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The Clinical Communiqué is an electronic publication containing narrative case reports about lessons learned from Coroners’ investigations into preventable deaths in acute hospital and community settings. The Clinical Communiqué is written by clinicians, for clinicians.
Associate Professor Nicola Cunningham
Welcome to the September edition of the Clinical Communiqué for 2023. Each year, on the 17th of September, the world recognises and celebrates the importance of patient safety. This crucial juncture came about at the 72nd World Health Assembly in May 2019, where all 194 member states of the World Health Organisation (WHO), adopted the World Patient Safety Day Resolution (Resolution WHA 72.6), and endorsed the establishment of an annual World Patient Safety Day in recognition of the importance of patient safety as a global health priority.
The objectives of World Patient Safety Day are to increase public awareness and engagement, enhance global understanding, and spur global solidarity and action to prevent avoidable harm in health care and promote patient safety. In September 2020, the WHO urged the world to, “speak up for health worker safety!” In September 2021, the focus was on “the need to prioritise and address safety in maternal and newborn
care”, while 2022 saw the theme of “medication safety” highlighted. This year, the theme for World Patient Safety Day is “Engaging patients for patient safety”, with the call to “Elevate the voice of patients!”.
In my experience of more than two decades of reading and reviewing coronial findings, the disconnect between the concerns of families, carers, friends, and patients themselves, and a health care system’s response, is all too painfully common. A breakdown in communication, an unheard voice, a silenced question, is a familiar thread that runs through almost every story. Those moments may not have always been found by the coroner to be the main cause of preventable harm, but they were almost certainly a contributing factor, and undeniably, a source of long-term suffering for those whose concerns went unanswered.
The two cases in this edition were from different decades but sadly told the same story. Families who felt they were not listened to by the nurses and doctors caring for their loved ones. A perceived lack of engagement and a failure of escalation that led to the patients’ deaths. In many respects, it is incomprehensible that it has taken this long, where yet another decade has passed, for the world to formally recognise, on a global
scale, the importance of engaging patients for patient safety.
What is heartening to see is some of the incredible work that individuals and organisations are putting into humanising health care – that is, strengthening the patient voice by placing them in their rightful place at the centre of the health care system. Such a fundamental and obvious notion, yet such a complex paradigm to achieve. It requires culture change, and co-designing policies and procedures with patients (consumers), at all levels of the health care system and by national and international regulatory bodies. Without a consumer focus on all that we strive to achieve in health care, there will always be missed opportunities for improvement.
The two expert commentaries in this edition were written by two incredible women who have dedicated their careers to advocating for consumer centred health care. Elizabeth Deveny is the Chief Executive Officer of Consumers Health Forum of Australia (CHF), the national peak body representing the interests of Australian healthcare consumers. Belinda MacLeod-Smith is a health consumer leader who amongst her many areas of expertise, is involved in partnering and co-design in health care with Safer Care Victoria. It is an immense privilege to read how their personal experiences have shaped their work, and it is their courage in sharing their own stories that speak to their dedication in achieving equitable and safe health care for all.
As I put this edition together, I was struck by a singular recurring thought. I am a clinician… but I am also a user of the health care system. As a daughter, a mother, a partner, a friend, I have had my own good and bad experiences of the health care system, and I know that there will be many more moments to come where I exist as the health care user accessing services and not the clinician providing care. That is the universal, inescapable, actuality for all clinicians. So why then, do we still have so much to learn about consumercentred health care? How did such a chasm develop between the outlook of clinicians versus the experiences of consumers that we needed the emergence of consumer advocates to open our eyes to the failings in the system? I look to the consumer advocates that I have come to know as good friends and wise colleagues in my various work roles, and I thank them. For their insights, and for their persistence in holding a mirror up to us all. For continuously reminding us that we can do better – for their loved ones, and for our own. Thank you for elevating the voice of patients.
Click on the image to access the September 2023 Clinical Communique
In partnership with First Nations Peoples from clinical, education, design, and consumer advocacy backgrounds, this critical edition of the Clinical Communiqué presents two coroners’ cases where a lack of cultural safety in the health care system led to preventable and tragic consequences. Special thanks to Mr Olli Wynyard Gonfond who narrated this episode, and Dr Jordana Stanford for her guest apperance.
This is Episode Eleven of our podcast series and features material from our March 2023 print edition of the Clinical Communiqué.
Episode Contents
- 01:07 Editorial by Associate Professor Nicola Cunningham
- 07:46 Guest Editorial by Ms Belinda Gibb
- 18:33 Case #1: A culture of care by Dr Glenn Harrison
- 28:42 Case #2: Seen but not heard by Dr Jordana Stanford
- 40:11 Expert Commentary by Dr Olli Wynyard Gonfond: Developing cultural safety behaviours and capabilities in health care
- 46:41 Expert Commentary by Ms Jacqui Gibson: Why cultural safety improves patient safety
Click here to access the Clinical Communique Podcast Episode #11
Every day, with every patient we aim to deliver comprehensive care. This involves partnering with our patients and families to identify risk and develop comprehensive care plans that supports delivery of best care and reduces risk of harm.
Central to WH’s approach is recognising that all comprehensive care domains are ‘linked’ and influence other domains. WH health care teams ensure delivery of person-centred care, by involving the patient, families, carers and other support people in the setting of patient goals.
I am proud to lead the ‘Sensational 7’ NSQHS Std 5 Comprehensive Team that brings together nursing, medical, allied health, education, quality, mental health experts and comprehensive care expertise to support our ongoing compliance with this National Standard. We have worked closely with Western Health’s Person-Centred Care Committee to ensure we are continually monitoring, reviewing and improving our comprehensive care practices.
We have had a productive year with a continued focus on creating dashboards that provide accurate data, and support timely identification of improvement opportunities and subsequent development of improvement plans for each comprehensive care domain. Working with our multidisciplinary advisory groups and consumer representatives, we have reviewed processes, tools, systems, training requirements and consumer education options to ensure we align with evidence based practice and , support best possible patient outcomes.
Please continue reading to find out more about our comprehensive care strategies, achievements and opportunities for improvement.
Rebecca Woltsche
NSQHS Std 5 Comprehensive Care Team Lead
Seeing the Person in the Patient
Shane Crowe, Executive Director of Nursing & Midwifery shares his thoughts on Person-Centred Care:
“Person-centred care means we treat each patient as an individual, and we involve them and their family in all aspects of their care. We take into consideration their preferences, their goals and their needs, as we are planning, implementing and evaluating their care.
In day to day practice, in our busy days, it is easy to be caught up in tasks that we have to undertake. Taking that moment to engage with the patient, and making sure they are being treated as a person, that we’re meeting their needs every step of the way, doesn’t actually take a lot of extra time but it really makes a huge amount of difference to the patient and their experience of health care.
We want patients and their families to feel informed, educated and involved in their care. We went them to feel empowered; we want them to feel they’re part of the decision making process in terms of their care, and we want them to feel genuinely cared for and treated as the individual person they are”.
The Comprehensive Care Standard supports Western Health to provide Person-Centred Care.
Western Health’s approach to Comprehensive Care draws upon requirements of this Standard and supports the monitoring, review and improvement of person-centred care.
Western Health’s approach to Comprehensive Care draws upon requirements of this Standard and supports the monitoring, review and improvement of person-centred care.
Programs and strategies that support comprehensive care include:
- Comprehensive policies, procedures and guidelines to support delivery of Comprehensive Care
- Comprehensive Risk assessments to identify patients at increased risk of harm.
- Comprehensive Care Plans (IPOC) and Electronic Medical Record (EMR) order sets to help support delivery of Comprehensive Care
- Performance Dashboards providing real time data on falls, pressure injuries, nutrition and delirium to drive improvement
- Comprehensive Care Clinical Nurse Consultant inpatient services
- Online Comprehensive Care WeLearn modules
- Bi-monthly WH newsletters on Falls and Pressure injury prevention
- Annual training days for Falls, Pressure injury, Delirium and Nutrition champions.
We are proud of the following achievements for 2022/23:
- Our pressure injury, falls prevention, nutrition and delirium champion programs supporting implementation of organisational initiatives and engagement in ward-based improvement activities
- The development of an Electronic Medical Record Ward Overview Page to communicate the identified risk profile of ward patients
- The development and roll-out of a suite of new and revised Comprehensive Care WeLearn (staff education) Modules
- Launch of new Comprehensive Care performance dashboards to support the identification of variances, subsequent review and improvement of care
- Development and/or progression of a suite of Comprehensive Care Clinical Practice Improvement Plans
- Multiple optimisations of the EMR to improve the quality and completion of risk assessments.
- Facilitating a Health Service Falls Collaborative with 15 other health services to discuss barriers and enablers in implementing World Hospital Falls Prevention Guidelines.
- Supporting local ward Comprehensive Care projects to improve patient outcomes
- Upgrade of Fall Prevention, Pressure Injury and Advanced Care Planning Intranet sites.
- Facilitating both Falls Champion and Pressure Injury Champion Collaboratives enabling our champions from various clinical areas to share their learnings and celebrate successes.
- Supporting the development of Comprehensive Care plans (IPOCS) across the whole patient journey
- Appointing a malnutrition dietician to identify and support patients at high risk of malnutrition
- Developing a new suite of Comprehensive Care risk assessment and care planning tools at Bacchus Marsh Hospital to support comprehensive risk assessment and care planning.
- Supporting implementation of the AICED education program, supporting implementation of Comprehensive Care assessment and planning at the bedside.
Click here to view more Improvement News
A number of systems support us to monitor comprehensive care.
Incidents and near misses are entered into the Incident Management System (RiskMan), with incident reports developed for reporting at ward level, divisional level, and through our Person-Centred Care and Best Care Committee structures.
