News

An ongoing Standard of the Month program has been introduced to support us to remain ‘accreditation ready’ at all times. This involves a focus on one Standard per month, with communications and walkarounds to help staff be aware of how Best Care at Western Health reflects this Standard, to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what our practice at Western Health looks like.​

We are excited that NSQHS Standard 7: Blood Management is to be the focus of April’s Standard of the month. This will run from Tuesday 2 April to Friday 26 April. Look out for friendly Fab 5 Team Members, Best Care Co-ordinators, and other staff who will visit clinical areas/departments to discuss Blood Management with you.

Click here to view a calendar of Blood Management Standard of the Month activity.​

Our aim is to have every clinical department/service across Western Health visited within the month. Click here to access the NSQHS Standard 7 Walkaround template that includes Q&As plus a checklist of ‘what can you see’. This template can be used at any time by staff to keep Accreditation Ready for NSQHS Std Accreditation Survey.

To get up-to-date with accreditation readiness and Blood Management, read the NSQHS Standard 7: Blood Management Bulletin. An ‘at a glance’ one pager on the Standard is also available and will be distributed on walkarounds.

‘Reframe your response’ is a new training package that uses virtual reality to simulate real-world scenarios in a healthcare setting.  Based on the premise that ‘where there is an event, you have a response to that event, that creates an outcome’ the aim of the training is to demonstrate how self-awareness and emotional regulation during difficult situations can shape and influence an outcome.  Reframe Your Response is an educational workshop developed to increase healthcare staff members’ skills in preventing and de-escalating behaviours of concern in the workplace.

The program combines educational content with experiential learning, and the production of individualised plans for staff to increase their awareness and approaches to manage stress over time.

Wearing VR headsets, training participants view the scenarios from the perspective of the patient in order to better understand and empathise with their experience of being in hospital. The second scenario is a Ward Scene, in which the user experiences a nurse’s perspective of interacting with a stressed visitor (a family member of an acutely unwell older woman). In the latter scenario, the user is presented with various decision points that impact the outcome of the interaction.

Using virtual reality’s capacity to better connect people emotionally with training material, the immersive Reframe training helps increase the confidence, compassion and safety of participants.

The new Virtual Reality training was introduced on 27 March 2024 and is really amazing and innovative – and shown to have a positive impact on staff learning.

Links to the registration below:

• Staff from High Risk OVA areas (Emergency Departments, Ward GC, Ward 2A, Ward 3E)
• Staff from other areas

Please note that staff from Mental Health & Wellbeing undertake a different bespoke OVA education program.

The current shortage of IV Paracetamol 1000mg/100mL vials/bag in Australia is anticipated to continue until June 2024 due to unexpected increase in demand and production delays.

Clinicians are requested to consider alternative routes of administration and to reserve the use of IV vials for situations where alternative routes are not suitable.

Western Health has limited stock available, and hence usage of stock is being monitored closely. Over the past week usage of this product has not reduced sufficiently despite various interventions, and subsequently our projected stock holdings continue to decline. Hence, we are now taking the measure of removing stock from additional Western Health imprest sites except for ICU, Theatre and Emergency Department locations.

Paracetamol suppositories have been added to all imprests currently/previously stocking IV preparations and should be used as a first-line alternative for patients unable to have oral preparations.

Please contact Pharmacy for individual requests for paracetamol IV supply in locations where it has been removed from imprest.

National Close the Gap Day was recently held on 21 March 2024, and recognises the national agreement to overcome inequality experienced by Aboriginal and Torres Strait Islander people and achieve life outcomes equal to non-Indigenous Australians.

Each year progress on the 19 national socio-economic targets across areas that have an impact on life outcomes for Aboriginal and Torres Strait Islander people is reported.

They range from ensuring babies are born at a healthy birthweight, supporting children to thrive, and ensuring there are appropriate pathways for education and employment.

Progress has been made, but it has been too slow and the gap is still too wide. For instance, Aboriginal and Torres Strait Islander people still have a life expectancy that is 10-11 years less than non-Indigenous Australians!

Western Health has a growing Aboriginal and Torres Strait Islander community and is committed to self-determination. As part of our efforts to close the gap we are incredibly proud of the culturally responsive care options we have designed to ensure that Aboriginal and Torres Strait Islander patients receive respectful, high-quality care with greater access and choice. These include:

A small team of dedicated midwives and doctors, who provide culturally-safe continuous care to Aboriginal and Torres Strait Islander families and babies. You can read more about how this service is improving outcomes for our community on our website.

