NSW Health WSLHD Safety & Quality Account 2020-21

NSW Health WSLHD Safety & Quality Account 2020-21

Western Sydney Local Health District

Safety & Quality Account 2021-2022 2021-2022 Report | 2022-2023 Future Priorities

We Acknowledge

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.

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


WSLHD Safety & Quality Account 2021-2022


Western Sydney Local Health District (WSLHD) works in partnership with the community to ensure our patients receive safe, equitable and high-quality healthcare. The WSLHD Safety and Quality Account is a reflection of safety and quality in WSLHD, bringing together initiatives from across the district that are designed and implemented by our staff to meet the needs of our community and continually improve our services. Healthcare has faced significant challenges over the last 2 years due to COVID-19. Quality and safety performance has not been immune to these challenges. Globally, and across metropolitan Sydney, quality and safety performance has reflected the extraordinary challenges placed on the healthcare system. WSLHD has pivoted the way safety and quality is promoted, adopting the view that safety is everybody’s business. This new outlook is reflected in the way in which our staff have adapted and innovated during the COVID-19 pandemic. After a challenging year in testing and treating COVID-19 in 2020, staff from all corners of the organisation came together once again to roll out the COVID-19 vaccination program to continue to serve and protect our community. WSLHD was recognised across the state for designing the state’s largest vaccination centre at Qudos Bank Arena and commended for the design of sensory and culturally safe vaccination environments at Blacktown and Mount Druitt hospitals. Patient Experience is central to what we do. The theme for this year has been the power of storytelling which allows us listen and learn from the community to improve the way we deliver care. You will notice in this year’s account that our patient safety data is accompanied by consumer feedback. We have presented the data in this way to help us remember that there is a patient and a family behind the data and to ensure the patient is kept at the centre of all of the decisions we make as a district. Previously, WSLHD was guided by the Better West Strategic Priorities (2017-2021) whereby we achieved noteworthy results. Beginning in 2022, WSLHD will enter a new period of strategic direction, aligning with the NSW Future Health: Guiding the next decade in NSW 2022-2023 Strategic Framework: • Patients and carers have positive experience and outcomes that matter • Safe care is delivered across all settings • People are healthy and well • Our staff are engaged and well supported • Research and innovation, and digital advances inform service delivery • The health system is managed sustainably It is important to us that we provide an inclusive environment to achieve the health outcomes that matter most to every patient. The achievements outlined in this account highlight the extraordinary work our staff do every day and how they have come to grow, adapt and learn from another challenging year of the pandemic. I would like to thank each and every one of our staff for their commitment to improving the safety of our services and the quality of our care in Western Sydney.






Chief Executive Foreword


Our Commitment to Safety and Quality




Our Care at a Glance 2020-2021


Snapshot of Key Achievements 2021-2022


Governance for Safety and Quality in WSLHD


National Standards and Accreditation


Improving the Patient and Carer Experience


How we measure what we do


Patient Experience Initiatives


Patient Experience Week 26-29 April 2022


Community and Consumer Engagement


A Workplace Culture that Drives Safety and Quality


Our Place. Our People. Our Culture.


Staff Member of the Year Awards


2021 Quality Award Winners




COVID-19 Vaccination


COVID-19: Care in the Community


COVID-19: Care In Hospital



Integrated and Community Health


Drug Health


Oral Health


Mental Health Services


Our Hospitals




Blacktown and Mount Druitt




Improving Health Outcomes for Aboriginal and Torres Strait Islands Peoples in our Community


Supporting the Community through COVID-19


Aboriginal Mental Health


Transforming WSLHD: Digital Health Solutions for Safety and Quality


Digital Health Services COVID-19 Response


eMR solutions


Research and Education Network


Clinical Practice Unit


A Review of Performance Indicators Against 2021-22 NSW Health Key Performance Indicators


Hospital Acquired Complications (HAC)


2022-2023 Future Priorities


Glossary of Abbreviations



Our Commitment to Safety and Quality


Our commitment to safety and quality

Western Sydney Local Health District (WSLHD) is committed to embedding safety and quality principles in the day-to-day work of all staff, with a focus on building organisational maturity in the way key lessons and learnings are shared across the district. The WSLHD Board, together with the Chief Executive, oversee the performance of the organisation and maintain relationships between WSLHD and state and local stakeholders. The Executive Director Nursing and Midwifery and Clinical Governance provides a high level of support to the WSLHD Board sub-committee, Health Care Quality Committee (HCQC). The function of this committee is to ensure WSLHD has appropriate safety and quality systems in place and to monitor performance and improve patient care.


