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QUALITY OF CARE 2009 - 2010 1
Otway HealtH & Community Services
Quality of Care Report 2009 - 2010
2 OTwAY HEALTH & COmmUnITY SERvICES
• 99%achievedinauditfromNationalChildcareAccreditationCouncil.Anecdotallyspeaking,theaccreditordescribedourchildcarecentreasoneofthebestinAustralia,metropolitanorrural!
• Stage1and2ofourrefurbishmentofChildCarecompleted,increasingourspaceandallowingintroductionofafterschoolcare.
• Introductionof“CountUsIn”forourresidents,helpingthemtoaccesstechnologyanduseitforcommunicatingwithrelatives.
• Kitchenstaffparticipatedin“World’sGreatestShave”andraisedover$5000intheprocess.
• ImplementationofRiskmanQforQualityReporting.
• Installationofanewnursecallsystem,includingreplacementofexistingCCTVsecuritycamerasystemanddoorintercomsystem,toincreasesecurity.
• NeedsstudywithLaversHillcommunitytoauspiceaNeighbourhoodHouse,withboardapprovingfundingforCoordinator.
• AnewambulancestationwasconstructedonOtwayHealthlandandparamedicshavebeenplacedpermanentlyatApolloBay.
• AYouthDevelopmentWorkerwasappointedandisconductinganeedsstudyinconsultationwithyoungpeopleandcommunity.
• FundingfromDepartmentofPlanningandCommunityDevelopmentresultedinsuchactivitiesaspaintingofanindigenousmural,launchofmural,andflagraisingceremonyofindigenousflag.
Childcare participating in indigenous mural activities at Marrar Woorn.
• SecondSailsOpportunityShopagainachievingrecordtakingswithadonationtoOtwayHealthof$155,000inNovember2009.
• Increasedusagebyclientsofallservices.(tablepage7)
Kitchen crew participate in Worlds Greatest Shave. Mini Field of Women. New Ambulance Station built on Otway Health and Community Services land.
QUALITY OF CARE 2009 - 2010 3
Throughnetworking,linkagesandpartnershipsenablepeopletooptimisetheirwellbeing.
Allpeopleinourcommunityhaveknowledgeofandaccessto,qualityhealthandcommunityservicesresponsivetotheirneeds.
PhotocourtesyofJefferyRichardson
Quality Of Care repOrt 2009 - 2010
02 Highlights for the Year
03 Mission, Vision
05 About Us
06 Services That We Provide
07 Client Participation
08 Communication With The Community
09 How Can We Improve The Quality of Care Report
07 How We Compare
11 Country of Birth
13 Clinical Governance
14-15 Volunteers
16 Quality and Safety
17 Staff Education
17 Risk Management
18-19 Clinical Care Review
20 Aged Care
21 Medication Safety
22 Emergency Care
23 Aged Care
24-26 Community Services
table Of COntentS
4 OTwAY HEALTH & COmmUnITY SERvICES
QUALITY OF CARE 2009 - 2010 5
Our CatchmentOtwayHealthservicesthesouthernhalfoftheColacOtwayShire,runningfromSeparationCreekjustwestofLorne,alongtheGreatOceanRoadtoYuulong(40kmwestofApolloBay)andstretchesasfarinlandasForrestandLaversHill.Withapopulationbaseinexcessof3,000whichswellstoover15,000duringpeaktouristseason,thispopulationisspreadoverahugeareaofmountaintracks,NationalParks,andwindingbeachroads.
Accommodationandtouristbasedindustriesheadtheemploymentopportunities(Census2006),however,theseasonalnatureensuresthatthemeanincomeofourcatchmentiswellbelowtheHendersonPovertyline(seetablebelow).Alongtheseaboard,thereisahigherthanaverageratioofretireeswhencomparedtonationalaverage.
Ourphysicalisolation,widelyfluctuatingpopulationnumbers,anddemographicsprovidechallengesuniquetoourhealthservice.
