Eastern Health Quality Account 2016

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In the patient’s shoes QUALITY ACCOUNT 2016




Providing positive health experiences for people and communities in the east

Eastern Health is one of Melbourne’s largest metropolitan public health services. We provide a range of emergency, medical and general healthcare services, including maternity, palliative care, mental health, drug and alcohol, residential care, community health and statewide specialist services to people and communities that are diverse in culture, age, socio-economic status, population and healthcare needs. We deliver services from 21 locations to 773,992 people across a geographic area of 2816 square kilometres. 1

Healesville Hospital



Healesville Hospital offers general medicine, general surgery, geriatric evaluation and management, palliative care, endoscopy, antenatal care, renal dialysis, specialist outpatient clinics and midwifery home care.


Marysville Narbethong

Yarra Valley Health Yarra Valley Health offers a GP clinic, counselling, allied health, Aboriginal health, health promotion, district nursing and wellness programs across the Yarra Ranges.

Steel Creek

Chum Creek

Yarra Glen

Healesville Hospital and Yarra Valley Health


Kangaroo Ground Eltham Warrandyte Templestowe



Yarra Ranges Health

Wandin Kew

Box Hill Hospital 3

Glen Iris


Peter James Centre 4


Woori Yallock

Maroondah Hospital

Hoddles Creek Wantirna Health




Angliss Hospital




Lysterfield Gembrook


Yarra Ranges Health Yarra Ranges Health offers a variety of day surgery procedures, oncology and chemotherapy services, and a range of specialist clinical, rehabilitation and outreach services.



Peter James Centre Peter James Centre offers rehabilitation, geriatric medicine, aged persons' mental health services, aged care assessment services, aged psychiatry assessment, haemodialysis, residential care and transition care.

Box Hill Hospital Box Hill Hospital offers emergency care, general and specialty medicine, intensive care services, surgery, maternity, paediatrics, specialist outpatient clinics, mental healthcare, allied health services, teaching and research.


Upper Beaconsfield


Wantirna Health Wantirna Health offers palliative care, rehabilitation and specialist clinics.


Maroondah Hospital Maroondah Hospital offers emergency care, general and specialty medicine, intensive care services, general and specialist surgery, paediatrics, specialist outpatient clinics, allied health services and adult mental healthcare.

CONTENTS 04 Welcome

28 Acting on your wishes


04 Meeting the highest of standards

30 Diversity and inclusion


05 The consumer’s voice 06 Opening the door to services

30 Consumers help plan for


08 Acting on patient surveys to

the future

31 Providing a positive workplace

support quality care

32 Resident and family engagement

09 Flu Fighters on the ground Woods Point

in aged care services

09 Waste prevention on track

33 Doing it with us, not for us

10 A continuous commitment to

34 Experiencing our kitchens

12 Ensuring safe and appropriate

35 Going NUTS


"Closing the Health Gap"

use of medications

35 Hand hygiene still number one

13 The N initiative Cambarville


in infection prevention

14 The quiet room

36 Tapping on

15 Barbecue brings better

37 My Health Diary


38 Project supports catching up

16 Talking our patients' language

39 Starter kits introduced to prevent

18 Family engagement a key to

“golden staph”


39 Surgical review has us on track

20 Staff understand patient safety


21 Redevelopment requires relocation 22 Planning ahead Toorongo


40 Patients supporting patients to

23 Family violence is Eastern Health’s

keep hearts strong

business too

42 A prescription for safety

25 Intensive planning produces

43 Your feedback is important.

great patient outcome

We are listening.

26 Peer workers make a significant

44 Contact us



39 Eastern Health Maternity

Angliss Hospital


Angliss Hospital offers emergency care, general medicine, surgery, maternity, paediatrics and rehabilitation.



Spectrum is a statewide service that supports mental health services to provide treatment for people with personality disorders.



Turning Point Turning Point is a statewide service that provides treatment, research and education in the fields of alcohol, other drugs and gambling.

36 14 Eastern Health Quality Account 2016


Welcome On behalf of the Board and staff at Eastern Health, we are delighted to present “In the patient’s shoes” – the Eastern Health Quality Account 2015-16. Our Quality Account is produced in collaboration with staff from across the health service and in partnership with consumers. Members of the Community Advisory Committee provide valuable insight on the consumer journey through our services as well as feedback on the report’s content. This report is designed to increase community awareness about Eastern Health’s commitment to providing safe, high-quality care for all our patients, clients, residents and their families. Articles cover a range of programs that deliver clinical services to 773,992 people in Melbourne’s east and through statewide services. Eastern Health is innovative and forwardthinking, as reflected in this report. We continue to develop improvement initiatives based on research and best practice to support great patient care. We value our patients’ opinion. We listen and we respond. Since establishing a connection with Patient Opinion* in 2015, 225 stories about Eastern Health were published and read a total of 86,836 times 2015-16. This is in addition to the more traditional forms of patient feedback to which we also respond.

Meeting the highest of standards Maintaining accreditation


s a progressive, responsive and innovative health service, Eastern Health demonstrates commitment to excellence through external accreditation against a range of standards, including the National Safety and Quality Health Service Standards. Recent accreditation achievements September 2015

The Australian Council on Healthcare Standards (ACHS) Periodic Review

Continued accreditation confirmed

March 2014

The Australian Council on Healthcare Standards (ACHS)

Full accreditation for four years

These were achieved following an extensive organisation-wide survey in September 2013 when Eastern Health was assessed against the new National Safety and Quality Health Service Standards, ACHS Evaluation Quality Improvement Program National Standards, National Standards for Mental Health Services and Community Care Common Standards. The next organisation-wide survey will be in March 2018 which is for four years of accreditation.

We commend our staff and volunteers for their ongoing commitment to providing quality, innovative healthcare and thank our community for their support and ongoing engagement with Eastern Health as together, we strive to deliver great health and wellbeing for our community. We hope you enjoy reading about the progress we have made during the past 12 months.

Adjunct Professor David Plunkett

Professor Pauline Nugent

Chief Executive Eastern Health

Chair Quality Committee

* See page 43.


National Association of Testing Authorities

Annual accreditation program

Australian Aged Care Quality Agency* (formerly Aged Care Standards and Accreditation Agency)

Royal Australian College of General Practitioners

Pathology laboratories Medical imaging Cardiology service Northside Nursing Home Monda Lodge Mooroolbark Residential Aged Care Edward Street Nursing Home Yarra Valley Health general practice clinic

* Full accreditation was in 2015 (full survey occurs every three years). Unannounced visits occur approximately every six months to monitor continuing compliance with standards. Full compliance continues to be maintained.


Community Advisory Committee member Jane Oldham attends the monthly Medication Management Expert Advisory Committee meetings as a consumer representative.


astern Health is committed to working in partnership with patients, clients and residents, carers and community members. At Eastern Health we believe that hearing the voice of consumers is essential in everything we do – from the patient information we produce to the redevelopment of our buildings. Eastern Health’s Community Advisory Committee (CAC) is a committee of the Eastern Health Board and serves as a key means of ensuring effective community participation.

Capital projects such as the Healesville Hospital and Yarra Valley Health redevelopment, Angliss Hospital expansion and Maroondah Hospital Breast Cancer Centre. We have also worked hard to ensure our consumers participate fully and effectively. We have provided the following support for our consumer representatives during the past 12 months:

Two CAC members completed a consumer leadership course

A number of consumers attended various conferences and presented stories of successful engagement within Eastern Health

In addition to the CAC, we have consumer representatives on 40 committees.

Consumer forums were held throughout

Consumers are involved in:

The Consumer and Carer Corner

Staff training sessions Improvement workshops Conducting audits Providing input into our new strategic plan

Presentation of staff awards

If you would like to join our consumer register and be involved in some of the ways we have described, please call the Manager of Consumer Participation & Patient Experience on 8804 0483 or email feedback@easternhealth.org.au

the year to bring together members of the CAC and consumer register newsletter was established and featured articles written by consumers working in all areas of the health service, including mental health and statewide services

Every consumer on a committee received support from a member of that committee, as well as the Manager of Consumer Participation & Patient Experience. Eastern Health Quality Account 2016


Volunteer transport service driver Gary Drewett assists clients like Patricia Gordon to get to and from their rehabilitation appointments at Peter James Centre and Wantirna Health each week.


ttending rehabilitation following a stroke, joint replacement surgery, loss of physical function or deconditioning due to a medical illness is important in a person’s recovery. Upon hearing from clients that they were experiencing difficulties in attending appointments because of a lack of access to suitable transport, the Community Rehabilitation Programs at Peter James Centre and Wantirna Health began exploring ways to better support clients’ transport needs. “We were hearing that patients were finding it difficult to attend appointments due to driving restrictions as a result of their medical condition, difficulty using public transport because of mobility problems, limited family support and restrictions on accessing local council volunteer transport programs,” Rehabilitation and Specialist Clinics Manager Cynthia Fong said. “In July 2015 we established a Volunteer Transport Program for clients who had no other options for transport to attend centre-based therapy appointments. “Three volunteer drivers were initially recruited and trained which enabled the service to commence at Wantirna Health. Following immediate success in terms of clients using the service and therefore attending appointments more regularly, additional volunteer drivers were recruited and the program expanded to Peter James Centre.” The program is now supported by five drivers who provide a daily transport service for rehabilitation clients, enabling them to attend sessions on a regular basis.


