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WELCOME                                                                               PAGE 1

                WELCOME FROM CEO &
           We are so proud of our achievements made this year. Congratulations to

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
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

                                 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.

                         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

                          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
                                                    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
• 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
• 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

                     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

                     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
                                                  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.


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.

                              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.


                              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.

                         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

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.

                    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
  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

• Delivering news about Yarrawonga Health         RESPECT • EXCELLENCE • COMPASSION • INTEGRITY • TEAMWORK
  more frequently via a variety of different


                                            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
                                                   “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”.


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

                             HELPING HANDS
                                                                                                         HELPING HANDS



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
                                                                                                  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.

                 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


                                  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.



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 2020


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.


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.


                                    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 interventions


                                    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.


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 improve


    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
  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%).

                       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?’
  • 100% of respondents felt that health                   • Dec 2017 – 83%
    workers took their concerns seriously                  • Dec 2018 – 92% (Vic 77%)
    (Vic 88%).

                        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.


We would like to hear from you what you think.

1. What do you think of the information in this Quality Account? (please circle)

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2. What do you think of the way we have presented this information? please circle

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3. Is there any other information you would like to see in the Quality Account?


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
www.yh.org.au/feedback                                                        Yarrawonga Health Director of Clinical Services Kaye Gall and
                                                                              Nursing Unit Managers

33 Piper Street, Yarrawonga VIC 3730
Phone: (03) 5743 8111
Feedback to: qualityaccount@yh.org.au
or phone: (03) 5743 8198
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