QUALITY ACCOUNT YARRAWONGA HEALTH 2018-2019
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YARRAWONGA
HEALTH
QUALITY
ACCOUNT
2018-2019
HEALTH
WELCOME PAGE 1
WELCOME FROM CEO &
BOARD
We are so proud of our achievements made this year. Congratulations to
everyone!
Yarrawonga Health welcomes you to the of everything we do and the aim of the
2018- 2019 Quality Account our annual quality account is for us to report the ways
scorecard showing you exactly how we we can partner with you to improve patient
performed in our key quality measures safety, care, and your experience.
against patient expectations.
Your feedback on this report is warmly
Every year we compile this report and we
are astounded by the achievements our small welcomed and can be provided to us on the
leading rural health service has achieved, the last page via a feedback slip, to tailor this
dedication of our staff and volunteer’s and publication to your needs.
their commitment to enhancing health care
for the community. On that note thank you to our Community
Advisory Committee for giving this
We are immensely proud of all our publication their tick of approval and the
achievements this year and would like to say
continual service they provide to our health
thank you to all our staff and volunteers for
service.
the differences they make everyday to our
patients and their families.
We hope you enjoy reading.
At Yarrawonga Health we place our patients,
consumers and our community at the heart Yours in service,
Elaine Mallows Erin York
Chief Executive Officer Board Chair
PAGE 2
TABLE OF CONTENTS
To help you find your way!
Welcome from the CEO and Board......................................................................................................Page 1
Consumer Carer and Community Participation..............................................................................Page 3
Your Feedback Our Actions ..................................................................................................................Page 4
Your words to us .....................................................................................................................................Page 5
Our Quality Team.....................................................................................................................................Page 6
Embracing diversity and working with our community ................................................................Page 7
Community Voices...................................................................................................................................Page 11
Quality and safety for every patient ...................................................................................................Page 15
Residential aged care .............................................................................................................................Page 20
Community Health Services Victorian Healthcare experience Survey......................................Page 22
Your experience with our team............................................................................................................Page 24
What did you think about this publication........................................................................................Page 27
A warm welcome from our reception staff.
PAGE 3
CONSUMER CARER AND
COMMUNITY PARTICIPATION
Putting smiles on the faces of our consumers!
Yarrawonga Health is committed to discharge process and how we can
providing safe and high-quality care better partner with our consumers to
for all our patients. We are always
improve our results, refine our
reviewing our services and seeking
ways to improve. consumer discharge information in
consultation with our Consumer
The following table displays results Advisory Committee and increase
taken from the Victorian Healthcare patients perception of cleanliness via
Experience Survey (VHES) in both the
Acute Service and Community reviewing and continually auditing for
Services. cleanliness in our health service.
We are very proud of these results, We have also increased staff education
but the hard work for us doesn’t stop
on the use of care boards to foster more
there we are continually looking for
ways to improve our health service. collaborative goal setting to partner with our
In Acute, we are focusing on the consumers.
VHES SURVEY RESULTS
Question Yarrawonga Health Score State Target
Overall how would you rate Quarter 1 – 98% 95%
the care you received in Quarter 2 – 100%
the hospital? Quarter 3 – 100%
Answered Very good or good
Overall, the rating for the Quarter 1 – 88% 75%
discharge process Quarter 2 – 89%
Quarter 3 – 90%
Answered Very good or good
Patient perception of Quarter 1 – 96% Full compliance with
cleanliness Quarter 2 – 90% Internal audit.
Quarter 3 – 93% Nil target set- State
Answered Very good or good average 75% VHES
PAGE 4
YOUR FEEDBACK
OUR ACTIONS
See how we respond to your feedback!
Victorian Healthcare Experience Survey cost, increased signage at the reception
2017-2018 Community Survey desk and in the waiting room to inform
clients of costs of service.
In Community Services we have still focused
on the improvements identified in our action Overall (Q 43-49)
plan from the 2017-2018 VHES Community • 100% of respondents felt they were treated
Survey.
with dignity and respect (Vic 92%).
• 0% of respondents felt that they were ever
From October to December 2017 we received
more than 35 responses to the VHES treated unfairly by the health service (Vic
Community Survey with the grand finding 91%)
being that 100% of our respondents indicated • 97% of respondents rated the care that they
they had extremely positive results accessing received as ‘very good’ or ‘good’.
our community services.
Improvements made (Q43)
For results less than 80% or that fell If you need to, do you know how to make a
below the state average we have made complaint at the health service?
improvements in the following areas: • Dec 2017 – 64%
• Dec 2018 – 73% (Vic 57%)
Information (Q 36-42)
This section was very positive in the
Actions Taken
responses.
