NSW Health WSLHD Safety & Quality Account 2020-21

Western Sydney Local Health District

wslhd.health.nsw.gov.au

Safety & Quality Account 2022-2023 2022-2023 Report | 2023-2024 Future Priorities

Western Sydney Hospitals and Community Health Centres

Artwork by Leanne Tobin. Leanne’s artwork reflects the vibrancy and transitional motions of the dragonflies as they move through their journey of life.

Western Sydney Local Health District would like to extend our sincere appreciation and acknowledgment to the dedicated group of individuals

who authored this account. Thank you for the exceptional contributions of our consumer representatives: Caroline Gayatri Lina Matthew

The Hills Shire LGA

Russell Satoko Tas Your dedication to ensuring the consumer’s voice is heard and considered throughout this account is deeply appreciated. Your perspectives, lived experiences, and contributions have elevated the quality and impact of this year’s annual account. Data Sources: All demographic data included in this report on Local Government Areas (LGAs) in Western Sydney is from the ABS Census 2021 Data Local Government Profiles. WSLHD Social and Health Atlas 2022 and HealthStats NSW produced by Western Sydney Local Health District Epidemiology and Health Analytics. Western Sydney Local Health District PO Box 574 Wentworthville NSW 2145 https://www.wslhd.health.nsw.gov.au/ Produced by: Western Sydney Local Health District This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission fromWestern Sydney Local Health District. ©Western Sydney Local Health District August 2023

Blacktown LGA

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See footnote*

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Mount Druitt Hospital

Blacktown Hospital

Cumberland Hospital

Parramatta LGA

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Westmead Hospital

Cumberland LGA

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Auburn Hospital

1. Mount Druitt Community Health Centre 2. Doonside Community Health Centre 3. Blacktown Community Health Centre 4. The Hills Community Health Centre 5. Parramatta Community Health Centre 6. Merrylands Community Health Centre 7. Auburn Community Health Centre . * Hatched area of Parramatta LGA is outside Western Sydney Local Health District

Acknowledgement of Country

Western Sydney Local Health District acknowledges the first people of the land. The overarching Aboriginal nation in Western Sydney is the Darug nation. We pay our respect to Elders past, present and emerging. We acknowledge the significance of land, water, spirit, kinship and culture, and the importance that these elements have to the health, well-being and future of the Aboriginal community. Please be aware that this publication contains the images of Aboriginal and Torres Strait Islander people who may now be deceased.

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Foreword

Western Sydney Local Health District (WSLHD) is committed to delivering exceptional healthcare services. At the heart of our mission lies a fundamental belief that every individual deserves access to healthcare that is not only comprehensive but, above all, safe and of the highest quality. We recognise that every individual is unique, and it is this very diversity that enriches our communities. Our commitment is to embrace this diversity, to foster a culture of inclusivity, and to ensure that healthcare is accessible to all members of Western Sydney. In this account, we explore our dedication to delivering safe and high-quality care. We reflect on the strategies, initiatives, and efforts of our staff in partnership with patients, families, and carers, putting patient safety and the provision of exceptional care at the forefront of their responsibilities. This account is a testament to our dedication to learn, grow and evolve as a Local Health District. It serves as a reminder that safety and quality are daily practices built into our ‘Business as Usual’ approach to providing high-quality care. We are immensely proud of what we have achieved over the last 12 months. The first half of this account highlights our focus on moving towards a comprehensive approach to healthcare delivery where various health and social support services are coordinated and interconnected to provide a seamless and holistic experience for patients. This approach focuses on breaking down silos between different agencies to enhance the quality, safety and efficiency of care. The second half of this account focuses on the delivery of safe and quality care in our five hospitals and over 100 health services. As we look ahead, our resolve to enhance safety and quality care remains as our focus. It is our privilege and responsibility to serve the diverse and vibrant communities of Western Sydney, and we stand firm in our pursuit of healthcare excellence. We extend our gratitude to our dedicated healthcare teams, community partners, and, most importantly, our patients and their families and carers, for their trust and collaboration. Together, we continue to strive for a healthier, safer, and brighter future for all communities in Western Sydney.

Graeme Loy WSLHD Chief Executive

Loretta Di Mento WSLHD Board Chair

Safety & Quality Account 2022-2023 Western Sydney Local Health District

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Contents

About Western Sydney Local Health District

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Our Care at a Glance 2022-2023

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Snapshot of Key Achievements 2022-2023

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Governance for Safety and Quality in WSLHD

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Our Clinical Governance Framework

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Accreditation under the National Safety & Quality Health Service Standards

Creating Healthy Communities Together

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Population Health

Aboriginal & Torres Strait Islander Health

Multicultural Health Matters

Refugee and Asylum Seeker Health and Wellbeing Better Supporting Individuals with Disability

Child, Adolescent and Family Health

Delivering Safe and Quality Services

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Partnering With Consumers to Improve Patient and Carer Experiences

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Human Experiences Week 1-7 May 2023