“In July 2015 we established a Volunteer Transport Program for clients who had no other options for transport to attend centre-based therapy appointments." – Cynthia Fong


82 clients referred to Volunteer

Transport Program

850 transport trips provided

Taxi transport costs incurred by

rehabilitation service significantly reduced


100% of clients found the service helpful

100% of clients reported they were given

sufficient information about the service and how it works

0% of clients experienced problems

with the service

100% of clients reported they would use

the service again

WHAT OUR CLIENTS HAVE TOLD US: “Brilliant, wouldn’t be able to get there if it wasn’t for him. Very efficient. Checked that everything okay. Very impressed.” “Very good service. Handy as I wasn’t able to drive after a stroke and needed to get to appointments.” “I thought the preparation phone call was useful to alert me when the driver was coming so I knew how much time I had to get ready and that I would get to my appointment on time.”

WHAT OUR DRIVERS HAVE TOLD US: “Very rewarding, meet many people with different stories who are very appreciative of the service.” “It is an opportunity to meet interesting people and it is satisfying in a small way to assist them at what may be a challenging time.”

Eastern Health Quality Account 2016


Acting on patient surveys to support quality care


very three months, Eastern Health receives results from the Victorian Healthcare Experience Survey (VHES). This survey is undertaken at all public hospitals across the state and there are different surveys for inpatients, emergency department patients and maternity patients, as well as surveys for adults and children. Eastern Health reports the results to a number of committees. Six consumers on the Patient Experience of Care Expert Advisory Committee work with Eastern Health to review the results and make recommendations about improvements.

At Eastern Health, we have been working towards increasing our overall score on the Victorian Healthcare Experience Survey. The below graph shows how this score has changed during the past 18 months.

Overall Experience Score (%) 98 94 90 86 82 78

On the ground improvements

Jul-Sep 2014

Oct-Dec 2014

Peter James Centre has used the VHES data to develop action plans and initiatives to address the following:

1 Reduce noise in the wards 2 Provide gender-specific rooms 3 Improve the timeliness of providing

medications for patients to take with them when leaving hospital

4 Improve communication within

teams, availability of information for patients and involvement of patients in the development of care plans

5 Improve availability and use of interpreters

6 Improve patient privacy 7 Provide discharge summaries to GPs 8 Review the timely provision of pain medication for patients

9 Improve the time taken to respond when patients ask for assistance.

We look forward to providing an update in next year’s report about the above initiatives.


Patient Wilfred Woods speaks with an Eastern Health nurse.

Jan-Mar 2015

Apr-Jun 2015

Jul-Sep 2015

Oct-Dec 2015

Jan-Mar 2016


All Eastern Health staff are encouraged to receive an annual seasonal influenza vaccination. Year on year, healthcare worker immunisation rates for influenza prevention have increased by five to eight per cent.


In 2015, Eastern Health introduced the Flu Fighter campaign, resulting in 71 per cent of staff receiving a seasonal influenza vaccination.


Eastern Health has set a target of 80 per cent in 2016 to support providing optimal safety for our patients, visitors and healthcare workers and their families.



lood is precious and Australian hospital rely on voluntary donations for their blood supply. Blood and blood products are a life-saving resource used in our hospitals daily and we all have a responsibility to ensure donations are used appropriately and not wasted. It is inevitable that some blood will be discarded, but we can reduce the volume of waste. Eastern Health focuses on ensuring the safe and appropriate use of blood and monitors blood wastage. “In 2015-16, a Stop the Waste campaign across Eastern Health was undertaken to raise awareness of blood and blood product waste, and the strategies that are in place to reduce it,” Transfusion Nurse Consultant Clare Hennessy said.

While blood donation is voluntary, the collection, processing, testing and distribution of blood and blood products is costly. Based on the National Blood Authority’s price lists, Eastern Health has reduced blood and blood product waste during the past three years from $341,377 to $249,277. “There is still room to further reduce waste,” Clare said. “This is being addressed with interventions such as inventory review, stock rotation, continuing education and dissemination of monthly wastage data.”

Transfusion Nurse Consultant Clare Hennessy helps staff minimise blood product waste.

There has been a significant decrease in red blood cells, platelets and overall blood waste at Eastern Health during the past three years. Eastern Health Quality Account 2016 09

Aboriginal Hospital Liaison Officer Joanne Voce supports staff to build positive relationships with Aboriginal patients.

As a member of the Eastern Health Closing the Health Gap Advisory Committee, Joanne also supports the organisation to provide culturally-appropriate care for Aboriginal patients and their families.

What is your role as the Aboriginal Hospital Liaison Officer? To provide patients with culturally-appropriate guidance when they present to Eastern Health’s bed-based services, specialist clinics and emergency departments. I also support staff with building positive relationships with Aboriginal people and to make sure there is appropriate ongoing care.

Why is your role so important to Aboriginal people? A patient’s journey through a hospital and subsequent services can often be quite daunting. My role is to ensure Aboriginal and Torres Strait Islander patients have access to the information they need, giving them a more positive experience and improving their outcomes. I also focus on ensuring appropriate supports are in place for Aboriginal and Torres Strait Islander patients when they leave hospital.

What is your background?



n 2014, Eastern Health welcomed Joanne Voce as an Aboriginal Hospital Liaison Officer. Joanne plays a vital role in supporting Aboriginal patients and their families while in hospital, attending clinics or in the community.


I am a Taungurung/Wiradjuri woman from Healesville and have been working in healthcare for a number of years. Before taking on this role, I shared my working week with the Healesville Pharmacy and Eastern Health’s Aboriginal Health Team, where I co-ordinated planned activity groups for Aboriginal elders.

Upon reflection of the future… I enjoy working with the local community and providing advocacy for Aboriginal and Torres Strait Islander patients. Through this role I can ensure that support will be provided to more Aboriginal and Torres Strait Islander people, increase staff education on the specific needs of Aboriginal people and help develop strategies to improve healthcare services for Aboriginal and Torres Strait Islander patients.

In June 2015, Eastern Health launched an online cultural awareness training program.

79 per cent or 6342 staff have completed the package since its implementation.

Eastern Health's progress towards the Improving Care for Aboriginal Patients (ICAP) Framework Engagement and partnerships

We have established a partnership with Worawa Girls’ Secondary College in Healesville to support

Establishing collaborative partnerships with local Aboriginal Community Controlled Health Organisations, elders and Aboriginal community members

Our Adult Mental Health Koolin Balit Clinical Engagement Project is progressing with a key aim of engaging with Aboriginal community organisations to support improvements in access to recovery-oriented adult mental health services.

creating easier access to our services (and partners).

We are continuing to liaise with Mullum Mullum Indigenous Gathering Place, Healesville Indigenous Community Services Association and a range of community members to promote health careers, employment opportunities and activities at Eastern Health. We have collaborated with Ngwala Willumbong on shared care of alcohol and other drug clients to establish pathways to substance use treatment programs. We are working towards formalising our partnership with Boorndawan Willam Aboriginal Health Service to strengthen pathways of care for people who have experienced family violence. We have commenced a Cultural Advisory Committee for community members to provide feedback about the Aboriginal Health Team. We have representation on a number of network meetings that foster partnerships with the local Aboriginal community, including the Indigenous Family Violence Regional Action Group, the Regional Aboriginal Justice Advisory Committee, Worawa College’s Social and Emotional Wellbeing Committee and the Shire of Yarra Ranges Indigenous Advisory Committee.

Workforce development

We have an Aboriginal Employment Plan for 2016-2019.

Eastern Health is committed to supporting our Aboriginal workforce

We were successful in securing four Koolin Balit grants of $17,000 each in 2014 that supported us to establish four traineeships in the areas of drug and alcohol, mental health and theatre (surgical services).

Organisational development

We have signed a “statement of intent” with the local Aboriginal community.

Aboriginal health is a stated priority, as reflected in our strategic and business plans, as well as in a specific Aboriginal health action plan

Systems of care Culturally-sensitive care and a holistic approach to healthcare are provided to Aboriginal patients with regard for the place of family

We have established an Aboriginal staff network.

Our Aboriginal Hospital Liaison Officer attends ongoing clinical training. Our Aboriginal Health Team has established a traineeship position for an Aboriginal health worker, who will undertake the Certificate IV in Aboriginal Health Work at the Victorian Aboriginal Community Controlled Health Organisation. This position was designed with feedback from a local elder who subsequently became a member of the interview panel.

We conduct annual events such as NAIDOC Week and Reconciliation Week celebrations, and the annual Family Sports Day in Healesville that brings together staff and the community. We have implemented an “Asking the Question” protocol, flowchart and readily-accessible resources for all Eastern Health staff. The above actions are embedded in our organisational policy under the Aboriginal Health Standard. The priorities are regularly reviewed by our Closing the Health Gap Advisory Committee.