• 100% of respondents stated that they Updated information provided to clients in
received ‘The Right Amount’ of information written and verbal forms during the intake
about their care or issue (compared to Vic process to be more clearly collect feedback
State 88%). processes. Signage in the waiting room and
• 100% of respondents stated that they knew feedback box a more prominent.
who to contact if they had any questions
about their care (Vic 85%)
Improvements made (Q 38)
If there was a cost for the health services you
used, were you aware of how much it would
be?
• Dec 2017 = 67% positive
• Dec 2018 = 79% positive (Vic state = 69%)
• Actions taken – updating of our community
services information booklet with pricing
information. Ensuring that during intake
phone calls clients are aware of the service
PAGE 5
YOUR WORDS TO US
Consumer Experience Quotes 2018-2019
Feedback from community members “Thank you to our lovely district nurses, with
accessing after hours emergency services much appreciation - a huge thank you”
was that access was not well known and - District Nursing
assessment was inconsistent.
“Really glad we were able to have our baby so
A revision of the admission, assessment, close to home and have one on one support
care pathways and improvements in Sepsis for our first baby”
recognition and timelines of care contributed - Maternity.
to a patient’s mother saying.
This quote after her son was seen at our
Urgent Care Centre with urgency to triage
for escalation of care – “if I could think of
a greater word than thank you, fantastic,
extraordinary, amazing… that would be for all
of you” “The attention and care you gave
me was exceptional”
- Urgent Care Centre
“I am exceptionally impressed regarding the
standard of care, along with the consistent
kindness, compassion and attention to detail
that I have observed.” - Aged care “We are so
appreciative of your time, care and support”
- Aged care
“I can only thank and praise all the staff that
looked after me” - Theatre “A patient made
a note to thank the dialysis nurse on the
clinical decisions she made”
- Dialysis
“Staff were very professional, but friendly and
reassuring in their treatment of me”
- Acute services
“Compliment from a relative of the aged
care newsletter about the attention and the
happiness it bought a resident”
- Administration
PAGE 6
OUR QUALITY TEAM
Yarrawonga Health would like to thank our exceptional team of highly
skilled doctors for the important work they do!
Yarrawonga Health would like to thank our Our Doctors have an exceptional
exceptional team of highly skilled doctors for commitment to quality and safety
the important work they do providing care to participating in learning reviews of clinical
our community. cases and in the provision of input and advice
They are an integral part of the
into procedural and clinical pathways. They
multidisciplinary team providing care to
our patients and residents. They are highly are part of the very fabric and DNA that
skilled, local and responsive to Yarrawonga makes our great community thrive. Our
Health’s needs balancing their workloads medical workforce strengthens health in our
from local medical centers and clinics with community and safeguards the wellbeing of
Yarrawonga Health patients. each and every one of us on a daily basis.
In our rural community, every person counts,
and everyone looks out for each other.
Having good access to healthcare, made
possible by our team of doctors, is such a
fundamental part of what makes our small
town thrive, we thank all of them for their
commitment and celebrate them as part of
our community and part of the Yarrawonga
Health team.
Congratulations to Dr Clyde Ronan The first recognises general practitioners
Dr Clyde Ronan received two esteemed and medical specialists who have shown
awards at the Rural Doctors Conference in professional and personal commitment
May this year, taking away the Outstanding to regional and rural communities, often
Rural GP award as well as a Length of Service going above and beyond with services and
for his 35 years in practice.
involvement in the community.
The length of service award is presented to
general practitioners and medical specialists The second category recognises doctors who
who have served rural and regional Victoria are establishing their careers in rural health
for over 35 years, recognising their extensive and have demonstrated an outstanding
commitment to providing health services, contribution to their profession and
often to many generations of the same family community.
and their continued involvement in the
community.
Yarrawonga Health is very proud to have
The second of Dr Ronan’s awards, the Dr. Ronan as part of our team and the
Rural Doctor award has two subcategories: contribution he has made to rural medicine
Outstanding Contribution and New Rural locally in Yarrawonga and surrounding
Doctor. communities.
PAGE 7
EMBRACING DIVERSITY & WORKING
WITH OUR COMMUNITY
Interpreter Services developing strategies and actions to
As part of the admission process, all patients encourage access for people within our
or their families/ carers are asked whether community with one or more disabilities and
they require access to interpreters to ensure to eliminate practices that may discriminate
optional communication. Interpretation against these people.
and translation services are provided to all
patients and residents when required at There are multiple actions within this
no cost to them. In 2017-2018 one patient plan which will benefit people accessing
identified as requiring an interpreter. Our Yarrawonga Health including an Access Audit
language service procedure was up to
to assess our infrastructure and buildings,
date, and staff knew how to access this
investigating opportunities for employment
service. We also publish an icon on all
or volunteering for people with a disability
our publications to show our support and
and community engagement specifically for
willingness to use this service.
people with a disability.