WSLHD Consumer Council

Creating a Safety Culture and Empowering Safety and Quality Excellence Celebrating our Staff’s Achievements in Safety & Quality Using Research, Technology and Data to Drive Quality Improvement

Safety & Quality Account 2022-2023 Western Sydney Local Health District

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Our Services

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Drug Health Services

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Integrated and Community Health

Mental Health Services Oral Health Services

Auburn Hospital

Blacktown & Mount Druitt Hospital

Westmead Hospital

Review of Performance Indicators 2022-2023

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2023-2024 Future Priorities

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WSLHD Attestation Statement

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Glossary of Abbreviations

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Safety & Quality Account 2022-2023 Western Sydney Local Health District

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Western Sydney Local Health District (WSLHD) covers a large area of 780 square kilometres, encompassing 120 suburbs in the local government areas (LGAs) of Blacktown, Cumberland, Parramatta, and The Hills Shire. About Western Sydney Local Health District

The land is traditionally owned by the Darug people, with over 16,000 people identifying as Aboriginal and Torres Strait islander living in the WSLHD catchment. Our local health district has: 5 hospitals and over 100 health services Over 500 early childhood education services 19 family day care service providers Over 200 primary schools Over 100 high schools 7 TAFE campuses 5 Western Sydney University campuses 25 local libraries

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1,052,990 residents in WSLHD. There are

WSLHD is not only focused on improving health outcomes but also fostering trust, inclusivity, and resilience within the communities we serve, creating a stronger and healthier Western Sydney for generations to come. Recognising the diversity and unique needs of the population we serve, WSLHD works hand-in-hand with communities to co-design our services and gain insights into the specific health challenges faced by different communities.

1,198,907 It is estimated by 2030 the population will grow to

Half of our residents were born overseas.

16,000 Aboriginal and Torres Strait Islander peoples. We are home to

10,000 babies are born each year. (The highest birth rate in NSW) Approximately

54.3% of our residents speak a language other than English at home.

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Our Care at a Glance

207,480 Emergency Department Presentations

167,521 Inpatient Admissions

34,704 Elective Surgeries

21,496 Emergency Surgeries

3,243,992 Outpatient Occasions of Service

142,761 Healthcare Interpreter Sessions

9,869 Babies Delivered

3,842 Mental Health Inpatient Admissions

3,243,606 Drug Health Occasions of Service

1,508 New Staff Recruited

1,306 Emergency Avoidances Achieved by inTouch Residential Aged Care Facility Pathway

127,857 Oral Health Occasions of Service

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Snapshot of our Key Achievements 2022-2023

WSLHD has continued to prioritise safety and quality over the last 12 months.

OUR KEY ACHIEVEMENTS IN 2022-2023:

Delivering patient-centric care with enhanced care coordination via the inTouch Residential Aged Care Facility Pathway The Integration & Transformation team developed the inTouch Residential Aged Care Facility (RACF) pathway to keep residents with acute health concerns out of hospital by offering direct access to specialist advice via telehealth. From 1 April 2022 to 31 March 2023, the inTouch RACF pathway received 3,131 referrals for residents living in 65 Residential Aged Care Facilities (RACFs) across WSLHD. The service achieved 1,306 emergency department avoidances over these 12 months, resulting in an overall emergency department avoidance rate of 31%. Launch of the WSLHD Disability Inclusion Action Plan The inaugural WSLHD Disability Inclusion Action Plan was launched in November 2022 and sets out specific actions that will be undertaken across the LHD, to support equitable access to services and employment for people with disability in the Western Sydney area over the next three years. Opening of the Westmead Hospital Mother and Baby Unit In March 2023, Westmead Mother and Baby Unit was opened to support mothers to remain with their infant during psychiatric care and prevent the effects of separation on the parent-infant relationship. Launch Of New Consumer Partnership Committees (CPCs) Embedding consumer engagement at a local facility/service level has been promoted through the establishment of Consumer Partnerships Committees (CPCs) in 2022 at each facility. Whilst the District Consumer Council remains an active, vibrant, and peak district Consumer Council, the CPCs engage Consumer Representatives and staff to co-design and partner at a local facility/ service level. WSLHD Patient Experience Coordinators Top the State in GoShare Bundle Distribution in March 2023 GoShare is a cloud-based platform from which bundles of health literate information (video or text) can be sent directly to patient’s mobile or tablet devices. Bundles of information can be sent in various languages to patients attending WSLHD Emergency Departments (EDs), including videos explaining what to expect in the Emergency Department.

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WSLHD CLINICAL GOVERNANCE REPORTING STRUCTURE

WSLHD BOARD

Quality Related Committees

WSLHD Board Committees

New Interventional Procedures Committee

Audit and Risk Committee

Health Care Quality Committee

Finance, Performance and Asset Committee Aboriginal Health Advisory Committee

Drug Committee

Policy and Procedure Committee

Safety & Quality Operational Committee

Infection Prevention and Control Committee

Research and Development

WSLHD Clinical Council

Professional Education

Facility Quality & Safety Committee

Nominations Committee

End of Life Committee

Risk Management Steering Committee

Escalation process including Morbidity & Mortality

WSLHD Consumer Council

Patient Safety agenda items on department/ward meetings

Falls Committee

Management of Complaint and Concern about a Clinician Committee

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Governance for Safety & Quality in WSLHD

Clinical Governance is the systematic framework that WSLHD works within to ensure our care is of high-quality and is safe.