Apollo Bay marengo
Lavers Hill Beech Forest
Forrest wye River Skenes Creeknational Figures
Population 1371 208 170 144 122
Average Household Income 682 956 638 601 1027
Over 65 years of age 20.20% 8.20% 11.80% 11.80% 27.00% 13.30%
25-54 years of age 41.40% 48.60% 45.30% 55.60% 41.00% 42.20%
Australian by birth 83.40% 76.90% 76.50% 93.80% 79.50% 70.90%
English Spoken at Home 93.40% 95.20% 90% 93.10% 91% 78.50%
Employed Full time 50% 52% 42% 50% 35.70% 60.70%
Part time 35% 35% 39.50% 34.10% 54.80% 27.90%
Unemployed 4.20% 4.10% 8.60% 8.50% 0.00% 5.20%
Industry of employ 2 highest categories
Accom14.9%ResBuildConst5.9%
Accom13.6%Cafes,
Restrnts11%
Accom9.5%Hospitals10.8%
Accom16%Hospitals8%
Accom9.5%Building9.5%
Accom1.3%Hospitals3.3%
OtwayHealthandCommunityServices(OHCS)isanintegratedhealthserviceoperatingundertheMultiPurposeService(MPS)modelofhealthcare.Receivingfundingfromlocal,state,andfederalgovernments,beingaMPSallowsOtwayHealththeflexibilitytorespondeffectivelytothechangingneedsofthisremoteruralcommunity.
6 OTwAY HEALTH & COmmUnITY SERvICES
Clinical CareEmergencyCare24/7
AcuteCare
AidsandEquipmentHire
BeautyTherapy
DayRespiteCare
FoodServicesProgram
NeedleExchangeProgram
NurseClinic
PalliativeCare
Aged CareResidentialAgedCare
ResidentialRespiteCare
SeaMistVillas
Community ServicesAdultandCommunityEducation
Advocacy,Counselling&SupportServices
CentrelinkAgency
ChildCareCentre
CommunityNursing
CommunityWelfare
ChronicDiseaseManagement
CommunityTransport
DeliveredMeals
Dietetics
EmergencyRelief
ExerciseTherapy
FallsPreventionProgram
ForrestNeighbourhoodHouse
GriefandBereavementSupport
HealthPromotion
HomeandCommunityCare
Immunisation
InfantWelfare
IntegratedServicesforYoungChildren
LactationConsultancy
MarrarWoornCommunityCentre
MaternalHealth
NeighbourhoodHousePrograms
OccupationalTherapy
ParentingInformation
PropertyMaintenance
PlannedActivitiesGroup
Physiotherapy
SeniorCitizensCentre
SocialSupport
VolunteerSupport
VisitingServices
AustralianHearing
FinancialCounselling
Eyecare2You
BarwonPodiatry
ColacOtwayShireMaternalChildandHealth
ColacAreaHealthDrug&AlcoholNurse
InsightNutrition&PrivateDietetics
YouthDevelopmentWork
Corporate ServicesAudits
Administration
AssetManagement
BuildingsandGrounds
Cleaning
FinancialManagement
Fundraising
GovernanceSupport
HumanResourcesManagement
InformationTechnology
InformationManagement
InfrastructureMaintenance
OccupationalHealthandSafety
PublicRelations
QualityImprovement
RiskManagement
SecondSailsOpportunityShop
We are committed to continuously improving
our health service in terms of quality of care
and scope of services to meet the needs of
our community
– Linda West, CEO
tHat we prOvide
QUALITY OF CARE 2009 - 2010 7
AREA 2008/09 2009/10Health Promotion Programs Number of Participants 2124 1580Number of Programs 115 72Community WelfareOccasions of Service 927 967 Number of Clients 137 121Hours of Counselling 967 959Emergency Relief Occasions of Service 72 100Number of Clients 37 32Marrar Woorn Neighbourhood House Ongoing Groups 25 28 Activities 315 384 Activity Hours 868 1080 Forrest Neighbourhood House Ongoing Groups 9 12 Activities 161 160 Activity Hours 335 603 Assessment ServicesCase Conferences with GP 12 7Case Conferences without GP 48 13Planned Activity Group Hours of Client Contact 2152 2587 Number of Clients 27 30Community NursingNumber of Clients 44 50Number of Hours 1056 1160 Centrelink Occasions of Service 1872 1704 Child Care Number of Children Attending 53 48EFT Childrens’ Places 15.91 15.56 Physiotherapy Number of Clients 471 460 Maternity Services Number of Clients 27 23Group service classes 18Postnatal nursing visits 44Postnatal/antenatal classes 80Home & Community Care Personal Care Clients 80 163Home Care Hours 2930 3399Delivered Meals 4366 4316Occupational Therapy 48 60Clinical CareNurse/Wound Clinic 216 202Radiology 77 42ECU Presentations 1063 1070 Acute Admissions 85 66Needle Exchange 2755 1093Respite Aged Care 38/375 47/256High Level Residential Aged Care 2800 3206Low Level Residential Aged Care 4597 4675
I would just like to
formally acknowledge
the outstanding
care your residents
receive, the level
of care and respect
would be hard to find
in similar facilities
in Melbourne, even
the one I work for!