We are progressing with the development of posters, brochures and other visual prompts for all Eastern Health service areas. We endeavour to create an accessible and welcoming environment for consumers from a diverse range of backgrounds. For the Aboriginal community, we display posters, symbols, artwork and information brochures. We are introducing a cultural audit across the organisation to measure and ensure services are culturally-sensitive. Processes have been developed and implemented for each of our services regarding how to refer consumers to the Aboriginal Hospital Liaison Officer or the Aboriginal Health Team. We have developed a cultural awareness training package for all staff, with 79 per cent completing the package as at 30 June 2016.

Eastern Health Quality Account 2016




nsuring high standards of patient care through the quality use of antimicrobials* is a priority of the Antimicrobial Stewardship Program (AMS) at Eastern Health. The AMS team, consisting mainly of infectious diseases specialists and specialist antimicrobial pharmacists, is largely responsible for ensuring patients receive the most appropriate and safest drug therapy for their infection. “We know from previous studies that inappropriate and overuse of antibiotics can be up to 50 per cent in hospitals,” antimicrobial pharmacist Sonia Koning said. “The AMS team works to minimise inappropriate use of antimicrobials, including antibiotics, antifungals and antivirals in support of patient-centred care. “This is achieved by developing up-to-date prescribing guidelines that are accessible, current and evidence-based to support our clinical teams to prescribe the safest and most effective antimicrobial therapy for patients.” The AMS team regularly conducts reviews of patient-prescribed antimicrobials in the hospital, measuring use and appropriateness of antimicrobials (compared to national figures and standards) and educating staff and consumers. Between January 2016 and April 2016, the AMS team reviewed 947 patients leading to interventions or recommendations for 589 patients to optimise antimicrobial therapy. “Reviews ensure patients have reduced exposure to potential adverse drug outcomes, including unnecessary drug interactions, antimicrobial-associated diarrhoea and most importantly, reducing treatment failures.”


The most common recommendation from the Antimicrobial Stewardship Program team is to switch from intravenous therapy to oral therapy. This has major positive implications for patient satisfaction and further reduces the risk of intravenous line infections. * Antimicrobials refers to antibiotics or medications that are chemical substances which kill or inhibit the growth of bacteria, viruses and fungi, including yeasts and moulds.

Antimicrobial pharmacist Sonia Koning works with clinical staff such as Dr Caroline Beckett to ensure safe and appropriate use of medications.

The N initiative Patients rely on timely administration of medications to achieve the fastest recovery time possible. As part of Eastern Health’s commitment to safe, high-quality care, the medication delivery process has been optimised by the general medicine and pharmacy teams at Maroondah Hospital. The system involves the use of a highly visible purple colour-coded alert sheet with the letter N attached to a patient’s chart. This serves as a reminder to nursing staff that a medication has not been dispensed due to temporary unavailability and requires sourcing and prompt administration.

“When there is a prolonged delay in the administration of medications, the potential for poor health outcomes and extended length of hospital stay increases,” Director of General Medicine, Dr Vikas Wadhwa said. “The N initiative ensures the nurse unit manager, pharmacy and medical teams are alerted to any potential medication delays as early as possible. This then encourages communication between staff and helps fast-track the process of medication supply and distribution. “Reducing the wait time for medications is a real priority for us”.

Nurse Jeeba Dominic and Dr Thinza Moediscuss place a reminder on patient Glenyse Hunter’s file regarding medication administration.

“The N initiative ensures the nurse unit manager, pharmacy and medical teams are alerted about any potential medication delays as early as possible. ” – Dr Vikas Wadhwa

Eastern Health Quality Account 2016


Consumer representative Eddie Thomson has been working with Box Hill Hospital Midwifery Unit and Maternity Inpatient Services Manager Jillian Donnelly, social worker Nikki Harris-Allan and spiritual care adviser Karen Veldhuizan to establish a quiet room.

THE QUIET ROOM Supporting families at a time of immense loss


elcoming a baby into the world should be a time of joy, exhilaration and excitement. But for some, it can be a time of heartbreak, devastation and immense grief. Sadly, six babies are stillborn in Australia each day* and experiencing the death of a baby can be a life-changing experience. Following feedback from families who have experienced the death of a baby due to miscarriage, stillbirth or shortly after birth, and from discussions between consumers and staff, the Eastern Health Maternity Service at Box Hill Hospital established “The Quiet Room”, a private space for families to spend time with their babies. “It is a special place where families can bath and dress their baby, create memories by taking photos and making ceramic moulds of hands and feet,


as well as in memory ceramic tiles,” Midwifery Unit and Maternity Inpatient Services Manager Jillian Donnelly said. “The space can also be used for conducting rituals such as naming ceremonies or blessings.” Spending time with their babies is incredibly important to families, right up to the time their baby is given to the funeral director. “Babies are passed over directly from The Quiet Room, rather than the mortuary, giving families the comfort of knowing where their baby will be at all times. Many choose to stay with their baby until the funeral director arrives,” Jillian said. The Quiet Room is not just a space for families experiencing the loss of a baby. It is also a space where our staff can reflect on their experiences and support families at a very difficult time. The space was officially blessed in late 2015 and the service receives donations from the community, including beautiful handmade clothing and blankets. A free professional photography service is also provided to assist families to create memories.

“The Quiet Room plays an important role in the healing process at a very difficult time for families. The space allows families, in a private and respectful area, to say their goodbyes in a dignified and personal way.” - Eddie Thomson, consumer representative on the maternity services bereavement working party

* Source: Stillborn Foundation Australia stillbirthfoundation.org.au/stillbirth/



family barbecue initiative is bringing patients at Wantirna Health closer to their loved ones. Held once a month, patients from North Ward, a 32-bed geriatric medicine unit, and East Ward, a 32-bed palliative care unit, are encouraged to invite family members to join them in the relaxed surrounds of Wantirna Health’s courtyard

or communal dining rooms for a chat and barbecue lunch. Director of Nursing Kathy Marshall said the barbecue brought comfort to patients who may be missing home. “Many patients are elderly and in hospital for extended periods or palliative care. Having a social lunch with family and fellow patients encourages friendships and helps integration into the ward,” Kathy said. “The initiative not only brings families together but also gives patients a casual outdoor meal to make them feel more at home.”

Wantirna Health patient Joyce Scorgie enjoys the relaxing environment that a barbecue gathering can bring with her husband William.

Kathy said the initiative was just one example of Wantirna Health’s commitment to patient-centred and family-focused care. “We are always looking for new ways to enhance the comfort of our patients and their families, and to make their transition into Wantirna Health as smooth as possible,” she said. “In fact, the idea of a barbecue lunch was suggested by one of our patients who missed his favourite meal. It really is the small pleasures in life that can have the biggest impact.”

“Many patients are elderly and in hospital for extended periods or palliative care. Having a social lunch with family and fellow patients encourages friendships and helps integration into the ward.” – Kathy Marshall Eastern Health Quality Account 2016


Interpreter Weilin Gao with Language Services Manager Cynthia Zupan.


astern Health provides services to a culturally diverse community and being able to communicate with our consumers in their preferred language is a key priority.

We have an in-house team of accredited interpreters who speak Cantonese, Mandarin, Greek and Chin Hakha, as well as a casual pool of staff who can cover other languages when needed across Eastern Health, including home visits. We also engage an accredited external agency for the provision of interpreters when required. “We regularly have new non-English speaking families relocating to the Eastern Health community and language should not be a barrier to accessing healthcare,” Language Services Manager Cynthia Zupan said.

“Be it a young family from Sudan or an elderly Greek woman who has lived in Australia for 40 years but is unable to speak or understand English, the Eastern Health team is committed to supporting patients through their healthcare journey.” The healthcare system is complex and the language used by doctors, nurses and support staff can be just as complicated. The team works to simplify the system and break down the language barriers in order to support an equitable system for everyone.

“The translation and interpreting services provided have not only helped me tremendously but also eliminated my fear when I visit doctors. My interpreter today was Gabrielle. Her smiles and interpreting services made me feel relaxed. She clearly interpreted the doctors’ questions. This eliminated my long-term worries.” – Hong Liao









2014: 463 2015: 1877



Interpreter services provided in-house

Interpreter services provided by agencies


















Chin Hakha













































Chin Zomi


















* Data sets – Admissions and Emergency Department presentations Single patient can have multiple admissions or arrivals to the emergency department so will be recorded multiple times in this overall count Numbers are patients being recorded as “needing an interpreter service” only Interpreter service received – not able to validate.

^ Calender year

Eastern Health Quality Account 2016


“We have spoken to many carers about what they would do to prevent falls for their loved ones and found their input valuable, relevant and sometimes very simple.” – Alison Cooper, South Ward Nurse Unit Manager


educing patient harm, including falls prevention, is one of Eastern Health's top 10 priorities. A fall can lead to significant complications for a patient. These include the discomfort of bruising and skin abrasions to the more complex issues associated with fractures and head injuries. These injuries may result in a longer hospital stay. South Ward at Peter James Centre, a ward that cares for older patients experiencing a mental illness who are often at high risk of falling, includes family members when designing interventions or strategies to reduce their loved ones' risk of falls.


“Following a patient fall, team members will gather to review the incident, discuss strategies that are in place and plan additional actions aimed at reducing the risk of further falls,” Service Planning Manager and Redesign Facilitator Katrina Hall said.