WH’s MaP (Monitoring and Reporting) system brings together data from WH’s operational systems to support monitoring of comprehensive care. As well as drawing patient incident data from Riskman, MaP also integrates with the EMR to provide live and historical data on patient risk assessment and care planning. This supports day-to-day care and auditing of care processes.
Available dashboards include Falls, Pressure Injury, End Of Life Care, Delirium and Nutrition. The Self-harm and Suicide dashboard is due for release Oct 30th.
Auditing of care is also supported through activity such as six-monthly ABC (Audit Best Care) process
WH has an operational risk register that records risks relating to comprehensive care, with risks monitored through the Person-Centred Care Committee.
The Victorian Health Experience Survey (VHES) reports quarterly on patients’ experience of comprehensive care, with indicators on areas such as involvement in clinical decision making reported through the WH Best Care Report. Comprehensive care data is also submitted externally to support analysis and comparative review through for example the Health Roundtable (HRT).
What has our data told us?
Falls
Falls in hospital remain most prevalent in patients over the age of 65 years. Western Health has experienced stubbornly high patient fall rates, indicating peaks during the COVID surge in Dec/Jan 2022/23 and again during winter 2023. There was also an increase in falls when Western Health began providing services for mental health care in July 2023.
A Western Health Falls Improvement plan and framework was released in April 2022 outlining 70 action items of which 66 have been completed. These included the establishment of a Falls champion program, now with over 100 staff trained as falls prevention experts in all clinical areas.
A Falls Improvement Plan for 2023-24 has been developed, with a strong focus on staff training and education.
In August, Western Health has facilitated an inaugural Health Services Falls Collaborative, with 15 health service attending to discuss the increasing number of falls across the health sector and evidence-based falls strategies. This has created a community of practice and sharing of ideas. It also identified the increase in patient falls and patients with BPSD has been a shared experience across all health services, and reflects an increasingly complex inpatient population together with increasing rates of dementia never seen before.
Delirium
Western Health compares favourably with like health services / hospitals for instances of delirium in hospital, a reflection on the risk assessment and management tools in place across our organisation.
Within the past year, our Delirium Champion program has been relaunched and increased completion of our Delirium WeLearn module has been noted.
A Delirium online dashboard has also been developed and we also now have access to delirium related clinical indicators through a new Victorian Agency for health Information hospital-acquired complication dashboard.
Our Delirium Clinical Nurse Consultant works closely with our clinical teams to support patient care planning and staff education.
Pressure Injuries
We have made some good inroads into reducing our rate of hospital-acquired pressure injuries over the second half of 2022-23 and Western Health compares favourably with peer hospitals.
A Western Health Pressure Injury Improvement Plan for 2023-24 has been developed and has a strong focus on staff training and development.
The Pressure Injury Prevention Champion program has trained over 110 local experts and continues to support clinical practices and improve use of equipment and tools aimed at preventing pressure injuries or increased severity of injuries. This training has resulted in an increase in pressure injury identification and subsequent reporting. However not all of the reported pressure injuries are accurately staged when initially reported on Riskman, and this is reflected by our much lower clinically coded hospital acquired pressure injury HAC rate.
In response to the data, Western Health coordinated a Stop The Pressure multi-site expo in November 2022, focusing on preventing pressure injuries on the foot. Together with PIP resources and ongoing education, WH are seeing a reduction in serious hospital acquired foot pressure injuries.
Nutrition
There has been a good improvement in compliance with weekly weighing of patients in hospital, a key tool in the identification and management of malnutrition risk.
The development of the nutrition dashboard has assisted clinical areas to identify opportunities for improvement.
An increase in education on the importance of weighing patients on admission and weekly has contributed to improved practice.
Displaying weights on the Ward Overview page has also enabled clinical inpatient areas to quickly identify patients that have not been weighed
Implementation of the Red Dome program continues to support the identification of patient requiring assistance with feeding.
Click here to access the full set of comprehensive care dashboards.
The Person-Centred Care Committee is responsible for overseeing the multiple processes adopted across Western Health to support clinicians deliver comprehensive care and ensures robust systems for monitoring are embedded.
To achieve Best Care the interdisciplinary Committee undertakes the following actions:
- Receives regular performance reports from eight advisory groups and two working groups ensuring compliance with the NSQHS Comprehensive Care Standard and alignment with the Best Care framework.
- Oversees annual Improvement Plans developed by each advisory group to mitigate identified risks.
- Monitor, review and endorse organisational policies, procedures and guidelines related to the delivery of Comprehensive Care.
- Receive reports of clinical education and training activities related to Comprehensive Care.
- Monitor quality and patient safety indicators, patient feedback, clinical audits, trend reports, benchmarked data and other relevant information relating to Comprehensive Care.
- Monitor the operational risks related to comprehensive care
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Comprehensive Care
- Our Risk Profile for Std 5 Comprehensive Care
- Improvement News Stories aligned with Std 5 Comprehensive Care
- The online Performance Dashboard reporting aligned with Std 5 Comprehensive Care
- The Clinical Audits that support good practice against Std 5 Comprehensive Care
- The training programs available to support Comprehensive Care
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Looking forward, we continue our focus on …
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Data Analysis |
Key Messages |
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| Understanding and implement person centred comprehensive care | More than 1000 staff have completed the WeLearn modules
Launch of the AICED bedside coaching education program to reinforce Comprehensive Care at the bedside |
Be familiar with the relevant policies, procedures and guidelines relating to comprehensive care at Western Health |
Identify potential risks to patients during health care |
85% of patients have the comprehensive care risk assessments completed on admission (EMR Dashboard) | Complete a comprehensive risk assessment using appropriate screening tools on every patient on admission and every shift or if patient’s condition changes.
Partner with our patient to educate them on identified risks and how they can reduce risk of harm whilst in hospital. |
| Implement targeted risk minimisation strategies to prevent harm. | 89% of patients have the have the comprehensive care IPOC initiated on admission (EMR Dashboard) | Ask the patient and their family/carers what matters to them to provide person centred care
Identify patient goals of care Develop a Comprehensive Care plan together with the patient, family and multidisciplinary health care team Monitor progress toward goals |
Treatment with blood and blood products can be lifesaving; however their use is not without risk and can lead to complications and adverse outcomes for patients. The National Blood Management Standard aims to ensure patients’ own blood is safely and appropriately managed, and any blood and blood products patients receive are safe and appropriate.
I have been proud to lead the ‘Fab 5’ NSQHS Std 7 Blood Management Team that brought together nursing, medical, education, quality and blood management subject matter experts to support our ongoing compliance with this National Standard. We have worked closely with Western Health’s Blood Management Committee to ensure we are continually monitoring, reviewing and improving our blood and blood product management practices.
It was a great experience to be involved in the ‘Standard of the fortnight’ initiative for NSQHS Std 7. This ran from Monday 29 May to Sunday 11 June. Our Blood Management Clinical Nurse Consultant Team, Fab 5 team members, Best Care Co-ordinators and others enjoyed popping into clinical areas/departments to to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.
We have had a busy and productive year with a continued focus on developing the systems, staff knowledge and engagement with patients and families to manage blood and blood products in a timely way and with the best possible patient outcome.
Please continue reading to find out more about our blood management strategies, achievements and opportunities for improvement.
Jo Mapes
NSQHS Std 7 ‘Fab 5’ Team Lead
Director of Nursing & Midwifery, Footscray Hospital
Division: Perioperative and Critical Care
The Blood Management Standard aligns with Right Care and aims to ensure that patients’ own blood is safely and appropriately managed, and that any blood and blood products that patients receive are safe and appropriate.
The Blood Management Standard supports Western Health to provide Right Care.
Western Health’s comprehensive approach to Blood and Blood Product Management draws upon requirements of this Standard and supports the monitoring, review and improvement of coordinated care.
Blood and blood products include:
1. Fresh blood products
- Red blood cells
- Platelets
- Fresh frozen plasma
- Cryoprecipitate
- Cryodepleted plasma
2. Plasma-derivatives and recombinant products
- Albumin
- Factor Concentrates
- Immunoglobulins, including immunoglobulin replacement therapy (e.g. IVIg) and hyperimmune globulins
Programs and strategies to help support Blood Management include:
- Informed patient consent for blood and blood products
- Use of key performance indicators, incident and adverse reaction reporting, and audits to review and enhance blood and blood product management
- Blood and blood product policies, procedures and protocols which support clinical practice in line with National Patient Blood Management Guidelines
- Participation in the Victorian State Haemovigilance Reporting Scheme.
- Blood product and transfusion medicine educational resources for clinical and ancillary staff
- Optimisation and conservation of patient’s own blood
- Equipment and processes to minimise blood and blood product wastage
We are proud of the following achievements for 2022/23:
- Return of the Blood Management Newsletters distributed to all staff members, providing updates on upcoming changes or matters (previously on hold due to Covid-19)
- Our new team of Blood management Clinical Nurse Consultants
- Our progress towards managing our risks and improving patient identification practice
- Integration of Bacchus Marsh & Melton blood management processes and forms into WH systems and policies
- Launching our new blood management dashboard for data reporting
- Our progress to ensure emergency supplies of blood and blood products at Bacchus Marsh Hospital
- Increasing the completion of mandatory training for Blood management & safety
- Improving the systems and equipment used for transport and storage of blood and blood products
Click here to view more Improvement News
Western Health aims to adopt the person-centred care approach, which ensures patients are involved in their own care throughout their inpatient stay.
Documented informed consent to blood product administration is required for all patients and guidelines are available for the care of patients who refuse blood products. Patients are actively involved in decisions concerning blood transfusion and information about blood products and transfusion is provided and available on the hospital intranet site and the WH Internet for patients and health professionals. This information is from authoritative sources and available in multiple languages including those common to the Western Suburbs community.
A number of systems support us to monitor identification and management of patient deterioration practice and outcomes.
