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Welcome to The Kilmore & District Hospital QUALITY OF CARE REPORT 2014 Calendar for 2015

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Page 1: Welcome to The Kilmore & District Hospital...The updated hospital website has gone live following review by the committee as well as The Kilmore Hospital face book page. VoLunteers

Welcome to

The Kilmore & District Hospital

QualiTy of Care reporT 2014

Calendar for 2015

Page 2: Welcome to The Kilmore & District Hospital...The updated hospital website has gone live following review by the committee as well as The Kilmore Hospital face book page. VoLunteers

Message froM the Ceoit is with pleasure that i introduce the 2013/14 Quality of Care report. The purpose of this report is to inform our community and other interested parties about the services we provide and highlight how we are improving the quality of those services. We are proud of the services we provide and recognise that we are not the provider of all services. our vision however is to be your “preferred provider and facilitator for whole-of-life health related services”. if we do not provide the service, we will help you navigate the health system to attain the services you need. We continue to strive to improve the range of services available for our community. in May 2011, we were approved for a $20 million redevelopment which will see our hospital grow from 30 to 60 acute beds.We will also build an outpatient facility which will accommodate a range of community services to improve the continuum of care. The building phase is progressing well with the construction and the project expected to be completed by february 2015.Copies of this report are provided to the Department of Health, the Hospital’s reception and waiting areas, local doctors’ surgeries, local pharmacies, Nexus primary Health and the Kilmore and Wallan libraries.a copy of the report can also be found on our internet site: www.kilmoredistricthospital.org.au.

Bart Ruyter, Chief Executive Officer

CoMMunityKilmore is a township of the Mitchell Shire Council and is located 60km north of Melbourne, the capital of Victoria, and is close to the state’s geographical centre.Kilmore is Victoria’s oldest inland settled town and has a diverse socio-economic mix.The area is Taungurung country and was developed as a rural farming area by early irish and Scottish settlers with sheep and cattle as primary industry. Kilmore’s current strengths include education, health, horse racing, automotive, manufacturing, transport, commerce, farming and tourism.Kilmore provides an easy commute to the Northern suburbs and Melbourne via the Hume freeway. it is estimated several hundred people travel to Melbourne to work each day, an hour’s drive or train ride from the Kilmore east Station. Population predictions project significant growth in the future, particularly to the south of Mitchell Shire which was included as part of the urban Growth Boundary in June 2012.The Kilmore & District Hospital provides comprehensive acute and aged care services to our rapidly increasing catchment population of 25,000 that extends from Kilmore to Broadford and pyalong in the North, Wallan and Craigieburn in the South and Lancefield and Romsey to the West.

Page 3: Welcome to The Kilmore & District Hospital...The updated hospital website has gone live following review by the committee as well as The Kilmore Hospital face book page. VoLunteers

1 New Year's Day 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 Australia Day 27 28 29 30 31

Notes:

JANUARY 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

S M T W Th F Sa1 2 3 4 5 6

7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25 26 2728 29 30 31

December 2014S M T W Th F Sa1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 28

February 2015

Page 4: Welcome to The Kilmore & District Hospital...The updated hospital website has gone live following review by the committee as well as The Kilmore Hospital face book page. VoLunteers

the Kilmore & District hospital is a Publicly funded Community hospitaland is fully accredited with the aChs and aCsaa Care

for further information, please telephone 5734 2000

aCute WarD• 30 bed inpatient ward – medical, surgical, maternity and

palliative care. referral via local Gp and visiting surgeons.

Maternity serViCes• Comprehensive low risk Maternity Services provided. • Models of care provided are Gp led care and public

antenatal care. referral through Gp or self referral.

oPerating theatre• Types of surgery include ear, Nose & Throat,

orthopaedic, Gynaecology, urology and General surgery. referral through local Gp to visiting specialists.

urgent Care Centre• our urgent Care Centre is staffed with Nurses who are

able to provide first line care.• General practitioners support the department on an on

call basis.

ConsuLtant sPeCiaLists• Gynaecology, General Surgery, ear Nose & Throat,

Cardiology, Cancer and urology. referral via local Gp.