Disability Action Plan
In 2018-2019 the Yarrawonga Health Senior As part of this plan, Yarrawonga Health will
Operational Committee has worked to engage and develop a disability reference
develop a Disability Action Plan that forms group of community members, staff and
part of the Yarrawonga Health Diversity Plan. health consumers to ensure that regular
engagement and feedback is provided into
The purpose of this plan is to provide actions and evaluation of the plan over the
direction for Yarrawonga Health in next three years.
PAGE 8
MANY MOBS
Improving Aboriginal Health
Yarrawonga Health has continued a strong • Ensuring that Acknowledgments of Country
partnership with the local Many Mobs are included at Board level and community
Aboriginal Community Group over the 2018- – attending meetings
2019 year. Our organisation has a strong • The provision of cultural competence
commitment to Reconciliation, and to training that is available for staff at all levels
working in partnership with Aboriginal and
across the health service.
Torres Strait Islander people to ensure that
• Engagement with local Aboriginal artists
the services we are providing are welcoming,
and the procurement of numerous pieces
appropriate and provide equitable access to
all people at all times. of artwork that are displayed with pride
around our health service, along with flags
This year we continued to support our at each entrance.
local Aboriginal community in holding their • And of course, a display of public
monthly meetings on site, and worked commitment each year at our NAIDOC
together to provide the community with celebrations.
our third annual NAIDOC celebration with
more than 250 people in attendance. The This year we where also proud to unveil a
community attended a walk across the couple of new additions to our health service
traffic bridge from Mulwala to Yarrawonga,
in the form of Acknowledgment plaques that
lunch on the Yarrawonga Health front lawn,
will be displayed on the two main external
and then an afternoon of traditional Daya
entrances to our health service and are a
games at Kennedy Park for local school and
kindergarten children. permanent and visible acknowledgement
of country for all who enter into our
We have also completed many other actions organisation. We also have future plans to
that formed part of our Diversity Plan include similar plaques on the additional
including; entrances.
PAGE 9
LGBTI
A Health Priority Community Group
Over the past twelve months, Yarrawonga • Multiple on-site ‘Listening lunch’ meetings
Health has undertaken many actions to with LGBTI community members and the
improve the service experience for the development of the LGBTI Community
Lesbian, Gay, Bisexual, Transgender, and Catch-Up meetings.
Intersex (LGBTI) community who access • All male/female designated toilet and
our health services. The LGBTI community bathroom facilities within the health service
is a priority population for Community have had signs removed and replaced with
Health services as it is recognised that they unisex toilet signage.
often have poorer health outcomes and are • Implemented rainbow stickers at entrance
less likely to access health services when and rainbow symbols on publications.
compared to the general population.
The Yarrawonga Health Inclusive LGBTI
action plan was endorsed in September 2017
and since then the following actions have
been completed:
• Training provided for staff in LGBTI
inclusive practice.
• LGBTI-inclusive practice principles added
to staff orientation.
• Links created with local LGBTI
organisations and services.PAGE 10
FAMILY VIOLENCE
Central Hume Strengthening Hospital Response to Family Violence project
Yarrawonga Health is proud to
be a partner of the Central Hume
Strengthening Hospital Response to
Family Violence project, a regional
health group partnership led by
North East Health Wangaratta and
including Benalla Health, Mansfield
Health, and Alpine Health to
improve our response and support
people experiencing family violence.
We have been part of this project
since it’s commencement in 2018
and are committed to raising
the knowledge and recognition
of family violence within our
community. Key achievements have
included working with community
members, local organisations and
service providers to improve the
coordination and ability to respond
by local and referral support
systems currently working in this
space.
As a health service, we know we
have a significant role to play in
potentially being the earliest point
of contact for victims and in early
identification of this issue.
So far more than 90% of our staff
have attended family violence
training and we have visiting
trained counselors from Primary
Care Connect and Goulburn Valley
Centre Against Sexual Assault on-
site by appointment, who specialise
in family violence and offer a free
confidential support service.PAGE 11
COMMUNITY VOICES
Our Community Engagement Strategy
Yarrawonga Health Community Engagement • Increasing patient experience surveys and
Strategy provides a clear structure and • Providing consumers with opportunities to
pathway for consumer participation at be directly involved in those committees
Yarrawonga Health. The Community Advisory where quality and safety decision- making
Committee sits at the top of our consumer occur.
participation organisational structure and
is supported by our maternity, fundraising, You can pick up a copy of our Consumer
seniors and youth reference groups. Engagement Strategy at Yarrawonga Health
or download it from our website www.yh.org.