I know...(she)...
appreciates the
freedom of choice
and kindness shown
to her although
she does not often
express it. Keep up
the good work
– Resident’s Daughter
8 OTwAY HEALTH & COmmUnITY SERvICES
witH tHe COmmunity
communication noun theimpartingorinterchangeofthoughts,
informationoropinionsbyspeech,writingorsigns
OtwayHealthplacesgreatimportanceonprovidingthesafestandbestqualityserviceswecanandinordertodothis,wehavetolistentowhatourusersandthecommunityhavetosayabouttheirexperienceofOtwayHealthandlearnfromtheirfeedback.
Anumberofwayshavebeendevelopedtodevelopandimproveourconversationswithourcommunityincluding:
• AnewCommunityParticipationWorkingGrouphasbeendevelopingamoreeffectivemeansofconsultingwiththecommunityabouttheirneedsandtogatherfeedbackaboutthewayservicesareprovided.
• Clientfeedbackaboutserviceshasbeensoughtthroughfeedbackcardsandresultsindicatethat84%ofresponsesindicatedclientswereveryhappywiththeserviceprovidedbyOtwayHealth.
• AprofessionallyproducedDVDillustratingOtwayHealthservicesandactivitieswasproducedanddistributedwidelytogroups,partneringagencies,localbusinesses,governmentdepartmentsandtheDVDmadefreelyavailabletomembersofthecommunityasrequested.
• ANeedsStudyatLaversHillconductedbyOtwayHealth,supportedlocalresidentstodeterminetheactivitiesandservicesthattheyneedtoenhancetheircommunity.TheoutcomehasbeenthedevelopmentofaneighbourhoodhouseprogramforLaversHill.
• TheNewssheetpageenablesOtwayHealthtopromoteservicesandeventsandadvertiseforpositionseachweek.
• WebsitepostingsprovideinformationaboutnotableeventsandhighlightsnewservicesatOtwayHealthaswellasprovidesaccesstopreviousreportsandplansthatguidethedirectionsofOtwayHealth.
• Localpapercoverage.
• Boarddeterminesitemsformediareleasesateverymeeting.
• FeedbackregisterinRiskman.
QUALITY OF CARE 2009 - 2010 9
witH tHe COmmunity
tHe Quality Of Care repOrt
FeedbackfromthelastreportsuggestedthattheQualityofCareReportwaswellreceivedandthatitwouldbeimprovedbygreaterparticipationofstaffreportingfromallprograms.
Thisyearstaffmembersfromallprogramsanddivisionsareinvolvedincontributinginformationabouttheirprogramstothequalityofcarereportsothattheactivityoftheentireorganisationisreflectedinthereport.
Improving distribution and feedback Lastyeartheavailabilityofthe2009QualityofCareReportwaspromotedthroughtheNewsSheetanddistributedwidelytolocalgroupsinthecommunity,alllevelsofgovernment,localbusinessesandotherhealthagenciesintheregion.
TheAnnualGeneralMeeting(AGM)providedafocusforOtwayHealthtopresenttheAnnualandQualityofCareReportstothecommunityhighlightingtheperformanceofOtwayHealthoverthepreviousfinancialyear.EveryoneattendingtheAGMreceivedacopyofthereportandallwereinvitedandencouragedtoprovidefeedbacktoOtwayHealthonthefeedbackformsincludedinthereport.
