CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services

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CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
CALENDAR 2020

HEALTHY COMMUNITY. BEST CARE.
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
External Reviews: Our Accreditation Process
                                                     All public health services are required to meet various healthcare standards and accreditation
                                                     processes related to the services that they provide.
                                                     KDHS participates in regular accreditation surveys to ensure we are meeting the required criteria.
                                                     KDHS is fully accredited against the following:

                                                      Accreditation Framework         Status                                    Details

                                                      National Safety and             Fully accredited in May 2017              Applies to Hospital and
                                                      Quality Healthcare Standards    for a 3 year period.                      Community Health Services

                                                      Commonwealth                    Fully Accredited June 2019 till August    Applies to Sheridan Aged Care
                                                      Aged Care Accreditation         2022. Next full survey March 2022

                                                      Community Common                Fully accredited August 2017.             Applies to Commonwealth Home
                                                      Care Standards                  Next survey will be in July 2020          Support Program Community Home
                                                                                      Although this will next be under          Care Program, District Nursing &
                                                                                      the Aged Care Quality Standards           Social Support Program

                                                      Victorian Early Childhood       Fully accredited in May 2018. Next        Applies to the ENRICH Wellbeing –
                                                      Intervention Standards          Survey will be under the National         Early Childhood Intervention Service
                                                                                      Disability Insurance Scheme (NDIS)
                                                                                      Practice Standards

                                                      Health Service Standards        Fully accredited in September 2018.       Social Support Program
                                                                                      Next survey will be under the National
                                                                                      Disability Insurance Scheme (NDIS)
                                                                                      Practice Standards

OUR CARE AT A GL ANCE

Kyabram District Health Service (KDHS) provides
a comprehensive range of acute, sub-acute,
residential aged care and allied & primary
health care services. KDHS has been providing
services to the community since 1933.                                                Message from                                 Message from
For the 2018/2019 Quality Account, we are pleased to present you                     the Interim CEO                              the Board Chair
a colourful and informative calendar format.                                         On behalf of the Board and the staff at      Quality in health care at KDHS
                                                                                     Kyabram District Health Service, we are      means the right care, at the right
                                                                                     proud to present the 2018/19 Kyabram         time leading to the best outcome.
         4,688                                    1,069                              District Health Service Quality Account.
                                                                                                                                  Our vision Healthy Community Best
         Patients Admitted to hospital            Operations Performed               Our vision Healthy Community Best            Care, drives what we do, we hope
                                                                                     Care, drives what we do and we hope          that as you read the report you will
                                                                                     that as you read the report you will see     see it. The Board and staff of KDHS are

         4,418                                    7,745                              it evidenced in our performance and
                                                                                     the improvements in quality and safety
                                                                                                                                  committed to striving towards this
                                                                                                                                  goal and continue to work closely with
         Urgent Care Presentations                Primary Health Visits              made over the last twelve months.            our community to ensure continuing
                                                                                                                                  high quality care delivery in our region.
                                                                                     The Quality Account also provides

         393                                      1,634                              us with an opportunity to share
                                                                                     with you some of the activities we
                                                                                                                                  Yours sincerely,

         Cancer Treatments                        Renal Dialysis Treatments          are planning to further enhance the
                                                                                     quality of services we provide.

         276                                      93%                                Engagement with the community
                                                                                     and the people who use our service
                                                                                                                                  Nicole Ryan
                                                                                                                                  Board Chair
         District Nursing Clients                 Average Occupancy for              is important to us. If you have any
                                                  Sheridan Aged Care                 feedback or ideas for improvement
                                                                                     we would love to hear from you.
         7,031                                    79,963                             Yours sincerely,
         hours of Volunteering provided
                                                  Meals Prepared

         329                                                                         David Edwards
         Staff Employed
                                                                                     Interim Chief Executive Officer

KYABRAM DISTRICT HEALTH SERVICE
                                                                                                                   HEALTHY COMMUNITY. BEST CARE.                              1
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
2

                                                                                        Improving Patient
                                                                                        Experience
                                                                                         Patient Experience is measured
                                                                                          through many ways. One of
                                                                                          these is the Victorian Healthcare
                                                                                          Experience Survey (VHES).
                                                                                         VHES provides us with feedback
                                                                                          regarding patient experience during
                                                                                          their stay in hospital. Performance is
                                                                                          compared with other hospitals across
                                                                                          the state and targets are set each year.

                                                                                         From VHES data and patient surveys
                                                                                          improvements have been made to
                                                                                          discharge arrangements such as
                                                                                          embedding a multidisciplinary ward
                                                                                          round, providing a comprehensive
                                                                                          discharge form and utilising a
                                                                                          discharge medication form.