Western Sydney Local Health District

Clinical Governance Framework 2023-2025

Our safety and quality priorities: 1. Strengthening Governance & Accountability 2. Enhance System Improvement Capability 3. Using Data to Drive Quality Improvement 4. Partnerships, Inclusion, and enhancement of Patient & Carer Experience 5. Strengthening a Strong Safety Culture

The WSLHD Clinical Governance Framework 2023-2025 is the District’s principal document which provides guidance on: • Processes, structures, and systems that are in place to monitor and enhance the delivery of healthcare services across WSLHD. • Relationships we establish with staff, external organisations, patients, consumers, carers, and families to create a safe environment and involve individuals in their own care and the design and delivery of our services. • The safety and quality responsibilities of all staff in the organisation to maintain high standards of clinical practice, patient safety, and effective management of clinical risks in their day-to- day work.

SCAN HERE TO READ MORE

Our services are accredited to the National Safety and Quality Health Service Standards. In financial year 2022-2023 Auburn Hospital, Blacktown Hospital, Drug Health Services and Mental Health Services were all assessed by the Australian Council on Healthcare Standards and achieved accreditation. Achieving accreditation requires a rigorous evaluation process where our practices are thoroughly examined against the NSQHS standards which include areas such as clinical governance, infection control, communication, and patient-centred care. Successfully meeting these standards demonstrates our organisation’s adherence to best practices and dedication to continuous improvement and patient satisfaction.

Dr Richard Alcock AO, Board Chair (2017–2023) and Ms Loretta Di Mento, Board Chair (August 2023–Present)

SCAN HERE TO READ ABOUT THE STANDARDS

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Creating Healthy Communities Together

The WSLHD Health Service Plan to 2026 and The Community and Consumer Partnerships Framework 2021-2025 guides howWSLHD partners with consumers and communities to improve the health and wellbeing of Western Sydney communities.

Our collaborative approach not only improves the way we deliver care, but also emphasises health promotion and disease prevention, empowering individuals to take charge of their own health and wellbeing. This enables WSLHD to deliver culturally sensitive, high-quality and cutting-edge services that meet the needs of the community to prevent, treat and manage illnesses and prolong mental and physical wellbeing. Over the past 12 months, our commitment to delivering healthcare to everyone in our community is reflected in the significant gains we have made achieving various health initiatives that have positively impacted our communities in the areas of: Population Health Aboriginal & Torres Strait Islander Health Multicultural Health Matters Refugee and Asylum Seeker Health and Wellbeing Better Supporting Individuals with Disability Child, Adolescent and Family Health

Health Services Plan

This framework guides how Western Sydney Local Health District will partner with consumers and communities to improve the health and wellbeing of Western Sydney communities from 2021-2025 Community and Consumer Partnership Framework 2021-2025 Western Sydney Local Health District

Growing Good Health in Western Sydney

Communicating, listening, responding

SCAN HERE TO READ MORE

SCAN HERE TO READ MORE

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Population Health

WSLHD is investing in population health initiatives to extend access to services, promote healthy behaviours, and address the social determinants that influence health outcomes. Investing in population health translates to increased productivity, reduced healthcare costs, and a more equitable and resilient society, reflecting a commitment to the shared pursuit of a healthier and brighter future for all. In 2023, WSLHD launched our WSLHD Centre for Population Health Strategic Framework which outlines the shared vision, purpose, values, and focus areas of our Health Promotion and Public Health services for the next two years as we continue to transition from the COVID-19 pandemic response to ‘living with COVID-19’.

Centre for Population Health

Public Health

Health Promotion

Healthy Early Years

Communicable Disease

Healthy School Years

Healthy Adults

Environmental Health

Healthy Ageing

Immunisation

Healthy Places

Centre for Population Health Western Sydney Local Health District

SCAN HERE TO READ MORE

Strategic Framework 2022 - 2024

Smoking and Vaping Prevention

Public Health Response Epidemiology

Communications

NSW School Vaccination Program The Centre for Population Health Immunisation Team works in partnership with 109 high schools in Western Sydney to offer the vaccines recommended and funded for adolescents by the National Health and Medical Research Council. In 2021, the School Vaccination Program was impacted by school closures, student absenteeism due to COVID-19 and the diversion of accredited nurse immunisers from the program to COVID-19 vaccine hubs. This resulted in a considerable drop in vaccine coverage and the need to offer a second chance for vaccination to students who missed their vaccinations. A “Catch-up School Vaccination Project, 2022” was developed to restore immunisation coverage to pre-pandemic coverage in high school children. The planning, resources and roll out of this project were immense tasks that achieved the delivery of 13,145 catch-up vaccines, bringing the total number of vaccines administered by the School Vaccination Program in 2022 to 49,496 vaccines. The program has ensured a larger proportion of students are protected from these diseases and their serious complications.