The Blood Management Clinical Nurse Consultants (CNCs) facilitate a comprehensive audit program. Audit results are accessible through the new Blood Management online dashboards and are tabled at the Blood Management Committee (BMC) where they are reviewed to identify potential or actual risks and opportunities for improvement. Effectiveness of improvement strategies/processes is assessed through ongoing KPI review.
Surveys of the patient’s understanding of the consent to transfusion process are undertaken by the Blood Management CNCs, collated and reported to the BMC. Due to the COVID19 situation the number of surveys that have been able to be undertaken in the previous 2
years has been minimal. The Blood Management CNCs are currently working on conducting 100-120 patient experience surveys by the end of 2023.
An annual report is prepared by the BMC for the Safe Care Committee and Blood Management activities are also included in the WH Annual Quality Account report.
State and national benchmarking is enabled through participation in the Victorian Blood Matters program audits. Blood and blood product Discard as a Percentage of Issue (DAPI) data is collated monthly and benchmarked against State and National percentages.
Reports of blood related incidents, near misses and adverse reactions are reviewed by the Blood Management CNCs, presented at BMC meetings and where applicable referred to the Clinical Council to assess and identify whether these could be reduced by improvements to policies, protocols and procedures.
What has our data told us?
Wastage of Blood Products
Red blood cells which are prescribed for patients who have anaemia are the most frequently transfused blood product at Western Health.
Donated red blood cell units have a life span of 42 days after which time they cannot be given to patients and must be discarded. For this reason, we work very closely with our pathology service providers to continually review the stock (inventory) of blood products especially red blood cell units we keep onsite in the laboratories and closely monitor our wastage.
We measure our performance against the State and National discard rates that are provided by the Blood Service monthly.
Western Health’s red cell unit discard rate is consistently lower than one or both of the State or National discard rates.
Appropriate Use of Blood Products
Australia has one of the safest blood supplies in the world, however the transfusion of blood products is not without risk and can lead to complications and adverse outcomes for patients. Blood transfusions should only be given if the potential clinical benefits outweigh the potential risks to the patient.
As part of our Blood Management clinical audit program we undertake regular audits of transfusion episodes to review:
> Alignment of our practice against the National Patient Blood Management Guidelines
> Documentation of clinical indication for transfusion
Of the two hundred and eighty three red cell transfusion episodes audited between July 2022 and June 2023, 94.3% were assessed as being aligned with the National Patient Blood Management Guidelines.
Of the three hundred and eighty three transfusion episodes audited between July 2022 and June 2023, 92.19% had clinical indication for transfusion documented.
| The Blood Management Committee is the key committee within Western Health for facilitating and promoting the safe and appropriate use and management of blood and blood products.
The Blood Management Committee includes senior clinicians from haematology/oncology, emergency medicine, anaesthetics, critical care, medicine, obstetrics, Dorevitch Pathology senior scientists and a representative from the Blood Service. The Committee meets quarterly. In accordance with the NSQHS Blood Management Standard the Blood Management Committee has developed key performance indicators and implemented a comprehensive clinical audit program to evaluate practice and identify potential opportunities to facilitate improvements in patient safety and systems for the safe and appropriate use and management of blood and blood products. The Committee also reviews adverse events and suspected or confirmed reactions to blood products. KPI data and audit results are tabled for review and discussion at BMC Meetings. The Committee works with other staff, departments, services and consumers to develop, implement and evaluate initiatives to achieve Best Care. |
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Std 7 Blood Management
- Our Risk Profile for Std 7 Blood Management
- Improvement News Stories aligned with Std 7 Blood Management
- The online Performance Dashboard reporting aligned with Std 7 Blood Management
- The Clinical Audits that support good practice against Std 7 Blood Management
- The training programs available to support good Blood Management Practices
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Looking forward, we continue our focus on …
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Data Analysis |
Key Messages |
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| Blood Management and Safety | Blood Management training is a core requirement for clinical staff involved in transfusion practice. | Let’s reduce the risk of adverse events with blood or blood products by:
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| Correct patient ID processes | Patients must be correctly identified prior to blood or blood products being ordered, prescribed or administered. |
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| Safely manage any adverse reactions to blood or blood products | All reactions or adverse outcomes must be reported. |
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| Ensure no blood or blood products are wasted unnecessarily | Blood and blood products must only be used when indicated and wastage must be avoided through correct storage, prescribing and administration. |
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Medication prescribing, dispensing and administration are key areas where errors can occur and have a serious impact on patient care and safety.
We are proud of the commitment of our staff to ensure all medications used within our hospitals are prescribed, dispensed, administered and stored safely.
I have been proud to lead the ‘Sensational 8’ NSQHS Std 4 Medication Safety Team that brought together nursing, medical, allied health, education, quality and our Pharmacy Team to support our ongoing compliance with this National Standard. We have worked closely with Western Health’s Medication Safety Committee to ensure we are continually monitoring, reviewing and improving our clinical deterioration practices.
It was a great experience to be involved in the ‘Standard of the fortnight’ initiative for NSQHS Std 4. This ran from Monday 10 April to Friday 21 April. Our Best Care Co-ordinators, Exceptional 8 team members, Pharmacists and others enjoyed popping into clinical areas/departments to to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.
We have had a busy and productive year with a continued focus on developing the systems, equipment, staff knowledge and engagement with patients and families to manage medication safety.
Please continue reading to find out more about our medication safety strategies, achievements and opportunities for improvement.
Nicole Davies
NSQHS Std 4 ‘Exceptional 4’ Team Lead
Director of Nursing & Midwifery, Williamstown
Division: Emergency, Medicine & Access
The National Medication Safety Standard aims to ensure clinicians safely prescribe, dispense and administer appropriate medicines, and monitor medicine use. It also aims to ensure that consumers are informed about medicines, and understand their own medicine needs and risks.
The Medication Safety Standard supports Western Health to provide Safe Care.
Western Health’s comprehensive approach to Medication Safety draws upon requirements of this Standard and supports the monitoring, review and improvement of safe medication management practices. Programs and strategies to help support safe medication management include:
- Medication Safety Clinical Governance Structure
- Regular medication safety audits such as the Medication Safety Initiatives Audit and Drug Security Audit
- Processes and procedures to support appropriate documentation of allergies and adverse drug reactions
- Processes and procedures to support medication review of high risk patients and to manage storage and supply of high risk APINCH medication
We are proud of the following achievements for 2022/23:
- Strong links to the education and training team with regular medication safety slides and communication to our intern training program and nursing and midwifery educators
- Constant engagement with consumer representatives on the Medication Safety Committee (MSC)and the commencement of patient story presentations at MSC
- Collaboration with our capital development team to plan and improve medication management at future sites
- Involvement in interstate benchmarking of innovative medication safety practices to inform Western Health future state strategies
- Integration of Bacchus Marsh and Melton, Mental Health and Wellbeing, Dame Phyllis Frost Centre medication safety clinical governance processes
- 93 Medication Safety Initiatives Audits conducted across all WH sites
- Anaphylaxis PPG published
- Growing our digital capability with the expansion of our Electronic Medical Record (EMR) systems
- Developing a medication safety champion program across Western Health wards and departments
- Roll out of bins to support appropriate disposal of medication waste
- Anticoagulation stewardship working group established
- Sunshine Hospital Robotics Project
- Adoption and display of the SHPA NMBA storage chart to assist with expiry management
- Development of a Medication Safety Dashboard for staff to review, analyse and work towards reducing the number of medication errors in their areas.
Click here to view more Improvement News
Patient Story
“Tell me about your experience with how you are provided your medications”.
Karen presented to the Emergency Department on Sunday afternoon with difficulty breathing. From the Emergency Department Karen was admitted to SSU then transferred to RADU.
Karen provided the ED team with a medication list she was given on a recent discharge from Western Health. Karen stated not all of her medications were charted in ED or SSU from the list and she did not receive all of her usual medications until she was admitted to RADU more than 24 hours from when she presented to ED. She missed her usual doses of antidepressant and Symbicort. Some of the medications that were charted in ED were not her usual doses. This has all been resolved now.
“Do the staff check and scan your ID wristband before administering medication”?
Karen stated that the nursing staff check her ID band and ask what she is allergic to before giving medications. Karen stated she has not had her ID scanned prior to medication administration.
“Have you been provided with any information about your medications while in hospital”?
Karen stated she still has information about her medication from her previous stay in hospital and she has been seen by the ward pharmacist who has reviewed her list of medication and crossed out the medications no longer required or charted. Karen stated this was a great help to understanding her medications.
“Is there something you would like us to improve related your medications”?
Karen would like the doctors to inform the nurses when they change medications as the nurses are often confused about why the changes have occurred. Karen would also like to know when her medications have been changed or stopped.
A number of systems support us to monitor medication safety practice and outcomes.
Policies, Procedures and Guidelines (PPGs) are accessible, with monitoring of in-date status via Prompt. Use of medication outside WH
formulary criteria is restricted and reviewed through the Drugs and Therapeutic Committee.
Practitioner scope of practice is monitored through Medical Appointments and Credentialing Committee, Nursing and Midwifery Scope of Practice and Credentialing Committee and the Health Science Credentialing, Competency and Capability Committee. Pharmacy Clinical Co-ordinators at each site ensure that new staff are oriented and credentialed.
System wide medication management risks are reviewed regularly by Medication Safety Committee (MSC) and escalated to the Safe Care Committee as required.
Medication incidents and near misses are documented by staff into RiskMan. These incidents are investigated by the area managers. Recommendations and actions arising from incident investigations are implemented and monitored to ensure medication safety improvements.
Incident data is reviewed and presented monthly (with focus on APINCH) at MSC as well as at divisional Quality and Safety meetings.
Hospital acquired complications related to Medication Safety are also monitored. The Medication Safety Dashboard allows for clinicians to access this information to guide local awareness, improvement & innovation.
The Victorian Health Experience Surveys and the CARES outpatient pharmacy surveys provide direct feedback from patients in addition to ongoing input from consumers on MSC & Safe Care Committee on medication management & safety.
