7.44 NAOct-Dec
2019
Timeliness & accessibility
Percentage of patients who spent ≤ 4hours in Emergency Department
≥ 78% 59.0% NoFYTD
Jun-20
Percentage of patients transferred from ambulance to Emergency Department in ≤ 30 minutes
≥ 90% 85.5% NoFYTD
Jun-20
Data availability for these measures varies depending on the current programs reporting process.
Data extracted from NSW Health Monthly Performance Report June 2020 and Quality Improvement Data System (QIDS) database July 2020
A hospital acquired complication
(HAC) is where a hospital risk
mitigation strategy may reduce
the likelihood of the complication
occurring. The national list of
16 HACS was developed by the
Australian Commission on Safety
and Quality in Health Care with
version 3 released early 2020.
Unplanned readmissions is used as
a measure for quality and safety.
Reducing avoidable hospital
readmissions can lead to better
health outcomes, improved patient
safety and increased health system
efficiency. While WSLHD is still not
performing unplanned readmissions
in the Aboriginal population, the
percentage has improved over
the last year.
Delays in patients being able to
access appropriate care through
the Emergency Department (ED)
can have a significant impact on
patient outcomes and on ambulance
resources. Two key performance
measures are the percentage of
patients who are still in the ED within
4 hours of presentation and the
percentage of patients who are not
transferred from the ambulance to
an ED cubicle within 30 minutes.
WSLHD is not performing or
underperforming in both these areas
with no improvement from last year.
PHOTO: Staff promoting “Stop Pressure Ulcers”.
Formal Results
WSLHD Safety & Quality Account
48
Fall Related Injuries
Measure Fractures or intracranial injuries that occur as a result of a
fall in hospital.
More than one in three people over the age of 65 years will fall at least once per year. Patients in hospital can be more at risk of falling. Falls can result in fractures and brain damage.
Falls in hospital are one of the leading causes of injury and death in older Australians. A fall in hospital causing injury can increase the length of hospital stay and the likelihood of discharge to an aged care facility rather than home.
Prevention strategies include assessments for risk factors, equipment to aid safe mobilisation, medication management, education and communication.
WSLHD has a target rate of less than 4.6 fall related injuries per 10,000 episodes of care. Currently WSLHD is at 4.6 which equates to 72 fall related injuries for 57 patients.
Healthcare Associated Infections (HAI)
Measure Infections that occur
after admission to hospital.
One of the most common complications affecting patients in hospital are infections that develop after the patient has been admitted. Healthcare associated infections (HAI) significantly increase morbidity and mortality, as well as the risk of readmission within 12 months.
Prevention and control practices are essential to patient safety and to reduce HAIs. Patients, visitors and staff all play a role in HAI prevention, which includes, hand hygiene and following cough etiquette.
WSLHD has a target rate of less than 95.3 HAI per 10,000 episodes of care. Currently WSLHD has a rate of 102.6 which equates to 1674 infections for 1009 patients.
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
FALL RELATED INJURIES
0
1
2
3
4
5
6
NSW WSLHD WSLHD Target <4.6
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
HEALTHCARE ASSOCIATED INFECTIONS
0
10
20
30
40
50
60
70
80
90
100
110
120
83.5
98.7
NSW WSLHD WSLHD Target <95.3
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
PRESSURE INJURIES
0
1
2
3
4
5
6
Data extracted from QIDS MMM DD 2020
NSW WSLHD WSLHD Target <5.8
IMPROVEMENT INITIATIVES
• Knock on Effect project- video
• Appointment of nominated champions
• Implementation of 5-Ps (Pain, pallor, pulse, paresthesia and paralysis) plus 6Th P – Power outlet
• Education and guidelines developed for managing prone patients in the ICS due to recent COVID-19 and increase in PI.
IMPROVEMENT INITIATIVES
• A project collaborating with consumers on falls education is being scoped
• Initiative for toileting to be commenced
• Lessons learned forums held at each facility
• Building capacity in fall champions to promote appropriate falls risk mitigation.
• Leading Better Value Care initiatives.
IMPROVEMENT INITIATIVES
• Reinforcement of Bare below elbows practice
• Increased vigilance regarding hand hygiene practices
• Large body of education on standard precautions donning/doffing PPE and transmission based precautions has been completed
• Business plan developed for a vascular access team, inclusive of district wide access to nurse practitioner.
Pressure InjuryMeasure Stage 3 or 4 deep tissue or unspecified hospital acquired
pressure injury.
A pressure injury is when the skin and tissue under the skin are damaged by constant pressure or friction. Pressure injuries can happen to a patient when they are unable to move due to illness, surgery or injury.
Pressure injuries can be painful and take a long time to heal. They can increase hospital length of stay and impact short and long term quality of life.
Prevention strategies include risk assessment, management plans, regular position changes, a healthy diet and keeping skin clean and dry.
WSLHD has a target rate of less than 5.8 pressure injuries for every 10,000 episodes of care. We have achieved a rate of 2.7 for 2019-20 which equates to 36 pressure injuries involving 34 patients.
49
Formal Results
WSLHD Safety & Quality Account
Blood Clots
Measure Blood clots that occur
while admitted to hospital
A venous thromboembolism (VTE) or blood clot is when blood thickens inside a vein and blocks the flow of blood. Blood clots are one of the leading causes for preventable death in Australia, causing more deaths than road traffic accidents.
Blood clots can cause distressing symptoms including pain, swelling, limited mobility and respiratory distress.
Key prevention strategies include risk assessment on admission and every 7 days throughout the admission; medication that helps prevent blood clots from forming. Patients play a key role in prevention by staying as mobile as possible and asking about their risk assessment.
WSLHD has a target rate of less than 6.4 VTEs (Blood clots) per 10,000 episodes of care. Currently WSLHD has a rate of 6.2 and equates to 98 VTE (Blood clot) incidents for 77 patients.
Medication Complications
Measure Medications given in hospital that lead to respiratory complications, hypoglycaemic events or haemorrhagic disorders due to blood clot prevention medication.
Use of medication to treat a patient is one of the most common interventions that occurs in hospital. Because medications are used so frequently, it is more likely that an error may occur. It is estimated that 27% of clinical incidents that occur each year are a result of medication error.