Together these groups, along with au/aboutus
community groups, and individuals give all
consumers a voice and input into how things
are done at Yarrawonga Health.
This year we have consulted with these
groups, residents and our community to
inform service change improvements to: HEALTH
• Review Acute Unit access, assessment and
care planning management Consumer and
• Make improvements to our food options Community
in the aged care sector via direct feedback Engagement Strategy
2018-2020
from residents.
• Support the Community Advisory
Committee to coordinate our Consumer
Engagement strategy and offer support/
training to formally use their voice across
the organisation.
When we asked how consumers would like
to engage more with us – you told us that
you would like to have more of say in how
services are planned and delivered. Themes
included:
• Delivering news about Yarrawonga Health RESPECT • EXCELLENCE • COMPASSION • INTEGRITY • TEAMWORK
more frequently via a variety of different
mediumsPAGE 12
VOLUNTEERS
Our Heroes
Each year over 60 volunteers give their time “I like it for a social occasion and that I am
to our health service and provide invaluable giving back to our community through
support and assistance to families, patients,
building friendships with the residents
residents and staff at Yarrawonga Health.
in Karana that I do knitting with – it’s
Our volunteers freely give their time to like sharing a mutual passion and doing
support our organisation and our community something good at the same time”
and are involved in many areas of Yarrawonga
Health such as the Community Advisory
“Volunteering for me on Yarrawonga Health
Committee, Helping Hands Fundraising
Senior Advisory Committee is an opportunity
Committee, Aged Care, Acute and many
other areas. to speak and learn more about what is going
on in Aged Care services, that will impact
People of all ages and from all walks of life me one day, help me to support a loved one
become volunteers. It can provide a sense
and allows me to hear what my local health
of purpose and meaning, keeping people
service is doing”
connected and engaged in their local
community.
“I like getting out amongst the community
So if becoming a volunteer appeals to you and making a residents day in aged care, its
please direct your inquiry to Deidre Poll on
just the little things I do like reading that
03 5743 8538 or email deidre.poll@yh.org.au
gives them so much joy and pleasure for such
Here are some quotes about why some of our a simple act. It’s the smiles on their faces you
volunteers love volunteering with us: just can’t beat”.PAGE 13
YARRAWONGA HEALTH COMMUNITY
ADVISORY COMMITTEE
Yarrawonga Health Community Advisory inform the broader community
Committee is comprised of interested • Provide a consumer voice to the delivery of
members of our community who meet bi- health care at Yarrawonga Health.
monthly to:
• Advise on any concern or identified If you are interested in being part of this
improvement from the community committee, please contact Nedean Clarke,
perspective. Executive Assistant, on 03 5743 8130.
• Review patient information to make sure it Members of this committee assist with the
is easy to read and understand
production of the Quality Account each year
• Provide a comment about services which
are being introduced or reviewed and we give heartfelt thanks to our members
• Receive information about the general for their wonderful assistance with this
business of Yarrawonga Health so they can report!
Taking a walk in the shoes of our consumers
– Margaret Duff video
This year Yarrawonga Health produced a walk
in my shoes training video for staff to educate
them on the importance of partnering with
the consumer in healthcare and what the
consumer values as important.
In a short six minute video shown to all
staff Margaret Duff an established member
of our Consumer Advisory Committee
bravely told staff about her experience in
a variety of different hospitals and how
important communication and the simple
act of kindness can be to consumers in
transforming their stay in a hospital setting.
Thank you Margaret Duff for allowing us to
film you and for sharing your experience in
healthcare contributing to our staff training
and ability to respond to the needs of our
patients.PAGE 14
HELPING HANDS
HELPING HANDS
HEALTH
Donations
Yarrawonga Health is so proud of the Bernadette
achievements of its Helping Hands volunteer “I am just starting to explore my new bed
fundraising committee who has successfully and its features – it’s great that it can adjust
raised over $100,000 for our health service to different heights and I can’t wait to get
allowing us to purchase over 50 new beds the land lifter to attach. Thank you so much
for our patients since being established over Helping Hands”.
three years ago by Yarrawonga Health Board.
DONATIONS REGISTER 2018/2019
Yarrawonga Health is most grateful for the generous support
The committee is comprised of Vivian Spilva received from our community and beyond during 2018/2019. We
(Co-Chair), Andrew Shell (Co-Chair), Racheal recognise and greatly appreciate the contribution by the following
individuals, businesses, service groups and clubs.