 JANUARY 2020
 SUNDAY          MONDAY           TUESDAY   WEDNESDAY    THURSDAY   FRIDAY   SATURDAY

 29              30               31        1            2          3        4

                                            New
                                            Year’s Day

 5               6                7         8            9          10       11

 12              13               14        15           16         17       18         POSITIVE PATIENT
                                                                                        EXPERIENCE RESPONSES

                                                                                            KDHS          State
                                                                                                                         Target
                                                                                           Results       Average
                                                                                                                         95.00%
                                                                                           98.33%        92.67%

 19              20               21        22           23         24       25

                                                                                        POSITIVE RESPONSES TO
                                                                                        DISCHARGE CARE

 26              27               28        29           30         31       1              KDHS          State
                                                                                                                         Target
                                                                                           Results       Average
                                                                                                                         75.00%
                                                                                           89.00%        75.57%

                 Australia Day
 Australia Day   Public Holiday

KYABRAM DISTRICT HEALTH SERVICE
                                                                                        HEALTHY COMMUNITY. BEST CARE.                3
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
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                                                                                   Working with Community
                                                                                   to Improve Services
                                                                                    Annually a Victorian Health Experience
                                                                                     Survey (VHES) is conducted throughout
                                                                                     the Primary Health department,
                                                                                     for clients accessing services.
                                                                                    The Community Health VHES is handed
                                                                                     to clients, unlike the inpatient VHES
                                                                                     which is mailed out after discharge.

                                                                                    In 2018 the response rate to the
                                                                                     Community Health VHES declined,
                                                                                     therefore due to the small response
                                                                                     rate there can be a margin of
                                                                                     error in interpreting the results.

 FEBRUARY 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY   FRIDAY   SATURDAY

                                                                                   Actions taken in Primary
 26             27            28        29          30         31       1
                                                                                   Health to improve the
                                                                                   Overall question set in
                                                                                   the VHES results.
                                                                                   Improve the community awareness
 2              3             4         5           6          7        8          of our feedback process

                                                                                    Information has been displayed
                                                                                     in the Primary Health area.

                                                                                    Education provided to our
                                                                                     Primary Health Staff.
 9              10            11        12          13         14       15
                                                                                   Improve community awareness
                                                                                   of the services provided

                                                                                    Greater communication to
                                                                                     the community about services
                                                                                     provided and how to access.
 16             17            18        19          20         21       22          List of services provided by Primary
                                                                                     Health Team available on our website.

                                                                                    Primary Health Promotions
                                                                                     Team has increased activity
                                                                                     on our Facebook page.

 23             24            25        26          27         28       29

KYABRAM DISTRICT HEALTH SERVICE
                                                                                   HEALTHY COMMUNITY. BEST CARE.              5
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
6

                                                                                   Improving access
                                                                                   The Community Health VHES survey
                                                                                   is an important tool that has enabled
                                                                                   KDHS to identify areas where we can
                                                                                   improve our services for the community.
                                                                                   A priority area to address from the
                                                                                   VHES survey is Access to the Health
                                                                                   Service. KDHS has worked on the
                                                                                   following action to improve access.
                                                                                    Improve Car Park Access:
                                                                                     By ensuring car parking at the
                                                                                     front of the health service is
                                                                                     available for patients, clients and
                                                                                     visitors and ensuring that staff
                                                                                     utilise areas further away from
                                                                                     the health service or by using the
                                                                                     designated staff parking areas.

                                                                                    Increase Service Awareness:
                                                                                     By promotion of the Community
                                                                                     Health services within KDHS has also
                                                                                     been identified as a target area which
                                                                                     is being focused on through social
                                                                                     media and other platforms.

 MARCH 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY   FRIDAY   SATURDAY

 1              2             3         4           5          6        7

 8              9             10        11          12         13       14

                                                                                   Environment
                Labour Day                                                         and Facilities
                                                                                   Another area addressed in the VHES
 15             16            17        18          19         20       21         survey is a set of question about
                                                                                   Environment and Facilities. These questions
                                                                                   resulted in 100% positive results.
                                                                                   The question “Were you given enough
                                                                                   privacy at reception?” resulted in
                                                                                   83% of responses of yes “Always”
 22             23            24        25          26         27       28
                                                                                   and 17% of yes “Sometimes”.
                                                                                   KDHS identified that there is an issue
                                                                                   with privacy at the main front reception
                                                                                   and have addressed this issue by
                                                                                    Using the blue waiting area
 29             30            31        1           2          3        4            sub-reception

                                                                                    Provide education to staff on the
                                                                                     suitability and timing of discussions
                                                                                     about personal details with
                                                                                     consumers in public places.