What has our data told us?
Medication Complications
For 2022-23, Western Health’s rate of medication complications compares well against other health services
Medication Incidents
In 2022/23 there was a rise in the number of medication incidents but within acceptable limits.
It is noted that post July 2023, the number of medication incidents has increased. This is due in part to the total number of patients cared for at Western Health growing due to transition of mental health and custodial services.
High Risk Medication Incidents
In 2022/23 there was a rise in the number of high risk medication incidents but within acceptable limits.
It is noted that post July 2023, the number of high risk medication incidents has increased. This is for the same reasons as noted above.
Western Health (WH) ensures appropriate governance of medication management through the Medication Safety Committee (MSC) which reports directly to the Safe Care Committee.
MSC is also responsible for a broad overview of Electronic Medical Record (EMR) medication management governance.
Active consumer representation on MSC assists with implementation of systems for medication management with a ‘Consumer First’ perspective when designing patient centred care.
There are a number of sub-committees reporting to MSC – Adverse Drug Reaction Committee (ADRC), Chemotherapy Governance Committee (CGC) and Drug & Therapeutics Committee (DTC). The Antimicrobial Stewardship Working Group (AMS WG) reports to DTC. Anticoagulant Stewardship working group reports to MSC.
Pharmacy, Operational Management Committees and the Best Care Coordinators also support medication safety management within Western Health.
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Medication Safety
- Our Risk Profile for Medication Safety
- Improvement News Stories aligned with Medication Safety
- The online Performance Dashboard reporting aligned with Medication Safety
- The Clinical Audits that support good practice against Medication Safety
- The training programs available to support good Medication Safety Practices
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Looking forward, we continue our focus on …
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Data Analysis |
Key Messages |
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| Labelling of Intravenous Therapy Lines | ABC audit indicated 57% compliance with correct labelling of Intravenous lines in June 2023. | Let’s reduce the risk of incorrect Intravenous line labelling by:
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| S8 & S11 Documentation | Medication Security Audit conducted in June 2022 demonstrated an overall 82% compliance with documentation of S8 & S11 medication security requirements. | Let’s reduce the risk of errors in S8 and S11 documentation by:
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| Locked Medication Drawers | Medication Safety Initiatives Audit conducted in 2022 demonstrated an overall compliance of 89% with locking of patient medication storage drawershttp://Key and Lock Managemen | Let’s reduce the risk of unlocked medication storage draws by:
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| Monitoring of medication fridges | Medication Safety Initiatives Audit conducted in 2023 demonstrated an overall compliance of 65% with monitoring of medication fridge temperatures | Let’s reduce the risk of temperature excursion by:
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| Involving our patients and carers in their medication management | Recent medication safety patient stories have told us we can improve communication to our patients when medications are prescribed or changed | Let’s reduce the risk of medication errors by:
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Western Health recognises the importance of effective communication between patients, carers and families, multi-disciplinary teams and clinicians, and across the health service organisation, to support continuous, co-ordinated and safe care for patients.
I am proud to lead the ‘Fab 5’ NSQHS Std 6 Communicating for Safety Team that brings together nursing, medical, education, quality and communicating for safety subject matter experts to support our ongoing compliance with the National Standard of the same name. We have worked closely with Western Health’s Communicating for Safety Committee to ensure we are continually monitoring, reviewing and improving our communicating for safety practices.
It was a great experience to be involved in the ‘Standard of the fortnight’ initiative for NSQHS Std 6. This ran from Monday 8 May to Sunday 21 May. Our Fab 5 team members, Best Care Co-ordinators and others enjoyed popping into clinical areas/departments to to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.
We have had a busy and productive year with a continued focus on developing the systems, staff knowledge and engagement with patients and families to manage communicating for safety in a timely way and with the best possible patient outcome.
Please continue reading to find out more about our communicating for safety strategies, achievements and opportunities for improvement.
Douglas Mill
NSQHS Std 6 ‘Fab 5’ Team Lead
Director of Nursing & Midwifery
The National Communicating for Safety Standard aims to ensure there is effective communication between patients, carers and families, multi-disciplinary teams and clinicians, and across the health service organisation, to support continuous, co-ordinated and safe care for patients.
The Communicating for Safety Standard supports Western Health to provide Safe and Co-ordinated Care.
The NSQHS Standard 6 – Communicating for Safety is aimed at improving communication within healthcare organisations and reducing the risk of harm to patients.
Western Health’s comprehensive approach to Communicating for Safety draws upon the requirements of this Standard and supports the monitoring, review and improvement of safe care. Programs and strategies to help support communicating for safety include:
- Communication learning packages to support staff knowledge and use of effective communication techniques.
- Reviewing clinical incidents to look for themes around clinical communication and identify areas for improvement.
- Clinical handover protocols to support good communication between our healthcare teams and clear documentation of patient information.
- The use of an electronic medical record to help ensure patient information information is easily accessible and up-to-date, which can improve communication between the healthcare team.
- Key roles and responsibilities related to patient identification processes across clinical and clerical workflows.
We are proud of the following achievements for 2022/23:
- Refocusing on use of ISOBAR/ ISBAR in handover processes through an updated Clinical Handover PPG and accompanying WeLearn module extended to all staff
- Use of EMR data as part of dashboards to inform patient care in timely manner (e.g. overdue cannulae)
- The extensive and active involvement of Language Services across Western Health to ensure patients and their carers and families are kept informed about clinical care and treatment planning
- EMR 2.1 GoLive in July which brings clinical services into the one EMR to increase visibility of the patient journey and to reduce fragmentation of information (reducing hybrid workflows)
- Updating ‘What Goes Where’ staff resources as we transition from current systems to the EMR to help staff navigate to the relevant source of information to ensure they have the full picture
- Re-establishing routine audits (eg Consent, Handover) to inform improvement approaches
- Updating and standardizing patient communication boards across WH
- Supporting staff to publish ward round information on EMR in a more timely and effective manner
Click here to view more Improvement News
Gwenda is a 78 year old woman who was admitted overnight from Footscray ED after becoming unwell at home with a suspected chest infection. She takes a number of medications including regular pain relief because this helps to keep her arthritis pain managed. She has established a regime at home which she finds works for her and fits in with her day’s activities. It’s important for Gwenda that she is able to continue to work as a volunteer at a community group.
Gwenda is relieved that the antibiotics she is receiving via IV will begin working as she was worried that she was just not getting better. The nurse allocated to Gwenda overnight asked her important questions about her health and safety and asked about the medications she takes.
When the am shift started, the two nurses and Gwenda participated in a handover of care and Gwenda was able to raise her concern that she didn’t have her regular pain relief. The bedside handover provided a systematic walkthrough of Gwenda’s current health situation, clinical problems and the plan of care using EMR data to highlight areas for clinical focus, including follow up with the medical team and the ward pharmacist to ensure that Gwenda’s pain management was prioritised so that her goals for care are met. This information is going to be used as part of her discharge summary which will ensure continuity of care back in the community from her physio and GP.
A number of systems support us to monitor identification and management of communicating for safety practice and outcomes.
WH’s MaP (Monitoring and Reporting) system brings together the data from WH’s operational systems to support monitoring of communication for safety.
Incidents and near misses are entered into the Incident Management System (RiskMan, VHIMS2), with incident reports developed for reporting at ward level, divisional level, and through the Best Care Committee Structure.
To ensure organisational PPGs aligned with Communicating for Safety are routinely updated, a monthly report is generated that reports the status of the PPGs as either in-date, out-of-date or will be out-of-date, within the next 6 months.
WH maintains an operational risk register that records risks relating to communicating for safety, with risks monitored through the Communicating for Safety Committee and updated on a six-monthly basis.
Feedback in the form of complaints, compliments, suggestions and enquiries is also entered into RiskMan. Complaints are divided into themes, one of which is communication. The Victorian Health Experience Survey (VHES) reports quarterly on patients’ experiences communicating with staff and is reported and included for discussion on a quarterly basis at the Best Care Steering Committee.
WH’s audit schedule provides the framework for monitoring performance beyond feedback and incidents. The Audit schedule defines the audits that are required to be completed, their data collection method, and frequency of completion, the responsible standard committee and reporting line. WH’s primary audit is the Best Care Audit which is a tool used to monitor our delivery of Best Care and provides us with an opportunity to identify areas for improvement in how we deliver that care. This audit has a number of questions relating to Communicating for Safety.
What has our data told us?
Patient Identification
Patient identification is crucial for providing safe and effective healthcare. It ensures that each individual receives the right care, medications, and treatments, while minimising the risk of errors.
The number of reported patient identification and procedure matching related incidents over 2022-2023 was low. Reported incidents were near misses or minor incidents that caused no harm to patients.
Clinical Handover
Clinical handovers are vital for patient safety. They enable clinicians to exchange critical information about a patient’s condition, treatment, and needs when there is a change of staff shift or transitioning care. Effective handovers ensure continuity and prevent mistakes.
The ISBAR tool is a valuable asset in clinical handovers. It stands for Identify, Situation, Background, Assessment and Request. Western Health uses ISBAR to help clinicians communicate efficiently and ensures crucial information is passed accurately. It’s a simple but effective way to support best care. Following expansion of the use of our Electronic Medical Record (EMR), more staff and services are supported to consistently apply the principles of ISBAR to clinical handovers.
Of two hundred and sixteen episodes of clinical handover (nursing, medical and allied health) audited recently, there was good use of ISBAR and communicating of critical care information. There is an opportunity however for enhanced focus on patient goals and preferences and their involvement in handover.
Discharge Planning
Discharge planning and communications are essential for best care. They help ensure a smooth transition from the hospital to home or another care setting. By coordinating post-hospital care and medications, it enhances patient recovery, reduces readmissions, and promotes overall well-being. In essence, discharge planning is a key part of comprehensive and effective healthcare.