“It is families and carers who have intimate knowledge of their loved ones, so we should not be surprised that it is through listening and working with them and our patients that we are able to identify strategies to prevent future falls.

South Ward has taken this process one step further. When the doctor or nurse contacts the family or next of kin to notify them that a fall has occurred, staff also invite the family to attend the postfall review in person or by telephone.

“Improved communication and the involvement of patients and their families has led to better planning for individualised patient care.”

“The family is encouraged to share their ideas and experience to help the team better design individual strategies to reduce the risk of another fall,” Katrina said. “Many families have taken up this offer and the team has found their input valuable.”

This initiative is just one in a broader Eastern Health commitment to reduce injury-related falls. This team has been able to establish a simple and effective way to engage families and carers to reduce the risk for individual patients.

Nurse Joy Khan works with patients like Catherine Lawson and their families to develop individual falls prevention strategies.

Addressing falls at the frontline Patient falls and falls resulting in harm are major causes of illness and mortality and is an extreme clinical and organisational risk for Eastern Health. In 2014 and 2015, the By Leadership, Action, Support and Teamwork (BLAST) Falls Project was implemented to specifically address falls and harm from falls. The aim of the project was to achieve 100 per cent compliance with the Assessing and Preventing Falls/Harm from Falls in Bed-Based Services Practice Guideline. The BLAST Falls Project has been established across 25 inpatient wards at Eastern Health. In 2015, an evaluation of the project’s effectiveness was completed using data analysis and staff surveys. Overall, half of the staff who responded to the survey believed the BLAST Falls Project had been effective in reducing falls and harm from falls. Since implementation of the BLAST initiative, Eastern Health has seen a marginal reduction in falls resulting in harm at both ward and organisational levels, while the total number of falls has not increased in light of additional services being provided. Five key elements of BLAST:

1 Staff launches 2 Monthly falls data display 3 Weekly auditing of ward compliance with the practice guideline

4 Post-fall meeting immediately after incident

5 Weekly falls review meeting Eastern Health Quality Account 2016



astern Health participates in the Victorian Government’s People Matter Survey which provides useful staff feedback about many areas of the health service, including patient safety. This enables Eastern Health to continue to deliver quality healthcare for patients and clients in an environment that is focused on patient safety. Employee feedback relating to patient safety in the 2014 survey was positive, with between 82 per cent and 96 per cent agreement across the eight patient safety questions. This reflects that Eastern Health has appropriate strategies to support patient safety, according to our staff. Feedback from staff resulted in numerous service improvements, effective change management and increased engagement of employees, which are the key objectives of Eastern Health’s People Strategy 2013-16.



In 2015-16, 97 per cent of staff completed the Occupational Health and Safety and Equal Opportunity online training program.

Redevelopment requires relocation Staff and services based at Healesville were temporarily relocated in September 2015 to make way for significant redevelopment of the Healesville Hospital and Yarra Valley Health site. “Although most community health services, including district nursing staff, were not initially required to move, the exciting redevelopment works did bring with them some challenges for our staff and services," Yarra Valley Health Manager Michelle Fleming said. “These included three staff being redeployed, pathology, midwifery and specialist clinics being relocated and a number of minor changes to operational and support services.” About two months after the relocation, all staff were encouraged to complete an Employee Experience of Change Survey. In response to the survey, Yarra Valley Health implemented a number of changes and strategies for future changes across the site. These included: Managers undertaking additional change management training (completed March 2016) Creating a project officer role to provide support to managers when co-ordinating site issues while the redevelopment is underway, including further relocation of staff and services Incorporating learnings within the planning process for a second relocation of community health and district nursing staff, which included greater staff engagement in planning and improved and more localised communication Training staff on how to respond to change, resilience and managing workplace stress Giving greater consideration to signage and pathways for staff and client access during the relocation phase. “Anecdotal feedback from staff about the change management initiatives has been very positive," Michelle said.

Nurse Tessa Harris with patient Maria Giannoukos in Ward 6.1 at Box Hill Hospital.

“The second relocation of staff and services in early 2016 was much larger with 80 per cent relocated and significant changes to operational and administrative processes required. Staff have been satisfied with how the change was managed.”

Eastern Health Quality Account 2016


Dr Harsh Thakkar talks with Chiara De Ivlio about plans for her discharge from hospital.



rom admission to discharge, Eastern Health is planning ahead for the next step in the patient’s journey with us. Delays when waiting for discharge can be frustrating for patients and their families. Delays are also challenging for hospital staff supporting patients who are well enough to leave. Eastern Health’s General Medicine Program has been investigating opportunities to support more timely discharge of patients with planning for discharge starting from admission. According to Maroondah Hospital's Director of General Medicine Dr Vikas Wadhwa, “We have developed a robust process for the safe and timely discharge of patients from hospital once they meet clearly defined criteria. Referred to as Criteria Led Discharge, we discuss with patients their discharge on admission so they are better informed of the planned journey ahead.”

Traditionally, patient discharges from hospital are decided on the day following a medical review. Without forward planning, the exact timing of the discharge is often not known and medication prescription writing and transportation arrangements on the day can lead to delays.


“Criteria Led Discharge provides for earlier and better planned discharges from hospital without patients having to wait to be seen by the medical team,” Dr Wadhwa said. Patients are informed of the protocols associated with Criteria Led Discharge upon admission. These include whether their condition has stabilised and improved to a point that they can be considered for discharge without further review by the medical team. Following discussions with nursing and allied health teams, medical staff and the patient, a patient discharge form that summarises their admission, treatment and further instructions is completed and provided to the patient.

“If a patient agrees to Criteria Led Discharge, discharge medication prescriptions and all paperwork are completed in advance,” Dr Wadwha said. “The nurse in charge reviews the patient against the criteria and if they have been met and there are no new concerns, the patient is discharged. “Criteria Led Discharge is a great initiative that supports our patients to return home safely in a more timely manner.” All general medicine units at Eastern Health have been engaged in this process and more than 100 patients have been successfully discharged using the Criteria Led Discharge method. “There has been positive feedback from staff and patients, and we aim to continue to expand this practice.”

Family violence advocate and 2015 Australian of the Year Rosie Batty, spoke with Eastern Health staff about how to address family violence. She is joined here by social workers Zola Yang, Lauren Riddle, Enyah Flannery and Elaine Pacheco and nurse Adam Dalzotto.

FAMILY VIOLENCE IS EASTERN HEALTH’S BUSINESS TOO Photo courtesy of Leader Newspapers photographer Steve Tanner


ealth services have a crucial role to play in preventing and identifying family violence, and responding to people experiencing family violence. All programs and services across Eastern Health are working together to address this critical issue. In response to the statewide family violence plan, Victoria’s action plan to address violence against women and children: everyone has a responsibility to act, Eastern Health has established a Response to Family Violence Working Group. This group will review existing processes, capability and partnerships to ensure a comprehensive system is in place at Eastern Health to identify, report and respond to both suspected and confirmed instances of family violence impacting any person, using the Strengthening Hospital Responses to Family Violence framework.

The working group is benefiting from the input of community groups and family violence survivors.

Cold, hard facts on family violence

Activity is multi-faceted, including:

Health promotion, including our commitment to gender equity and partnership with the AFL in the eastern region and Yarra Ranges League to challenge men’s attitude and behaviour towards women and violence.

Child Safety Committee, formed in response to the Victorian Government’s Betrayal of Trust Inquiry into the handling of child abuse by religious and other non-government organisations. An action plan to address gaps in our compliance with Child Safe Standards has been developed.

Developing and implementing actions in response to the Together for Equality and Respect Strategy, an initiative by Women’s Health East and the Victorian Government Gender Equality Strategy.

New Wellbeing Leadership Group, which is developing and implementing a number of initiatives for staff, including support for those who are victims of family violence. Preventing family violence is everyone’s business and Eastern Health is taking the necessary steps to ensure we play our role.

On average, two women are killed every week*

One woman is hospitalised every three hours** In the eastern metropolitan region:

4090 Police attended

incidents of family violence in 2009-10 Between 2001 and 2012, the Eastern Centre Against Sexual Assault provided counselling/advocacy to


past and recent survivors of sexual assault * Source: Sophie Pointer, deputy director of the Research Centre for Injury Studies at Flinders University, SA ** Source: 7.30 Report, ABC, 13 April 2015

Eastern Health Quality Account 2016



hen Fay Martin was admitted for rehabilitation at Peter James Centre, the team’s attention was immediately drawn to a stage four pressure wound. Pressure wounds are a major risk for patients because they increase their susceptibility for infection,” Centre Ward Nurse Unit Manager Helen Marsham said. “Furthermore, they can have a significant impact on their recovery and overall wellbeing.” Pressure wounds are categorised by their severity and complexity of management with a stage four wound considered most significant, resulting in severe skin breakage, causing exposure of the bone, tendon or muscle. Fay was not medically fit for surgery and her prognosis for healing, remaining infection-free and regaining her mobility were initially considered to be poor.