DiagnostiC serViCes• Healthscope pathology undertake blood tests and

electrocardiograph testing on site.• Capital Health radiology provide X-ray, CT scanning and

ultrasonography. referral via local Gp.

resiDentiaL ageD Care• 30 bed Caladenia Nursing Home and 30 bed Dianella

Hostel (respite available in both homes).• providing residential aged care for elderly people with

nursing care needs and also those who require assistance with their activities of daily living.

• applications can be made directly to Dianella Hostel and Caladenia Nursing Home once the aged Care assessment Team has undertaken the required assessments.

DistriCt nursing serViCes• Home nursing care provided including personal care,

specialist wound care, administration of intravenous medication, post surgical follow up care. referral through Gp, Hospital or self referral.

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1 2 3 4 5 6 7

8 9 10 11 12 13 14 Valentines Day

15 16 17 18 19 Chinese New Year 20 21

22 23 24 25 26 27 28

Notes:

FEBRUARY 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

S M T W Th F Sa1 2 3

4 5 6 7 8 9 1011 12 13 14 15 16 1718 19 20 21 22 23 2425 26 27 28 29 30 31

January 2015S M T W Th F Sa1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 2829 30 31

March 2015

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ConsuMer, Carer anD CoMMunity PartiCiPationThe Consumer and Community participation Committee (CCpC) continues to advise on matters of consumer participation as well as consumer equity of access. a number of items have been achieved over the past 12 months. The group have reviewed 20 patient and resident information brochures and provided feedback which has enabled us to develop more user friendly, accessible and informative brochures.in response to feedback provided by the Committee, wheelchair access has been improved at the rear of the hospital. This includes an automated door for entry and exit of the buildingThe updated hospital website has gone live following review by the committee as well as The Kilmore Hospital face book page.

VoLunteersWe owe a depth of thanks to the work of all our volunteers. Their efforts come totally from the heart and conversations with residents, families, patients and staff bear witness to just how highly they are regarded. Volunteering has gone from strength to strength over the past year. our programs particularly enjoy the enthusiasm and energy injected by our volunteers. in addition, the Hospital auxiliary and the Hospital opportunity Shop continue to raise funds for much needed equipment and support for both our hospital and aged care facilities.it’s been fantastic to see an increase in the number of men who are choosing to become involved. equally exciting is when our local school students decide to become volunteers. We welcome new volunteers and anyone interested is asked to contact the hospital by phone or through our hospital website. our volunteer coordinator will discuss opportunities on offer, their interests and availability.

pictured above: Volunteers at CaladeniaBelow: The Hospital’s ‘opp Shop’ Volunteers

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1 2 3 4 5 6 7

8 9 Labour Day Holiday 10 11 12 13 14

15 16 17 St. Patrick's Day 18 19 20 21

22 23 24 25 26 27 28

29 30 31

Notes:

MARCH 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

S M T W Th F Sa1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 28

February 2015S M T W Th F Sa

1 2 3 45 6 7 8 9 10 11

12 13 14 15 16 17 1819 20 21 22 23 24 2526 27 28 29 30

April 2015

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soCiaL ButterfLies at CaLaDeniaThe newly created Social Butterflies program at Caladenia brings together as many community volunteers as possible at the one time as to interact with residents over a special morning or afternoon tea.Just as many of us enjoy going out for tea, coffee and cake with a friend; volunteers and residents enjoy the same on a fortnightly basis. The only difference is the coffee ‘house’ is set up inside so that residents unable to venture out can still enjoy a cuppa and chat with a friend.

sensory MeSimilarly this program again utilises our volunteers on a weekly basis and recognises that a shared occasion is often so much more valued and enjoyed.each activity in the ‘sensory me’ program is designed for heightened sensory stimulation.examples include:— a gentle touch whilst listening

to soothing and relaxing music together;

— a resident arranging and delivering the gift of flowers to others;

— our perfumery that focused on residents love of scents;

— the ice-creamery that engendered reminiscences of ‘Mr Whippy Vans’ and favourite flavours;

— or our ‘Willy Wonka - Chocolatier’ which incited residents obsessions and cravings for chocolate.

Crafting anD Creating at DianeLLaDianella is renowned for its celebration of special events such as The royal Children’s Hospital appeal; Cuppa for Cancer; NaiDoC week; rSpCa Cup Cake Day; and Kilmore’s own Scaretactics event held each october. Volunteers are central to making sure that things happen from making props and crafts to assisting directly on the day.