The Centre for Population Health Immunisation team deliver the School Vaccination Program to protect high school students from vaccine preventable diseases.

Vaccination coverage for dose 2 HPV (human papillomavirus) has

Vaccine coverage for dTpa (diphtheria, tetanus and pertussis) has

Vaccine coverage for MenACWY (meningococcal) has

increased by 71%

increased by 19%

increased by 18%

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Stepping On for Over 65s Over 2022-23, the Centre for Population Health Healthy Ageing team ran free, seven week falls prevention programs for people 65 years and over living in the community. The program was advertised via local Councils, retirement villages, older adults’ services, and Library Health Month activities. 100% of participants who completed the program said: • they gained information/knowledge about falls prevention. • they applied what they learned from the program in their daily life. • the program increased their sense of wellbeing, self-esteem, and independence.

29 face-to-face programs completed.

65 –92 years average participant age range.

10 English and 11 culturally and linguistically diverse programs.

435 participants enrolled.

Participants of Stepping On

Developing the WSLHD E-cigarette Action Plan A WSLHD E-cigarette Planning Workshop, led by the Centre for

Population Health’s Health Promotion team, took place on 22 May 2023, with participation from a broad range of key stakeholders across WSLHD. The workshop aimed to understand the significant initiatives being undertaken by WSLHD services in relation to e-cigarettes and establish a strategic and coordinated approach through the development of a WSLHD E-cigarette Action Plan (2023-2025). The General Manager, Integrated & Community Health has committed to the formation of a District Governance Committee and working groups that will spearhead local implementation of the new action plan.

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WSLHD Leads the Way on New Key Research about Vaping in Schools In May 2023, the WSLHD Prevention Education and Research Unit shared their research findings during the ‘Voices from the Community on the Prevention of Youth Vaping’ forum. Conducted across seven different high schools in greater Western Sydney, this leading study presents key findings and preferred strategies to address this pressing issue. More than 160 students, 130 school staff and 30 parents participated in the research, which employed an interactive, strengths-based approach, engaging students, staff, and parents to understand their perceptions and concerns regarding e-cigarette use among adolescents.

The key research findings by the team include: • There is no ‘one size fits all’: Schools request tailored education and engagement. • Education for young people needs to centre on effective learning approaches for tackling vaping. This means a focus on how and what young people learn, and the best ways to engage. • Prevention messaging needs to resonate with the children’s peer group. • A holistic approach to combat vaping needs to be embraced across the school, with supportive strategies, policies, and parent/staff education. • Focus on collaborative efforts between health and education for wellbeing-centred vaping prevention strategies. The participating schools will be involved in the next phase of the project– The Action Phase , which will include co-designing educational resources and workshops for students.

“If you were to sit us down and lecture us for an hour on the dangers of vaping, nothing would get through. This worked because we got involved and it was engaging.” –Student Feedback

“I felt like our choices mattered and our opinions mattered.” –Student Feedback

Western Sydney Diabetes: Changing Diabetes Initiative In December 2022, the Western Sydney Changing Diabetes initiative was launched in collaboration with the global healthcare company Novo Nordisk to improve diabetes awareness, detection, and prevention for the Western Sydney community. Since the launch, Western Sydney Diabetes (WSD) has partnered with Workers Lifestyle Group (Blacktown Workers) to conduct free diabetes detection programs every fortnight along with healthy cooking demonstrations once per month. As a result of these initiatives, Workers Lifestyle Group won the Club NSW and Community Awards.

Western Sydney Diabetes Leaders Alliance meeting held at Blacktown Workers on 19 June 2023.

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Since May 2023, in commemoration and continued acknowledgment of the NSW Health formal apology to survivors of the Stolen Generations in 2022, WSLHD displays this plaque across our health facilities.

Aboriginal and Torres Strait Islander Health

WSLHD is committed to achieving health equity for Aboriginal and Torres Strait Islander peoples in NSW and to providing services and work environments that respond to the needs and aspirations of Aboriginal and Torres Strait Islander peoples. We recognise the importance of the cultural knowledge and life experiences held by our Aboriginal and Torres Strait Islander staff and consumers for the successful delivery of quality health services. Over the last 12 months WSLHD has strengthened partnerships with Aboriginal and Torres Strait Islander communities and Aboriginal Community-Controlled Organisations to ensure we provided culturally appropriate care that respects and integrates traditional knowledge, while also ensuring equitable access to healthcare services. To support this, WSLHD is on the way to increase the number of Aboriginal and Torres Strait Islander peoples employed at WSLHD to 3% by 2026. Our roadmap to achieve this is outlined in the WSLHD Aboriginal Workforce Plan.

We have one of the

largest urban populations of Aboriginal and Torres Strait Islander peoples in Australia. 1.6% of our population identifies as Aboriginal or Torres Strait Islander. The WSLHD catchment is home to 16,531 Aboriginal and Torres Strait Islander peoples.