Key prevention strategies include a comprehensive risk assessment on admission and ongoing monitoring of medication strategies implemented for care.
WSLHD has a target rate of less than 25.8 medication complications per 10,000 episodes of care. Currently WSLHD has a rate of 28.9 which is an increase from last year. This equates to 366 medication complications involving 341 patients. Of the 366 medication complications, 308 were for hypoglycaemic events.
IMPROVEMENT INITIATIVES
• Designated areas in one of the smaller facilities for chest drain management initiated
• Chest tube insertion and management initiative developed to review complications arising from chest tube use. Educational strategies and training opportunities have been implemented for nursing and medical
• Initiative commenced to review oxygen use to minimise complications of CO2 retention. Oxygen prescription now occurring and greater vigilance with ceasing oxygen therapy when no longer required
IMPROVEMENT INITIATIVES
• Individual patient assessment for risk of hypoglycaemia
• Appropriate management of patients who are fasting prior to surgery
• Review of guidelines where hypoglycaemia can occur as a result of treatment
IMPROVEMENT INITIATIVES
• WSLHD has introduced an electronic reminder for doctors to complete the VTE risk assessment
• The GoShare platform is a platform used to provide information electronically to patients in the outpatient or community setting. Westmead Hospital is trialling the GoShare platform to provide patients with information on how to prevent blood clots from forming
Respiratory Complications
Measure Patients with respiratory failure and acute respiratory distress syndromes that require ventilation. Patients who acquire aspiration pneumonia.
Patients with respiratory complications can experience extremely distressing symptoms including shortness of breath, fatigue, fevers and anxiety. Respiratory complications increase the patient’s length of stay in hospital.
Prevention strategies include completing a risk assessment to identify risk factors, developing a prevention plan and ensuring that routine respiratory observations are taken.
WSLHD has a target rate of less than 17.3 respiratory complications per 10,000 episodes of care. Currently WSLHD has a rate of 19.8 which has increased from the previous year and sits outside the target range. WSLHD’s current rate equates to 269 respiratory complications for 246 patients.
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
RESPIRATORY COMPLICATIONS
0
2
4
6
8
10
12
16
18
20
14
22
NSW WSLHD WSLHD Target <17.3
Note: Respiratory Complications were not previously reported in Service Level Agreements so 2018/19 data is reported against 2019/20 targets.
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
VENOUS THROMBOEMBOLISM
0
1
2
3
4
5
7
6
NSW WSLHD WSLHD Target <6.4
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
MEDICAL COMPLICATIONS
0
2
6
4
8
10
12
14
16
18
20
22
24
26
28
30
32
NSW WSLHD WSLHD Target <25.8
Formal Results
WSLHD Safety & Quality Account
50
Cardiac Complications
Measure Cardiac complications that
occur after admission to hospital
Cardiac complications that occur after admission include heart failure, arrhythmias and cardiac arrest. These can be caused by too much intravenous fluid, medications that lead to complications, unstable angina or worsening condition. Cardiac complications can cause significant pain and discomfort as well as increasing the length of stay in hospital.
A key strategy is identifying those patients at risk of clinical deterioration.
WSLHD has a target rate of less than 43.7 cardiac complications per 10,000 episodes of care. While WSLHD current rate is within the target at 41.8, it has increased from last year when it was 33.2. This equates to 601 cardiac complications involving 515 patients.
Vaginal Tears in Childbirth
Measure 3rd & 4th degree perineal lacerations that occur while giving
birth vaginally
Perineal lacerations, also called vaginal tears, occur when the skin does not stretch enough as the baby’s head is being born or the baby’s head is too big. The severity of the tear is classified from 1-4, with 4 being the worst. First and second degree tears are relatively common and take a few weeks to heal. Third and fourth degree tears are more serious and can take longer for complete healing to occur. They can cause ongoing problems including urinary and faecal incontinence, sexual discomfort and psychological distress.
Key strategies include assessment of the perineum, slow controlled birthing of the baby, providing perineal protection during birth and episiotomy when required.
WSLHD has a target rate of less than 378.2 for 3rd or 4th degree lacerations per 10,000 vaginal births. The current rate for WSLHD is 336.4 which equates to 160 patients.
Neonatal Birth Trauma
Measure Trauma that occurs at the time of birth including cranial haemorrhage, nerve damage and injuries to the skeleton.
Babies that are larger than average, a difficult labour or when the mother’s pelvis is the wrong size or shape, are among the factors that increase the likelihood of trauma occurring at birth. Quite often these births require the use of hands or instruments to enable the safe delivery of the baby.
While most injuries that occur at birth heal with no complications, birth trauma can be significant and have lifelong consequences.
Key strategies include comprehensive antenatal risk assessments and following best practice guidelines for delivery.
WSLHD has a target rate of less than 63.9 for birth trauma per 10,000 births. WSLHD current rate is 47.5 which equates to 53 injuries involving 50 babies.
IMPROVEMENT INITIATIVES
• Trilogy 202 ventilators have been procured exclusively for the Code Blue/Advanced Life Support (ALS) team to manage inpatient acute pulmonary oedema in a timely manner
• Chest pain pathway review for management in both Emergency and inpatient settings
IMPROVEMENT INITIATIVES
• Both Blacktown and Westmead hospitals have introduced care bundles. These care bundles are made up of a number of evidence based interventions which when used together lead to better outcomes
IMPROVEMENT INITIATIVES
• A comprehensive data analysis of the cases is being undertaken by a multidisciplinary team of experts to identify potential improvement initiatives
• Policy in development for use of foetal pillows to minimise injury related to manual manipulation
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
CARDIAC COMPLICATIONS
0
5
10
15
20
25
30
40
35
45
NSW WSLHD WSLHD Target <43.7
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-200
50
100
150
200
250
300
350
400
3rd and 4th DEGREE PERINEAL LACERATIONS
NSW WSLHD WSLHD Target <378.2 NSW WSLHD WSLHD Target <63.9
Data extracted from QIDS MMM DD 2020
Num
ber
of
Inci
den
ts p
er 1
0,0
00
bed
day
s
2018-19 2019-20
NEONATAL BIRTH TRAUMA
0
5
10
15
20
25
30
35
40
45
50
55
65
60
51
Formal Results
WSLHD Safety & Quality Account
The domains of safety, effectiveness, human centred culture, timeliness & accessibility and appropriateness are focused on in Strategy 3.