The Victorian Health Experience Survey (VHES) includes patient feedback on planning for discharge from our inpatient services. The Department of Health and Human Services has a target of 75% of very positive responses to questions on discharge care.
The following graph shows the percentage of our patients who provided very positive responses to questions on discharge planning, care and communication from 1 July 2022 to 30 June 2023. Our results have been close to, but consistently below, the Department of Health and Human Services target.
Western Health continues to upload patient information to the My Health Record to the Australian My Health Record, a secure and centralised online system storing important health information for consumers. The Australian Digital Health Agency has launched its first consumer mobile application (’My Health’), which enables users to more easily access My Health Record information.
At a local level, Western Health continues to explore better ways of sharing health care information with the General Practitioners (GPs) of consumers using our health care services.
The Communicating for Safety Committee is responsible for reviewing clinical communication practices across Western Health (WH) and facilitating alignment with the provision of Best Care. This Committee reports directly to the Safe Care Committee, one of the four domains of the WH Best Care framework.
Objectives of this committee include:
- Identifying and addressing gaps in practice against the National Safety and Quality Health Service Standards for Communicating for Safety
- Establising systems to ensure the identify of the patient is used to safeguard the patient receives care intended for them
- Establishing systems for effective and co-ordinated communication that supports the delivery of continuous and safe care for patients
- Ensuring essential information is documented in the healthcare record to ensure patient safety
- Establishing systems to effectively communicate critical information and risks when they emerge or change and are used to ensure safe patient care
- Establish processes to ensure structured clinical handover is used to effectively communicate about the health care of patients
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Std 6 Communicating for Safety
- Our Risk Profile for Std 6 Communicating for Safety
- Improvement News Stories aligned with Std 6 Communicating for Safety
- The online Performance Dashboard reporting aligned with Std 6 Communicating for Safety
- The Clinical Audits that support good practice against Std 6 Communicating for Safety
- The training programs available to support good Communicating for Safety Practices
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Western Health aims to ensure consumers are partners in the design, delivery and evaluation of our healthcare systems and services, and that consumers, carers and/or their family are supported to be partners in their own care
I am proud to lead the ‘Fab 5’ NSQHS Std 2 Partnering with Consumers Team that brings together nursing, medical, education, quality and partnering with consumers subject matter experts to support our ongoing compliance with the National Standard of the same name. We have worked closely with Western Health’s Consumer First Committee to ensure we are continually monitoring, reviewing and improving our partnering with consumer practices.
It was a great experience to be involved in the ‘Standard of the fortnight’ initiative for NSQHS Std 2. This ran from Monday 26 June to Sunday 2 July. Our Fab 5 team members, Best Care Co-ordinators and others enjoyed popping into clinical areas/departments to to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.
We have had a busy and productive year with a continued focus on developing the systems, staff knowledge and engagement with consumers and the community to support partnering with consumers for the best possible patient outcomes.
Please continue reading to find out more about our partnering with consumer strategies, achievements and opportunities for improvement.
Rohan Vaughan
NSQHS Std 2 ‘Fab 5’ Team Lead
Director of Nursing & Midwifery, Melton
Division: Drug Health Services
The National Partnering with Consumers Standard aims to ensure that consumers are partners in the design, delivery and evaluation of healthcare systems and services, and that consumers, carers and/or their family are supported to be partners in their own care.
The Partnering with Consumers Standard supports the ‘Pillars’ of our Best Care Framework … the quality systems that support our staff to lead, drive and create Best Care.
Western Health’s comprehensive approach to Partnering with Consumers draws upon requirements of this Standard and supports the monitoring, review and improvement of quality care. Programs and strategies to help support partnering with consumers include:
- Our Consumer First Framework (pictured right) and supporting Systems
- Frameworks and Plans supporting Diversity, Equity and Inclusion
- Dedicated roles such as the Operations Manager of Diversity and Inclusion, and the
Manager of Consumer Partnerships - A Consumer First Committee with consumer representation
- Resources and procedures to support Consumer First Systems
- Orientation and Learning Packages designed to support staff understand the value of partnering with consumers and how to do this effectively.
- A consumer advisor workforce to engage in and support consumer participation activity
- In-house and externally sponsored opportunities for consumers to provide feedback on best care
- Engagement of consumers in service co-design and development activity.
We are proud of the following achievements for 2022/23:
- Re-instating our Consumer First Committee
- Commencing consumer engagement forums for the New Melton Hospital
- Increasing the number of consumer representatives supporting our operational Best Care Committees
- Appointing our first WH Lived Experience Advisor
- Welcoming Mental Health and Correctional Lived Experience Advisors &/or consumer representatives to Western Health
- Further development and implementation of Plans supporting Cultural Safety and Diversity, Equity and Inclusion
- Reviewing and updating 300 documents in our Patient information library
- Reviewing our consumer information posters and patient information booklets
- Reviewing our Consent processes and further developing aligned audit programs
- Promoting opportunities for our staff to welcome and inform consumers to wards and departments and partnering in their healthcare
- Industry benchmarked a payment framework for Consumer Advisors recognising the high value Western Health places on advice provided by our Consumers
Click here to view more Improvement News
“I had minor surgery in March 2023. I just wanted to say a huge thank you to every single person I came into contact with on the day, including the admissions nurse, the theatre team and the recovery team. Everyone was so kind, professional, thorough and compassionate and made me feel so comfortable. I was actually quite nervous but everyone took the time to have a chat and make me feel more comfortable. Cannot say enough, how impressed and appreciative I was of the care you provided me. Thank you!”
A number of systems support us to monitor identification and partnering with consumer practice and outcomes.
Patients are asked about their satisfaction with partnerships to involve them in their care through WH’s participation in the Victorian Health Experience Survey (VHES). VHES results are incorporated within WH Best Care dashboards that are reported through the WH Best Care
Committee structure.
The Consumer Advisors engaged in committees play an integral role in reviewing existing strategies for partnering with consumers and setting priorities for action. They provide input on committee work plans, including all Best Care committees, the Community Advisory Committee (CAC) and diverse communities committees such as the Disability Advisory Committee, LGBTIQ Committee and Aboriginal Health Steering Committee.
WH clinical auditing activity encompasses review of patient care partnerships through, for example, perioperative and blood management patient consent audits. Data review also encompasses the communication focus areas of language services and complaints management.
The Consumer First Committee brings together the systems and improvement activity supporting partnering with consumers in health service design and governance
The WH Best Care Committee structure accommodates and supports Consumer First related reporting, with WH’s Live Best Care microsite and annual Quality Account publication supporting the sharing of Consumer First related systems and activity.
What has our data told us?
Measuring a positive patient experience
The Victorian Health Experience Survey (VHES) is a statewide survey that reviews people’s experience of receiving health care in Victorian public hospitals. The survey is sent to a random selection of patients one month after leaving hospital. Responses are collected by an independent company contracted by the State Government and are anonymous.
Data collected from the survey is provided to Western Health on a range of measures of patient experience.
We use overall patient care ratings from the survey as part of a person-centred care performance dashboard presented to our Best Care Committees and the Board.
Consumer satisfaction ratings on overall hospital care have been above or slightly below the average of Victorian public hospitals over the past 12 months
Consumer Feedback
To provide Best Care, we must be able to see care from the perspective of our patients, their families and carers, and the community we serve.
Consumers can share their patient experiences and suggestions for improvement through a number of avenues, including survey, phone, email or in person.
To enhance these methods of feedback, we have implemented a consumer centred phone service with direct answer of consumer calls during business hours.
We have also developed online dashboards that help us to provide timely response to feedback and identify feedback themes.
The key feedback themes from the last 12 months are noted in the graph below.
Informed Consent
Informed consent is a fundamental principle in healthcare. It means that consumers have the right to receive all relevant information about their treatment or care, including potential risks, benefits, and alternatives.
The following graph from the Victorian Health Experience Survey Program shows an improving trend on patient satisfaction with information provided about the risks and benefits of treatments received, with the latest report showing a rating on par with the Victorian public health service average.
The role of Western Health’s Consumer First Committee role is to inform, guide and oversight an organisation-wide ‘Consumer First’ framework supporting systems and improvement activity to partner with consumers in planning, design, delivery, evaluation and improvement of care. This Committee reports directly to the Best Care Steering Committee.
Objectives of this committee include:
- Guiding the development and ongoing review of a ‘Consumer First’ Framework for Western Health, based on the Safer Care Victoria (SCV) Framework on Partnering for Healthcare.
- Guiding the development and ongoing review of key policies, procedures and guidelines supporting ‘Consumer First’ and aligning with NSQHS Standard 2
- Guiding the development and operation of systems, processes and business rules supporting ‘Consumer First’ across the health service
- Monitoring WH training offerings and uptake aligned with ‘Consumer First’
- Monitoring KPIs/performance dashboards and audit results that relate to ‘Consumer First’
- Providing a central point to ensure oversight of ‘Consumer First’ strategies and projects
- Facilitating review and improvement planning based on patient/consumer feedback
- Supporting system review and development against NSQHS-Standards, 2nd edition requirements, including self-assessment and action plan implementation
- Support any Safer Care Victoria reporting requirements regarding partnering for healthcare
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Std 2 Partnering with Consumers
- Our Risk Profile for Std 2 Partnering with Consumers
- Improvement News Stories aligned with Std 2 Partnering with Consumers
- The online Performance Dashboard reporting aligned with Std 2 Partnering with Consumers
- The Clinical Audits that support good practice against Std 2 Partnering with Consumers
- The training programs available to support good Partnering with Consumer Practices
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Western Health supports and continually develops the quality systems that support our staff to lead, drive and create Best Care.
I am proud to lead the ‘Fab 5’ NSQHS Std 1 Clinical Governance Team that brings together nursing, medical, education, quality and clinical governance matter experts to support our ongoing compliance with the National Standard of the same name. We have worked closely with Western Health’s Best Care Committees to ensure we are continually monitoring, reviewing and improving our clinical governance practices.