Aboriginal & Torres Strait Islander Community Consumer Council

In 2022, the Expressions of Interest to recruit 15 Aboriginal and Torres Strait Islander Consumer Representatives was opened. The WSLHD Aboriginal and Torres Strait Islander Community Consumer Council will start in 2023 Quarter 3. The Council will bring a consumer voice and perspective for Aboriginal and Torres Strait Islander communities.

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Launch of theWSLHD Aboriginal Workforce Plan On 27 June 2022, WSLHD launched the Plan with esteemed Journalist and Wiradjuri and Kamilaroi man, Stan Grant, leading the discussions about howWSLHD will increase our representation of Aboriginal and Torres Strait Islander peoples in WSLHD.

Western Sydney Local Health District (WSLHD)

Aboriginal Workforce Plan

BUILDING A STRONGER HEALTH SYSTEM INWSLHD – 2022-2026

SCAN HERE TO READ MORE

This event opened the conversation in WSLHD about how the organisation will build lasting relationships with Aboriginal and Torres Strait Islander communities and create opportunities for people to enter the workforce, stay in the organisation and to have those pathways to feel safe, heard and valued. “If you don’t hear the voices, if you don’t know who you’re talking to, you can’t possibly devise a strategy to meet their needs” –Stan Grant, Australian Journalist Launch of the Aboriginal and Torres Strait Islander Nursing and Midwifery Networking Forum In 2023, WSLHD established the Aboriginal and Torres Strait Islander Nursing and Midwifery Networking Forum. This new monthly event brings together Aboriginal and Torres Strait Islander nurses and midwives to foster collaboration, highlight opportunities, and address the unique challenges faced by Aboriginal and Torres Strait Islander nurses and midwives. The introduction of this forum is based on the valuable feedback WSLHD received from our staff at the Aboriginal and Torres Strait Islander Workforce Forum. This feedback was heard, and WSLHD’s Nursing & Midwifery Executive is committed to creating a culturally safe environment that nurtures the growth and professional development of Aboriginal and Torres Strait Islander nurses and midwives.

L-R: Michelle Ashworth, WSLHD Training and Development Manager, Stan Grant, Australian Journalist, Belinda Cashman, Acting Director, WSLHD Aboriginal Health Strategy.

Supporting Western Sydney Aboriginal and Torres Strait Islander Mums-To-Be The WSLHD Aboriginal and Torres Strait Islander Mums and Bubs Program Steering Committee is working with communities to develop programs to break down the barriers to accessing antenatal care for Aboriginal and Torres Strait Islander mums- to-be and their families in Western Sydney. This Committee is made up of more than 30 representatives across WSLHD, with 40% identifying as Aboriginal and Torres Strait Islander. One example of an initiative developed by this Committee is the Westmead Dragonfly Midwifery program which offers culturally safe midwifery care for women from Aboriginal and Torres Strait Islander families with a service that runs 24/7 during pregnancies and up to six weeks following birth. The Dragonfly group provide antenatal, neonatal, and postnatal support, organise transport and doctor appointments at the Dragonfly clinic, liaison and advocate for parents at their appointments, help with housing issues, and create fun activities such as belly-casting, painting and cooking to ensure a positive and supportive experience.

The first mother through the WSLHD Dragonfly Midwifery Clinic Joelle Harland-Sykes with her twins Jacob and Zakariya.

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Multicultural Health Matters

538,565 people in our communities speak a language other than English at home.

The WSLHD catchment is home to 499,241 people born overseas.

There are approximately 200 languages spoken within our communities.

The plan identifies 12 strategic priorities in the following focus areas: 1. Improved safety and cultural responsiveness of care and services. 2. Improved communication and health literacy. 3. Improved engagement, participation, and partnerships. 4. Improved data collection on identities, needs and experiences. 5. Governance, implementation, and monitoring.

Our vision is to provide exceptional care and services with no barriers, so culturally and linguistically diverse patients, carers, families and communities are well informed and supported to have the best possible experience using our service and achieve good health outcomes. Over the past 12 months we have partnered with members of culturally and linguistically diverse communities to improve their experiences and develop programs on health issues that matter to the community. WSLHD has launched the Multicultural Health Plan 2022-2025. The Plan identifies systemic changes and actions required to improve the district’s capacity to recognise and address the health needs, language and culture of culturally and linguistically diverse (CALD) consumers and communities.

Multicultural Health Western Sydney Local Health District

Multicultural Health Plan 2022-2025

Top 5 languages spoken across WSLHD:

Mandarin

SCAN HERE TO READ MORE

Arabic

Hindi

Cantonese

Punjabi

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Engaging Culturally and Linguistically Diverse Patients in Clinical Trials The WSLHD Research and Education Network (REN) have partnered with WSLHD Interpreter Services to improve participation of culturally and linguistically diverse patients in clinical trials. A priority interpreter booking process for clinical trials patients has been introduced to enable patients who speak a language other than English to participate in research. 81 interpreting sessions have been conducted for patients in clinical trials. Interpreting sessions have been offered in 12 different languages. This is one of the first initiatives in NSW Health to empower culturally and linguistically diverse patients to participate in clinical trial conversations with their treating clinicians and researchers.