2014 ViCtorian heaLth Minister VoLunteer aWarDs We are very proud of the work of our many volunteers and this year we again made three nominations to the ‘2014 Victorian Health Minister awards’ for outstanding achievement and contribution to volunteering in rural health.our nominees were Maria almeida at Caladenia Nursing Home and laraine Carbis at Dianella Village Hostel for their continued support and generosity of spirit in their interactions with our residents. our third nomination was for the team of women and men of the Hospital opportunity Shop for their never-ending fundraising efforts.

pictured are our Winners of the Victorian MinisterVolunteer Health award in 2013

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1 2 3 Good Friday 4 Passover

5 Easter Sunday 6 Easter Monday 7 8 9 10 11

12 13 14 15 16 17 18

19 20 21 22 Earth Day 23 24 25 Anzac Day

26 27 28 29 30

Notes:

APRIL 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

S M T W Th F Sa1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 2829 30 31

March 2015S M T W Th F Sa

1 23 4 5 6 7 8 9

10 11 12 13 14 15 1617 18 19 20 21 22 2324 25 26 27 28 29 3031

May 2015

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CoMMunity eQuity of aCCess anD inCLusion strategy

This strategy was developed some years ago and is updated annually to include recommendations in the “Doing it with us not for us Strategy”, “Care for aboriginal patients strategy”, “Cultural Diversity” and “Disability action plan”.

This strategy can be accessed on our website:

www.kilmorehosptial.org.au

We are currently working our way through the Quality improvement tool aboriginal Health in acute Settings with our Consumer and Community participation Committee (CCpC) to identify opportunities for improvement and address priorities identified through the journey.

Some of the strategies in place to increase our cultural responsiveness include:

• Senior Project Officer for Closing the Health Gap Lower Hume is an active member of our CCpC.

• The hospital is represented on the Mitchell Cultural Diversity Group.

• NaiDoC week is celebrated.

• regional cross cultural training is offered to staff on site.

• Aboriginal Liaison Officer support is sought as required to assist with referrals and discharge planning.

• aboriginal representation is encouraged on the CCpC.

We believe we are on the way to improving consumer, carer and community participation in our services.

our Consumer Directed Care Working Group aims to bring together components of the active Service Model, patient Centred Care, Consumer Directed Care, health literacy and holistic palliative Care to implement a more strategic and seamless approach to our service.

COMMUNITYEQUITYOFACCESSANDINCLUSIONSTRATEGYThis strategy was developed some years ago and is updated annually to include recommendations in the “Doing it with us not for us Strategy”, “Care for Aboriginal Patients strategy”, “Cultural Diversity” and “Disability Action Plan”. This strategy can be accessed on our website. www.kilmorehosptial.org.au We are currently working our way through the Quality Improvement tool Aboriginal Health in Acute Settings with our Consumer and Community Participation Committee (CPCC) to identify opportunities for improvement and address priorities identified through the journey. Some of the strategies in place to increase our cultural responsiveness include:

Senior Project Officer for Closing the Health Gap Lower Hume is an active member of our CPCC

The hospital is represented on the Mitchell Cultural Diversity Group.

NAIDOC week is celebrated Regional cross cultural training is offered to staff on

site Aboriginal Liaison Officer support is sought as

required to assist with referrals and discharge planning.

Aboriginal representation is encouraged on the CPCC We believe we are on the way to improving consumer, carer and community participation in our services. Our Consumer Directed Care Working Group aims to bring together components of the Active Service Model, Patient Centred Care, Consumer Directed Care, health literacy and holistic Palliative Care to implement a more strategic and seamless approach to our service.

COMMUNITYEQUITYOFACCESSANDINCLUSIONSTRATEGYThis strategy was developed some years ago and is updated annually to include recommendations in the “Doing it with us not for us Strategy”, “Care for Aboriginal Patients strategy”, “Cultural Diversity” and “Disability Action Plan”. This strategy can be accessed on our website. www.kilmorehosptial.org.au We are currently working our way through the Quality Improvement tool Aboriginal Health in Acute Settings with our Consumer and Community Participation Committee (CPCC) to identify opportunities for improvement and address priorities identified through the journey. Some of the strategies in place to increase our cultural responsiveness include:

Senior Project Officer for Closing the Health Gap Lower Hume is an active member of our CPCC

The hospital is represented on the Mitchell Cultural Diversity Group.