Quality Related Committees

WSLHD Board Committees


New Interventional Procedures Committee

Audit and Risk

Health Care Quality Committee

Drug Committee

Nominations Committee

Safety & Quality Operational Committee

Venous Thromboembolism

Research and Development

Infection Prevention and Control

Professional Education

Facility Quality & Safety Committee

Finance Performance and Assets

End of Life

Escalation process including Morbidity & Mortality meetings

Falls Committee

Patient Safety agenda items on department/ward meetings

Left: Blacktown Paediatric Ward Ministerial visit. Far right: Westmead Jacqui Cross (Chief Nursing and Midwifery Officer) thanking staff for their effort during the pandemic.


About Western Sydney Local Health District



Western Sydney Local Health District is home to a diverse and multicultural community. Over 1.18 million people call western Sydney home, with 50% of residents born overseas and speak a language other than English at home. Our focus as a health district is to help people in western Sydney to live well, stay well and manage well. WSLHD provides a range of primary and secondary healthcare services for people living in the Auburn, Blacktown, The Hills Shire, Holroyd and Parramatta Local Government Areas (LGAs), and tertiary care to residents of the Greater Western Region. The population in WSLHD continues to grow, with highest birth rate in NSW. The population is also aging. It is forecasted from 2016-2026 there will be a 59% increase in people aged 70 years and over, and a 54% increase in people aged 85 years and over (ABS 2016 census).


46.8% of WSLHD residents were born overseas 50.3% Speak a language other than English at home-Arabic, Mandarin, Cantonese, Hindi & Koren

Estimated population in 2022 1.18 M (healthstats NSW)

1.5% Percentage of people who identify as Aboriginal or Torres Strait Islander ABS 2016

We are committed to delivering healthcare to priority groups in our community, including: children, young people and families, people living with a mental illness, older people, Aboriginal and Torres Strait Islander peoples, people with chronic and complex conditions, and people from diverse cultural backgrounds.

Top: Westmead Redbank house Holi festival celebration. Bottom: Outreach Vaccination Clinic NRL Indigenous All Stars game.


WESTERN SYDNEY HOSPITALS 1. Mount Druitt Hospital 2. Blacktown Hospital 3. Westmead Hospital 4. Cumberland Hospital 5. Auburn Hospital WESTERN SYDNEY COMMUNITY HEALTH CENTRES 6. Mount Druitt Community Health Centre 7. Doonside Community Health Centre 8. Blacktown Community Health Centre 9. The Hills Community Health Centre 10. Parramatta Community Health Centre 11. Merrylands Community Health Centre 12. Auburn Community Health Centre