Cartwright, Debbie Cooper, Liz Seeliger,
CWA Yarrawonga and Border Yarrawonga Lions Club
Jackie Smith, Jeanette Bennett, Micheal Sister Schneider Hadar Homes
O’Neil, Robin Wall and Gill Cunningham. This Estate John James Saunders
Mulwala Water Ski Club
Lake Mulwala Community Action Group
Yarrawonga Mulwala Multi Sport Festival
group does an incredible job reaching out Club Mulwala Thyme for Coffee
Yarrawonga Mulwala Golf Club Resort Gary Wise
to our community and fundraising for our Rotary Club of Yarrawonga/Mulwala Yarrawonga Lawn Tennis – Tuesday
equipment needs that can be fast-tracked Rosa Marshall
Yarrawonga & Border Country
Competition
Bundalong Tavern
through community donations. Woman’s Association Criterion Hotel
Yarrawonga/Mulwala Combined Ritchies IGA Supermarket
For more information on Helping Hands Churches McBurnie Group
Uniting Church Bundalong Yarrawonga Yarrawonga Football Netball Club
please contact Yarrawonga Health. Memory of A Tufvesson T & J Bradshaw
Roger MacDonald Eric Scott
Memory of L Goldsack Robert Vessio
John Dunstan U Campbell J. Ramsdale
B McDonald Central Murray Credit Union
“Thank you to the Helping Hands team and Warrina Craft Ladies AIM Breakfast
community for fundraising to get me a new Northeast 60 & Over Bowlers Group Inc
Memory of G Moyle
Yarrawonga Garden Club
Kennedy Builders
bed this year – the bed provides me with Yarrawonga Medical Clinic Yarrawonga Denis Medical Group
Tungamah Auxiliary Steve Buckley
such a better nights sleep, is extremely T & K Hargreaves O’Meara Kennedy First National Real
D. Smith Estate
manageable, comfortable and even allows me Yarrawonga Innerwheel Jodie Cartwright and Melissa Ritches
to move it in multiple ways so I can have my Purtle Electrical Memory of T Booth
morning coffee- such an improvement. I can
Thank you to all members of the community who have nominated
now even make my bed in the morning as it Yarrawonga Health through Ritchies IGA Supermarket.
We also thank all those members of the community who have
lowers to different heights so I can regain supported Helping Hands and contributed to their many
some independence.” fundraising events.
Dani Kennedy O’Meara Kennedy First Ritchies IGA Yarrawonga. Alan Rowe CEO ClubMulwala.
National Real Estate.PAGE 15
QUALITY AND SAFETY –
FOR EVERY PATIENT
Your Feedback And Our Actions
This financial year YH received a total of 104 compliments which has doubled from 2018 (52)
from patients, students, residents carers and loves one, reflecting the culture of Yarrawonga
Health as supported by the organisational values.
At Yarrawonga Health we pride ourselves on having strong and robust processes to capture
feedback and the following are some of the actions initiated by your feedback:
Area for Improvement Outcome
Refurbishment of Warrina We redecorated rooms in Warrina and outdoors areas – based
– feedback received from on resident feedback including a residence focus group,
residents and family individual review of lighting options
members at Warrina.
Urgent Care Centre (UCC) YH received complaints over the year 2018 regarding our UCC.
– feedback received from A UCC Working Group has been created and overseen the
consumers UCC Consumer revised registration of presentations, assessments, and triage
Advisory Committee and the education support of Registered Nurses working within
this area.
Food Services When a food complaint is made, the complaint is distributed to
the Support Services Supervisor and the manager of the area
that the complaint has been made and whom from. Discussion
occurs with the consumer to endeavor to look towards
improvement in the service. The nutrition portfolio project
works hard to review all food compliments and complaints to
ensure better improved meals.
Laundry Services A process of the delivery of clothing to the residents.
Reduced lost personal items.
Complaint system Review complaints/Compliment and suggestion form - educate
staff - the entry of a complaint can now be entered directly on
YH Website
We appreciate all feedback as it assists Yarrawonga Health to further improve our services.
To provide feedback, forms are available at all health service entry points and on our website at
www.yh.org.au.PAGE 16
LISTENING TO OUR TEAM
Safety Is Everyone’s Business
Our staff are the most important patient acknowledge this we created a Yarrawonga
safety advocate we have, and it is through Health Occupational Violence and
our people that high standards of care are Aggression (0VA) project-working group
delivered 24 hours a day, 7 days a week. commenced in 2017,with a cross section
of our organisation staff to strengthen
Each year, every member of our team is Yarrawonga Health response to security in
invited to participate in the People Matter this area. We increased staff education in
Survey conducted by the Victorian Public the areas of reporting Occupational Violence
Sector Commission. The survey measures and Aggression and on how to respond to
various aspects of workforce culture and unarmed and armed violence, and invested
patient safety culture within our workforce. capital for equipment such as CCTV, Duress
It focuses on employees’ perspectives on Alarms, UHF radios and major refurbishments
not only the principles and values of the in the areas of Urgent care, Acute secure
workplace but also on the public sector medication room, and Yarrawonga Health
values. This year 136 people responded to Memory Support facilities to ensure staff and
this survey out of 25O staff and 85% of them consumer safety.
agreed that as an organisation, we make
patient safety a priority in comparison to the
State target of 80%.