Following a preliminary review and consultation with wound nurse specialist Bataa El-Erakey, the nursing, medical and allied health teams working across rehabilitation and transition care, devised an intensive wound management plan to best support Fay with her recovery. “As a result of taking a collaborative approach to developing an intensive personalised pressure wound plan for Fay, she was able to be discharged from Peter James Centre with her wound completely healed, improved mobility and with a weight gain,” Helen said. “All these outcomes were not thought possible upon her admission.” According to Fay’s daughter Jo, the family could not have been happier with the care and personalised support afforded to her mum. “By working together in such a collaborative way, although it took time, I feel mum would not have recovered as well as she did. This just goes to show how imperative collaborative care is when providing quality care.”

“As a result of taking a collaborative approach to developing an intensive personalised pressure wound plan for Fay, she was able to be discharged from Peter James Centre with her wound completely healed, improved mobility and with a weight gain.” – Helen Marsham

Pressure injuries are a major risk for hospital patients, especially those who are restricted to a bed or chair. Upon admission, all patients are reviewed for evidence of existing pressure injuries and assessed for pressure injury risk. Strategies for prevention of pressure injuries include adequate fluid intake to support skin hydration, regular skin checks by nursing staff, provision of beds that have pressure-relieving mattresses, staff ensuring there is regular movement to relieve pressure on high-risk sites and early and prompt treatment of pressure injuries.


Wound care specialist nurse Bataa El-Erakey reunites with her patient Fay Martin who now lives in a residential aged care facility following her recovery from a stage four pressure wound.


Fay has approved use of her name and story in this publication

Eastern Health Quality Account 2016


Peer worker Chris Dixon’s contribution to staff education has helped reduce the use of restraints and seclusion in mental health inpatient units.


pton House, a 25-bed acute adult mental health inpatient unit at Box Hill Hospital has taken an innovative approach to peer engagement, which has led to a 70 per cent reduction in the use of restrictive interventions such as mechanical restraints and 66 per cent decrease in seclusion within the unit during the past 18 months.


Working with the peer workers has led to an increased use of sensory modulation*, advance statements** and family involvement during periods of increased distress and it has contributed to less use of restrictive interventions and a better experience for our clients. “We now have a greater understanding of how restrictive interventions are extremely distressing for our clients, their carers and our staff,” Kate said. “The peer workers have been directly involved in developing a training video in which we hear directly from consumers, families and staff about the effects of seclusion and restraint. “The team has also developed a post-event debriefing intervention designed to reduce the traumatic effects of seclusion or restraint and further developed more informed practices and processes to reduce the likelihood of restrictive interventions being required.” * Sensory modulation is the process in which the brain is taking in all of the various types of sensory input and messages and sorting it all out. (www.asensorylife.com/sensorymodulation.html) ** An advance statement sets out a person's treatment preferences in case they become unwell and need compulsory mental health treatment. A person can make an advance statement at any time if they understand what an advance statement is and the consequences of making one. (www2.health.vic.gov.au/mentalhealth/.../mental-health.../advancestatements).

occasions per 1000 bed days

Mechanical restraint 20 15 10 5 0

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 2015 2015 2015 2015 2015 2015 2016 2016 2016 2016 2016 2016 2016




During a period of eight months, there has been no use of mechanical restraint within the aged persons’ acute unit, eight months in the adolescent unit and three months in the adult unit. Rates of mechanical restraint within the adult unit have significantly dropped in comparison to the previous financial year and where mechanical restraint was required, significant safety concerns for the patient’s wellbeing were the catalyst for use.

Physical restraint occasions per 1000 bed days

Both workers have a lived experience of mental illness.“The presence and leadership of our peer workers has resulted in a significant contribution to culture change,” Nurse Unit Manager Kate Lumsden said. “Through learning from their experiences and by taking their lead, our understanding of client needs is far more comprehensive and compassionate.”

The Mental Health Program monitors and reports on seclusion rates and use of restraints on a monthly basis. There is a whole-of-program Reducing Restrictive Interventions Committee, chaired by the Director of Nursing (Mental Health) with membership from all areas of mental health, as well as a consumer and carer consultant. Decision-making on the use of restraint or seclusion is always individually assessed with consumer needs the core principle.

16 12 8 4 0

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 2015 2015 2015 2015 2015 2015 2015 2015 2016 2016 2016 2016 2016




Across the spectrum of inpatient mental health services there has been a need to use physical restraint at different points of patient care. Such occasions are managed with great care and respect for the patient in support of their safety, and the safety of fellow patients, staff and visitors.

Seclusion rates occasions per 1000 bed days

The Upton House team led a project in which two peer workers were employed to work in the unit; one as a consumer peer worker and the other as a carer peer worker.

40 30 20 10 0

Jul 2015

Aug 2015

Sep 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016


Feb 2016


Mar 2016

Apr 2016

May 2016


Eastern Health’s rates of seclusion have remained well below the state target of 12 per 1000 bed days. The readmission of two high-need consumers in one adult unit resulted in an increase between January 2015 and April 2015. Across the three adult acute inpatient units, there were five months in which no seclusion was required and the overall rate within the adult services remained well below target. In the aged persons’ mental health service environment and the adolescent inpatient unit, seclusion has rarely been required. One consumer in the adolescent unit required multiple occasions of seclusion during a four-week period because of the nature of their presentation and concern for their safety and those around them.

Eastern Health Quality Account 2016


Advance Care Planning Program Lead Sam Brean meets with patients Allan and Susan Havelock to ensure their wishes are respected and acted upon.


istening to and understanding a patient’s wishes is the cornerstone of patient-focused care.

People want to be involved in decisions about their care and as a healthcare provider, Eastern Health wants to ensure that staff understand, respect and act upon these wishes. One way Eastern Health is achieving this is by educating and providing information to staff, patients, carers, families and the community about the development of Advance Care Plans. Eastern Health’s Advance Care Planning team provides a service that highlights why developing plans is so important and how it gives Eastern Health the capacity to act on a patient’s wishes should the need arise.


From the Advance Care Planning team’s perspective What is advance care planning? It provides an opportunity for people to think, discuss and plan for the medical treatment they would prefer if they became too ill to express their wishes.

Eastern Health and more broadly with GPs and community health services. We regularly accept invitations to speak to community groups. Resources are also available and we help people complete advance care plans in their home or in a clinic setting.

From the patient’s perspective

Why is advance care planning so important?

Why I developed an Advance Care Plan

It is about people taking control of their healthcare wishes. It gives service providers an understanding of a patient’s values, beliefs and preferences for care.

It has given me a voice because it acts as a guide for others and enables me to nominate the person I want to advocate for me should I be unable to do so.

What does the Advance Care Planning team do?

What does having an Advance Care Plan mean for me?

We offer a range of services that aim to empower patients and healthcare professionals with the knowledge and skills to undertake advance care planning. We do this by running education workshops for health professionals at

Peace of mind. I have sat down with my family and discussed and documented my wishes. They understand and know what I would want and can act as my advocates with the knowledge that they are respecting my wishes.

PATIENT-CENTRED END OF LIFE CARE In 2014, following increasing recognition of the need to provide safe, high-quality end of life care, Eastern Health established an End of Life Care Expert Advisory Committee. The role of the committee, which includes medical, nursing, allied health, spiritual and consumer representatives, is to guide staff on best-practice standards in end of life care to support safe, quality care for patients and their families and carers. Since 2010, the Advance Care Planning team has experienced significant growth in referrals to the service and development of Advance Care Plans.



Completed ACP

2010 2011 2012 2013 2014 2015 2016 (as at August 2016)

50 81 110 533 544 610 333

35 35 38 357 328 439 260




2010 2011 2012 2013 2014 2015 2016 (as at August 2016)

48 41 25 82 70 78 31

811 508 360 1416 1151 1103 353

Education sessions

The committee has completed a number of key actions including: Completion of a gap analysis against the guiding principles of the national consensus statement “essential elements for safe and high-quality end of life care” released by the Australian Commission on Safety and Quality in Health Care The drafting of an end of life standard (policy) that aligns four clinical practice guidelines under one standard – advance care planning, resuscitation planning, care of the dying and bereavement care. “The End of Life Care Expert Advisory Committee is working to ensure patient-centred care is delivered seamlessly across care settings for all patients,” Palliative Care Director Dr Margaret Bird said. “In further recognition of Eastern Health’s focus on quality end of life care, we have partnered with Monash University to support the Vivian Bullwinkel Chair in Palliative Care Nursing and Clinical Lead for End of Life Care in order to establish a centre of research and academic excellence in end of life care.” This is the first partnership of its kind between Eastern Health and Monash University.

Eastern Health Quality Account 2016


Diversity and inclusion


n February 2016, Eastern Health launched its Diversity and Inclusion Framework which guides our work in addressing the diverse needs of our community. There is a range of activities and projects that assist us to achieve the objectives of the framework including:

Participation of staff in the Eastern

Region Health Literacy Development Course 2016

Participation in the Eastern Region Refugee Health Forum

Diversity training sessions for staff and volunteers

Engagement with community groups and local and state government departments, including the 2016 Pride Cup football match

Site development planning sessions, such as the Maroondah Breast Clinic

Improving the way we communicate with consumers who have communication difficulties

Same gender maternity services. Work has commenced to develop action plans that are aligned to the recommendations of the following statewide plans and directions:

Victorian State Disability Plan

2013-16, to be superseded by the Victorian State Disability Plan 2017-2020 (under development)

Lesbian, Gay, Bisexual, Transgender and Intersex Health and Wellbeing Action Plan for Victoria 2014-2018

Victoria’s action plan to address

violence against women and children: Everyone Has A Responsibility to Act 2012-2015

Betrayal of Trust Inquiry (child safety) Royal Commission into Family Violence

Victorian State Gender Equality Strategy (under development).




ancer is the leading cause of death in Victoria, affecting one in three Victorians up to the age of 75.