Strategy 3: Integrate Systems to Deliver Truly Connected Care
Measure WSLHD target
WSLHD result
Have we improved since last report?
Data period
Effectiveness
Percentage of Domestic Violence routine screening
≥ 70% 34.4% NAJan-Mar
2020
Percentage of referrals for victims of sexual assault receiving an initial psychosocial assessment
≥ 80% 88.7% NoFYTD
June-20
Timeliness & accessibility
Average time from Aged Care Assessment Timeliness referral to delegation
< 5 days
1.3 YesFYTD
Jun-20
Human centred culture
Percentage of electronic discharge summaries completed and sent to the State Clinical Repository
> 48.7% 48.7% NAFYTD
Jun-20
Mental Health
Effectiveness
Acute Post-Discharge Community Care - Follow up within seven days (%)
≥ 70% 81.6% YesFYTD
Apr-20
Acute readmission - Within 28 days (%)
< 13% 17.6% YesFYTD
Apr-20
Appropriateness
Acute Seclusion Duration – Average
< 4 hours
11.9 No 19/20 FY
Human centred culture
Percentage of Mental Health patients who scored their experience with the service as Very Good or Excellent.
≥ 80% 79% YesApr - Jun
2020
Data availability for these measures varies depending on the current programs reporting process.
Data extracted from NSW Health Monthly Performance Report June 2020.
Discharge from a mental health inpatient admission and transition to
community-based care is a critical point for people receiving specialised
mental health care. People leaving hospital after an admission for an episode
of mental illness may be more vulnerable and are at increased risk of harm,
relapse or readmission without adequate follow up. In the FYTD Apr-20,
81.6% of inpatients being discharged from a mental health admission received
public mental health community follow-up within the first 7 days of their
discharge, which is above the NSW Health target of >70%.
Readmission to an acute mental
health inpatient unit within 28
days of discharge from mental
health inpatient care is often used
as an opportunity to monitor the
overarching performance of a
mental health system. High rates of
mental health readmission within
28 days point to opportunities for
improvement in hospital treatment
or community follow up care, or a
combination of the two. In the FYTD
Apr-20, 17.6% of inpatients being
discharged from a mental health
admission were readmitted within
28 days of discharge, which is above
the NSW Health target of <13%.
Consumer and care engagement in
comprehensive discharge planning
and timely community mental health
follow-up in the community often
support a reduction in acute mental
health readmissions within 28 days
of discharge.
According to the Bureau of Health
Information, the collection and
use of seclusion and restraint data
is a well-recognised strategy to
help reduce the use of restrictive
seclusion and restraint practices,
used in accordance with the NSW
Mental Health Act 2007. Information
on seclusion and restraint events
occurring in specialised mental
health units are collected by staff in
NSW public hospitals. In the 19/20
FY incidents of seclusion were on
average 11.9 hours in duration, which
is above the NSW Health target of
<4 hours. The program in WSLHD
Mental Health Services is based on
the Creating Positive Cultures of
Care Program and the Safe Wards
Program. The Program includes
the following strategies: leadership,
workforce development, trauma-
informed care, improving the
therapeutic environment, incident
review, consumer and carer
co-design and the use of data.
Formal Results
WSLHD Safety & Quality Account
52
The recommendations from the
Review of seclusion, restraint and
observation of consumers with a
mental illness in NSW Health facilities
are being implemented.
The Mental Health Your Experience
of Service (YES) consumer survey
within WSLHD was completed by
3060 mental health consumers
in the FY19/20 in relation to both
their community and inpatient
mental health care. Of the surveys
completed, 79% of the consumers
reported an Excellent or Very Good
overall experience, in the Apr – Jun
2020 period, which was above
the NSW average of 76%.
Mental Health Services
Seclusion and restraint data Use of Seclusion and Restraint in
Mental Health inpatient units
WSLHD Mental Health Services has undergone extensive change in recent years, incorporating a multi-faceted approach in the Service’s aim to reduce the use of Seclusion and Restraint in Mental Health settings. Overall, since July 2014, fewer patients are going into seclusion, less frequently and for less time. The program in WSLHD Mental Health Services is based on the Creating Positive Cultures of Care Program and the Safe Wards Program. The Program includes the following key strategies: leadership, workforce development, trauma-informed care, improving the therapeutic environment, incident review, consumer and carer co-design and the use of data.
WSLHD has a target rate of less than 5.1 incidents of Seclusion per 1000 bed days. The number of incidents of seclusion has reduced from 6.1 per 1000 bed days (324 incidents) in the 18/19FY to 5.6 per 1000 bed days (295 incidents) in the 19/20FY. The use of Restraint has increased from 5.7 per 1000 bed days (303 incidents) in the 18/19FY to 6.2 per 1000 bed days (330 incidents) in the 19/20FY. While there has been an increase in restraint events there has been a concurrent decrease in seclusion events, in both frequency and duration.
IMPROVEMENT INITIATIVES
• Monthly Seclusion and Restraint Reduction Forum
• The Seclusion and Restraint Database has enabled timely access to new and relevant data, which informs practice in a monthly forum with key stakeholders, as well as improving efficiency in mandatory data collection
• The use of trauma informed care
• Increased focus in the development, maintenance, use and collaboration with patients in planning their care
• Continued engagement in sensory modulation activities, including sensory gardens; art therapies such as mindfulness colouring; physical and rehabilitation activities; massage chairs; diversional therapies; and an activities program
WSLHD WSLHD Target <5.1 WSLHD No Target Rate Set
Data extracted from WSLHD Seclusion and Restraint database 1 July 2020
Does not include restraint events for mental healthpresentations in the Emergency Department.