NAIDOC week is celebrated Regional cross cultural training is offered to staff on

site Aboriginal Liaison Officer support is sought as

required to assist with referrals and discharge planning.

Aboriginal representation is encouraged on the CPCC We believe we are on the way to improving consumer, carer and community participation in our services. Our Consumer Directed Care Working Group aims to bring together components of the Active Service Model, Patient Centred Care, Consumer Directed Care, health literacy and holistic Palliative Care to implement a more strategic and seamless approach to our service.

COMMUNITYEQUITYOFACCESSANDINCLUSIONSTRATEGYThis strategy was developed some years ago and is updated annually to include recommendations in the “Doing it with us not for us Strategy”, “Care for Aboriginal Patients strategy”, “Cultural Diversity” and “Disability Action Plan”. This strategy can be accessed on our website. www.kilmorehosptial.org.au We are currently working our way through the Quality Improvement tool Aboriginal Health in Acute Settings with our Consumer and Community Participation Committee (CPCC) to identify opportunities for improvement and address priorities identified through the journey. Some of the strategies in place to increase our cultural responsiveness include:

Senior Project Officer for Closing the Health Gap Lower Hume is an active member of our CPCC

The hospital is represented on the Mitchell Cultural Diversity Group.

NAIDOC week is celebrated Regional cross cultural training is offered to staff on

site Aboriginal Liaison Officer support is sought as

required to assist with referrals and discharge planning.

Aboriginal representation is encouraged on the CPCC We believe we are on the way to improving consumer, carer and community participation in our services. Our Consumer Directed Care Working Group aims to bring together components of the Active Service Model, Patient Centred Care, Consumer Directed Care, health literacy and holistic Palliative Care to implement a more strategic and seamless approach to our service.

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1 2

3 4 5 6 7 8 9

10 Mother's Day 11 12 13 14 15 16

17 18 19 20 21 22 23

24 25 26 27 28 29 30

31 Notes:

MAY 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Falls Awareness Week Falls Awareness Week Falls Awareness Week Falls Awareness Week

S M T W Th F Sa1 2 3 4

5 6 7 8 9 10 1112 13 14 15 16 17 1819 20 21 22 23 24 2526 27 28 29 30

April 2015S M T W Th F Sa

1 2 3 4 5 67 8 9 10 11 12 13

14 15 16 17 18 19 2021 22 23 24 25 26 2728 29 30

June 2015

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Continuity of CareThe care we give individual patients, residents and clients varies according to need.We work with different teams of health professionals to assist each person to receive the care they need at the appropriate time, and in the appropriate setting.Care can be coordinated on the ward, in the uCC, at home, in residential homes or in the community and is focused on responding to the specific needs of each individual. an example of this is the Transitional Care programme (TCp) provided in Dianella Hostel. Clients are supported with medical, nursing and personal care needs in a home like atmosphere to regain their independence and confidence before returning home after hospital admission.The programme is accessed via referral to the Transitional Care Team from the Hospital, followed by an assessment by the aged Care assessment Team.placement into the programme is for a short term only (6-12 weeks) and identifies specific goals for the client. During their stay the client is further supported by their community based case manager and/or social worker and other appropriate allied health professionals.

an essential part of Continuity of Care is to maintain effective communication with patients.With this in mind we conduct bedside handovers in each of the clinical departments. This enables patients to be involved in planning their care. We have also recently implemented bedside discharge planning meetings.a recent audit of discharge documentation showed that 70% of patients had their discharge summary discussed with them. We are working towards increasing this to 100%.Surgical patients are contacted by our preanaesthetic nurse 5 to 7 days before admission. This provides patients with the opportunity to ask questions and for us to establish referral to a social worker, district nursing, physiotherapist, or post-acute care for assistance on discharge as required.We also conduct post discharge phone calls to surgical day procedure and urgent Care Centre patients, to check they are managing at home and assist if there are any issues.