Lynda Smith, Clinical Midwifery Consultant, Dipti Zachariah, Statewide and Specialist Programs Team Leader and Dr. Ngatho Mugo, Community Education Officer.

Make Your Voice Heard WSLHD Multicultural Health Services are working alongside women who have experienced Female Genital Mutilation/Cutting (FGM/C) and with males in the community as part of the NSW Education Program on FGM/C. The program aims to support women and girls affected by or at risk of the FGM/C to be healthy and achieve their full physical and emotional potential using prevention, health promotion and early intervention approaches. The WSLHD Multicultural Health Service hosted an ‘International Day of Zero Tolerance’ event to discuss the fight against FGM/C. Over 85 people attended the event, including community members, foreign diplomats, and partner organisations. Attendees had the privilege of hearing from distinguished speakers, including Dr. Ngatho Mugo who shared preliminary findings from the formative research on understanding men’s perceptions, views, and opinions about the practice of FGM/C.

Multicultural Women’s Health Program Sora Machida is a dedicated

Multicultural Women’s Health Program Officer who works tirelessly to increase health literacy and ensure women have the necessary information and support to access healthcare facilities. Sora’s primary responsibility is to assist women’s groups and organisations in accessing health information and hospital services, ultimately empowering them to take charge of their health. Sora works closely with mothers’ groups and senior support groups, helping women navigate the health system and understanding their needs, challenges and health-related enquiries.

Sora Michida, Multicultural Women’s Health Programme Officer

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Refugee and Asylum Seeker Health and Wellbeing

Almost 12,000 refugee and humanitarian entrants have settled in our communities in the past 10 years.

An estimated 85%

of refugees who live in the WSLHD catchment report poor or no English proficiency.

Refugee Camp in My Neighborhood In April 2023, WSLHD partnered with the City of Parramatta and the NSW Refugee Health Service to create a simulated refugee camp experience. Our staff experienced the journey of a refugee to gain a better understanding of the challenges they face as they arrive in Australia, including the challenges of navigating the Australian health system. As a significant and growing number of WSLHD patients are refugees and asylum seekers, this tour helped staff understand the experiences of our most vulnerable patients and clients and deliver healthcare that assists them to have a trusting and positive experience when engaging with WSLHD services. Tours were delivered by guides from a range of refugee and asylum seeker backgrounds, including staff from NSW Refugee Health and WSLHD. The interactive tour helped staff: • Understand how the refugee experience can impact on wellbeing. • Develop an understanding of risk factors for refugees. • Improve their ability to engage effectively with people from refugee backgrounds. Ukrainian Refugee Dual Vaccination Clinic WSLHD partnered with the Ukrainian Youth Centre in Lidcombe to establish a dual COVID-19 and flu vaccination pop-up clinic for Ukrainian refugees new to Australia. The clinic ran in the month of July 2022 and was developed to protect the new members of the Ukrainian community who moved to a new country and were adjusting to a new life.

An estimated 23,000 asylum seekers live in the WSLHD catchment.

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Better Supporting Individuals with Disability WSLHD is supporting greater inclusivity and empowerment for people with disability, their carers, and their families in the community, as well as for staff with disabilities in the workforce.

1.23% of WSLHD staff report having a disability.

An estimated 23,000 asylum seekers live in the WSLHD catchment.

It is estimated more than 180,000 residents live with a disability.

Disability Inclusion Action Plan The inaugural WSLHD Disability Inclusion Action Plan was launched in November 2022 and sets out specific actions that will be undertaken across WSLHD, to support equitable access to services and employment for people with disability in the Western Sydney area over the next three years. The plan is focused on four key areas: • Promoting a positive attitude and behaviour regarding disability inclusion • Creating liveable communities for people with disability • Providing equitable systems and processes • Supporting access to meaningful employment opportunities

One Stop Shop Clinic The “One-Stop-Shop” hospital clinic trial was started by Dr Peter Smith and rehabilitation physician Dr Rummana Afreen after noticing people with complex disabilities were turning up in emergency departments with otherwise preventable conditions. The clinic allows adults with complex physical and intellectual impairments to comfortably receive routine tests such as blood work, dental checks, scans, eye tests, ear checks, urine, and bowel assessments to manage their health. In one case, 17 different specialty teams were involved in the care of a patient. The One Stop Shop has been a successful example of an integrated multidisciplinary clinic that significantly improves the quality of life, health outcomes and experience when accessing healthcare for individuals with disabilities. This trial is the first step to improving the way we care for individuals with complex disabilities. “I work as a cleaner at Westmead Hospital. It’s hard to find work having an intellectual disability but Westmead has treated me like family. I have been here for nearly 20 years and this is my happy place. Every day I try to do my best and make everyone around me happy. My team is always supportive of me and I feel like they always have my back. I appreciate it.” – Westmead Hospital Cleaner

Marlene Miller (Consumer) sharing her personal and family journey through the health systemwith Bobbi Henao Urrego, Acting District Director of Allied Heath.