Gosford >

The Hills Shire LGA

Rouse Hill

Marsden Park

Blacktown LGA


Castle Hill





See footnote*





Macquarie Park




Sydney Harbour Bridge

Parramatta LGA




Cumberland LGA



Future Western Sydney Airport

Prospect Reservoir



Sydney Olympic Park



Bondi >

Sydney Airport


* Hatched area of Parramatta LGA is outside Western Sydney Local Health District





197,429 Emergency Department Presentations

14,834 Emergency Surgeries

110,823 In patient admissions

15,598 Elective Surgeries

3,717 Mental Health in patient admissions

3,083,694 Outpatient occasions of service

511 HITH admissions

9,938 Babies delivered

5,574 COVID-19 ward admissions

236,250 Drug Health occasions of service

1,706 ICH occasions of service

18,602 In-Touch admissions

584 COVID-19 ICU admissions

522,853 Total vaccinations delivered

349,531 Vaccinations delivered QBA

27,398 Vaccinations delivered Outreach


Snapshot of Key Achievements 2021-2022


Snapshot of key achievements 2021-2022

COVID-19 Vaccination Program Western Sydney Local Health District provided a total of 552,853 vaccinations to both staff and community members through the Westmead Hospital, Blacktown Hospital, Kimberwalli (page 53) Granville and Qudos Bank Arena (page 32) vaccination centres and through means of community outreach and low sensory clinics (page 31). COVID-19 inTouch The COVID-19 inTouch program was developed to monitor and treat COVID-19 patients in the community who were at risk of hospitalisation. InTouch provided support to over 14,000 patients and continues to grow, improve and adapt to continue meeting the needs of the western Sydney community (page 33). INTOUCH PROVIDED SUPPORT TO OVER 14,000 PATIENTS AND CONTINUES TO GROW Telehealth and Video Interpreting Throughout 2021, virtual care (formerly known as telehealth) was increasingly used throughout all services in WSLHD to continue to deliver accessible, COVID-safe care to the western Sydney community via means of video conferencing and phone consults. New models of care were designed, implemented and evaluated by staff and interpreters were heavily utilised to ensure information was appropriately communicated. SafeHaven As a part of the Towards Zero Suicides program, Safe Haven was developed as a drop-in service providing an alternative to ED presentations for people in suicidal distress/crisis. The service was co-designed with young people with lived experience and is staffed by Mental Health Services Peer Workers (page 42).

Top: WSLHD Qudos Arena Vaccination Clinic Opening. Sophie Wehrle (Vaccinating Student). Middle: Blacktown Diabetes Telehealth Best Care Medical Clinic. Left to right: Dr Abu Kabir (GP), Sham Kumar (Patient), Sharon McClelland (Community Diabetes Nurse Consultant). Bottom: From left, Redbank House Safe Haven peer workers Mitchell Farrell and Aishah Mohammed. Year 12 students wait for their vaccinations at Qudos Bank Arena.


Governance for Safety and Quality in WSLHD

Clinical Governance functions to provide support to a range of services across WSLHD, promoting an environment that encourages accurate reporting of incidents and openness to acknowledging errors. In line with Standard 1: Clinical Governance from the National Standard for Safety and Quality in Health Care (NSQHS), Clinical Governance in WSLHD recognises the importance of governance, leadership, culture and patient safety systems, performance and environment in the delivery of high-quality care and forms the foundation for and efficient, effective and safe healthcare service. The Clinical Governance portfolios are:

Patient Safety

Quality and Accreditation

Patient Experience

These portfolios and key governance structures are in place to support safety and quality in WSLHD and are reflected in each facility. Underpinned by evidence-based practices, Clinical Governance has developed a range of accountability frameworks for awareness of roles and responsibility in relation to safety and quality to ensure that policies are adhered to and procedures are followed to maintain practice compliance against policy.

Victor Syquia, Department Head of Social Work Cumberland Hospital.


National Standards and Accreditation

The National Safety and Quality Health Service (NSQHS) Standards were developed by the Australian Commission on Safety and Quality in Healthcare in collaboration with the Australian Government, clinical experts, patients and carers.

The aim of the NSQHS Standards is to improve the quality of health service provision. The eight NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health services. The second edition of the National Standards was initially released in November 2017 and updated in May 2021 to accommodate lessons learned from the response to SARS-CoV-2 (COVID-19) and to better support health service organisations to prevent, control and respond to infections that cause outbreaks, epidemics or pandemics, including novel and emerging infections. To support assessors and improve the review process, the Commission has developed an assessment framework for safety and quality systems. The framework describes the assessors’ roles and responsibilities through the review process. A key part of this framework is PICMoRS methodology. PICMoRS methodology is a structured assessment method used when interviewing members of the workforce to comprehensively review the processes that make up safety and quality systems specified in the NSQHS Standards.

In June 2022, Blacktown and Mount Druitt Hospital (BMDH) underwent accreditation using this framework: • Process • Improvement • Consumer participation • Monitoring • Reporting and; • Systems Blacktown and Mount Druitt Hospital (BMDH) underwent National Accreditation in June 2022. Feedback from the independent accreditation assessors identified strengths in consumer engagement and representation of diverse local community, prioritisation of Aboriginal and Torres Strait Islander health and medication safety. It was noted that BMDH have a strong safety culture that will continue to be built to improve safety and quality practices. A series of recommendations were made to continue to strengthen safety and quality at BMDH. National Standards Accreditation occurs every 3 years. From January 2019, health

service organisations moved to a three-year assessment cycle, with no further mid-cycle assessments.

Top: Auburn Aboriginal Liaison Officer Michelle Pearce with Sarita Sharma (Reg Nurse) Bottom: Westmead General Services Rommel Martin.


Improving the Patient and Carer Experience


Improving the patient carer experience

The Beryl Institute defines patient experience as, “The sum of all interactions, shaped by an organisation’s culture, that influence patient perceptions across the continuum of care.” WSLHD is committed to providing positive patient experience in all aspects of our care and to understand through feedback from patients what we are doing well and what we can improve.