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1 2 3 4 5 6

7 8 Queens Birthday 9 10 11 12 13

14 15 Men's Health Week 16 Men's Health Week 17 Men's Health Week 18 Men's Health Week 19 Men's Health Week 20 Men's Health Week

21 Father's Day 22 23 24 25 26 27

28 29 30

Notes:

JUNE 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Men's Health Week

S M T W Th F Sa1 2

3 4 5 6 7 8 910 11 12 13 14 15 1617 18 19 20 21 22 2324 25 26 27 28 29 3031

May 2015S M T W Th F Sa

1 2 3 45 6 7 8 9 10 11

12 13 14 15 16 17 1819 20 21 22 23 24 2526 27 28 29 30 31

July 2015

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DistriCt nursing — a story Through our District Nursing Service, we became involved with a 68 year old gentleman living on isolated rural property with multiple environmental issues.He had chronic complex health care and multiple behavioural issues around non compliance.Difficult social circum-stances existed in the multi generational home and support was being provided

by a primary health provider and twice weekly visits from the Kilmore District Nursing Service.The Hospital aged Care Staff engaged in discussions with the resident, wife and family. The client was admitted for respite care initially and eventually accepted permanent placement. He remained withdrawn and depressed for months. 12 months on: With emotional support and medical issues stabilised, the resident acknowledges he has a sense of control over his situation and he describes his current circumstances as “pretty good.”Multiple visits home on social leave resulted in the resident and family deciding they can now cope at home; as the family have had time to re energise.The resident has been discharged from our Nursing Home and has returned to our home visiting service.

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1 2 3 4

5 NAIDOC Week 6 NAIDOC Week 7 NAIDOC Week 8 NAIDOC Week 9 NAIDOC Week 10 NAIDOC Week 11 NAIDOC Week

12 13 14 15 16 17 18

19 20 21 22 23 24 25

26 27 28 29 30 31

Notes:

JULY 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Awareness Week Awareness Week Awareness Week Awareness WeekSkin Integrity Skin Integrity Skin Integrity Skin Integrity

S M T W Th F Sa1 2 3 4 5 6

7 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25 26 2728 29 30

June 2015S M T W Th F Sa

12 3 4 5 6 7 89 10 11 12 13 14 15

16 17 18 19 20 21 2223 24 25 26 27 28 2930 31

August 2015

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Listening to our Patients, resiDents anD CLientsWe aim to listen to feedback from patients, resident and clients and learn from their experiences.on admission all patients, residents and their families are given a complaints resolution brochure and their rights explained to them to encourage them to talk to us. face to face feedback is conducted regularly by a member of the Clinical leadership Team. patients and residents are selected randomly at point of care, to discuss their experience openly and informally.This was implemented in response to feedback received that many people do not feel the need to have formalised written responses to their feedback and emphasised the values of being listened to in a timely manner. all feedback is recorded and forwarded to appropriate department manager and tabled at Care Coordination Committee for review and monitoring. in our aged Care homes, as a result of feedback from our 2013 Satisfaction Survey, we have expanded our leisure and lifestyle programme to give residents a varied choice of activities.

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1

2 3 4 5 6 7 8

9 10 11 12 13 14 15

16 17 18 19 20 21 22

23 24 25 26 27 28 29

30 31 Notes:

AUGUST 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

S M T W Th F Sa1 2 3 4

5 6 7 8 9 10 1112 13 14 15 16 17 1819 20 21 22 23 24 2526 27 28 29 30 31

July 2015S M T W Th F Sa

1 2 3 4 56 7 8 9 10 11 12

13 14 15 16 17 18 1920 21 22 23 24 25 2627 28 29 30

September 2015

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QuaLity anD safetyfalls – what do we do to prevent falls and related injuries occurring?each person is risk assessed on admission. injury is prevented by the following strategies: use of alerts, mobility aids, increased supervision, alarm mats, signs and instructions, hip protectors, continence management, medication review, nurse call bell system. our falls minimisation programme has been in place now for some years.our discreetly posted “autumn leaves” alert all staff, volunteers and visitors to residents in our aged care homes who are at high risk of falls.all residents and patients are assessed to ascertain the degree of mobility and risk of falling to allow falls prevention strategies to be implemented in a timely manner in consultation with the patient and/or family and carer.initial, annual and as needs assessments are undertaken by our physiotherapist for all residents and patients. all residents are encouraged to participate in weekly exercise programmes.aged Care indicator 2: prevalence of falls and fall related fractures (per 1000 occupied bed days) shows we are below state average: Caladenia 6.04, Dianella 3.06, State wide rate being 7.15.