A program promoting the health and developmental outcomes of First Nations children in Melbourne’s Western Suburbs (the City of Melton and Moorabool Shire). Establishing and building on strong networks, the program supports children and their families in their engagement with child health and promotes cultural safety in health.   

It won the Excellence in Aboriginal Health and Wellbeing Award at the Victorian Public Healthcare Awards in 2023.  Read more.

A culturally safe, general medicine stream clinic for Aboriginal and Torres Strait Islander adults with chronic health conditions who do not require urgent care.

It is designed to provide a wrap-around service for patients with longer appointment times, a multidisciplinary focus, assistance with any barriers to attending and the individualised support and advocacy of an Aboriginal Hospital Liaison Officer (AHLO). Read more.

Wilim Berrbang Manager (Acting) Ashleigh Vandenberg and Wiradjuri woman said that everyone has a part to play in helping us achieve health equity for all Australians. “We all have a role to play in closing the gap and our actions can have a positive impact on the health and wellbeing of Aboriginal and Torres Strait Islanders and society more broadly,” Ashleigh said.

New support for Aboriginal Menal Health consumers

To improve the way we support consumers and their families seeking support with their mental health and wellbeing, Western Health has appointed our first Aboriginal Mental Health Liaison Officer in Wilim Berrbang.

Maddie DePetro (pictured right) is from the Yorta Yorta & Dja Dja Warrung clan and is passionate about ensuring Aboriginal and Torres Strait Islander patients feel heard within the healthcare system.

Referrals can be made to Maddie via the Wilim.Berrbang@wh.org.au, via phone on 0482 130 724, or on EMR select: Aboriginal health- Other- Request AMHLO support.

How can I make a difference?

You can make a difference by being educated and informed on ways you can provide culturally-safe care:

• Read more about Closing the Gap on its website. The latest report was released on 21 March.
• Read Western Health’s Cultural Safety Plan.
• Complete our cultural awareness training on WeLearn to improve your understanding of Aboriginal and Torres Strait Islander cultures, histories and successes.
• Visit the Wilim Berrbang team staff intranet page.

The latest benchmark reports from the Health Roundtable that go up to September 2023 have recently been released, that show how our delivery of Best Care compares to other health services across Australasia.

Let’s look at how we perform in the area of Medication complications, which include drug related respiratory complications/depression, haemorrhagic disorder due to circulating anticoagulants, movement disorders due to psychotropic medication and serious alteration to conscious state due to psychotropic medication.

Medication Complications:

At Western Health as a whole the rates of medication complications per 10,000 episodes has been consistently green. We are amongst some of the best outcomes in Australia. This is a wonderful result.

The last quarter this has decreased again to green.

Well done to all of our Western Health teams.

It gives me great pleasure in announcing that the Australian Council of Healthcare Standards has formally awarded 3 years accreditation to Western Health.

This fantastic result is based on the findings from:

1. The accreditation survey held during the week of 4-8 December 2023, where 12 surveyors from across Australia intensively assessed Western Health against the eight National Safety and Quality Health Service (NSQHS) Standards.
2. The accreditation final assessment where 2 surveyors visited our sites on 14 March to review the two areas identified in December as requiring some improvement.

It would be remiss if I didn’t take a moment to reflect on the commendations received from surveyors throughout our accreditation journey.

1. There was high praise from the surveyors about the standard of care, commitment to being person-centred, our culture of respect and teamwork and involvement and empowerment of consumers in their care.
2. The surveyors commented on how it was apparent that innovation is in Western Health’s DNA, and they were unanimous in their praise for our people.
3. The lead surveyor commented that they spoke to a large number of patients and consumers throughout the week, and every single one of them had positive things to say about our people and the care that they were receiving – which she said is unusual.
4. All elements of the care that we provide to our patients, women and consumers were highly praised, and it was evident that it was actively being practised at the point-of-care.
5. There was noteworthy acclaim from the surveyors about the considerable amount of work undertaken to improve both medical credentialing and the reporting of our learning requirements during the final assessment.

Click on the following links to access final accreditation reports and our new certificate:

• NSQHS Stds – WH Certificate of Accreditation 2024
• NSQHS Stds – WH Initial and Final Assessment Reports
• NSQHS Stds – WH Clinical Trials Framework Accreditation Report

Every single Western Health employee, volunteer and consumer advisor should feel immensely proud of this achievement – your commitment to continually improving is inspiring. My sincere thanks to everyone for your tireless dedication in continually delivering or supporting the provision of Best Care to our community every day.