It was a great experience to be involved in the ‘Standard of the fortnight’ initiative for NSQHS Std 1. This ran from Monday 22 May to Sunday 28 May. Our Fab 5 team members, Best Care Co-ordinators and others enjoyed popping into clinical areas/departments to to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.
We have had a busy and productive year with a continued focus on developing the systems, staff knowledge and engagement with consumers to support clinical governance for the best possible patient outcomes.
Please continue reading to find out more about our clinical governance strategies, achievements and opportunities for improvement.
Lisa Gatzonis
NSQHS Std 1 ‘Fab 5’ Team Lead
Director of Nursing & Midwifery Workforce
The Clinical Governance Standard aims to ensure that there are systems in place within health service organisations to maintain and improve the reliability, safety and quality of health care.
The Clinical Governance Standard supports the ‘Pillars’ of our Best Care Framework … the quality systems that support our staff to lead, drive and create Best Care.
Western Health’s comprehensive approach to Clinical Governance draws upon requirements of this Standard and uses clinical, safety, and quality systems integrated with governance processes to improve the safety and quality of health care for patients. Programs and strategies to help support clinical governance include:
- The Best Care Policy and Framework providing guidance to all staff on how they can provide, lead, govern and support Best Care.
- Mechanisms for capturing and responding to consumer feedback.
- The Policy and Procedure Framework supporting easy access to best practice information via PROMPT.
- The progressive implementation of the Electronic Medical Record
- Live Best Care Improvement framework providing tools and resources to support staff to complete improvement activites at organisational and local levels and showcase outcomes.
- Organisational strategies and systems for providing a safe environment such as Emergency procedure management, engineering preventative and reactive maintenance, OVA prevention and management, cleaning schedules and audits, way finding, inclusion and diversity, Aboriginal Health plan.
- Supporting the workforce to understand their role and responsibilities through the Best Care policy, orientation & training, credentialing, individual performance reviews and clinical supervision.
- Utilising purposeful information collected from audits, indicators and incidents to analyse, share and respond to identified risks and opportunities.
We are proud of the following achievements for 2022/23:
- Redesigning our WH Live Best Care microsite as the one stop shop for staff and accreditation surveyor
- Upgrading our Riskman system to support timely incident and feedback reporting & review across WH
- Re-instating the WH Right Care Committee
- Introducing and engaging staff with WH’s new Policy, Procedures & Guidelines (PPG) system, PROMPT
- Staff engagement in the newly introduced Serious Adverse Patient Safety Event (SAPSE) reviews
- Staff participation in the Best Care Excellence & Improvement Project (BCEIP), component parts of which Safer Care Victoria are considering replicating for broader application
- The launch of NSQHS Standard aligned online dashboards through the WH Dashboard Project
- Redesigning our WH Best Care Report to focus on clinical variation profiles informed by WH’s operational risk register
- Our Best Care Quality Systems encompassing Mental Health and Correctional services transitioning to WH
- Launching two new committees that integrate divisional and org-wide clinical practice monitoring and improvement – Clinical Council, Best Care Performance Meeting
- Launching a new WH Improvement Register and the ‘LifeQI’ Improvement Platform
- Implementing a redesigned New Technology and Clinical Practice Committee and associated processes integrated with credentialing/scope of practice
- Launching a centralised recommendation register to support clinical practice improvement following the review of serious adverse events
- Bringing together and refining auditing systems and the reporting of clinical variation
- Understanding and documenting how National Clinical Care Standards are applied at WH
- Showcasing our localised performance and improvement activity through our KHWD Boards
Click here to view more Improvement News
“My husband Malcom was taken to the Footscray Hospital, after he collapsed at home.
He was subsequently admitted to a ward.
From there over a period of 19 days, he had the most wonderful of care.
He was treated with respect, kindness and caring.
He was gravely ill and the medical treatment he received, was exceptional.
Dr Albert and his medical team were amazing.
The nurses explained to Malcom what they were going to do for him and what was going into him via the canula.
Nothing was too much for them, to do for him. He said there were no negatives from him.
Funny thing that Malcom commented to me in Emergency … Dr Albert came to examine Malcom and then told me he would be coming in upstairs to the ward. I told Malcom that was the doctor and he would be admitted upstairs to a ward. Malcom said “ that wasn’t a doctor, he was too young and looked like a teenager !” Funny !!! Dr Albert and his team saved my husband’s life.
Next there was a problem for me of his rehabilitation. What was going to happen ? But that was all solved by the wonderful staff.
We were set off home, with all the equipment we needed, example; toilet seat, shower seat, walking frame and of course the bottle (savior for not having to get up during the night). All Equipment was purchased by us, as we are getting older.
The next day “Gem@Home” came into our lives for two weeks. How great is this program ?!!
The team that came to visit us were exceptional! Phone call in the mornings and the professionals would come and visit Malcom, to get him through his rehab.
Malcom is now not needing to go to community Physio at Sunshine Hospital – WOW! He does his exercises every day. I could go on and on.
When I called to Purchase the equipment, I spoke to a gentleman named Ray. I asked if he had been with Footscray Hospital long and he said yes. And it works out that he provided me with a nebulizer for my daughter at the age 2 and a half … way back in 1980.
It was like a trip down memory lane. Ray provided exceptional care that night in casualty with my daughter, and was lovely, just like recently.
At our Christmas eve dinner Malcom made a little speech, and it said the if it wasn’t for the wonderful staff that looked after him at Footscray Hospital, he probably wouldn’t be with us. Thank you, with all our heart.”
The continuing review of PPGs is flagged through reporting of scheduled document review and operational reporting mechanisms such as variation monitoring, Morbidity and Mortality reviews and the report and management of clinical and non-clinical incidents.
WH’s Monitoring and Performance reporting solution (MaP) brings together current data from WH’s health records and operational patient and incident systems to provide a single source of truth for performance reporting. This data, plus the output from a number of quality and safety systems, informs the reporting to WH’s Best Care Committees that are integrated into the overall WH Committee Structure.
Reporting includes a bi-monthly WH Best Care Report generated against the dimensions of Person-Centred, Co-ordinated, Right and Safe care.
Informing and supporting the activity and ongoing review and improvement of WH’s quality and safety systems is our engagement with Safer Care Victoria and the Victorian Agency for Health Information. This includes the completion of an annual Organisational Strategy Improvement Matrix (OSIM) self-assessment on the maturity of WH’s improvement systems.
WH staff also provide feedback on their awareness and engagement in quality and safety systems through the WH ‘Live Best Care’ learning package.
An annual Quality Account publication is submitted to the WH Board and the DH, and is accessible to WH staff, volunteers and members of the community via the WH Intranet and Internet. This Report brings together the activity and outcomes of a number of quality and safety
systems to report on performance against the WH vision of providing Best Care that is Person-Centred, Co-ordinated, Right and Safe.
What has our data told us?
Engagement of Staff in Best Care
As reflected in a Best Care Survey, staff feel they understand their role and responsibilities for providing and/0r supporting Best Care
Patient Safety
The following graph from the Victorian Health Experience Survey Program shows consistently high consumer satisfaction ratings with feeling safe while in hospital.
Listening to and addressing consumer complaints
Improved pathways and processes to respond to consumer feedback has resulted in a significant improvement in complaint turnaround time
The following statements reflecting what best care means to patients guides how our front-line staff provide Best Care, how our managers & senior clinicians lead Best Care, and how the Executive and Board govern Best Care.
To receive best care … it is important to my family and I that:
- I am seen and treated as a person (Person-Centred Care)
- I receive help, treatment and information when I need it and in a co-ordinated way (Co-ordinated Care)
- I receive care that makes me feel better (Right Care)
- I feel safe (Safe Care)
The role of the Western Health’s operational Best Care Steering Committee (BCSC) is to oversight and support the translation of these statements into day-to-day behaviours and active quality systems supporting the monitoring, review and improvement of person-centred, co-ordinated, right and safe care. A number of sub-committees support this role and the BCSC provides a conduit for clinical governance reporting between operational and board committee levels.
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Std 1 Clinical Governance
- Our Risk Profile for Std 1 Clinical Governance
- Improvement News Stories aligned with Std 1 Clinical Governance
- The online Performance Dashboards reporting aligned with Std 1 Clinical Governance
- The Clinical Audits that support good practice against Std 1 Clinical Governance
- The training programs available to support good Clinical Governance Practices
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Western Health’s comprehensive infection prevention and control program is responsible for the monitoring, prevention and control of hospital acquired and/or healthcare-associated infection.
This program is supported by our wonderful Infection Team run by Maureen Canning and Richard Bartolo who worked extra hard over the COVID-19 period to support our patients, staff and visitors to remain safe. We are very proud of the way all staff at Western Health contributed to a COVID-19 safe environment and continue with the everyday activity that supports keeping our patients safe from infection.
I have been proud to lead the ‘Sensational 7’ NSQHS Std 3 Infection Prevention Team that brought together nursing, medical, allied health, education, quality and infection prevention expertise to support our ongoing compliance with this National Standard. We have worked closely with Western Health’s Infection Prevention Committee to ensure we are continually monitoring, reviewing and improving our infection prevention and control practices.
We were excited that the Infection Prevention Standard was the focus of the first cab off the rank for the ‘Standard of the fortnight’ initiative. This ran from Monday 27 March to Friday 7 April. Our Best Care Co-ordinators, Sensational 7 team members, Infection Prevention Team and others enjoyed popping into clinical areas/departments to ask staff possible Surveyor questions and answers, and to walk in a surveyor’s shoes to see what WH practice looks like.
We have had a busy and productive year with a continued focus on a COVID safe environment and the implementation of a number of initiatives to support staff to continue with the everyday activity that keeps our patients safe from infection and manage infection if it does occur.