skin integrity – how do we maintain it?pressure wounds and skin tears are common risks in aged care. To reduce the risk of both we routinely assess our residents to identify potential contributing factors.each person is assessed on admission to acute services for the risk of developing a pressure injury. We then work with the patient and/or family and carers to minimise the incidence of pressure injury The introduction of an organisational wide wound monitoring programme has been instrumental in the early detection of early stage pressure ulcers and the subsequent decrease in the prevalence of Stage 3 and 4 pressure ulcers in our aged care homes. aged Care indicator 1: prevalence of pressure ulcers shows that both aged care homes are well below state wide rate: Caladenia 0.00, Dianella 0.00 State wide rate being 0.03.

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1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18 19

20 21 22 23 24 25 26

27 28 29 30

Notes:

SEPTEMBER 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Awareness Week Awareness Week Awareness Week Awareness WeekManual Handling Manual Handling Manual Handling Manual Handling

S M T W Th F Sa1

2 3 4 5 6 7 89 10 11 12 13 14 15

16 17 18 19 20 21 2223 24 25 26 27 28 2930 31

August 2015S M T W Th F Sa

1 2 34 5 6 7 8 9 10

11 12 13 14 15 16 1718 19 20 21 22 23 2425 26 27 28 29 30 31

October 2015

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QuaLity anD safetyMedication safetyMedications include tablets, injections, sprays, medicated patches, eye drops, inhalations and ointments. Given that on average it takes 10 mins per resident per day to order, prepare & administer a resident’s medication it is obvious medication management is a huge component of quality care.aged Care indicator 4: incidence of residents prescribed more than 9 Medications prescribed for residents (polypharmacy), show we are above state rate in high and mixed level care. Caladenia 4.23, state wide 4.30. Dianella 5.25, state wide 2.22This year we implemented a more robust checking system in Dianella Hotel. The after Hours Supervisors check the medication orders with pCas to make sure errors do not occur and orders are not missed. residential Medication Management review (rMMr) are undertaken for all residents over a 12 month period by an accredited pharmacist. reviews seek to identify, resolve and prevent such issues as polypharmacy, potential adverse medication interactions and ineffective medications.outcomes of the incidents for 2013 for the patients/residents were mild or no harm and the number trending is downwards. The majority were; missing administration of a medication or not signing for a medication.

Blood and Blood ProductsThe hospital participates in an annual state wide audit of blood and blood products with Blood Matters Victoria. This year the aim of the audit was to improve the quality of care provided to adult patients.

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1 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 27 28 29 30 31 Halloween

Notes:

OCTOBER 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

S M T W Th F Sa1 2 3 4 5

6 7 8 9 10 11 1213 14 15 16 17 18 1920 21 22 23 24 25 2627 28 29 30

September 2015S M T W Th F Sa1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 2829 30

November 2015

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incident reportingWe use incident reporting as a mechanism of identifying ways to improve the care we provide.

We promote a culture of no blame at Kilmore Hospital and know that reporting is important to allow for appropriate and timely action to minimise the impact and the recurrence of incidents.

The information received is used to identify trends on which we base changes to practice, education and staff developmental plans.

in 2012-2013 we recorded 772 incidents and near misses. in 2013-2014 we recorded 935 incidents and near misses.

restraint in aged Carerestraint is not used at Kilmore Hospital. legally restraint may only be used to address the risks a person poses to him/herself, to others or to property and not for the convenience of staff or to overcome lack of adequate supervision.

aged Care indicator 3: incidence of restraint once again shows we are performing well. Caladenia 0.00, Dianella 0.00, State wide rate being 0.72 and 0.32 respectively. allied Health access.

unplanned Weight Lossresidents are weighed on admission and monthly thereafter. all residents have a dietician review on admission, annually and when unplanned weight loss is identified.