It is a complex set of diseases to diagnose and treat, and represents a significant concern for patients and their families. Throughout 2015, in collaboration with patients, consumers and staff across Eastern Health, and external service providers, a comprehensive five-year cancer services plan was developed to guide future cancer services provided by Eastern Health.

“The Eastern Health Cancer Services Plan responds to trends in population health, workforce issues, the increasing complexity and cost of cancer care and the shift of cancer treatment," Eastern Health Director of Cancer Services, Associate Professor Phillip Parente said. “We have identified more than 50 initiatives that support patient-centred care, including ensuring patients and carers receive the individualised support and information they need, equity of access, workforce development and research and education.” Importantly, the plan focuses on the patient and long-term patient and carer needs. Cancer patient Ivan Pimm said: “Being involved in the development of this plan has given me a real sense of the scope of services provided to cancer patients by Eastern Health.

"Working with patients from many of Eastern Health’s facilities provided an opportunity to positively add to the plan from my experience as a patient.” A/Prof Parente said the plan provided clear direction to ensure equity of access to comprehensive cancer services. “It addresses the needs of patients in the areas of prevention, screening, diagnosis, treatment and follow-up, including survivorship and palliative care. It is driven by a commitment to quality and guided by our vision of providing great health and wellbeing for people and communities in the east.” Cancer services at Eastern Health have experienced a five per cent increase in patient admissions and 27 per cent increase in medical oncology outpatient attendances between 2014-15 and 2015-16. A further 10 per cent increase is expected across inpatient, outpatient and day oncology units in the next 12 months.

North Ward staff at Wantirna Health strive to achieve a positive work environment.



astern Health is committed to providing a safe environment for all our staff and volunteers. To support this, we aim to foster a positive work culture across all sites and services.

In promoting a positive work culture we have:

1 2

Improved policies to prevent bullying, harassment and sexual harassment, manage grievances and ensure equal opportunity, based on best practice


Developed and provided training sessions to build our managers’ understanding of how to lead change effectively and fairly, how to provide staff feedback and practise positive behaviours

Established supervision structures and provided supervision skills training to nursing managers

Bullying and harassment are unacceptable at Eastern Health. Training is offered to managers to increase understanding of their responsibility to foster a positive workplace that is free of bullying and harassment. More than 125 senior managers participated in positive workplace culture training between February 2016 and May 2016. All employees are expected to undertake an annual online training program relating to bullying, harassment, equal opportunity, sexual harassment and grievance management. As part of the new employees’ orientation program, staff complete numerous learning packages to promote patient safety and greater understanding of what is expected in a positive work culture at Eastern Health.

Eastern Health Quality Account 2016




astern Health is dedicated to the continuous improvement of residential aged care services. During 2015-16, multiple avenues have been explored across Eastern Health’s four aged care facilities in order to achieve this. A specific focus has been listening to feedback and requests from residents, carers, families and staff. Monthly meetings have been held at each facility to encourage open discussions and suggestions about improvements to food services, hygiene, leisure activities, patient health and safety, the environment and any other topics they wish to discuss. In March 2016, an aviary was installed at Monda Lodge in Healesville after a suggestion from one of the residents at the monthly meeting. The aviary provides a space for residents to reflect, relax and enjoy interaction with the birds. Eastern Health reports quarterly on six key patient care indicators: pressure injuries, falls, physical restraint, medication use (greater than nine) and unplanned weight loss.

The tables opposite reflect the reporting quarter of January 2016 to March 2016.



QUARTER THREE JANUARY 2016 – MARCH 2016 Prevalence of pressure injuries This is assessed through a quarterly audit of all residents with data inclusive of pressure ulcers that were present on arrival, as well as those acquired in care.


Suspected Unstageable Deep Tissue Pressure Injury Stage 4 Injury

Stage 1

Stage 2

Stage 3

Monda Lodge Statewide average

0.00 0.17

0.00 0.24

0.00 0.03

0.00 0.00

0.00 0.00

0.00 0.00

Edward Street* Statewide average

0.45 0.46

0.00 0.48

0.00 0.13

0.00 0.02

0.00 0.00

0.00 0.00

Northside* Statewide average

0.00 0.46

0.40 0.48

0.00 0.13

0.00 0.02

0.00 0.00

0.00 0.00

Mooroolbark Statewide average

0.00 0.46

0.00 0.48

0.00 0.13

0.00 0.02

0.00 0.00

0.00 0.00

All four facilities were below Statewide average rates across all stages of pressure injuries. * Edward Street and Northside pressure injuries were acquired while the resident was in acute care.

Care plans were reviewed and updated for the residents with pressure injuries, including provision of a pressure-relieving mattress.

Falls Prevalence of falls and fall-related fractures are identified through quarterly analysis of resident falls data.

Falls Facility Rate

Falls with Fracture Rate

Monda Lodge Statewide average

0.00 5.69

0.00 0.13

Edward Street Statewide average

1.36 7.95

0.00 0.13

Northside Statewide average

5.62 7.95

0.00 0.13

Mooroolbark Statewide average

2.62 7.95

0.00 0.13


All four facilities were below the Statewide rate for the third quarter (high care 7.95 and low care 5.69).

Physical restraint Data on the use of restraint is collected monthly by Eastern Health’s residential aged care facilities. It is routine practice within Eastern Health not to use restraint. Throughout 2015-16, there have been no occasions of physical restraint in residential aged care services.

Incidence of polypharmacy – residents prescribed more than nine medications Polypharmacy Facility Rate

Statewide Average

Monda Lodge



Edward Street










Incidence of polypharmacy for all four facilities was below Statewide average rates.

Information about the frequency of unplanned weight loss and trends are recorded by auditing the monthly weight records of all residents. If, over the three-month period, a resident shows a significant unplanned weight loss (greater than three kilograms) then the change is recorded.

Weight loss greater than three kilograms Facility Rate

Statewide Average

Monda Lodge



Edward Street









* All residents who experienced weight loss were reviewed by a dietitian with supplements or other recommendations implemented and continued, as necessary. Planned weight loss was recorded for one resident while two other residents’ weight loss was attributed to progressive illness.

t Eastern Health, we work in partnership with our consumers. To facilitate this, we recognise that consumers, carers and community members require orientation, training and mentoring so they can actively participate. We support our consumers to fulfil their roles and participate fully and effectively in the following ways:

An orientation session is held for new members of the Community Advisory Committee (CAC), which is a committee of the Eastern Health Board

Consumers who participate on committees have When consumers join specific committees, a support person is nominated to provide all relevant information and ongoing support

Consumers on committees participate in an annual evaluation survey to assess their satisfaction with their involvement and the support they receive. Results of this survey are reported to the CAC. CAC and consumer register members receive information about relevant training sessions and are supported to attend. During the past year, we have provided funding for consumers to attend a number of courses including:

Health Issues Centre (HIC) Consumer Participation Certificate – 2015

HIC Consumer Leadership Course – June 2016 (four consumers)

HIC CAC Forum – June 2016 (four consumers)

In addition, if a resident shows an unplanned weight loss of any amount every month over three consecutive months in a quarter, this is also recorded.

Critical Care Clinical Forum – May 2015 Health Literacy Course – August 2016

Unplanned weight loss of any amount every month over three consecutive months Facility Rate

Statewide Average

Monda Lodge



Edward Street











position descriptions

Unplanned weight loss


Doing it with us, not for us

* Unplanned weight loss for this quarter was below the statewide average for all four facilities.

In response to a survey of all members on our consumer register to identify needs relating to orientation, training and mentoring, and following discussion of the results with our CAC, we have established consumer forums with consumer register members and CAC members. These forums provide an opportunity for training, support, sharing ideas and developing an understanding of the range of roles for consumers across the health service. Evaluation surveys are conducted at the end of each forum to ensure consumer needs are met on an ongoing basis. All consumers on committees are able to contact the Manager of Consumer Participation & Patient Experience for ongoing support. Eastern Health Quality Account 2016


Joshua Sek from Box Hill Hospital’s Emergency Department participates in the Kitchen Immersion Hour initiative.



or the first time, Eastern Health staff are experiencing first-hand how meals are prepared, how they taste and how they are delivered to our patients. Introduced initially at Box Hill Hospital and Peter James Centre, the Kitchen Immersion Hour allows staff to tour the kitchen, observe how meals are prepared and plated, see why it is so important to correctly record diet codes, learn more about the role of menu monitors and taste the meals being prepared for the day. “Participating in the Kitchen Immersion Hour provides us with an opportunity to expand our knowledge and take a moment to explore the meal options available to our patients,” Box Hill Hospital Emergency Department Associate Nurse Unit Manager Brendan Logan said.

“I now have a better understanding of the complexity of providing the right meal to the right patient at the right time. It was certainly an eye-opening experience to witness the well-rehearsed and orchestrated catering operations within the kitchen environment.”