The People Matter Survey for 2018 found
that workplace wellbeing was an area of
opportunity for improvement as health
workers are amongst the top 10 occupations
most likely to be exposed to incidents of
Occupational Violence & Aggression. So to
Debbie Gleeson, Deputy Director of Nursing and
Education, clinical lead of YH’s OVA Working Group.PAGE 17
NETWORKING FOR SAFETY
Accreditations
One way that we can assure the community that we are doing our best to achieve excellent
standards of safety and quality is by demonstrating continuous improvement through our
accreditation processes.
Accreditation is the ongoing review of our performance against standards across a range of
areas to make sure we are doing our best to keep our patients safe as well as improve our
services. Yarrawonga Health is accredited by the Australian Council on Healthcare Standards
(ACHS) and against other key standards as outlined in the table below.
AREA ACCREDITATION BODY STATUS
National Safety & Quality Australian Council on 3-year accreditation achieved
Health Standards Healthcare Standards National Standards - March 2017
Expiry - June 2020
Home & Community Australian Council on Home Care Standards
Healthcare Standards 3-year accreditation achieved
-May 2017
Due June 2020
Residential Aged Care - Aged Care Standards and 3-year accreditation achieved
Karana, Warrina & Allawah Accreditation Agency Nov 2017
Expiry - Nov 2020
New Aged Care Standards July
2019 – This includes an annual
announced visit supporting the
current accreditation status.
Supported Accommodation Quality Improvement 18-month Submission –
Assistance Program and Community Services Due June 2019 – Compliant
Accreditation Department Next submission - 31 Dec 2021
of Health
Food Safety Plan Review Paul Maggs Food Safety May 2019 - Full compliance - Nil
ACS recommendations
Due May 2020PAGE 18
MANAGING ADVERSE EVENTS
It’s serious business to prevent adverse Infection Prevention
events in health care. They include infections,
falls resulting in injuries, and problems Staphylococcus Aureus Bacteraemia –
with medication and medical devices which Golden Staph
directly impact the patient.
In 2018-2019 Yarrawonga Health reported
Yarrawonga Health has a low rate of adverse zero Staphylococcus Aureus Bacteraemia also
events in comparison with its peers recording commonly called “golden staph”. We monitor
36 events in 2018 – 2019. closely for this infection that can commonly
occur in IV lines and that needs to be
Any significant incident is comprehensively treated immediately or as soon as possible.
reported to our Clinical Governance At Yarrawonag Health we are proud of this
Committee including any strategies identified result and that as a small rural health service
for improvement. Some examples of actions we have a robust Infection Preventable
made to our quality and monitoring systems, Program.
following an incident include:
Vaccinating against Influenza
• Clinical Review of the case/incident
identifying areas of improvement attended This year Yarrawonga Health 2018-2019
by both clinical and medical staff achieved a 94% compliance rate of Health
• Review of Occupational Violence and Care Workers (HCW) vaccinated against
Aggression incidents against staff - influenza (flu). Smashing the DHHS
improvements include new safer entrance compliance rate of 84% for the 2017-2018
to UCC. period.
• Targeted education to both Nursing and
Medical Teams A huge flu-fighting campaign was led by
• Policy and Procedure review/development Yarrawonga Health Executives and the Board
• Review of high-risk fallers to ensure all focussing on being prepared and getting
interventions are in place protected for Yourself, Your Family & Your
Patients – we aimed to achieve a goal of 95%
to exceed our 2018 result of 94%.
To achieve this result - static and mobile
influenza vaccination clinics were held from
2018 May to July providing flexibility for
staff to attend clinics when convenient, and
a significant internal education awareness
program, including individual information
sessions, were held across both the Acute
and Aged Care Sectors.PAGE 19
MUMS AND BUBS SAFETY
In 2018-2019 Yarrawonga Health recorded 40 women initially booked to delivery at
26 births with zero percentage of singleton Yarrawonga Health during their pregnancy,
babies with severe fetal growth restriction through antenatal care their risk factor had
delivered at 40 or more weeks gestation increased and therefore were referred to
and only 1/26 (3.8%) singleton full-term higher level of care to continue with their
baby (without congenital anomalies) was pregnancy.