How we measure what we do We measure patient experience in multiple ways, for example: compliments and complaints, My Experience Matters surveys real time feedback, Bureau of Health Information surveys and patient stories. We are committed to including consumers in developing improvement initiatives in response to feedback. In WSLHD we are continually working to improve the way in which we interact with consumers to measure experience and utilise the feedback. The Bureau of Health Information (BHI) measures patient experience of all hospitals in NSW with inpatient, outpatient, Emergency Department, and Cancer Services surveys. This information is reported retrospectively and aims to highlight some of the system-wide trends in patient experience for context and benchmarking purposes. BHI also provide Key Performance Indicators for patient experience and engagement which all hospital in NSW are measured against. Locally, WSLHD has implemented and promoted the use of My Experience Matters, where patients, carers and consumers can provide real time data feedback by completing surveys. This allows the organisation to identify opportunities for improvements in care and service provision. In 2021/22, WSLHD has significantly improved this platform by designing surveys to specifically capture Aboriginal and Culturally and Linguistically Diverse (CALD) feedback. My Experience Matters data is used throughout the organisation in both clinical and non-clinical settings and is an important part of our care delivery.

Patient Experience Initiatives Culturally and Linguistically Diverse Patient and Carer Experience In partnership with WSLHD Translation Services, the Patient and Carer Experience (PCE) team have committed to understanding the patient experience of patients who speak a language other than English. This commitment included translating our main patient experience surveys (inpatient outpatient and Emergency Department) surveys into Arabic and Chinese. These languages are the most widely spoken languages in Western Sydney. This brings Arabic and Chinese speaking consumers voice into the organisation to be able to identify issues and respond. Initial observations highlighted many areas where experiences were similar to English speaking consumers however, some areas such as access to interpreting services were identified to be a barrier for the CALD community and provided an opportunity for a targeted response. Feedback from patients in the COVID-19 Vaccination Clinics in WSLHD identified issues with interpreters being available for consent discussions. Health Care Interpreter Services re-designed their booking services and moved to the Microsoft Teams platform to streamline bookings and allow for virtual interpreter appointments to commence within a maximum of 15-minute margin prior to the patient’s appointment. Improved interpreting services ensures informed and inclusive decision-making for patients, carers and families of the WSLHD community.

“After all, we are all humans caring for humans and we all have a story to tell” Elevating the Human Experience - Ministry of Health

Left: Gurdwara Sahib Glenwood temple community member Sukhdev Kaur Brar. Right: WSLHD Outreach COVID Vaccination Gallipoli Mosque Auburn. Enes Ozkan (Imam), Dr Zarza Rashidi (Medical Officer) Blacktown Allied Health new physiotherapist TimWass starts.


Improving the patient carer experience

Transition to GoShare 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 as well as translated COVID-19 information. From July 2021 to April 2022: 238 translated ED information bundles were sent out with a response of 53.4% rating the information as “very helpful”. The GoShare platform is used in several clinics and inpatient settings across WSLHD which also send translated bundles of information specifically collected for the patient’s needs.

Aboriginal Health Outcomes In Partnership with WSLHD Director Aboriginal Health Strategy, the PCE team developed a cultural competence survey to determine if patients felt culturally safe, recognised and understood in WSLHD services. A demographic question has also been added to the WSLHD inpatient, outpatient and emergency department surveys asking if the respondent identifies as Aboriginal or Torres Strait Islander, helping WSLHD to understand Aboriginal and Torres Strait Islander experience with patients from other backgrounds to better appreciate what is important to our community and how services can be improved. During the COVID-19 vaccination roll-out, the PCE team created a site-specific patient experience survey to evaluate cultural safety at the Aboriginal and Torres Strait Islander Kimberwalli Vaccination Centre. A total of 84 surveys were completed with the majority of questions scoring highly and received positive feedback. Some of the feedback included comments such as:

11,587 bundles of information (in English) total have been sent out across WSLHD and Sydney Diabetes. GoShare will continue to be expanded and improved for use throughout WSLHD in 2022.

“Acceptance and respect was of the highest quality”

“The service makes you feel so welcome and wanted”

“Very friendly and informative throughout” The PCE team will be working with the WSLHD Director Aboriginal Health Strategy and Allied Health in the coming 12 months to review Aboriginal and Torres Strait Islander patient experience at Mount Druitt Emergency Department (ED). The ED Patient Experience Coordinators and the Aboriginal Liaison Officers will work together to develop strategies and resources to support for Aboriginal and Torres Strait Islander patients and their families in the ED.