ReportsweremadeavailableforclientsandvisitorsinwaitingareasandonreceptiondesksinClinicalCareandCommunityServicesatOtwayHealth.
OnlineaccessoftheAnnualReportandQualityofCareReportwasalsoavailableontheOtwayHealthwebsite.
Thisyearwewillimprovedistributionandfeedbackbyadoptingfurtherstrategiesfor
hardtoreachconsumersandcommunities,including:
• PromotingtheReportandrequestingfeedbackintheNewsSheet.
• ContinuingtoincludetheQualityofCareReportwiththeAnnualReport.
• PromotingonlineaccesstotheReportintheApolloBayNewsSheetandOtwayLight(LaversHill)andrequestingfeedbackbyphone.
• DeliveringReportstoouroutreachclientswhoreceiveservicesintheirhome.
• DistributingReportstoeveryhouseholdinourcatchmentviaAustraliaPost.
• DisplaycopiesoftheReportatpertinentpointsaroundOtwayHealthforconsumerstotakehome.
• ProvidecopiesoftheReporttoDoctorssurgeriesinourcatchmentaswellaspharmacists.
EvaluationTheeffectivenessofthesestrategieswillbeindicatedby:
• Thenumberofreportsdistributed
• TheamountandnatureofthefeedbackreceivedfromtheformsintheReport.
• Thenumberofpeopleaccessingthewebsite.
• ThenumberofpeopletelephoningOtwayHealthtoprovidefeedbackontheReport.
Everyone knows their rights and responsibilitiesCommunicationrequiresthateveryoneknowswheretheystandasfarastheirrightsandobligationsare.OtwayHealthensurespeopleunderstandtheirrightstorespect,privacy,qualitytreatment,information,andadvocacy.Clientsalsohavearighttomakeacomplaintandtoconsentorrefusetodiscloseinformation.
StaffatOtwayHealtharemadeawareofthesethrough:
• Ourinductionprogramreinforcedviasignagethroughoutourbuildings
• Writtenintoourstrategicplaninourbrochures
• Discussedatindividualassessmentsandreviewsand
• Implementedintoourprotocolmanagementprocedures(PROMPT)
10 OTwAY HEALTH & COmmUnITY SERvICES10 OTwAY HEALTH & COmmUnITY SERvICES
TheVictorianPatientSatisfactionMonitor(VPSM)providesfeedbackonthequalityofapublichospitalexperiencefromtheadultinpatient’sperspective.TheVPSMprojectisfundedbytheDepartmentofHealthandtheresultsofthesurveyprovideimportantinformationregardingareaswherequalityimprovementactivitiesshouldbedirected.FortheMarch2008-February2009reportingperiod,theOverallCareIndexforallVictorianHospitalswas78.2.Asyoucanseefromthetablebelow,OtwayHealthandCommunityServicesconsistentlyperformsabovethemean,andwhencomparedtootherMultipurposeServices,weconsistentlyperformwithintherange.
Comparison of all multi Purpose Service Provides In victoria for Yearly Overall Care Index (OCI) by Hospital
HospitalName 2008-09OCI
2007-08OCI
2006-07OCI
AlpineHealth[Myrtleford,MountBeauty&BrightCampuses]
83.1 82.9 86
MalleeTrackHealth&CommunityService 78.4* 81.1 84.2
OrbostRegionalHealth 86.3 80 82
OtwayHealth&CommunityServices 84.3* 82.2* 84.3*
RobinvaleDistrictHealthServices 83 79.5 79
Timboon&DistrictHealthcareService 89.7 88.5 87.5
UpperMurrayHealth&CommunityServices 81 83.9 83
*denotessamplelessthan30butgreaterthan10
QUALITY OF CARE 2009 - 2010 11
Asawayofmakingsurewecontinuetoprovideservicesrelevanttoourchangingcommunity,
wecontinuallymonitortheavailablestatistics,includingcountryofbirth.
Ourdataforthe2009-2010yearshowsthatthenumberofpatientsfromnonEnglishspeaking
backgroundshasremainedfairlystableacrossallareas.