L-R Bobbi Henao Urrego, Acting District Director of Allied Heath, Graeme Loy, WSLHD Chief Executive, Nicole Winters, Senior Aboriginal Health Worker -Supportive & Palliative Care, and Erin Wilkins, Director of Darug Custodian Aboriginal Corporation.

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Child, Adolescent and Family Health

WSLHD acknowledges the wellbeing of children and adolescents lays the foundation for their physical, cognitive, and emotional development, directly influencing their adult health. Family health promotes communication, emotional bonding, and a shared commitment to wellness. Recognising the interconnectedness between children, adolescents and families is the key to a holistic approach to health, as it shapes not only individual lives but also the lives of our communities and broader society.

Westmead Hospital Mother and Baby Unit

In March 2023, the Westmead Mother and Baby Unit opened to provide holistic, multidisciplinary specialist health care that is parent and infant-centred, family and carer inclusive, and culturally sensitive. The aim of the service is to support mothers to remain with their infant during psychiatric care and prevent the effects of separation on the parent-infant relationship.

Photos inside Westmead Mother and Baby Unit

The Westmead Mother and Baby Unit was co-designed with women with lived experience of perinatal mental illness, their families, and clinicians. The service delivers an 8-bed unit with ensuites; therapeutic spaces including loungeroom, dining and kitchen areas; outdoor courtyards; play areas; a 24-hour respite nursery; group spaces; a retreat room and patient consult rooms.

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Munch & Move Munch & Move is a play-based program led by WSLHD Centre for Population Health to support the healthy development of children attending early childhood education centres (ECEC) and family day care (FDC) through practices related to healthy eating, physical activity, breastfeeding and reduced screen time. WSLHD supports the local needs of 468 early childhood education centres and 19 family day care providers across Western Sydney, reaching approximately 32,000 children and their families. As part of the Munch & Move program, WSLHD Centre for Population Health have been supporting WSLHD’s ECECs and FDCs in teaching fundamental movement skills. These movement skills are an essential part of a child’s growth and development as they promote bone and muscle development, emotional and social wellbeing, improved learning and maintaining a healthy weight. The skills taught include running, skipping, catching, and throwing. MUNCH & MOVE OUTCOMES 2022-2023 404 eLearning completions 18 Cooking

WSLHD Cardiotocography (CTG) Solution An electronic medical records (eMR) solution was developed by Digital Health Solutions to provide WSLHD obstetricians the capability to remotely monitor CTG traces that measure the variability of a fetus heartbeat in a mother’s womb, particularly during critical situations when clinicians in a hospital require immediate diagnosis and advice from a consultant Obstetrician working remotely. This digital solution was integrated with Cerner eMR and enabled obstetricians to view CTG traces remotely, securely and in real time using their personal mobile devices. Shining a Light on Domestic and Family Violence in Western Sydney The WSLHD Integrated Violence Prevention and Response Service (IVPRS) and Uniting Youth Service organised a Domestic Violence Remembrance Day on 4 May 2023, where Western Sydney community members gathered in Centenary Square Parramatta for a candlelight vigil in honour of the women who have lost their lives this year to domestic and family abuse. The event helped raise awareness of the social and personal impacts of domestic and family violence and the need to work together to help support, believe and act on this epidemic. A ‘Hope’ artwork was created with community messages written on the leaves of a tree, reminding us that through collective efforts we can create a safe community together.

workshop attendees 444 Participants at professional development huddles 13 Family day care providers

87 Fundamental movement skills workshop attendees 225 Reflective practice tools completed

attended a workshop

Safety & Quality Account 2022-2023 Western Sydney Local Health District

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Delivering Safe and Quality Services

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Partnering with Consumers to Improve Patient and Carer Experiences

IN JULY 2022 TO JUNE 2023:

My Experience Matters Surveys WSLHD has invested in the My Experience Matters survey platform since 2016 as its key tool in hearing firsthand from our patients, carers and families through a set of questions and free text comments. My Experience Matters surveys are sent to all WSLHD discharged inpatient, outpatient, and Emergency Department patients. There are also surveys available for other specialist services in WSLHD such as Oral Health and Drug Health.

A total of 40,117

MY EXPERIENCE MATTERS SURVEYS 2022-2023

surveys completed by consumers and carers across WSLHD. 20,040 outpatient surveys completed 5,795 emergency department surveys completed 4,892 Oral Health Services surveys completed 8,852 inpatient surveys completed 364 Drug Health Services surveys completed 174 carers surveys completed

Emergency Department Patient 5,795

Carers 174

Drug Health 364 Oral Health 4,892

Inpatient 8,852

Outpatient 20,040

WSLHD My Experience Matters (MEM) survey response and comment sections allows our patients and their carers to tell us their stories. These stories may be short, but they do tell us what is important to the patient or carer when engaging with WSLHD staff, services, and facilities. Importantly, these stories demonstrate how staff interactions, big or small, can influence each patient’s experience of our care. Lessons learned from these experiences, both positive and negative, are critical to developing and elevating the human experience across WSLHD. These comments are distributed monthly to the managers or relevant staff of the service identified, to facilitate discussion and identify lessons learned with their teams.