KYABRAM DISTRICT HEALTH SERVICE
                                                                                   HEALTHY COMMUNITY. BEST CARE.                 7
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
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                                                                                         Planning Your Care
                                                                                          KDHS uses the Community Health
                                                                                           VHES to identify areas where
                                                                                           services can be improved.

                                                                                          Actions identified from results have
                                                                                           seen improvements made to goal
                                                                                           setting and care planning to ensure
                                                                                           all relevant people are included in
                                                                                           goal setting process and copy of goals
                                                                                           and care plan are provided to clients.
                                                                                           Ongoing auditing has identified and
                                                                                           overall improvement in this area.

 APRIL 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY   FRIDAY        SATURDAY

 29             30            31        1           2          3             4

 5              6             7         8           9          10            11

                                                               Good Friday

 12             13            14        15          16         17            18          Community Consultation
                                                                                          KDHS has partnered with the Cancer
 Easter         Easter
                                                                                           Council of Victoria to better meet the
 Sunday         Monday                                                                     information needs of people effected
                                                                                           by cancer in regional Victoria.

 19             20            21        22          23         24            25           A Cancer Information and resource
                                                                                           hub has been set up adjacent to
                                                                                           the Cancer Service Department.

                                                                                          This area is called the Cancer
                                                                             ANZAC Day
                                                                                           Wellness Hub and has been set up
                                                                                           in consultation with service providers
 26             27            28        29          30         1             2             and the extended community. It
                                                                                           is being supported by one of the
                                                                                           KDHS fantastic volunteers who is
                                                                                           coordinating the resources and can
                                                                                           provide support for information access.

KYABRAM DISTRICT HEALTH SERVICE
                                                                                         HEALTHY COMMUNITY. BEST CARE.               9
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
10

                                                                                         Influenza Immunisation:
                                                                                         Targets Achieved.
                                                                                          In 2018-2019 KDHS exceeded the
                                                                                           Department of Health and Human
                                                                                           Service’s target for the healthcare
                                                                                           worker influenza vaccination program.
                                                                                          To achieve target the number of free
                                                                                           immunisation clinics were increased,
                                                                                           mobile vaccination services provided,
                                                                                           promotional flyers displayed and
                                                                                           targeted education sessions were
                                                                                           provided across the service.

                                                                                            KDHS Results               Target
                                                                                              83.00%                  80.00%

 MAY 2020
 SUNDAY         MONDAY        TUESDAY         WEDNESDAY   THURSDAY   FRIDAY   SATURDAY

 31             27            28              29          30         1        2

 3              4             5               6           7          8        9

                                                                                         Working to reduce the
                                                                                         spread of infection
 10             11            12              13          14         15       16
                                                                                          Our Environmental team has continued
                                                                                           an audit regime known as Gel
                              International
                                                                                           Testing in high risk areas of KDHS.
 Mother’s Day                 Nurses Day
                                                                                          The implementation of this audit
                                                                                           regime has allowed us to achieve
 17             18            19              20          21         22       23           above the target of 95% in this area.

                                                                                          This audit has enabled education
                                                                                           for environmental staff and provides
                                                                                           visible feedback to staff on the
                                                                                           thoroughness of cleaning conducted.

 24             25            26              27          28         29       30
                                                                                         Protect yourself, your family
                                                                                         and our patients. It’s time to think
                              National                                                   about getting your flu vaccination.
                              Sorry Day

KYABRAM DISTRICT HEALTH SERVICE
                                                                                         HEALTHY COMMUNITY. BEST CARE.             11
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
12

                                                                                   Working Together
                                                                                    KDHS is committed to supporting
                                                                                     consumer engagement. We
                                                                                     acknowledge that consumers play
                                                                                     an essential role in continuous
                                                                                     improvement across the service.

                                                                                    The strong commitment to engaging
                                                                                     with consumers and community
                                                                                     to guide the development,
                                                                                     implementation and improvement
                                                                                     of the service is shown through
                                                                                     implementation of the Partnering
                                                                                     in Health Care Framework.

                                                                                    The chosen domains of working
                                                                                     together and shared decision making
                                                                                     along with current and new initiatives
                                                                                     aim to improve consumer experience
                                                                                     and outcomes.