“I think there is an historic misconception that hospital food is terrible. I now have a better understanding of the level of work that goes on behind the scenes to develop patient menus that meet the nutritional, cultural and personal preferences of patients.

Eastern Health research has shown that staff perception of patient meals has a direct effect on the patient’s perception of meals.

“Having the opportunity to watch the kitchen staff prepare the food diligently and professionally, as well as tasting the menu options, was a great experience. And to be honest, it really is not that bad after all.”

“My perception of patient meals has certainly changed since participating in the program through tasting the food and participating in this catering experience,” Brendan said.

The Kitchen Immersion Hour is being rolled out across all major Eastern Health sites in 2016.

“Participating in the Kitchen Immersion Hour provides us with an opportunity to expand our knowledge and take a moment to explore the meal options available to our patients.” – Brendan Logan 34

Box Hill Hospital Emergency Department Consultant Dr Paul Buntine helps junior medical staff like Dr Joshua Chung make good decisions when assessing patient conditions and diagnostic clinical tests.



atients who present to Eastern Health’s three emergency departments can be confident they are not being subjected to unnecessary tests to inform their care and treatment plans. “Historically, what was thought to be the best way to inform care and treatment plans was doctors ordering dozens of pathology, imaging such as x-rays or CT scans and specimen tests,” Emergency Medicine Clinical Director Associate Professor Debbie Leach said. “We also know that unnecessary investigations are recognised as a major problem worldwide – they waste valuable resources and in some instances, harm patients.” A dynamic team of emergency department staff at Box Hill Hospital investigated the factors that influence clinicians to order unnecessary tests and introduced a range of measures to counter these and support the provision of safe, quality care. “We call this “no unnecessary tests” or NUTS,” A/Prof Leach said. “The initiatives we have implemented include weekly education sessions for junior doctors, where we challenge them to think carefully about what tests are required and to consider more targeted questions for patients, some simple flowcharts to guide emergency department doctors when choosing tests and some changes to our computerised ordering system. “For our patients, NUTS is resulting in less invasive and unnecessary testing while maintaining quality care in the development of care and treatment plans”. Work is underway to expand this initiative across the broader hospital setting.

Hand hygiene still number one in infection prevention Good hand hygiene practice is the single most important activity to prevent healthcare-associated infections. Eastern Health has rigorous hand hygiene protocols, including ongoing observation audits of healthcare workers’ hand hygiene practices. These audits are performed by staff who observe, audit and support colleagues in hand hygiene compliance.

Department of Health and Human Services target – 80 per cent compliance


Eastern Health compliance – 83.4 per cent in 2015-16. Eastern Health has achieved greater than 80 per cent for the past two years. Eastern Health Quality Account 2016


Dr Andrew Maclean taps on to access patient records in Box Hill Hospital’s Emergency Department.

“The new card system allows us to build for the future and is an important step in Eastern Health's transformation from being a paper-based health service to a digital health service.” – Dr Andrew Maclean


he implementation of new “tap” card technology at Box Hill Hospital is giving staff prompt, easy and secure access to clinical information systems.


Part of Eastern Health’s Great Digital Information Strategy, the technology ensures clinicians have information quicker, allowing more time to spend with patients and less time searching for patient information. Once logged in, clinicians have the ability to tap on and off multiple computers to access patient information. This eliminates the need to enter passwords at each computer and saves valuable time for clinicians, particularly those who regularly move around the hospital to treat patients.

My Health Diary


ealthcare is complex. It can be an overwhelming experience for consumers, from navigating services available to filling out forms and receiving information from multiple sources.

Director of Emergency Services Dr Andrew Maclean believes the computer system is particularly valuable in achieving great health outcomes for patients.

“The poorer an individual’s health literacy is, the greater the likelihood of a poorer health outcome,” Community Health Promotion Officer Jo Stanford said. “Receiving and understanding information is most important to consumers to support decisions about their healthcare and treatment needs.”

"Fast access to information allows for efficient assessment, treatment and discharge of patients, which provides a more positive experience overall,” Dr Maclean said.

Health literacy refers to a person's ability to obtain, read, understand and use healthcare information to make appropriate decisions and follow instructions.

“The new card system allows us to build for the future and is an important step in Eastern Health's transformation from being a paper-based health service to a digital health service.”


According to the Australian Commission on Safety and Quality in Health Care, 60 per cent of Australians have low health literacy

www.safetyandquality.gov.au In partnership with Deakin University’s Ophelia research project, Eastern Health’s community health team has been working with consumers to develop My Health Diary. The concept is to support clients to maintain a diary where they can record appointments, make notes about conversations with healthcare service providers and keep track of their treatments, medications and health goals. “Our clients were encouraged to take their diary to each of their appointments and record information that was important to them, such as appointment times, test results or personal progress notes about their health goals in a language and form they could easily understand,” Jo said. Following a trial period, both consumers and staff were surveyed about the effectiveness of the My Health Diary concept. “For our consumers, the appointment page, contact information for clinicians and the medications record page were the most popular components,” Jo said. “And for our staff, the diary was useful as a cross-communication tool between service providers, especially GPs and the community health team. “Health literacy remains a priority area for the community health team, with plans to evolve the My Health Diary concept in response to the trial and further recommendations from our clients and staff.” The community health team will offer the diary to clients in the waiting room of the new Healesville Hospital precinct and promote its availability to healthcare providers and local GPs. Eastern Health Quality Account 2016


Phoebe Spry-Bailey, Turning Point's Senior Education and Training Officer (front) supports representatives from CALD community agencies to address alcohol and other drug issues across the community.



urning Point is continuing to forge strong links with Melbourne’s culturally and linguistically diverse (CALD) communities. Working in partnership with a range of multicultural agencies, Catching Up is an education program that aims to provide dual diagnosis support to CALD communities, as well as the alcohol and drug sector.

Organisations including Arabic Welfare, the Australian Vietnamese Women's Association, Spanish Latin American Welfare Centre, Polish Community Services and New Hope Foundation have also worked with Turning Point, as part of the Catching Up program.

Having been trained in how to respond to a range of alcohol, drug and mental health issues by Turning Point, groups of core community educators are now actively working within their own communities to increase understanding of addiction and mental health issues.

More than 1500 CALD community members have benefited from the program during the past four years.

This activity has included the development of resources in various languages, radio discussions and the provision of formal training and community education in their respective languages. Turning Point’s primary partner in the CALD community is the Multicultural Centre for Women’s Health, with a partnership dating back over a decade.


76% of CALD community members indicated they thought the training was “excellent”.

Strong involvement across the Arabic, Vietnamese, Spanish, Polish and Sudanese communities has been positive. “Activity and participation levels in all of the community organisations are contributing well to the overall project objectives,” Director of Statewide Services Research and Workforce Development, Dr Kieran Connolly said. In addition to providing education to CALD communities, there has been substantial training provided to metropolitan and regional alcohol and other drug workers on how to better engage and work with members of CALD communities. The project recently received funding for a further year to continue its vital work in this area.

Starter kits introduced to prevent “golden staph”


taphylococcus aureus bacteraemia (SAB), or as it is more commonly known, “golden staph”, is a serious bloodstream infection that might be associated with hospital care. The bacteria that leads to this condition is commonly found on skin and can cause serious illness if it finds its way into a patient’s blood stream. “Patients who develop bloodstream infections such as SAB are more likely to suffer complications that result in a longer stay in hospital and serious infections,” Infection Prevention and Control Associate Director Leanne Houston said. The key to prevention of healthcare-associated SAB is hand hygiene and aseptic technique*. To support staff in aseptic technique, Eastern Health has introduced IV Starter Kits. These kits include all the necessary equipment to prepare and insert intravenous catheters. “Historically, staff would have gathered each piece of equipment individually but through the implementation of these kits, staff have all the necessary resources in the one place,” Leanne said.

Eastern Health’s rate for SAB is 0.8 per 10,000 bed days. Eastern Health SAB rates are below the target set by the Department of Health and Human Services and consistent with similar health services in Victoria. * Aseptic technique is a method designed to prevent contamination from micro-organisms during procedures such as inserting intravenous catheters or during surgery. It involves applying infection prevention measures to minimise the risks of infection.

SURGICAL REVIEW HAS US ON TRACK E ach year, Eastern Health performs on average 31,000 surgical procedures.

“Surgery brings with it inherent risks. If a patient dies during or after surgery, it is imperative that the circumstances are reviewed to identify whether the outcome could have been prevented or to ensure it is not repeated in the future,” Surgery Program Director Martin Smith said. Eastern Health reports adverse surgical outcomes to the Royal Australasian College of Surgeons which administers the Victorian Audit of Surgical Mortality Register. “This is an independent, external peer review of surgical mortality (deaths associated with surgical procedures) in Victoria and is funded by the Victorian Department of Health and Human Services,” Martin said.