Num
ber
of
Inci
den
ts p
er 1
,00
0 b
ed d
ays
Num
ber
of
Inci
den
ts p
er 1
,00
0 b
ed d
ays
2018-19 2019-20
SECLUSION - MENTAL HEALTH
MENTAL HEALTH SECLUSION RATE PER 1,000 BED DAYS
1.0
2.0
3.0
4.0
5.0
6.0
7.0
2018-19 2019-20
RESTRAINT - MENTAL HEALTH
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.5
6.0
6.1
5.6
5.7
6.2
PHOTO: ENABLE graduate Hiro Kojo shows Minister for Mental Health Bronnie Taylor (left) how she uses sensory toys as an outlet for her anxiety.
53
Formal Results
WSLHD Safety & Quality Account
Access Block (Mental Health Presentation in ED >24hours)
Measure Mental health presentations to the Emergency Department (ED) that exceed 24 hours in duration prior to transfer or discharge
Chronic mental health conditions often coexist with other factors such as physical illness and alcohol and drug use that contribute to more frequent ED presentations and longer ED stays for these patients. Longer ED stays can be harmful to a patient’s mental state and increase the risk of adverse events for these patients. Therefore mental health presentations to the ED that exceed 4 hours, 12 hours and 24 hours are monitored with a target rate of 0 to exceed 24 hours.
Key strategies to reduce access block include effective patient flow; prompt, comprehensive mental health assessment; and acute mental health bed availability.
WSLHD has a target rate of 0 mental health presentations to the ED that exceed 24 hours. The number of mental health presentations to the ED that exceed 24 hours had increased from 16.7 per 1000 mental health ED presentations (92 incidents) in the 18/19FY to 45.7 per 1000 mental health ED presentations (270 incidents) in the 19/20 FY.
The number of mental health presentations to the ED that exceeded 24 hours in duration had steadily been declining, until late 2019 where a rise occurred in mental health presentations to the ED which resulted in a higher need for both mental health assessments in the ED and mental health acute inpatient beds.
At 49%, the primary driver during the 2019-20 financial year for breaching the 24 hours in the ED were due to mental health bed availability. This was followed by 11% of patients requiring acute medical care in the ED.
IMPROVEMENT INITIATIVES
• Child and Youth Mental Health ED Navigator clinicians situated in Westmead and Blacktown ED to support mental health presentations of people under the age of 18
• Improved Patient Flow Short Term Escalation Plan (STEP) with improved communication and escalation of patient waiting times in the ED
• Improved discharge planning to reduced access block to acute mental health beds
• Ensure correct coding of mental health presentations and prompt assessment and referral to mental health
• Collaboration with NSW Ambulance in the Mental Health Acute Assessment Team (MHAAT) to support a reduction in mental health presentation
WSLHD No Target Rate Set
Data extracted from Aladdin 1 July 2020
Denominator is all Emergency Department presentations coded as Mental Health
Num
ber
of
Inci
den
ts p
er 1
,00
0 M
enta
l Hea
lth
ED
pre
sent
atio
ns
2018-19 2019-20
ED > 24 HOURS - MENTAL HEALTH
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
16.7
45.7
Formal Results
WSLHD Safety & Quality Account
54
Inpatient Absconding
Measure Incidents of absconding from Declared Mental Health inpatient units by involuntary patients either directly from the inpatient unit or whilst on escorted leave from the unit
To support the safety of both the mental health inpatient and the broader community, the service has a responsibility to ensure that a rigorous process is in place to support the safe and appropriate multidisciplinary assessment of involuntary patients, prior to the approval of leave being granted and to reduce the risk of patients absconding.
Key strategies include an environmental measure to improve security, consumer observation and engagement, collaborative risk assessment and multidisciplinary care planning.
A continued decline has been noted in the number of inpatients absconding from Mental Health units, from 19.7 per 1000 episodes of care (for patients who were involuntary for all or part of their care) (38 incidents) in the 18/19FY to 17.7 per 1000 episodes of care (37 incidents) in the 19/20FY. Increased staff vigilance on consumer observation and engagement, risk assessments of courtyards and necessary minor capital works to replace courtyard furnishings with fixed furniture have all contributed to the continued decline.
IMPROVEMENT INITIATIVES
• Effective capital works programs to improve security and reduce the opportunity to abscond with the installation of airlock doors and fixed outdoor furniture
• Consumer observation and engagement
• Appropriate risk assessment and care planning with the consumer and their carer/family
WSLHD No Target Rate Set
Data extracted from IMS+ and IIMS 1 July 2020
Denominator is all Patients who were involuntary for all or part of their care
Num
ber
of
Inci
den
ts p
er 1
,00
0
epis
od
es o
f ca
re
2018-19 2019-20
ADSCONDING - MENTAL HEALTH
0.0
5.0
10.0
15.0
20.0
25.0
19.7
17.7
Strategy 4 focuses on the domain of human centred culture
Strategy 4: Develop and Support Our People and Culture
Measure WSLHD target
WSLHD result
Have we improved since last report?
Data period
Equity
Percentage of staff engagement with the People Matter Survey
≥ 58.4% 61.1% Yes FY2018/19
Data availability for these measures varies depending on the current programs reporting process.
The NSW People Matter Survey is run every year and provides an
opportunity for employees to provide feedback on their work place
experience. The percentage of completion is an important indicator
of staff wellbeing and a belief that change can occur.
PHOTOS: Bungarribee House registered nurse Joseph Toussaint looks after humans and aquatic creatures. Blacktown Hospital general services staff Binabahen Nizama and Rory Dunlop.
55
We said we would; this is what we did! Report Card 2019/2020
WSLHD Safety & Quality Account
FUTURE PRIORITIES0808
Future Priorities
WSLHD Safety & Quality Account
56Left: Dr Kanan Shah VMO Anaesthetist at Auburn Hospital.
Leadership
WSLHD Nursing & Midwifery Leadership Program
WSLHD is committed to providing our
nurses and midwives with opportunities to
grow professionally and supporting them
along their leadership journeys. Planning for
a WSLHD Nursing & Midwifery Leadership
Program is currently underway, with an aim
to develop and implement a standardised
leadership program that meets the needs
of emerging nursing and midwifery leaders
and maintains features of existing effective
leadership initiatives. This will involve a
mapping process of current strategies and
consultation with facility and service nurses
and midwives.
WSLHD Appreciative Inquiry and its application to clinical practice
WSLHD is facilitating two Appreciative
Inquiry five day workshops delivered
over three months. Team members are
encouraged to participate and focus on
an area for improvement within their unit.