considered in poor condition shortly after
birth with a low Apgar score. From this single Yarrawonga Health achieved compliance
birth a review with clinical staff including with the Better Care Incentive Program
expected management and monitoring of which demonstrates the maternity workforce
birthing process was conducted. compliance to successfully completing
maternity emergency response training,
As part of best practice Yarrawonga Health fetal surveillance training and neonatal
introduced routine third trimester pregnancy resuscitation
ultra scans are attended with follow-up ultra
sound for those with an initial indication of With ongoing education using PROMPT
suspected foetal growth reduction. Where (Practical Obstetrics Multi Professional
abnormalities are detected referral and Training) we have now identified, upgrades
assessment by a Obstetrician occurs to to our systems and policies to ensure that we
confirm appropriateness for delivery in a low can manage obstetrics emergencies and meet
risk model at Yarrawonga Health. our maternity services capability framework.PAGE 20
RESIDENTIAL AGED CARE
Monitoring Resident Care
DHHS: Public Residential Aged Care Service (PRACS)
Physical Restraint individual care plans. Significant weight loss
Yarrawonga Health Aged Care does not may result in residents with reduced appetites,
support the use of physical restraint. Both complications of their complex aging clinical
Warrina and Allawah demonstrate compliance needs. The monitoring of nutritional needs,
to this goal. In response to resident choice age related complications and the expertise
Karana has resident who request the use of a of the multidiscipline team including GP,
concave mattress. This is not recommended Speech pathologist, Dietitian, Registered
as the safest option. Therefore Yarrawonga Nurses and the clinical care team recommend
health provides a risk reduction approach with interventions including food and behavioural to
additional observation, regular review of the limit the impact of weight loss on the resident
resident/families goals to the safest use of this quality of life.
equipment that may hinder bed access.
Pressure Injury
Unplanned Weight Loss Yarrawonga Health actively reviews any
The management of residents weight both residents care that reports any level of
increase and loss are monitored and managed pressure injury. Through this process low
in partnership with the residents and their level injuries are identified and interventionsPAGE 21
RESIDENTIAL AGED CARE
Monitoring Resident Care
activated as part of the residents care. External Medication
reviews of the three services reports ongoing A review of the designated pharmacy
improvement’s in the skin integrity and dispensing system has assisted in reducing
management of pressure injuries. key errors in the use of Webster packs
(administration aide) across the aged care
Falls area. Errors involving high risk medications
Resident’s with complex aged care needs ie use of patches, insulin, thrombolytics
may be at risk of falls due to the debilitation, and S8 & S4 medications are investigated to
impaired memory, risk taking behaviour for identify the causative factors to the error.
example choosing to walk unsupervised while Interventions including additional education,
on medications. Yarrawonga Health attempts staff competency and the auditing systems
to minimize potential falls and the impact of have all been used to improve the safety of the
falls by providing individual assessments and medication administration system.
plan for each resident with consideration
for their personal input. This will include
consideration of the risk associated with falls
including fractures and skin soft tissue trauma.PAGE 22
COMMUNITY HEALTH SERVICES VICTORIAN
HEALTHCARE EXPERIENCE SURVEY
Patients Story service and the environment and facilities
Unfortunately, Clinton has spent a bit of time provided within the health service. The
at Yarrawonga Health in the past 12 months results from these questions are used to
so he is a familiar face to YH Urgent Care inform the actions and quality improvement
Staff. On one occasion, Clinton presented initiatives undertaken within the Community
unwell for elective surgery and was taken to Services Health division throughout the year.
our Urgent Care Centre then transferred out Overall, Yarrawonga Health receives very
to Wangaratta for escalation of care. positive results for all questions within these
areas, however, we have also made some
improvements based upon actions from our
Clinton speaks very highly of this experience
2017 survey.
and says that he “has always found the staff
respectful and accommodating at YH in all
Accessing the Health Service (Q 1-9)
his experiences with them – and that they
• 100% of respondents reported that the
have been effective and helpful in escalating politeness and helpfulness of the reception
my care needs when required” staff at the health service were ‘Very Good’
or ‘Good’.
• 100% of respondents thought the time
Community Health Services Victorian they spent in the waiting area before their
Healthcare Experience Survey appointment was ‘About Right’ (Vic 78%).
The Community Health Services Victorian • Actions – way-finding maps and
Healthcare Experience survey includes many numbered entrances were implemented
questions regarding Access to the health around the health service to improvePAGE 23
COMMUNITY HEALTH SERVICES VICTORIAN
HEALTHCARE EXPERIENCE SURVEY
the accessibility of different areas. Maps implemented many initiatives to
were included in intake paperwork improve how welcoming the health
mailed to clients on admission to service. service is, especially for community
In addition to this, an application was groups. Aboriginal artwork has been
made to the council to implement two
hung throughout the service, along with
and four-hour parking restriction zones
Aboriginal and Torres Strait Islander flags
surrounding health services.