The 2016 report contains a comparative analysis of 573 cases reported by Eastern Health between 1 July 2009 and 30 June 2015, and demonstrates that Eastern Health is largely equal to or better than other hospitals in Australia on several measures of surgical mortality. “The data has identified that prevention management of deep vein thrombosis (a blood clot that forms in the veins of the leg) was not optimum between 2009 and 2013 but has improved since," Martin said. “Following the report’s recommendations relating to deep vein thrombosis, we have established a Deep Vein Thrombosis Prophylaxis Committee, which includes surgical representatives, that is focused on developing improvement strategies to prevent the potentially fatal condition.”


Box Hill Hospital midwife Breanna Kellock with baby Henry and parents Jodie and Martin Abson.

Eastern Health provides birthing services at Angliss Hospital and Box Hill Hospital, and encourages women to be actively involved in their care throughout their pregnancy, birth and postnatal period. According to the Victorian Perinatal Services Performance Indicators 2013-14, Eastern Health has the highest rate of women referred to postnatal domiciliary care (care provided in the home post-discharge from hospital) in the state. Furthermore, Box Hill Hospital is identified as one of the most favourable sites, with the initiation of breastfeeding at 37 weeks.

“Eastern Health continues to look at ways to ensure our mothers and families are provided with the best possible care during their pregnancy to enhance their care experience.” – Paul Leyden, Acting Women and Children Program Director

Eastern Health Quality Account 2016


Volunteer Denis Cody supports patient Heather Sharp during her cardiac rehabilitation session at Angliss Hospital's Community Rehabilitation Centre.



ardiac rehabilitation plays an important role in supporting patients with heart disease.

The cardiac rehabilitation team consists of cardiac nurses, physiotherapists, allied heath assistants, occupational therapists, dietitians, social workers, pharmacists, advance care plan consultants and diabetes educators, who work together to improve the physical and emotional health of cardiac patients.

People who have experienced a cardiac event such as a heart attack may recover quicker and return to a productive life through participation in cardiac programs.

Volunteers also make an invaluable contribution to the team by helping patients to keep their hearts strong.

According to Eastern Health’s Cardiac and Heart Failure Programs Co-ordinator Georgie Shoebridge: “Cardiac rehabilitation programs are an essential part of the care and recovery journey. “The goal is to help patients slow or even reverse the progression of their cardiac disease. We can achieve this by educating our patients about changes in lifestyle, maximising their physical, psychological and social wellbeing, and ensuring appropriate use of their medication.” Cardiac rehabilitation programs are run from Wantirna Health, Angliss Hospital's Community Rehabilitation Centre and Yarra Ranges Health in Lilydale to ensure easy access for our clients.

Following their own cardiac events, volunteers such as Denis Cody, Brian Townsend and Grant Palmer joined the team with a commitment to help and support others participating in cardiac rehabilitation. “We have experienced heart problems and understand first-hand the impact this has on one’s life,” Denis said. “Supporting others who are experiencing cardiac conditions provides me with immense satisfaction and a sense of having given back in a real way. “It is one thing to have a fantastic team of doctors, nurses and other health professionals support you in your cardiac rehabilitation journey but for new patients to be supported by other patients who have experienced what they have, gives them a sense of reassurance that life can get back to normal.”

National Heart Foundation nurse ambassadors Heart attack patients admitted to Box Hill Hospital are benefiting from the National Heart Foundation’s Nurse Ambassador Program. The program provides nurses with the skills and resources to educate cardiac patients about their recovery and the importance of cardiac rehabilitation. Cardiac patients are also provided with a comprehensive book titled My heart, my life detailing their condition, the recovery process and the huge impact attending cardiac rehabilitation has on their quality of life.

Following its successful implementation at Box Hill Hospital in 2015, more than 700 patients have benefited from the program. The program has now been extended to Wantirna Health.

Eastern Health Quality Account 2016


Early Medication Reconciliation Pharmacist Geoffrey Haar and Maroondah Hospital Associate Director of Pharmacy Lauren Lawlor review patient medications in support of patient safety and wellbeing.



atient safety continues to be a key priority for Eastern Health’s pharmacy team with the appointment of an Early Medication Reconciliation Pharmacist (EMRP).

As part of the team’s commitment to provide clinical pharmacy services at a time and place when they are most needed, the EMRP will improve medication reconciliation for patients. Medication reconciliation refers to the process of obtaining a complete and accurate list of each patient’s current medicines and formally reviewing the efficacy of each medicine in conjunction with new or existing prescriptions and the patient’s care plan. “Safe prescription and administration of medication is a priority and we are continually looking for new ways to improve patient safety and wellbeing,” Maroondah Hospital Associate Director of Pharmacy Lauren Lawlor said. General Medicine Registrar Advanced Trainee Dr Betty Zhang said the new role had made the admitting process more efficient because she could fill in the drug chart quickly and completely on admission. Since the implementation of an EMRP in January 2016, the average time from admission to medication reconciliation for high-needs patients admitted to a general medicine ward has reduced from 30 hours to 20.6 hours. Based on the results, Eastern Health has been successful in obtaining a workforce


innovation grant from the Victorian Department of Health and Human Services to expand the project. A Partnered Pharmacist Medication Charting (PPMC) project will be implemented across the General Medicine Program at Eastern Health. The PPMC model involves a partnership between a pharmacist and medical officer with early medication review and charting on admission by a qualified pharmacist. It is anticipated that this project will further reduce the number of medication discrepancies on admission and continue to improve medication safety.

“Safe prescription and administration of medication is a priority and we are continually looking for new ways to improve patient safety and wellbeing.” – Lauren Lawlor

Your feedback is important. We are listening.


t Eastern Health we have many ways to seek feedback from our consumers and carers.

These include:

Complaints and compliments mechanisms, including a website feedback portal, via email, phone and mail, and online through independent third party services such as Patient Opinion (see opposite)

Victorian Healthcare Experience Survey participation (see page 8)

Leadership walkrounds whereby senior leaders visit wards and services to talk directly with patients about their experiences

Patient Opinion One of our newest ways to hear about the experience of our consumers and carers is through Patient Opinion. This is an independent website where people can write (anonymously if they choose) about their experience at a health service. Eastern Health established a connection with Patient Opinion in 2015 and it has since become a very popular resource for patients to provide feedback. In 2015-16, we had 225 stories about Eastern Health published on the Patient Opinion website which were read a total of 86,836 times. We share all stories with relevant staff and celebrate when we are providing excellent service, as well as look at ways to improve. The table below provides examples of stories we received via Patient Opinion and what improvements were made based on this feedback.

In 2015–16 Eastern Health received:

1,532 1,201 formal compliments and

formal complaints

Example of Patient Opinion feedback You said After three days in hospital, the doctor said my aunt was to be discharged. It was then early afternoon. The patient's next of kin asked if this would happen the following day. The doctor said it would happen later that afternoon. The family member requested that the doctor call the nursing home to update them on the aunt's condition and make sure they would be expecting her that afternoon. The doctor assured us she would phone the nursing home. She then returned to say the home had no record of her!

The hospital records were incorrect so the next of kin gave the doctor a card with the details of the relevant nursing home. May 2016

We did As a result of your feedback, we have identified that while there were hand-written updates with regard to your aunt's details, the Patient Master Index (PMI) had not been updated, hence the problems you encountered at the time of discharge. Therefore, the Director of Information Services will now be writing to all ward clerks and admitting clerical staff to reinforce the requirement to verify and update details on the PMI at the time of the patient's admission. This notification will also be distributed across the organisation to directors and department managers to maximise the learning in this regard.

How to provide your feedback Fill in our online feedback form at www.easternhealth.org.au Contact one of our Patient Relations Advisers on 1800 327 837 Patient Relations Advisers are available Monday to Friday from 9am – 5pm Send an email to feedback@easternhealth.org.au Write to us at: The Centre for Patient Experience Wantirna Health 251 Mountain Highway Wantirna South VIC 3152

Eastern Health Quality Account 2016


CONTACT US Eastern Health 1300 342 255 www.easternhealth.org.au 5 Arnold St, Box Hill VIC 3128

Telephone Interpreter Service Servizi Interpreti

PO Box 94, Box Hill VIC 3128 ABN 68 223 819 017

Eastern Health includes: Angliss Hospital Albert St, Upper Ferntree Gully VIC 3156

131 450

Box Hill Hospital 8 Arnold St, Box Hill VIC 3128 Healesville Hospital and Yarra Valley Health 377 Maroondah Hwy, Healesville VIC 3777 Maroondah Hospital Davey Dr, Ringwood East VIC 3135 Peter James Centre Mahoneys Rd, Burwood East VIC 3135 Spectrum 4 Bona Street, Ringwood VIC 3134 Turning Point 54-62 Gertrude St, Fitzroy VIC 3065

Eastern Health Foundation Eastern Health Foundation is the fundraising arm of Eastern Health. The Foundation raises additional funds that enable Eastern Health to better understand our patients and their health needs, and to improve and advance their care and treatment.

Ways to donate www.easternhealthfoundation.org.au

Wantirna Health 251 Mountain Hwy, Wantirna VIC 3152

Directly at any Cashiers

Yarra Ranges Health 25 Market St, Lilydale VIC 3140

PO Box 94, Box Hill VIC 3128

03 9895 4608

Š Eastern Health 2016

For more information about Eastern Health, visit www.easternhealth.org.au or follow us on Twitter and Facebook @easternhealth.au www.facebook.com/easternhealthau

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