Appreciative Inquiry is a collaborative
strength based approach to positive
change. It builds on positive experiences
to enhance day to day work and practice.
This methodology has been adapted for use
in health and is currently being used with
positive results. The use of Appreciative
Inquiry empowers and encourages inclusion
& participation, improves productivity
and reduces resistance to change. The
knowledge and skills learnt will assist in
coordinating local change initiatives.
Integrated & Community Health - HealthPathways
Thirty five percent (35%) of Australians have
a chronic condition and are high users of
health services. This population cohort often
receive treatment for their condition and
variable education to manage their condition
from multiple health service providers.
The aim of this project is to evaluate
the effectiveness of HealthPathways in
reducing unwarranted clinical variation
in chronic illness management education
to patients. The perceived non-compliance
with evidence based guidelines, may result
from a lack of formal training or available
guidelines for community clinicians.
Variable patient education in chronic illness
management results in patient confusion
with management plans, poorer patient
outcomes, an increase in avoidable hospital
admissions and additional stress on health
services. Health Pathways has the potential
to assist clinicians to adopt consistent best
practice and evidenced based guidelines,
and provide optimal health condition
management education to patients.
WSLHD is committed to providing our staff with opportunities to grow professionally and supporting them along their leadership journeys.
57
Future Priorities
WSLHD Safety & Quality Account
Culture
The WSLHD People & Culture directorate continues to
lay the foundations for the evolution of WSLHD culture.
In 2019 and early 2020, WSLHD collected feedback
from staff through various World Café events and the
Safety Symposium. The Culture Steering Committee was
established, and the Organisational Development team
and external culture partner Bendelta were recruited.
The Organisational Development team launched and ran
our Workplace Wellness initiatives throughout the district
including the facility Wellness Centres and the Staff
COVID-19 Assist Call Centre to help all staff feel
informed, supported, focused and valued.
We are recommencing our primary culture work
which includes:
• Reconnecting with the Culture Steering Committee
and the Executive to guide and confirm priorities
moving forward
• Bringing Bendelta on board, establishing our
operational practices and beginning to map all the
various culture concepts, initiatives and major projects
• Key culture focus areas:
- Developing our “culture branding and messaging”,
along with strategies to keep all staff informed of
the culture work we are engaging with including
goals, progress and achievements. This will include
developing a shared vision for the culture we want
in WSLHD and what behaviours underpin that.
- Launching our Leadership Development Program
focusing on the Executive team, Heads of
Department, Facilities and Services Management.
This will support the growth and development of
these leaders, particularly with the unique challenges
and numerous changes happening at WSLHD.
Part of this work will focus on embedding the
desired behavioural competencies to support
the desired culture.
- Mapping and restructuring the 100+ previously
identified culture “projects” into a manageable
program of prioritised culture initiatives to be
delivered over a number of years.
The WSLHD People and Culture directorate is in the
process of taking the 2019 Culture Strategic Framework
and updating it to a multi-year strategy underpinned by
evidenced-based culture frameworks relating to our
CORE values and patient-focused services.
Research
Blacktown End-Of-Life Communication Project
The Blacktown End-Of-Life (EoL) Communication
research project seeks to develop an intervention and
implementation strategy to improve communication
and shared decision-making in end-of-life discussion
between consumers, their families and clinicians;
including Blacktown Hospital medical, nursing and allied
health staff. The collaborative Health Literacy Hub/
Palliative Care Project team developed an End of Life
proposal which was submitted at the end of 2019 for a
Research Education Network (REN) Grant. The team
was successful in receiving a REN grant of $50K. Grant
funding will be used to employ a Research Officer and
undertake data analysis, training and communication
material development across 2020/2021.
Mental Health Literacy Initiative
The Sydney Health Literacy Lab was concurrently
awarded competitive funding from the Mental Health
Commission of New South Wales to evaluate the Mental
Health Literacy Initiative. In 2019, Western Sydney
Primary Health Network (WentWest) was selected as one
of two pilot implementation sites for the project, working
with WSLHD Health Literacy Hub as an official partner.
Over the next 2 years, the Primary Health Network will
work collaboratively to implement and evaluate the
Initiative in Western Sydney, with a focus on process,
outcome and economic evaluation.
Health Literacy capacity training for WSLHD Allied Health Staff
In collaboration with the WSLHD Allied Health Research
Group, a Research Fellow in the Hub developed and
evaluated a health literacy training program for allied
health professionals in WSLHD, and explored the
feasibility of implementing the program and adopting a
train-the-trainer model to support wider dissemination.
The program combined didactic and experiential
teaching methods and behaviour change techniques,
with a focus on teach back and developing easy-to-
understand written materials. The Hub received a HETI
Grant of $4,000 over 1 year to develop and implement
the training.
SUCCESS App - A program supporting culturally and linguistically-diverse adults with CKD to engage in shared decision making
Collaboratively, researchers from the University of
Sydney, Western Sydney LHD, Nepean Blue Mountains LHD,
Sydney LHD and Northern Sydney LHD have developed
a model of care and a multi-component App-based
intervention to build health literacy capacity and enable
shared decision-making for Chronic Kidney Disease
patients including those with lower health literacy
and/or from CALD backgrounds.
PHOTO: Blacktown National Sorry Day Ceremony. Helen Emmerson (A/g Executive Director People & Culture) and general public.
Future Priorities
WSLHD Safety & Quality Account
58
The SUCCESS App combines a standardised patient-
education system based on health literacy principles
with known effective behaviour change methodologies
and health literacy training skills. The feasibility of
implementing the App is currently being evaluated in
a multi-centre study and funding from the NSW Health
Translational Research Grant Scheme to conduct a larger
randomised controlled pilot trial over the next two years
has been received.