 JUNE 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY   FRIDAY   SATURDAY

 31             1             2         3           4          5        6

 7              8             9         10          11         12       13

                Queen’s
                Birthday

 14             15            16        17          18         19       20
                                                                                   We encourage the
                                                                                   community to become
                                                                                   involved at KDHS by:
                                                                                    Providing feedback (formal or informal)
 21             22            23        24          25         26       27          Participate as a consumer.
                                                                                    Becoming a volunteer.
                                                                                    Providing us with your feedback of
                                                                                     your experience/journey with KDHS.
                                                                                   Are you interested in being part
 28             29            30        1           2          3        4          of our consumer team, becoming
                                                                                   a volunteer or having input
                                                                                   into our Health Service?
                                                                                   Phone: 03 5857 0300
                                                                                   Email: info@kyhealth.org.au

KYABRAM DISTRICT HEALTH SERVICE
                                                                                   HEALTHY COMMUNITY. BEST CARE.               13
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
14

Sheridan Aged Care Service
To ensure accountability our Residential Aged Care service – Sheridan must report on their
performance against the five public sector residential aged care quality indicators.

PRESSURE INJURIES STAGE 1                                                                                     PHYSICAL RESTRAINT
                              1.00                                                                                                                 2.00
Number of pressure injuries

                                                                                                               restraint devices per 1000 days
                                                                                                              intent to restrain and the use of
                                                                                                                 Number of incidences with
                              0.80
   (per 1000 per days)

                                                                                                                                                   1.50
                              0.60
                              0.40                                                                                                                 1.00
                              0.20
                              0.00                                                                                                                 0.50
                                     JUL–SEP   OCT–DEC JAN–MAR APR–JUN    JUL–SEP   OCT–DEC JAN–MAR APR–JUN
                                                                                                                                                   0.00
                                      2O17      2O17     2O18   2O18       2O18      2O18     2O19   2O19
                                                                                                                                                          JUL–SEP   OCT–DEC JAN–MAR APR–JUN    JUL–SEP   OCT–DEC JAN–MAR APR–JUN
                                                                                                                                                           2O17      2O17     2O18   2O18       2O18      2O18     2O19   2O19
                                                KDHS STAGE 1 PRESSURE         STATEWIDE CARE RATES STAGE 1
                                                KDHS STAGE 2 PRESSURE         STATEWIDE CARE RATES STAGE 2
                                                                                                                                                                      SHERIDAN (A) INTENT           STATEWIDE HIGH CARE RATES
                                                                                                                                                                      SHERIDAN (B) DEVICES          STATEWIDE HIGH CARE RATES
Stage 1 Pressure injury rates within the service across the reported
time period continue to be less than the high care rates across                                               Physical Restraint within the service is measured in two ways –
all public sector residential aged care services. Stage 3, 4 and                                              Intention to restrain (Restraint A) and use of restraint devices
presumed deep tissue pressure injuries are not displayed due to                                               for any reason (Restraint B) – the service does record the use of
Sheridan Aged Care not having any incidences on these injuries                                                orientation rails i.e. rails up to assist in independent repositioning
within the service over the 2017 to 2019-time period.                                                         for residents while in bed and comfort in the data collection.

USE OF NINE OR MORE MEDICATIONS                                                                               FALLS & FRACTURES
                              6.00                                                                                                                15.00
medicines per 1000 days

                                                                                                              Number of incidences
  Residents using 9+

                              4.00                                                                                                                10.00
                                                                                                                 per 1000 days

                              2.00                                                                                                                 5.00

                                                                                                                                                   0.00
                              0.00                                                                                                                        JUL–SEP   OCT–DEC JAN–MAR APR–JUN    JUL–SEP   OCT–DEC JAN–MAR APR–JUN
                                     JUL–SEP   OCT–DEC JAN–MAR APR–JUN    JUL–SEP   OCT–DEC JAN–MAR APR–JUN                                                2O17      2O17     2O18   2O18       2O18      2O18     2O19   2O19
                                      2O17      2O17     2O18   2O18       2O18      2O18     2O19   2O19
                                                                                                                                                                    KDHS FALLS               STATEWIDE HIGH CARE RATES FALLS
                                                         KDHS           STATEWIDE HIGH CARE RATES
                                                                                                                                                                    KDHS FRACTURES           STATEWIDE HIGH CARE RATES FRACTURES

A medication review is being undertaken across the service in a
multidisciplinary team approach inclusive of geriatric specialists.