• ‘Was it easy for you to find the being displayed at all entrances. Rainbow
location of the health service?’ stickers and signage are displayed to
• Dec 2017 – 84% welcome the LGBTI community. All of
• Dec 2018 – 94% (VIC 84%). our publications include symbols for
diverse groups to improve inclusion.
Environment and Facilities (Q 10-14) We have also implemented a children’s
• 97% of clients reported that the health corner in the waiting area to provide a
service was ‘Very Clean’ (VIC 80%).
distraction for children while waiting for
• 100% of clients reported that they felt
appointments.
physically safe at the health service (VIC
93%). • ‘Did the health service feel
• 100% of clients were given enough privacy welcoming?’
during their appointment (VIC 94%). • Dec 2017 – 87%
• Actions – the health service has • Dec 2018 – 100% (Vic 89%).PAGE 24
YOUR EXPERIENCE
WITH OUR TEAM
The VHES Community survey includes • Team Work
responses regarding the client experience • 100% of respondents were referred to
with community health care workers, other services where appropriate to
planning of care and the teamwork of the
improve their health and wellbeing (VIC
service. Many positive results were received
for these aspects, and multiple improvements 89%).
continue to be made. • 100% of respondents stated that all
necessary information was provided to
other relevant services (GP, hospital staff,
etc) (VIC 77%).
• Actions – reduced duplication of
information gathered from clients by
streamlining intake and assessment
processes. Work instructions
provided to staff regarding care
planning and documentation to
improve communication between
health service staff.
• ‘Were there times you had to repeat
information that should be in your
• Your Experience with Health Workers record at this health service?’
• 97% of respondents stated that the health • Dec 2017 – 72% said no
worker introduced themselves and their • Dec 2018 – 87% said no (Vic 70%)
role (Vic 86%). • ‘Did people at the health service work
• 100% of respondents stated that the
together to help you with your health
health workers were compassionate (Vic
and wellbeing?’
87%).
• 100% of respondents felt that health • Dec 2017 – 83%
workers took their concerns seriously • Dec 2018 – 92% (Vic 77%)
(Vic 88%).PAGE 25
YOUR EXPERIENCE
WITH OUR TEAM
Acute Services – Sepsis Improvement with training continuing across the 3 aged
Project care facilities.
• Education ofmedical staffincluding
Sepsis is a medical condition that kills
a simulation exercise around sepsis
more people in Australia per year than the
identification and management for nursing
national road toll. The objective of the Sepsis
Improvement Project was to introduce an and medical staff.
adult sepsis pathway to decrease the number • Inclusion of the Sepsis pathway into
of related deaths to sepsis, ICU admissions, orientation process for clinical staff.
length of stay and decreased time to • Significant reduction (1 hour and 31
antibiotic administration. minutes) in average time to antibiotics for
patients meeting sepsis criteria.
Yarrawonga Health was invited to partner
• 38% reduction in length of stay for treated
for the project with Albury Wodonga Health
(lead agency), Northeast Health Wangaratta, patients.
Beechworth Health Service and Corryong • Compliance with state-wide best practice
Health, as well as being part of a wider guidelines significantly improved, with
collaborative with Better Care Victoria and increases in blood cultures collected,
Safer Care Victoria. lactates attended and more appropriate
antibiotic prescribing
Key achievements of this project included:
• Creation of “Sepsis Packs” for UCC to
• The implementation of Sepsis pathway ensure convenient access to equipment
across Yarrawonga Health required for patients meeting criteria and to
• Training of acute staff- 98% completed, prompt staff to complete all 6 key actions.PAGE 26
PAGE 27
WHAT DID YOU THINK OF THIS
PUBLICATION?
We would like to hear from you what you think.
1. What do you think of the information in this Quality Account? (please circle)
Poor 1 2 3 4 5 Excellent
2. What do you think of the way we have presented this information? please circle
Poor 1 2 3 4 5 Excellent
3. Is there any other information you would like to see in the Quality Account?
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Post the completed form to:
Community Engagement Manager
Yarrawonga Health
33 Piper Street
Yarrawonga Vic, 3730
You can also leave feedback by
contacting us on:
03 5743 8193
feedback@yh.org.au
www.yh.org.au/feedback Yarrawonga Health Director of Clinical Services Kaye Gall and
Nursing Unit ManagersHEALTH 33 Piper Street, Yarrawonga VIC 3730 Phone: (03) 5743 8111 Feedback to: qualityaccount@yh.org.au or phone: (03) 5743 8198 www.yh.org.au
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