Chronic and Complex Nursing - Joint partnership project in Wound Care
The DEBED Study is a nested quasi-experimental study
which will examine the benefits of advanced practice
wound debridement education on nursing processes
and patient outcomes. The study will facilitate improved
service planning, provide better value and best practice
health care by establishing a representative cross-sectional
view of patients receiving wound debridement and their
management. Measurement of the service impact will
include determining whether:
• Wound healing times decreased
• Health costs associated with length of admission
to community health via reduction in nursing time
and wound product use, reduction in presentation
& representation to Emergency Departments &
admissions decreased
• Depression and anxiety decreased
• Pain reduced
• Social isolation reduced
• Quality of life increased and improved
The information will be used to support further funding
applications for implementation of advanced wound
debridement and wound management options including
the NSW Health, Leading Better Value Care and
Tranche 2 initiative.
Harm Minimisation
Towards Zero Suicides
Towards Zero Suicides is one of the NSW Premier’s
priorities to reduce suicides. WSLHD Mental Health
Services will be using elements of co-design with its
three priority initiatives: Zero Suicides in Care; Assertive
Suicide Prevention Outreach Team; and Alternatives to
ED Presentations. Recruitment will commence in 2020
and all three projects will have a strong focus on service
innovation through co-design between staff and those
with a lived experience, either as a consumer or a carer.
Parenting Plus
The WSLHD Health Literacy Hub has collaboratively
worked with Integrated Community Health (ICH)
Child and Family Health to implement Parenting Plus,
an innovative evidence-based health literacy training
program for new parents. The program was built on a
model of health literacy skill development shown to be
effective with disadvantaged and culturally-diverse adults
in Australia. This program is unique because it embeds
adult education based literacy, numeracy training and
shared decision making skill development into core
content relevant to new parenthood, co-designed
with consumers and service providers. During the past
financial year, the Hub pilot-tested the Parenting Plus
program using a pre-test post-test design.
The Program content and structure was modified
(see table below) using an intensive co-design process
involving frontline and managerial health staff and
consumers. Version 2 of the Parenting Plus program is
now ready for wider roll-out. The Parenting Plus Program
will be adapted across 2020/21 to include a focus on
addressing risk factors for stillbirth.
Parenting Plus topics (+ examples of functional health literacy course skills)
Cross-cutting communicative and critical health literacy skills embedded using Sufficient Exemplar Training
Topic 1: Development and
milestones (Discerning when to seek medical advice:
Reading nutrition labels)
Topic 2: Healthy
Relationships (Early help-seeking: Accessing services;
Communication skills)
Topic 3: First aid
for children (Reading a thermometer;
Interpreting medicine labels)
Topic 4: Physical activity
and nutrition (Reading and
understanding dietary guidelines; Applying
guidelines in everyday life)
3. Skills for Behavioural Implementation
2. Skills for shared decision making
1. Skills for accessing and critically appraising health resources
59
Future Priorities
WSLHD Safety & Quality Account
Vulnerable People
Aboriginal Health
Whilst a large body of work was conducted at the onset
of the pandemic, WSLHD is committed to ensuring
we continue to support one of our most vulnerable
communities. The following activities are currently
underway and planned for 2020/2021.
• Launch of COVID-19 Competitions – We are currently
in the process of launching a video/art competition with
the local Aboriginal community on COVID 19 and what
they know, with various target groups and categories.
A prize package will be given to the top 3 most
innovative artwork pieces.
Integrated and Community Health - Child and Family
In response to the COVID-19 pandemic Community Family
Health Allied Health are in the process of implementing
new modalities of intervention via telehealth (telephone
and video-conferencing) with the aim to achieve:
• Telehealth capability across all services
• Meet consumer need and demand regarding how
services are provided in the COVID-19 context
• Keep families engaged in services including
therapy and interventions
• Support parenting capacity
• Improved health and development outcomes
for children and families
• New intervention modalities will undergo an evaluation
process to measure their impact.
The ‘Combining Health literacy skills And
Stillbirth Education’ (CHASE) intervention
embeds graded health literacy skills
(e.g. functional skills for reading nutrition
labels) across stillbirth awareness topics
(e.g. side sleeping). The program will be
iteratively revised with input from health
practitioners, health literacy and maternal
health experts, consumers and stakeholders
in WSLHD over the coming months and
evaluated in a multicentre feasibility study
across three Western Sydney sites.
Bilingual Community Educator Program (BCE) / Multicultural Health Service
The Bilingual Community Educator
Program (BCE) is the main health literacy
improvement strategy for CALD communities
in WSLHD. The program delivers culturally
sensitive health education on various priority
health topics using peer educators. The BCE
Program works regularly in collaboration
with many stakeholders including libraries
in Parramatta, Wentworthville, Greystanes,
Stanhope Gardens and Castle Hill, expanding
the reach of health education programs to
CALD communities.
A needs assessment was conducted
in 2019/2020 and a number of service
improvements have been initiated to
advance the program reach, effectiveness
and efficiency. In the same year, 40 BCE
programs across a range of topics including
but not limited to Cancer Screening (Bowel,
Breast, Cervical), Diabetes Awareness
in Your Community, Healthy Eating and
Physical Activity, Women and Children
Growing Together in New Country, New
Healthy Women and Changing Life Keep
your Balance were delivered. The programs
were delivered in various languages including
Tamil, Hindi, Punjabi, Urdu, Tagalog, Dari,
Mandarin, Cantonese, Arabic and Persian.
In 2020/2021, the BCE Program will focus
on advancing the implementation of
improvements identified and initiated
in 2019/20.
Future Priorities
WSLHD Safety & Quality Account
60
• Provision of material masks to reduce the risk of
non-compliance – The intent of this activity is to
supply our local Aboriginal communities with masks.
Aboriginal designed mask materials have been ordered
in anticipation that mask use will become compulsory.
The masks will be distributed to our local Aboriginal
communities to reduce the risk of disease transmission
and fines associated with mask compliance. Infection
Prevention and Control will provide approval to ensure
appropriate material selection.
• The Aboriginal Health Hub is exploring options to
become a primary service for those who require
telehealth services and do not have access to data,
phone and internet services. This will ensure effective
follow up with patients
• The supply of pamphlets and face masks, as well as
essential packs for the vulnerable, sick and elderly
will continue
• Ongoing attendance at meetings across all relevant
parts of the local health district ensures that we are
kept informed and can provide the community with
ongoing information
• A 3 tiered approach on visiting patients in hospital
specifically for the Aboriginal community is being
developed. This visiting process is currently in draft.