Please continue reading to find out more about our infection prevention strategies, achievements and opportunities for improvement.
Monique Sammut
NSQHS Std 3 ‘Sensational 7’ Team Lead
Director of Nursing Sunbury IP, CSSC, WPHU & COVID Response
Western Health’s Infection Prevention and Control Service—a dedicated and comprehensive program committed to ensuring the safety and well-being of our patients. Our mission revolves around adhering to the National Preventing and Controlling Healthcare-Associated Infection Standard, a pivotal framework designed to minimize the risk of patients acquiring preventable healthcare-associated infections (HAIs), manage infections effectively if they do occur, and curb the development of antimicrobial resistance.
At the heart of our service is a resolute commitment to providing Safe Care to our patients. We understand that infection prevention and control are fundamental aspects of healthcare delivery, and we prioritize these elements to safeguard the health of those we serve.
Our Infection Prevention and Control program is the cornerstone of our efforts. It is meticulously designed to align with the requirements of the Preventing and Controlling Healthcare-Associated Infection Standard and serves as the bedrock for monitoring, preventing, and controlling healthcare-associated infections within our healthcare system.
Guiding our approach is the Western Health Infection Prevention plan, a strategic document developed and endorsed by our Infection Prevention Committee (IPC). This plan outlines our organisational approach to infection prevention and control, ensuring a cohesive and systematic response to this critical aspect of healthcare.
Within our program, we have established a robust set of infection prevention tools and practices. These include standard infection prevention and control strategies such as hand hygiene, personal protective equipment (PPE) use, rigorous cleaning procedures, staff immunization, and effective management of invasive devices.
We recognize the importance of proper patient placement and the meticulous recording of patient records on admission to minimize the risk of cross-contamination and infection spread.
At Western Health, we are deeply committed to addressing the issue of antimicrobial resistance through our vigorous antimicrobial stewardship program. This program is designed to control the inappropriate use of antibiotics, deliver ongoing education and training, and ensure responsible antimicrobial use, aligning with the broader effort to combat the development of antimicrobial resistance.
The cleanliness and hygiene of our hospital environment are of paramount importance. To this end, we conduct regular audits of the hospital environment’s cleaning standards, maintaining accepted quality levels and reducing infection risk.
Behind every facet of our Infection Prevention and Control Service is our exceptional team. Our Infection Prevention team comprises experienced and qualified staff members who are dedicated to applying and supporting Western Health’s infection prevention and control practices.
Additionally, our Infection Prevention Link group program fosters collaboration by connecting clinical areas with our Infection Prevention team. This initiative aims to enhance awareness of infection prevention issues, promote best practices, and provide vital support for clinical teams.
At Western Health, we take pride in our commitment to the prevention and control of healthcare-associated infections. Our holistic approach, informed by the Preventing and Controlling Healthcare-Associated Infection Standard, underscores our dedication to ensuring the utmost safety and well-being of our patients.
We are proud of the following achievements for 2022/23:
Western Health is pleased to share a series of remarkable achievements and milestones for the year 2022/23. These accomplishments reflect our ongoing commitment to excellence in healthcare and patient safety:
- COVID Safe Environment: We are immensely proud of the dedication and efforts of all our staff in contributing to a COVID-safe environment. The successful introduction of the Business as Usual (BAU) COVID Matrix has played a vital role in maintaining safety within our healthcare facilities.
- Hand Hygiene Compliance: Western Health continues to set high standards by benchmarking strongly with other Australian healthcare services and national aggregates for hand hygiene compliance. Our unwavering commitment to hand hygiene significantly contributes to the well-being of our patients.
- Flu Vaccine Campaign: We are thrilled to lead the state with the 2023 Flu vaccine campaign results. An impressive 95% of all staff, along with 98% of Category A and B, have received the Flu Vaccine, bolstering our efforts to protect against seasonal influenza.
- Surgical Site Infections: Meeting all 2022-23 Statement of Priority Key Performance Indicators for surgical site infections surveillance is a testament to our rigorous infection control protocols. We are pleased to report nil significant infection rates and zero central line infections in our ICUs, underscoring our dedication to patient safety.
- RO Water Installation: The installation of Reverse Osmosis (RO) water in CSSD (Central Sterile Services Department) at Bacchus Marsh/Melton, Sunshine, and Williamstown marks a significant enhancement in our medical device sterilization capabilities, ensuring the utmost safety and quality in patient care.
- Staff Health EMR: The integration of the Medicare Australian Immunization Records into our staff health Electronic Medical Records (EMR) system demonstrates our commitment to keeping our healthcare workforce informed and protected.
- Safe Transition of Mental Health Services: Western Health has played a pivotal role in ensuring the safe transition of mental health services within our facilities, further aligning our commitment to comprehensive and compassionate patient care.
- Infection Prevention Dashboards: The launch of Infection Prevention online dashboards represents a significant stride towards real-time monitoring and transparency in our infection prevention efforts.
- RMD Tracking System: The introduction of a computerized tracking system for reusable medical devices (RMDs) in the Bacchus Marsh CSSD enhances the safety and efficiency of medical device management, furthering our dedication to patient safety.
- WH DIVA Pathway: The introduction of the WH DIVA (Difficult IV Access) pathway demonstrates our commitment to improving patient experiences and outcomes, especially in challenging intravenous access situations.
- PIVC Patient Information: Patient information screen savers for Peripherally Inserted Central Catheters (PIVC) serve as a valuable educational tool, ensuring that patients are well-informed about their medical procedures and care.
These achievements reflect Western Health’s unwavering commitment to providing high-quality, safe, and compassionate healthcare services to our community. We are proud of our staff’s dedication and our ongoing pursuit of excellence in all aspects of healthcare delivery.
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The IPC includes a consumer representative who plays an active role in reviewing and advising on matters related to providing information to consumers and carers. This ensures that the perspective of those receiving healthcare services is considered in infection prevention efforts.
The consumer representative received a complaint from a national patient advocate regarding the condition of a bathroom at Sunshine Hospital. This complaint triggered an internal investigation, leading to the identification and rectification of issues related to damaged floor vinyl and poor cleaning standards. Prompt action was taken, and the consumer representative conveyed the outcomes to the concerned family member, who greatly appreciated the response.
The IPC recognizes the value of patient experiences and includes “Patient Stories” on its meeting agendas. This practice allows for the sharing and learning from the experiences of consumers, validating the organization’s infection prevention and control approach. These stories are disseminated to Unit Managers, Operations Managers, and Divisional Directors, providing valuable insights for improvement.
Consumer involvement in “business as usual” processes is encouraged, particularly in supporting infection prevention efforts. This includes adherence to hand hygiene and personal protective equipment (PPE) requirements. Consumers are empowered to raise concerns and provide feedback if they observe staff members not following these critical infection prevention practices.
These initiatives reflect a commitment to patient-centred care and a culture of continuous improvement in infection prevention and control. Involving consumers and actively addressing their feedback not only enhances patient safety but also strengthens the trust and partnership between healthcare providers and those they serve. It’s a testament to the organisation’s dedication to delivering high-quality healthcare with a focus on patient and family engagement.
Monitoring infection prevention practices and outcomes is a crucial aspect of our commitment to maintaining a safe healthcare environment. We utilize several systems and processes to ensure effective monitoring and reporting:
Scheduled and Ad Hoc Audits. Regularly scheduled audits are conducted to assess infection prevention practices across our healthcare facilities. These audits provide a structured evaluation of compliance with established protocols. Additionally, ad hoc audits may be carried out in response to specific concerns or incidents.
Incident Reporting and Follow-Up. We have a robust system for reporting and documenting infection prevention-related incidents. This system enables the prompt reporting of any deviations from best practices. Follow-up actions are then initiated to address and rectify any identified issues, preventing future occurrences.
Surveillance Data Collection. Data collection plays a significant role in our monitoring efforts. We systematically collect data on various infection prevention parameters, including infection rates, hand hygiene compliance, and other relevant metrics. This data serves as a foundation for assessing the effectiveness of our practices.
Reporting to Jurisdictional and National Bodies. We recognize the importance of transparency and collaboration at broader levels. To this end, specific surveillance data is reported to jurisdictional bodies, such as VICNISS (Victorian Healthcare-associated Infection Surveillance System), as well as national organizations. Sharing this data ensures that our practices align with regional and national standards and contributes to a broader understanding of infection prevention trends.
Our commitment to monitoring infection prevention practices is rooted in our dedication to providing the highest level of patient safety. By systematically auditing, reporting incidents, and collecting data, we maintain a proactive stance in identifying areas for improvement. This ongoing monitoring not only ensures compliance with established standards but also fosters a culture of continuous improvement in our healthcare organisation.
What has our data told us?
Healthcare Associated Infection Benchmarking
Western Health’s rate of healthcare associated infection compares favourably with other health services
Western Health submits data on infections acquired in hospital to the HealthRoundtable, an independent knowledge-sharing group that provides detailed reports on a number of clinical indicators that compares our results against other health services.
Monitoring effective hand hygiene practices
The Western Health rate for observed correct hand hygiene practice for 2022/23 was 89% against a target of 85%
Effective hand hygiene is indisputably one of the most critical strategies in the prevention of healthcare-associated infections. Its significance has been particularly highlighted during the unprecedented challenges posed by the COVID-19 pandemic. At Western Health, we place a paramount emphasis on maintaining excellent hand hygiene practices as a foundational element of our commitment to patient and staff safety.
Throughout the COVID-19 pandemic, the importance of hand hygiene has been underscored as a fundamental measure in reducing the risk of infection transmission. Our healthcare workers have been vigilant in adhering to rigorous hand hygiene protocols to protect both themselves and our patients.
Moreover, we actively encourage our patients to take an active role in their own safety. Patients are empowered to inquire about whether their healthcare providers are following proper hand hygiene practices. This open and transparent communication ensures that patients are not only aware of the importance of hand hygiene but also feel comfortable in advocating for their safety.