When there is unplanned weight loss we more frequently include nutritional supplements in the resident’s daily intake and refer to the dietitian.

possible causes of weight loss such as general deterioration, swallowing

difficulties, ill fitting dentures or oral/dental problems are managed.

aged Care indicator 5: incidence of unplanned Weight loss greater than 3kgs shows we are well below the state rate. Caladenia 0.38, State wide 0.83. Dianella 0.00, State wide 0.0.76.

incidence of unplanned Weight loss each consecutive month shows we are well below the state rate. Caladenia 0, State wide 088. Dianella 0, State wide 0.60.

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1 2 3 Melbourne Cup 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30

Notes:

NOVEMBER 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Awareness Week Awareness Week Awareness Week Awareness WeekFire & Emergency Fire & Emergency Fire & Emergency Fire & Emergency

S M T W Th F Sa1 2 3

4 5 6 7 8 9 1011 12 13 14 15 16 1718 19 20 21 22 23 2425 26 27 28 29 30 31

October 2015S M T W Th F Sa

1 2 3 4 56 7 8 9 10 11 12

13 14 15 16 17 18 1920 21 22 23 24 25 2627 28 29 30 31

December 2015

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infeCtion ControLMinimising hospital infectionsHand Hygiene is an important way to prevent infections that can occur in hospitals and aged care homes. as part of our strategy to prevent infection, staff complete annual competency assessments and audits are conducted to ascertain levels of compliance with the 5 moments of hand hygiene.We also encourage our patients and residents to remind staff when they stray from best practise. it is reassuring to note results of the Victorian Health Services performance audit for Kilmore Hospital was 90% being well above the target of 70%. We participate in several audits throughout the year. audits are coordinated by the Hume region infection Control Consultants.The aS 4187 audit ensures the cleaning, disinfecting and sterilising of reusable medical and surgical equipment. The audit is divided into mandatory and best practice criteria. results are very pleasing.

Influenza VaccinationsInfluenza generally occurs as a seasonal illness typically in the autumn and winter months. The staff at The Kilmore and District Hospital are encouraged to have annual influenza vaccinations to ensure protection for themselves, their patients, residents and clients. Vaccinations are provided for free to all staff and volunteers.The vaccination uptake for staff within the organisation has increased annually. Whilst the 2014 data is yet to be finalised, it is on track to meet the Department of Health target of 75%.

infection surveillanceinfection surveillance is undertaken at the Kilmore and District Hospital and relates to blood stream infections, health care associated infections such as MrSa (Methicillin resistant staphylococcus aureus), Vre (Vancomycin resistant enterococcus) and clostridium difficile infections. Infection rates for the 2013/2014 financial year have remained at 0 for blood stream infections, MRSA, VRE and Clostridium difficile.Monthly infection surveillance occurs in our aged homes and includes infections of the urinary tract, respiratory tract, eyes, ears and mouth, skin and soft tissue and gastroenteritis. This surveillance allows us to monitor rates and determine strategies to prevent and control the transmission of infections in our residents. The organisation participates in an annual point prevalent survey which examines infections and antibiotic usage in residents during a 24 hour period. This data is submitted to the Victorian Healthcare associated infection Surveillance System.

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DECEMBER 2015Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Awareness Week Awareness Week Awareness Week Awareness WeekMedication Medication Medication Medication

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January 2016

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PHOTO HIGHLIGHTS FROM 2013/2014 Photo highLights froM 2013/2014

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USEFUL CONTACT NUMBERS

Ambulance/Police and CFA 000

The Kilmore & District Hospital 5734 2000- acute Ward Nurses Station 5734 2100- Caladenia Nursing Home 5734 2122- Dianella Hostel 5734 2155- District Nursing Service 5734 2149- Maternity (antenatal Queries): 5734 2162

Nurse on Call 1300 760 656

SeS 132 500Victorian Bushfire information line 1800 240 667Mitchell Shire Council 5734 6200

your feedback is important to us and can be made via:Email: [email protected]: 5734 2000Correspondence:The Kilmore & District Hospital, reply paid 185,Kilmore Vic 3764Website: www.kilmoredistricthospital.org.au

you can also like us on facebook: 540274112690158

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THe KilMore & DiSTriCT HoSpiTalrutledge Street, Kilmore, Victoria

po Box 185, Kilmore 3764phone: (03) 5734 2000

fax: (03) 5782 2019email: [email protected]