• We are working with schools to develop a pamphlet
to ensure parents are kept informed if their school is
affected and closed for deep cleaning
• We continue to support unwell families with exceptional
circumstances during the pandemic response
Aboriginal Elder Olympics
The Aboriginal Elder Olympics 2020 event was
dedicated to Auburn Hospital, to provide education to
the community about the services available at Auburn
Hospital. Due to COVID-19, the event was postponed
and has been rescheduled for 2021.
The event will host up to three hundred people with
team representation from the Auburn – Liverpool
Aboriginal Men’s group, the Mount Druitt Men’s Shed,
plus representatives from Dubbo, Kempsey, Armidale,
Tamworth and Gunnedah.
The event is held to encourage people over the age
of fifty who have chronic health conditions to exercise.
This event gives health services an opportunity to
promote their available services to the community and
build strong relationships for future program partnership
in program development. This would have been the third
year in succession of the Elders Olympics. The team is
eager to prepare for the 2021 games.
Safer Baby Program
The Safer Baby Program, in line with care bundles
developed internationally, has been developed and
implemented with the aim to reduce the number of
stillbirths and serious adverse outcomes in newborns, as
well as improve maternal health outcomes and increase
satisfaction with care. The program is designed with
five key elements that are implemented in stages
with WSLHD plans to complete implementation
November 2020.
Foot Referral Pathway
The Foot Referral Pathway is currently in draft and for
consultation within Chronic and Complex Care (CAC).
The aim of the foot referral pathway is to obtain a
common understanding of referral to and from acute
and community services to enhance client care.
Cystic Fibrosis
The Federal Government announced $65 million for the
construction of a Cystic Fibrosis Specialist Service at
Westmead Hospital. The service will include a 16-bed
adult inpatient unit, 10 consulting rooms, four day-stay
beds, a diagnostic area and education, training and
research amenities. The Westmead Redevelopment team
is currently working with key stakeholders and consumers
through the design phase of the project.
Collaborative Commissioning
Collaborative Commissioning is a whole of system
approach designed to enable and support delivery of
value based care in the community. The aim is to deliver
value-driven, outcome-focused and patient-centred
healthcare by leveraging the principles of the quadruple
aim and developing pathways of care tailored to the
community’s needs.
PHOTO: Aboriginal mother with her newborn.
61
Future Priorities
WSLHD Safety & Quality Account
In January 2020, the Collaborative Commissioning Joint
Development Phase commenced under a partnership
agreement with the Ministry of Health, WSLHD and
Western Sydney Primary Health Network to support
delivery of patient centred and value-based care in
the community.
In response to the COVID-19 pandemic, a supplementary
model of care has been proposed in addition to the two
approved work streams (Value Based Urgent Care and
Cardiology in Community). The additional model of care
will provide community based support for vulnerable
and identified high risk residents of WSLHD during the
current pandemic and will co-ordinate the comprehensive
care for confirmed COVID-19 positive patients in
the community.
Patient Experience Matters
Consumer information management: a consumer co-design project
The consumer information management project is part
of the overarching Redevelopment change program. The
project aims to create a consumer designed information
template on Westmead hospital services, access and
wayfinding details to improve information sharing and
care. The project will involve consumer representatives
interviewing clinical and non-clinical service leaders
to develop the information template and content.
The project is in partnership with the WSLHD
Community and Consumer Engagement Program.
WSLHD Youth Council
The WSLHD Youth Council identified future priorities with
a focus on health literacy, supporting patient reported
measures, development of Adolescent and Young
Adult space in Westmead Redevelopment and enabling
feedback from broader youth in Western Sydney.
The “Youth Hello Doctor” program was held at Arthur
Phillip High School in partnership with Youth Health and
Multicultural Health. This event bought together Year 10
students and youth services to celebrate young people
and raise awareness of the services available to them.
Future planned events including the recruitment of
new members with eligibility opened to 16 year olds+
(previously limited to 18-25 years old); Youth Week with
pop up stalls; Non-perishable food drive to donate to
Youth Health with collection bins situated in Westmead,
Blacktown and Mt Druitt reception areas and the
inaugural Youth Health Summit have all been
scheduled for the latter part of 2020.
Multicultural Health CALD Community and Consumer Engagement Program
Multicultural Health Services (MCHS) in partnership
with community stakeholders established a number of
working groups that involve CALD communities and
consumers to work with and support Multicultural
Health and the District. Establishment of groups
was essential to progress the development and
implementation of many MCHS projects including Hello
Doctor, African Communities Health Summit, health
needs assessments, health literacy initiatives and to
provide COVID-19 information to our CALD communities.
The groups assisted in identifying health issues and gaps
and planning culturally appropriate responses to address
the health needs of vulnerable migrant and refugee
populations in WSLHD.
In 2020/2021, MCHS will continue to work with
established groups and extend the service to Pacific
Communities and the African Australian Youth Suicide
Prevention Group. Work will focus on developing and
implementing new ways of delivering health information
and education, progressing cross cultural health
literacy projects, identifying priority health issues
for communities and working with them to develop
culturally respectful interventions.
The Chronic and Complex team
As an outcome of the research project, a catheter
Booklet: ‘How to care for your indwelling urinary
catheter at home’ will be developed.
The Research Project-IQ-IDC Study will evaluate the
effect of educational interventions for indwelling urinary
catheters to improve self-care and reduce catheter-
associated complications. In Australia, an estimated
380,600 additional annual public hospital bed days
are attributed to healthcare-associated urinary tract
infections primarily due to catheter-associated urinary
tract infections. Catheter-associated complications
such as recurrent urinary tract infections, catheter
blockages and urine leakage are common adverse events
experienced by patients with long-term catheters and
result in significant personal and healthcare system
related burden, adversely impacting the quality of life,
morbidity and mortality.
This study aims to improve the knowledge, self-care
practices and quality of life of patients living with
indwelling urinary catheters. This is achieved by providing
education and resources and preparing clients/carers to
self-manage the indwelling urinary catheter.
The project thus far has:
• Completed literature review and the paper has
been submitted for publication (under review with
Contemporary Nurse Journal)
• Received Ethics & Governance approval
• Successfully received ICH Research Launchpad grant
Future Priorities
WSLHD Safety & Quality Account
62
Due to COVID-19, Ethics re-submission is being
planned to replace face to face interviews and focus
group sessions with telephone and/or Zoom interviews.