UNPL ANNED WEIGHT LOSS
                              3.00
Consecutive weight loss

                              2.00
    per 1000 days

                              1.00

                              0.00
                                     JUL–SEP   OCT–DEC JAN–MAR APR–JUN    JUL–SEP   OCT–DEC JAN–MAR APR–JUN
                                      2O17      2O17     2O18   2O18       2O18      2O18     2O19   2O19

                                                         KDHS           STATEWIDE HIGH CARE RATES

KYABRAM DISTRICT HEALTH SERVICE
                                                                                                                                                                               HEALTHY COMMUNITY. BEST CARE.                       15
QUALITY ACCOUNT 2018 / 19
CALENDAR 2020 - HEALTHY COMMUNITY. BEST CARE. QUALITY ACCOUNT 2018 / 19 - Kyabram District Health Services
16

                                                                                         Improving our Health
                                                                                         Service Experience
                                                                                         for our Community
                                                                                         KDHS continues to improve the
                                                                                         service experience of our Aboriginal
                                                                                         and Torres Strait Islander Community
                                                                                         Members by providing the following:
                                                                                          Advocacy between community
                                                                                           and health services to coordinate
                                                                                           appointments.

                                                                                          Emotional support.
                                                                                          Transportation for community
                                                                                           members to attend community
                                                                                           health/medical appointments.

                                                                                          Cultural education for staff.
                                                                                          Assist community with arrangements
                                                                                           for hospital admission or discharge.
  WHAT IS NAIDOC?                                                                         Helps link patients to appropriate
  Local community celebrations are held across Australia for one                           community support programs,
  week in July to celebrate the history, culture and achievements of                       agencies, services and events.
  Aboriginal and Torres Strait Islander people. NAIDOC originally stood
  for National Aborigines and Islanders Day Observance Committee
  and its acronym has since become the name of the week itself.

 JULY 2020
 SUNDAY         MONDAY        TUESDAY    WEDNESDAY     THURSDAY      FRIDAY   SATURDAY

 28             29            30         1             2             3        4

 5              6             7          8             9             10       11

 12             13            14         15            16            17       18         Simone Guinan
                                                                                         Aboriginal Health Liaison Officer
                                                                                         Contact Number: 0466 466 303

                                                                                         WHAT IS AN ABORIGINAL
                                                                                         HEALTH LIAISON OFFICER?
 19             20            21         22            23            24       25         An Aboriginal Health Liaison Officer
                                                                                         (AHLO) is here to provide emotional, social
                                                                                         and cultural support to Aboriginal and
                                                                                         Torres Strait Islander patients and their
                                                                                         families and also to provide information
                                                                                         and support to staff to help them provide
 26             27            28         29            30            31       1          a culturally sensitive health service.

KYABRAM DISTRICT HEALTH SERVICE
                                                                                         HEALTHY COMMUNITY. BEST CARE.                 17
QUALITY ACCOUNT 2018 / 19
18

                                                                                                       Encouraging our patients,
                                                                                                       carers and consumers to
                                                                                                             “Talk with us”
                                                                                                        Clinical escalation processes are
                                                                                                         used across the service. Education
                                                                                                         is provided to patients and families
                                                                                                         on admission on speaking up and
                                                                                                         “talking with us”. This information
                                                                                                         is also displayed in rooms and
                                                                                                         on patient journey boards.
                                                                                                        Track and trigger observation charts
                                                                                                         with colour coded areas, along
                                                                                                         with clinical expertise are used to
                                                                                                         identify abnormal parameters or
                                                                                                         changes in a patient’s condition.
                                                                                                         These tools enable a response
                                                                                                         and initiate a clinical review and
                                                                                                         increased management as required.

        CASE REVIEW
        ■   Family sitting with patient and became concerned that their family member was
            experiencing new pain in the chest and started to appear unwell to them.
        ■   Called the number on the patient journey board and spoke to the Nurse In Charge.
        ■   The nurse assessed the patient, then escalated care by speaking with the doctor,
            administered pain relief and commenced investigations into the cause of the chest pain.

 AUGUST 2020
 SUNDAY          MONDAY         TUESDAY       WEDNESDAY      THURSDAY       FRIDAY          SATURDAY
                                                                                                       Keeping Everyone Safe
 30              31             28            29             30             31              1           Incidents are classified using Incident
                                                                                                         Severity Rating (ISR) 1 through to 4.
                                                                                                         ISR 1 or 2 incidents have investigation
                                                                                                         processes in place and are reported
                                                                                                         through to the board of directors on
                                                                                                         the Clinical Governance Dashboard
                                                                                                         and Clinical Governance Committee.
 2               3              4             5              6              7               8
                                                                                                        ISR 1 incidents are reported to
                                                                                                         Safer Care Victoria as a sentinel
                                                                                                         event and a Root Cause analysis
                                                                                                         (RCA) is conducted to investigate
                                                                                                         and identify improvements. An in-
                                                                                                         depth investigation is conducted
 9               10             11            12             13             14              15           in response to ISR 2 incidents.