At Western Health, we consider effective hand hygiene as a shared responsibility. It is a practice that both our healthcare workers and patients actively participate in to create a safe and infection-free healthcare environment. As we continue to navigate the challenges of the pandemic and beyond, we remain steadfast in our commitment to upholding the highest standards of hand hygiene to protect the well-being of all who seek our care.
Fighting the Flu and other vaccine preventable diseases
The successful achievement of a 95% influenza vaccination rate among Western Health staff in 2023, surpassing our target of 92%, is a significant milestone in our ongoing commitment to patient safety and public health.
Vaccine-preventable diseases, including influenza, measles, and chickenpox, pose serious health risks and can have severe consequences, including hospitalization and even death. Within the healthcare environment, there exists a unique responsibility to protect both our dedicated healthcare workers and the vulnerable patients under our care.
Healthcare workers, due to their close interaction with patients, have the potential to be exposed to and transmit these diseases. Therefore, it is imperative that we maintain high levels of immunity within our healthcare worker population. This not only safeguards the well-being of our staff but also acts as a crucial barrier against the transmission of these diseases between healthcare workers and patients.
Our annual influenza vaccination campaign is a testament to our proactive approach to public health. By encouraging all Western Health staff to receive the influenza vaccination each year, we strengthen our collective immunity and take a significant step toward preventing the spread of this highly contagious virus within our healthcare facilities.
The exceptional achievement of a 95% vaccination rate in 2023 underscores the dedication of our staff to patient safety and their commitment to public health. It is a reflection of our shared responsibility to protect both our healthcare workers and the individuals who trust us with their care. We will continue to promote and prioritize vaccination as a fundamental pillar of our patient-centred approach to healthcare.
Staphylococcus aureus Bacteraemia (SAB)
In 2022/23, Western Health’s SAB rate was 0.7, a favourable result against the new state-wide target of no higher than 0.7
Staphylococcus aureus, commonly known as ‘golden staph,’ is a prevalent bacterium that colonizes the skin and nasal passages of some individuals. While often harmless in these locations, it can become a significant health concern when it causes bloodstream infections, leading to severe illness and, in some cases, fatalities.
In healthcare settings, Staphylococcus aureus bloodstream infections (SABs) are frequently associated with the use of invasive medical devices, particularly peripheral intravenous catheters. At Western Health, we are committed to investigating all healthcare-associated SAB cases, collaborating closely with our Infection Prevention and Infectious Diseases teams, as well as the medical professionals in the respective areas.
During the COVID-19 pandemic, we observed a concerning increase in SAB cases, nearly doubling from 13 cases in 2018-19 to 27 in 2022-23. This surge in cases was likely influenced by the heightened use of gloves due to transmission-based precautions necessitated by the fear of COVID-19 self-infection and personal protective equipment (PPE) practices that emphasized glove usage. This continuous glove use may have inadvertently interfered with proper hand hygiene and aseptic techniques, thereby contributing to the rise in SAB cases.
In response to this challenge, Western Health has implemented a range of proactive strategies. These efforts include informative talks during our daily DOS meetings, in-depth case reviews, presentations by our Link groups, sharing patient stories, the establishment of a dedicated SAB Taskforce, and disseminating case studies to individual wards to enhance local awareness.
The result of these initiatives is evident in the positive impact on our SAB rate, as depicted in the accompanying graph. Through these collective endeavours, we have made significant strides in reducing SAB cases and reinforcing the importance of proper hand hygiene and aseptic techniques among our healthcare staff.
Our commitment to patient safety remains unwavering, and we will continue to prioritize strategies that prevent and manage SABs while upholding the highest standards of care in our healthcare facilities.
Central Line Blood Stream Infections (CLABSI)
Western Health had no cases of CLABSI in 2022-23
A central line, also known as a central venous catheter, is a medical tube that doctors often insert through a major vein in the neck, chest, or groin. It serves various purposes, such as delivering medication or fluids, and collecting blood for medical tests. However, when a central line is in place and a patient develops a bloodstream infection, it is known as a Central Line-Associated Bloodstream Infection (CLABSI). This is a severe medical condition that can lead to prolonged hospital stays and significant health complications.
At Western Health, the safety and proper management of central lines are of paramount importance. To ensure the correct insertion and management processes are followed, senior doctors within our Intensive Care Units take a hands-on approach. They personally oversee and train healthcare staff to adhere to best practices when it comes to central line procedures.
To maintain stringent standards and monitor essential principles related to central line care, we employ central line insertion checklists. These checklists cover critical aspects such as hand hygiene, skin preparation, selecting the appropriate insertion site, dressing techniques, and the type of catheter used.
In cases where bloodstream infections are identified, our highly trained infection prevention staff conducts thorough reviews to pinpoint the source of the infection. When a CLABSI is identified, a comprehensive investigation is initiated. This investigation is followed by the implementation of robust risk management strategies aimed at preventing the recurrence of such infections in our healthcare facilities.
At Western Health, we are unwavering in our commitment to patient safety and the highest standards of care. Our dedication to proper central line management, rigorous monitoring, and proactive infection prevention measures underscores our commitment to providing safe and effective healthcare to our patients.
Western Health’s dedicated Infection Prevention Committee (IPC) serves as the cornerstone of our commitment to patient safety and healthcare quality. Chaired jointly by an Infectious Diseases Physician (Clinical Lead) and the Director of Nursing for Sunbury Day Hospital and Standard 3, this committee plays a pivotal role in the prevention of healthcare-associated infections (HAIs) and the control of resistant organisms. Its overarching purpose extends to effectively communicating its work to the entire workforce to ensure positive outcomes.
Within the IPC, we have assembled a diverse team of members representing various disciplines and roles throughout our organization. Additionally, we proudly include a consumer representative, highlighting our dedication to patient engagement and involvement in the decision-making process.
To maintain a structured reporting hierarchy, the IPC delivers its findings and recommendations to the Safe Care Committee, which in turn, reports to the Best Care Committee. This hierarchical structure ensures that our infection prevention and control measures are seamlessly integrated into broader healthcare quality initiatives.
The IPC shoulders several key responsibilities, including the development of essential procedures, the creation of training resources, monitoring clinical compliance, gathering and analysing surveillance data, and aligning our efforts with the priorities outlined by the Department of Health (DH). This comprehensive approach ensures that our infection prevention and control strategies remain current and effective.
In addition to the IPC, our organization maintains a diligent focus on antimicrobial stewardship through the Antimicrobial Stewardship Working Group (WHAMSWG), which convenes quarterly. This group meticulously reviews antimicrobial prescribing practices and evaluates key strategies. It operates within the scope of the National Antimicrobial Stewardship Clinical Care Standard and reports its findings directly to the IPC.
During the first half of 2023, the IPC has concentrated its efforts on addressing the presence of biofilm, a slimy and resistant substance commonly found in moist areas like plumbing systems. In response, we established a dedicated working party to direct the initial and ongoing management of biofilm in sinks and drains. Our comprehensive approach includes measures such as steam cleaning, sink strainer replacements, and the use of advanced chemical disinfectants. Additionally, we conducted a trial of a new waste disposal process for IV fluids and launched an education campaign emphasizing correct sink usage.
At Western Health, our reporting focus is driven by a commitment to transparency, continuous improvement, and patient safety. Our collaborative and multidisciplinary approach ensures that best practices are implemented and shared throughout our organization, ultimately fostering a healthcare environment that prioritizes the well-being of our patients and staff alike.
We use our Best Care quality systems to continue with the everyday activity that supports keeping our patients safe from infection.
Click on the following quality system links to find out more about:
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- The PPGs supporting Infection Prevention
- Our Risk Profile for Std 3 Infection Prevention
- Improvement News Stories aligned with Std 3 Infection Prevention
- Incident reporting against Std 3 Infection Prevention
- The online Performance Dashboard reporting aligned with Std 3 Infection Prevention
- The Clinical Audits that support good practice against Std 3 Infection Prevention
- The training programs available to support good Infection Prevention Practices
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Looking forward, we continue our focus on …
| Biofilm in Clinical Hand Basins | Auditing told us there was high and higher level biofilm growth identified in up to 10% of clinical hand basins in flagged areas of concern at Sunshine Hospital | To reduce biofilm-associated hospital-acquired infections:
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| Healthcare-associated bacteraemia
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The numbers of Staph.aureus Bacteraemia infections (Healthcare-associated) fluctuated over 2022/23, but seem to have settled
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To minimize the risk of line infections, we implement the following practices:
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| Hand Hygiene | Hand Hygiene audit results are showing good results of almost 90% which is above Department of Health target | To sustain the reduction of hospital-acquired infections, we are committed to the following practices:
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| Needlestick Injuries | We are still recording too many avoidable sharps injuries | To minimize needle stick injuries and fluid exposures:
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| COVID | Ongoing vigilance is required to ensure there are no delays in the use of respiratory based precautions | To reduce healthcare-acquired COVID-19 infections:
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| Linen Handling | Observational auditing of linen handling show trolleys are occasionally uncovered when not in use and staff are touching linen without changing gloves | To lower contamination risk when handling linen:
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| No more on the floor | Observational auditing shows items such as dirty linen and stock and sometimes left on the floor | Let’s support our ‘No more on the floor’ campaign, which includes avoiding practices like inflating air mattresses on the floor. |
| Infectious Disease Screening | Preadmission Screening Tool Audit data show an 80% completion rate but significant variance between areas and delays in completion | Let’s reduce the risk of hospital infections to others by:
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| Ultrasound Probe Cleaning | Ongoing vigilence is required to appropriate manage the cleaning of ultrasound transducers | Let’s reduce the risk of infection from ultrasound transducers by:
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| Staff Immunisation | 95% of our staff had a flu vaccination this year – a great result! | Let’s keep reducing the risk of patients and staff acquiring influenza by:
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