Integrated and Community Health - (Health Literacy Hub)
The Health Literacy Hub, one of 10 focus areas identified
by the Ministry of Health, is aimed at improving patient
experience. This has been established in a collaborative
partnership between WSLHD and the University of
Sydney. The concept of the Hub was identified as an
innovative approach to providing a valuable source,
focus and dedicated resource for experimentation
and adaptation of health literacy interventions.
The proposal and governance framework has
been developed and established with state-funded
infrastructure and resourcing, to deliver coordinated
defined actions to improve health literacy across all
NSW LHDs and communities. In the latter part of 2020,
a Patient Experience Strategy will be developed
with recommendations.
2020 vision for the future of health
Patients at the heart of healthcare was the focus
of planning for the future at the “2020 Vision for
the Future or Health” forum led by Western Sydney
health organisations. The forum was initiated and led
by WentWest’s clinical and consumer councils with
representatives from NSW Health, Western Sydney Local
Health District (WSLHD) and Western Sydney University.
The main focus of the forum was finding ways to improve
integrated care in Western Sydney and how to best take
forward the WSLHD-Western Sydney Primary Health
Network (WSPHN) integrated care program.
The integrated care program aim is to keep people out
of our emergency departments and hospitals where
possible and allow patients to remain with their families
in the community because we know that patients recover
much quicker at home. The partnership that WSLHD
has with WentWest is one of the strongest relationships
in the state. As a result, we have been able to lead the
way in developing a number of integrated care models
in Western Sydney, to achieve improvements in service
delivery, hospital efficiency and patient outcomes.
A Secure Electronic Referral System to improve referral processes from Primary Care to WSLHD Outpatient Clinics and Services - Integrated & Community Health
Eliminating paper-based referrals in healthcare is a
key priority of the National Digital Health Strategy-
Framework for Action 2018. This is underpinned by the
eHealth Strategy for NSW Health 2016–2026, to boost
collaboration between care providers around patient
care needs through shared care plans, collaboration tools
and referral solutions that will benefit the experiences of
healthcare consumers and clinicians.
In FY 2018/2019, just over 200,000 referrals were
received by WSLHD Outpatient Services from Private
Practice General Practitioners. Most referrals were
received by fax, phone or delivered in person by the
patient. A secure electronic referral system is a solution
to improve the referral process and experience for all
stakeholders. The draft secure electronic referral system
project has been submitted for review and approval
to engage with a vendor. The project will improve
ICH compliance with the NSW Outpatient Services
Framework 2019.
PHOTO: WSLHD staff in training.
63
WSLHD Board Attestation Statement
WSLHD Safety & Quality Account
Health Western Sydney Local Health District
This attestation statement is made by Richard Alcock AO
Name of office holder/member of Governing Body
Holding the position/office on the Governing Body Chair
For and on behalf of the governing body titled
Title of office holder/member of Governing Body
Western Sydney Local Health District
Governing body's title (the Governing Body)
Western Sydney LHD -Auburn (110101) Western Sydney LHD - Blacktown and Mount Druitt (115100) Western Sydney LHD - Mental Health and Drug Health (115102) Western Sydney LHD - Westmead (150522)
Health service organisation name (the Organisation)
1. The Governing Body has fully complied with, and acquitted, any Actions in the NationalSafety and Quality Health Service (NSQHS) Standards, or parts thereof, relating to theresponsibilities of governing bodies generally for Governance, Leadership and Culture.In particular I attest that during the past 12 months the Governing Body:
a. has provided leadership to develop a culture of safety and quality improvement withinthe Organisation, and has satisfied itself that such a culture exists within theOrganisation
b. has provided leadership to ensure partnering by the Organisation with patients,carers and consumers
c. has set priorities and strategic directions for safe and high-quality clinical care, andensured that these are communicated effectively to the Organisation's workforce andthe community
d. has endorsed the Organisation's current clinical governance framework
e. has ensured that roles and responsibilities for safety and quality in health careprovided for and on behalf of the Organisation, or within its facilities and/or services,
64
WSLHD Board Attestation Statement
WSLHD Safety & Quality Account
are clearly defined for the Governing Body and workforce, including management and clinicians
f. has monitored the action taken as a result of analyses of clinical incidents occurringwithin the Organisation's facilities and/or services
g. has routinely and regularly reviewed reports relating to, and monitored theOrganisation's progress on, safety and quality performance in health care.
2. The Governing Body has ensured that the Organisation's safety and quality prioritiesaddress the specific health needs of Aboriginal and Torres Strait Islander people.
3. I have the full authority of the Governing Body to make this statement.
4. All other members of the Governing Body support the making of this attestationstatement on its behalf ( delete if there is only one member/director of the governingbody).
I understand and acknowledge, for and on behalf of the Governing Body, that:
- submission of this attestation statement is a pre-requisite to accreditation of theOrganisation using NSQHS Standards under the Scheme
- specific Actions in the NSQHS Standards concerning Governance, Leadership andCulture will be further reviewed at any onsite accreditation visit/s.
Signed
Position Chair, Western Sydney Local Health District
Date
Schedule of health service organisations covered by this attestation statement
Name of health service organisation Address
Auburn Hospital 18 Hargrave Road, Auburn NSW 2144
Blacktown and Mount Druitt Hospitals Blacktown Road, Blacktown NSW 2148
Mental Health and Drug Health Services 1-11 Hainsworth Street, Westmead NSW2145
Westmead Hospital Cnr Hawkesbury & Darcy roads, Westmead NSW 2145
65
References
WSLHD Safety & Quality Account
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Clinical Excellence Commission, Venous Thromboembolism (VTE) prevention, http://www.cec.health.nsw.gov.au/keep-patients-safe/medication-safety-and-quality/vte-prevention, viewed May 2020.
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References
YOUTUBE
WESTERN SYDNEY LOCAL HEALTH DISTRICT
PO Box 574 Wentworthville NSW 2145 +61 2 8890 9902 [email protected]
www.wslhd.health.nsw.gov.au