                                                                                                        In 2018-19 the number of adverse
                                                                                                         events that resulted in severe
                                                                                                         or moderate harm to patients
                                                                                                         was 0.9% of the total number
                                                                                                         of incidents occurred across the
 16              17             18            19             20             21              22           service. In 2018/2019 KDHS
                                                                                                         reported 1 sentinel event (0.1% of
                                                                                                         all incidents) and 8 ISR2 incidents.
                                                                                                        Outcomes/learnings from
                                                                                                         these events were:
 23              24             25            26             27             28              29             Improved multidisciplinary
                                                                                                            approach
                                                                                                           Improved documentation
                                                                                                           Improved escalation of
                                                                                                            clinical deterioration

KYABRAM DISTRICT HEALTH SERVICE
                                                                                                       HEALTHY COMMUNITY. BEST CARE.               19
QUALITY ACCOUNT 2018 / 19
20

                                                                                     Improving Patient Safety
                                                                                     KDHS measures patient safety through
                                                                                     several mechanisms. One of these, is
                                                                                     the People Matters Survey which is
                                                                                     a public sector staff opinion survey
                                                                                     run by the Victorian Public Sector
                                                                                     Commission and this provides us with
                                                                                     helpful feedback. Our performance is
                                                                                     compared to other hospitals across the
                                                                                     state. In terms of the Safety Culture
                                                                                     Questions, KDHS continues to be a leader
                                                                                     against other health services and have
                                                                                     exceeded our benchmark of 80%.

                                                                                           KDHS
                                                                                                                 Target
                                                                                          Results
                                                                                                                 80.00%
                                                                                          94.00%

                                                                                        Our figures represent the percentage
                                                                                           of respondents “agreeing” or
                                                                                         “strongly agreeing” with the eight
                                                                                          safety culture survey questions.

 SEPTEMBER 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY     FRIDAY   SATURDAY

 30             31            1         2           3            4        5

                                                                                     Looking after our
                                                                                     Staff is important to us
 6              7             8         9           10           11       12          KDHS celebrated its inaugural
                                                                                       R U OK Day across the organisation
                                                                                       conducted by our experienced
                                                                                       Social Worker Team.
 Father’s Day                                       R U OK Day
                                                                                      Promotional merchandise was
                                                                                       distributed across the organisation
 13             14            15        16          17           18       19           including a large banner, poster
                                                                                       displays, promotion on KDHS
                                                                                       Facebook page, some staff wore
                                                                                       yellow t-shirts and R U OK YouTube
                                                                                       clips were played on public TV’s.
                                                                                      All merchandise promoted the
 20             21            22        23          24           25       26           4 steps to encourage staff and
                                                                                       community members to ask friends,
                                                                                       family and colleagues if they are ok
                                                                                       and how they can offer support.
                                                                                      An all staff morning tea was held
                                                                                       and a talk was provided, expanding
 27             28            29        30          1            2        3            on the 4 conversation steps.

                                                                                     A conversation could
                                                                                     change a life. R U OK?

KYABRAM DISTRICT HEALTH SERVICE
                                                                                     HEALTHY COMMUNITY. BEST CARE.              21
QUALITY ACCOUNT 2018 / 19
22

                                                                                   Prevention and
                                                                                   Control of Healthcare
                                                                                   Associated infections
                                                                                   (Staphylococcus Aureus
                                                                                   bacteraemia rate)
                                                                                    KDHS infection control surveillance
                                                                                     monitors any incidences of
                                                                                     hospital associated Staphylococcus
                                                                                     aureus bacteraemia.

                                                                                    In 2018-19 there were no hospital
                                                                                     associated Staphylococcus aureus
                                                                                     bacteraemia identified.

                                                                                    A hospital associated infection is:
                                                                                     an infection that occurs 48 hours
                                                                                     after admission.