Clients born from non-English speaking countries accessing Community & Clinical services
main countries of origin
Rank 2007-08Numberof %ofClients 2008-09 % 2009-10 % ClientsPresented Presented 1 Germany22 1.4% India12 0.8% Holland16 0.9%
2 Greece11 0.7% Holland10 0.6% Greece12 0.7%
3 France8 0.5% Germany8 0.5% Italy10 0.6%
4 Italy7 0.4% Italy8 0.5% Turkey7 0.4%
5 India7 0.4% Greece6 0.4% Poland6 0.3%
6 Holland7 0.4% Poland5 0.3% Malta5 0.3%
7 Germany5 0.3%
8 India2 0.1%
12 OTwAY HEALTH & COmmUnITY SERvICES12 OTwAY HEALTH & COmmUnITY SERvICES
Staffcreatinga‘secretgarden’forchildrenduringtherefurbishment.Thegardenincludesherbs,rocks,andornamentsforacompletesensoryexperience.
QUALITY OF CARE 2009 - 2010 13
Clinicalgovernanceis,atitscore,aboutbeingaccountableforprovidinggood,safecaretopatientsandisfundamentaltocontinuousimprovementinpatientsafety.TheDepartmentofHealth(Vic)providesaframeworkonclinicalgovernanceand,forpublichealthservicesandpublichospitalscompliancewiththeframeworkismandatedinthePolicyandFundingGuidelineswhichunderpinStatementsofPrioritiesandHealthServiceAgreements.
Someoftheareasofresponsibilityinclude:
• Beingclientfocussed.
• Implementariskmanagementplan.
• Developingandmonitoringofaqualityplan
• Reportsandpublicationsarecommunicatedwithcommunityandstaff
• Strongclinicalleadershipandownership.
• Systemsandprocessesareinplacetosupportpatientsafety.
• Compliancewithlegislativeanddepartmentalpolicyrequirements,includinghospitalaccreditation.
• Rigorousmeasurementofperformanceandprogress,includingreportingandreview.
• Continuousimprovementofqualityandsafety.
• Clearlydefinedrolesandresponsibilitiesareunderstoodbyallparticipantsinthesystem.
ClinicalgovernanceishowOtwayHealthensuresthatsafecarequalitycareisprovidedtoclients.TheClinicalAdvisoryCommitteemeetsmonthlytoreviewcareandidentifyanyissuesarisingfromclinicalpractice.Thecommitteeincludes;representationfromApolloBayGeneralPractice,AlliedHealthStaff,NursingStaffandManagementwhomeettoreviewsafetyissuesandidentifyareasofimprovement.
Clinical governance
is...fundamental
to continuous
improvement in
patient safety.
IndigenousMural–MarrarWoorn.
14 OTwAY HEALTH & COmmUnITY SERvICES
Role of the BoardTheBoardofDirectorsisresponsibleforthegovernanceandstrategicdirectionofOtwayHealthandensuresthattheservicesprovidedcomplywithlegislativerequirementsandtheobjectives,mission,andvisionofOtwayHealth.TheBoardachievesthisbyhavingthecommitteesandworkgroupsreportbacktothemasshowninthecommitteereportingstructurediagramonthispage.
TheBoardmonitorsthequalityandsafetyoftheservicesprovidedatOtwayHealththroughregularmonthlyriskreportsaboutincidentsthathaveoccurredandhowthesewereaddressed.
TheAuditandRiskCommitteeoftheBoardisresponsibleforoverseeingauditsofpracticeinallareas,includingclinical,financialandadministrativetodeterminecompliancewithgoodpracticeacrosstheorganisation.
Board of Directors
Capital Works Committee
Audit and RiskCommittee
Finance Committee
Board Selection Panel
CEO Management Committee
Quality Improvement Committee
Home and Community Care Quality Improvement Group
Clinical Advisory Committee
Consumer Participation Group
Cultural Diversity Group
Patient And Client Records Workgroup
Residential Aged Care
Occupational Health and Safety
Quality Improvement Committee
Child Care Quality Committee
Committee Reporting Structure