Safety & Quality Account 2022-2023 Western Sydney Local Health District

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Patient Experience Scores are derived from the responses to the following questions: 1. Were you treated with kindness and respect? 2. W ere you involved, as much as you wanted to be, in decisions about care and treatment? 3. How likely are you to recommend this hospital or service to family and friends if they need similar care or treatment?

WSLHD -Patient Experience -Core Questions

100

Patient Experience Score

95

Were you treated with kindness and respect?

90

How likely are you to recomend this hospital or service to family and friends if they need similar care or treatment?

85

80 MEM survey response%

Were you involved, as much as you wanted to be, in decisions about care and treatment?

Target

75

Nov 22 Dec 22 Jan 23 Feb 23 Mar 23 Apr 23 May 23 Jun 23

Aug 22 Sep 22 Oct 22

Jul 22

Average scores for all inpatient responses for the reporting period July 2022 to June 2023 to the above questions are as follows:

Overwhelmingly our patients, carers and families tell us we treat them with kindness and respect; that they are very likely or likely to recommend our services to family and friends; but we need to improve how we involve them in making decisions about their care and treatment. There is a clear opportunity to improve WSLHD’s Patient Experience scores by focusing on local quality improvement projects targeting staff involvement of patients in decisions about their care. WSLHD now has a rich source of free text patient comments gathered over the last year from 40,117 My Experience Matters survey responses which are displayed in tables and word clouds.

Facility

Treated with kindness and respect

Involved in decisions about care

Likely to recommend

WSLHD

92

83

92

Auburn

91

84

92

Blacktown

92

83

90

Mt Druitt

95

87

95

Westmead

90

80

89

Performance Key:

Performing ≥85 Area for Improvement 82-<85 Not Performing as Expected <82

compassionate

kindly

thoughtful reassure patience

nurturing

understanding

“very patient” considerate

“were patient”

humble

empathy

sympathetic

“angel” “extremely patient”

gentle kind

reassuring

empathetic

Compassion Word cloud

Safety & Quality Account 2022-2023 Western Sydney Local Health District

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WSLHD Patient Experience Coordinators Top the State in GoShare Bundle Distribution in March 2023 GoShare is a cloud-based platform from which bundles of health information (video or text) can be sent directly to patient’s mobile or tablet devices. Bundles of information can be sent in various languages to patients attending WSLHD Emergency Departments (EDs) including videos explaining what to expect in the ED.

NSW ED Go Share Bundle Activity March 2023

6,000

5,000

4,000

3,000

2,000

Number of Bundles

1,000

0

LHD 1 LHD 16 835 771 3,180 1,000 869 392 1,090 0 3,740 0 1,310 1,110 400 362 959 5,530 3,380 472 274 1,560 547 366 206 395 0 1,580 0 587 469 198 208 471 2,400 1,360 LHD 2 LHD 3 LHD 4 LHD 5 LHD 6 LHD 7 LHD 8 LHD 9 LHD 10 LHD 11 LHD 12 LHD 13 LHD 14 LHD 15 WS LHD

Info bundles sent

Info bundles opened

Human Experience Week: All of Us–The Power of Community 1-7 May 2023 WSLHD was honoured to launch Human Experience Week for NSW Health on 1 May 2023.

The launch celebrations were held in-person and shared virtually. Patients, carers, consumers, and staff were able to watch the event, as it was live streamed and made available on WSLHD Facebook page after the event.

A kindness chatterbox activity at Integrated & Community Health.

Market stalls at Blacktown, Mount Druitt, and Drug Health.

WSLHD host a Family and

A visit by Therapy dogs to Blacktown and Westmead, and Guide dogs to Auburn.

A Multicultural Feature Map activity where individuals were invited to place a flag of their cultural heritage on a feature map.

Community Event for Aboriginal and Torres Strait Islander people, creating a continued dialogue with the community, and Close the Gap.

Safety & Quality Account 2022-2023 Western Sydney Local Health District

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WSLHD Consumer Council The WSLHD Consumer Council partners with staff to improve healthcare experiences and outcomes that meet the diverse needs of Western Sydney.

Consumer Representatives are the link between a consumer (someone who uses our health service) and staff to support and improve the safety and quality of healthcare. Consumer Representatives help health system change, bring equity to the consumer voice and co-design to improve human centred care and patient and staff experiences.

By valuing lived experience in the design, planning, delivery, monitoring and evaluation of the healthcare system, it makes sure that patients receive safe, and high-quality care. The Council sets a culture of partnering with staff to embed consumer engagement at all levels to make sure we meet patient, client and carer needs, giving a more holistic patient-centered healthcare system.

IN 2022:

69 Consumer

60 Expressions of interest were received

Representatives across WSLHD

27% of our consumers are from culturally and linguistically diverse backgrounds

51 interview panels included consumers

52% Of consumers identify as male

280 years of collective service

48% of consumers identify as female

6% of our consumers report they have a disability

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