                                                                                    KDHS maintains an active
                                                                                     infection prevention and control
                                                                                     program to prevent hospital
                                                                                     associated infections. Including

                                                                                       hand hygiene program
                                                                                        including education
                                                                                       aseptic technique education
                                                                                       clinical practice guidelines
                                                                                        (invasive devices)

 OCTOBER 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY   FRIDAY   SATURDAY

 27             28            29        30          1          2        3

                                                                                   To help reduce the spread of hospital
 4              5             6         7           8          9        10
                                                                                   infections, all staff, patients, carers
                                                                                   and consumers are reminded of
                                                                                   proper hand wash technique:
                                                                                   1. Wet your hands with clean,
                                                                                      running water (warm or cold), turn
 11             12            13        14          15         16       17            off the tap, and apply soap.
                                                                                   2. Lather your hands by rubbing
                                                                                      them together with the soap...
                                                                                   3. Scrub your hands for at
                                                                                      least 20 seconds...

 18             19            20        21          22         23       24         4. Rinse your hands well under
                                                                                      clean, running water.
                                                                                   5. Dry your hands using a clean
                                                                                      towel or air dry them.

                                                                                   HELP STOP THE SPREAD
 25             26            27        28          29         30       31         OF INFECTION
                                                                                   Please sanitise/wash your hands
                                                                                   when entering and exiting our
                                                                                   health service and patient rooms.

KYABRAM DISTRICT HEALTH SERVICE
                                                                                   HEALTHY COMMUNITY. BEST CARE.             23
QUALITY ACCOUNT 2018 / 19
24

                                                                                       Interpreting Services:
                                                                                       Breaking Down
                                                                                       the Barriers
                                                                                        KDHS aim to screen all patients
                                                                                         and clients to identify if an
                                                                                         interpreter is needed.

                                                                                        The main area of the service that
                                                                                         we have seen utilise interpreter
                                                                                         services in the past 12 month
                                                                                         either through telephone or face to
                                                                                         face has been the Primary Health
                                                                                         Department. Which have used 9
                                                                                         instances of interpreter services.

 NOVEMBER 2020
 SUNDAY         MONDAY        TUESDAY     WEDNESDAY     THURSDAY   FRIDAY   SATURDAY

 1              2             3           4             5          6        7

                              Melbourne
                              Cup

 8              9             10          11            12         13       14

                                          Remembrance
                                          Day

 15             16            17          18            19         20       21         INVESTING IN OUR COMMUNIT Y:
                                                                                       INCLUSION AND DIVERSIT Y
                                                                                       KDHS has developed a disability action
                                                                                       plan, with is currently in draft format
                                                                                       awaiting board endorsement. The plan is
                                                                                       for a three-year period and focuses on
 22             23            24          25            26         27       28
                                                                                       access, communication and exploration of
                                                                                       employment opportunities.
                                                                                       KDHS looks forward to bringing this action
                                                                                       plan to fruition with community members
                                                                                       through consultation, forums and targeted
 29             30            1           2             3          4        5          working parties. Once approved by the
                                                                                       board this action plan will be The Disability
                                                                                       Action Plan has been incorporated into
                                                                                       the Community and Cultural Governance
                                                                                       committee as standing agenda item.

KYABRAM DISTRICT HEALTH SERVICE
                                                                                       HEALTHY COMMUNITY. BEST CARE.                   25
QUALITY ACCOUNT 2018 / 19
26

                                                                                                 Your Feedback
                                                                                                 is Important to Us
                                                                                                  Feedback is a powerful tool that
                                                                                                   enables us to know how our patients
                                                                                                   and our community perceive our
                                                                                                   performance and provides us with
                                                                                                   the opportunity to improve our
                                                                                                   services to ensure that we provide
                                                                                                   best care and services to our
                                                                                                   patients and our community.
                                                                                                  There are many different ways our
                                                                                                   patients and consumers can provide
                                                                                                   feedback, whether it be a complaint,
                                                                                                   compliment or suggestion.

                                                                                                  In 2018/2019 KDHS received a total
                                                                                                   of 148 formal feedback responses.

                                                                                                  88 Compliments          60 Complaints

 DECEMBER 2020
 SUNDAY         MONDAY        TUESDAY   WEDNESDAY   THURSDAY        FRIDAY          SATURDAY     IMPROVEMENTS MADE
                                                                                                 FROM FEEDBACK
 29             30            1         2           3               4               5             Including Doctors name on
                                                    International                                  the referral acknowledgement
                                                    Day of People                                  letter so clients are aware who
                                                    with a                                         referred them to the service.
                                                    Disability
                                                                                                  Increased temperature checks
                                                                                                   on food when leaving kitchen
 6              7             8         9           10              11              12             for Social Support Program.