Authorisation, monitoring and reporting of restrictive interventions in Western Health Emergency Departments and Urgent Care Centres

Victoria’s new Mental Health and Wellbeing Act 2022 (MHWA) commenced on 1 September 2023.

The MHWA includes obligations and reporting requirements for the regulation of restrictive interventions in designated mental health services. Western Health became a designated mental health service on 1 July 2023 and so these changes apply to us.

What’s new?

From 1 April, changes to clinical practice and governance will come into effect in all of Western Health’s Emergency Departments (EDs) and Urgent Care Centres (UCCs) in relation to restrictive interventions.

Under the MHWA, the use of all restrictive interventions – bodily restraint, chemical restraint and seclusion – on people receiving a mental health and wellbeing service is reportable to the Chief Psychiatrist. This includes all voluntary consumers receiving a mental health and wellbeing service.

What does this mean for all divisions, programs and sites under the governance of Western Health?

As a designed Mental Health Service, Western Health is required to:

• Implement the provisions set out in the MHWA and apply these to ED and UCC settings from 1 April,
• Understand, by 1 April, mandatory reporting requirements and the Chief Psychiatrist’s expectations of best practice when using restrictive interventions outlined in the Chief Psychiatrist Guideline on Restrictive Interventions (advance final copy),
• Determine when a person is receiving a mental health and wellbeing service and apply the requirements of the MHWA accordingly in all settings where care is provided by Western Health,
• Comply with and give proper consideration to the mental health and wellbeing principles and the decision making principles set out in the MHWA, to guide staff in upholding the dignity and autonomy of people living with mental illness or psychological distress,
• Accurately complete all documentation to ensure authorisation, documentation and reporting requirements are legally compliant.

What supports are in place at Western Health?

 A comprehensive education program for staff working in EDs and UCCs, alongside the Mental Health and Wellbeing Services is raising awareness of legislative obligations under the MHWA. Further education in EDs and UCCs can be arranged through:

• Pallavi Pathak: Clinical Nurse Educator  Pallavi.Pathak@wh.org.au
• Leslie Mbatia: Clinical Nurse Educator  Leslie.Mbatia@wh.org.au

 WeLearn Modules

Western Health clinical workforce are encouraged to complete existing MHWA Modules on WeLearn. Module 6 (new) is now available for all staff working in EDs, UCCs, MHWS inpatient units and all inpatient wards.

Module 6 covers protections of the MHWA for the use of restrictive practices; definition of the forms of restraint intervention, monitoring and recording obligations and new reporting requirements.

A flowchart to outline the authorisation, reporting and monitoring of Restrictive Interventions and can be accessed via this link.

Mental Health and Wellbeing Act 2022 Q&A email address

Mental Health and Wellbeing Act 2022 questions can be sent to MHWA@wh.org.au. Emails will be responded to within 48 hrs Mon- Fri.  Urgent queries should be directed to your manager, senior medical officer or the Emergency Mental Health team.

Department of Health and Office of the Chief Psychiatrist Readiness Resources

The Chief Psychiatrist’s final guidelines, fact sheets and flow charts can be downloaded from:

• Office of the Chief Psychiatrist’s reform activities and news
• Restrictive interventions

Recorded information sessions are also available:

• https://vimeo.com/922753934/f6908e8042?share=copy
• https://vimeo.com/922755559/f06e9accb2?share=copy
• https://vimeo.com/927341964/c50494f4cb?share=copy

To finalise Western Health’s accreditation outcome, today two ACHS Surveyors visited us to review a couple of areas identified in December as requiring some improvement; namely medical credentialing processes and the reporting of training data.

There was high praise from the Surveyors about the considerable amount of work undertaken in these 2 areas, and the robust systems and processes implemented by Western Health.

As a result of this final assessment, the Surveyors have stated that the recommendations will be closed, meaning that Western Health will have met all accreditation requirements.

The next phase of the process is that the accreditation status of Western Health will be formally determined by the Commission for Safety and Quality via recommendation from ACHS and based on the findings of all Surveyors that have visited our services.

ACHS will then issue us with a Survey Report with the finalised outcome and a summary of findings. Once this report has been received it will be shared with our staff.

My sincere thanks to everyone involved in delivering or supporting the provision of Best Care to our community, and to those that have undertaken the awesome work in preparation for both Accreditation week and today’s Final Assessment.