                                                                                                 Feedback Process
                                                                                                         Feedback can be lodged in a
 13             14            15        16          17              18              19                   number of ways (see back cover).
                                                                                                         Complaints are acknowledged
                                                                                                         promptly and the complainant
                                                                                                         is advised on how his/her
                                                                                                         complaint will be managed.
 20             21            22        23          24              25              26                   If the complainant is not satisfied,
                                                                                                         we provide information about
                                                                                                         other options on how the
                                                                                                         complaint can be reviewed
                                                                    Christmas Day   Boxing Day
                                                                                                         or lodged.
                                                                                                         Complaints and actions to
 27             28            29        30          1               2               3
                                                                                                         address complaints are reported
                                                                                                         to our Clinical Quality & Safety
                                                    New
                                                                                                         Committee and our Clinical
                                                    Year’s Day                                           Governance Committee.

KYABRAM DISTRICT HEALTH SERVICE
                                                                                                 HEALTHY COMMUNITY. BEST CARE.                  27
QUALITY ACCOUNT 2018 / 19
28

KDHS District Nurses – Provide services to the community, assisting people to stay at home whilst still receiving nursing care.

NOTES

                                                                                                       Would you
                                                                                                       like to invest in
                                                                                                       the future of KDHS?
                                                                                                       Your donations and bequests help us to
                                                                                                       achieve our vision, enhance the quality
                                                                                                       of life of our residents and contribute
                                                                                                       to the well-being of our community.
                                                                                                       Donations of $2 and over are tax
                                                                                                       deductible and are a wonderful way
                                                                                                       to invest in your local health service.
                                                                                                       HOW TO MAKE A DONATION
                                                                                                       ■   Call us on 03 5857 0200
                                                                                                       ■   Directly at our main site
                                                                                                           86–96 Fenaughty Street, Kyabram
                                                                                                       ■   Cheque sent to:
                                                                                                             CEO
                                                                                                             Kyabram District Health Service
                                                                                                             PO Box 564
                                                                                                             Kyabram, Vic, 3619
                                                                                                       ■   Cheques can be made payable to
                                                                                                           Kyabram District Health Service

KYABRAM DISTRICT HEALTH SERVICE
                                                                                                       HEALTHY COMMUNITY. BEST CARE.             29
QUALITY ACCOUNT 2018 / 19
K YA B R A M H E A LT H       S TA N H O P E H E A LT H                     T O N G A L A H E A LT H
                             86-96 Fenaughty Street        35 Birdwood Avenue                            37 Mangan Street
                             Kyabram VIC 3620              Stanhope VIC 3623                             Tongala VIC 3621
                             Phone: (03) 5857 0200         Phone: (03) 5857 0451                         Phone: (03) 5857 0245
                             Email: info@kyhealth.org.au   Email: chealth@kyhealth.org.au                Email: chtongala@kyhealth.org.au

How can you provide us with feedback?                      How we manage complaints:
                                                           Complaint resolution at first point of contact:
       Face to face:                                       ■   Consumers are encouraged to raise complaints or concerns with the staff involved at the time
                                Send an email:                 the issue arises. This provides the best chance for concerns to be addressed quickly, and
       Interviews
                                info@kyhealth.org.au           prevent any ongoing problems.
       and surveys
                                                           If unresolved:
                                                           Investigation of complaint by Manager
                                                           ■  The Manager of the area investigates the problem, makes contact with the consumer and
       Feedback                 Complete our online
                                                              works with consumer and staff to resolve the issue in a timely manner.
       form: Available          feedback form:
       throughout KDHS          www.kyhealth.org.au        If unresolved:
                                                           Investigation by Senior Manager in Division
                                                           ■  When an issue cannot be resolved by the Manager, or when the issue is particularly complex
       Feedback via                                           for some other reason, we begin an investigation and collect and review all the information.
       Happy or Not             Phone:                        We ensure that the right people are involved with the consumer in addressing a complaint
       Stations: Available      +61 (03) 5857 0200            with the aim of resolving and preventing future problems.
       throughout KDHS
                                                           If Consumer is not satisfied with our response or needs further assistance:
                                                           ■   If you are not satisfied with our response, or need further assistance and advice you may contact:
                                                               ■    Disability Service Commissioner: 1800 677 342
                                Via social media:              ■    Health Complaints Commissioner: 1300 582 113
       Write to us:
                                facebook.com/                  ■    Office of the Public Advocate: (03) 9603 9500
       PO Box 564
                                kyabramdistrict                ■    Victorian Equal Opportunity: 1300 891 848
       Kyabram VIC 3719                                        ■    Aged Care Complaints Scheme: 1800 550 552
                                healthservice                  ■    Residential Care Rights: 1800 550 552
                                                               ■    Older Persons Advocacy Network: 1800 700 600
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