Western Sydney’s new patient experience coordinators (PECs) outside Westmead Hospital. Each PEC rotates between the District’s four emergency departments.


Improving the patient carer experience

Patient Experience Week 26-29 April 2022

Patient Experience Week is an annual global event to celebrate healthcare staff impacting patient experience every day. The Patient and Carer Experience Team liaised with facilities and services across WSLHD to recognise and promote patient experience. Patient Experience Week is a chance to recognise and thank staff for their continuous work improving patient experience and to provide the opportunity for the organisation to celebrate achievements and re-energise improvement efforts in this space. The theme for this year was The Power of Storytelling. In healthcare, sharing stories is a useful tool to engage people in quality improvement work through listening and learning from another person’s experience to shape, strengthen and challenge the way in which we deliver care in WSLHD. During the week many patients shared their stories and experience such as Lauren at Auburn who said, “You explained my issues to me, acknowledged my excruciating pain and told me the how, what and why in a way that I understood and felt genuinely cared about.” Activities The Patient Experience Team organised a range of activities to engage both staff and patients across the district, such as: District and facility executives were invited to join Clinical Governance to participate in ward rounds to meet and speak with several patients across a range of clinical areas including maternity, surgical, dialysis, cardiology, gastroenterology, Neonatal Intensive Care Unit, aged care, paediatrics and palliative care. Overall, the Patient Experience team visited patients and staff in 26 wards across Westmead, Auburn, Blacktown and Mount Druitt hospitals. During these rounds, the staff asked patients to share their stories with the aim of listening, learning and promoting the human experience. Patients were gifted themed tote bags to take home with them that included mindfulness activities and personal care packs. The Patient Experience team set up information stalls in the entrance foyers of Westmead, Auburn and Blacktown hospitals to raise awareness. Patients, carers and staff were invited to nominate a staff member to celebrate the work they have done to improve patient experience and enjoyed the company of the Nepean Therapy Dogs to launch the recommencement of the service in Westmead Hospital. Representatives from Mental Health Services joined the stalls to raise awareness of the services offered to staff and consumers in WSLHD.

Above from left: Jenelle Matic, General Manager Westmead Hospital, Two consumers, Deanna Aplitt, Deputy General Manager Westmead Hospital

REACH Recognise, Engage, Act, Call, Help is on its way (REACH) is a system that supports patients, family members and carers to escalate concerns about changes to a patient’s condition. The system encourages patients, carers and family to speak up if something doesn’t seem right and they feel the patient is becoming more unwell. This empowers people to become more involved in their own care and to speak up for safety. During the COVID-19 pandemic, visitors were not able to enter the facilities and so WSLHD published a landline number that could be accessed by family from outside of the hospital in addition to the internal number accessible by patients. WSLHD facilities have strongly promoted the program to patients and families to partner with them in care and raise clinical concerns. As a result of this promotion, there was a 27% increase in utilisation of REACH between 2020-2021 and 2021-2022. Patient Experience Coordinators (PECs) Patient Experience Coordinators work across all WSLHD Emergency Departments (EDs) during high-volume times of 11:30am and 10pm. PECs use the GoShare platform to send relevant information about the ED journey to patients in their preferred language. During the time when visitor access was limited, the PECs changed their models of care to provide additional support for patients to contact their family via video chat and to help organise pick-ups upon discharge. The PECs work alongside clinical and administration staff to support patients through triage. The PECs played a vital role in ensuring patients knew where they needed to go and were provided adequate seating, shade, water during changing COVID-19 triage models and were an asset to the organisation in providing a positive experience for patients during a particularly challenging time.


Improving the patient carer experience

Community and Consumer Engagement

The Community and Consumer Partnership Framework (2021-2025) outlines four priorities to engage Consumer Representatives and staff to partner and progress safety and quality initiatives in WSLHD.

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

Above: Nepean Therapy Dogs visit patients at Westmead Hospital. Motorcycle crash victim Johnathon took the chance to pet one of the dogs while being transported to surgery.

Communicating, listening, responding

Initial feedback from ward rounds The overall feedback from the ward rounds was positive across the four hospitals, with many patients commending the excellent technical skill and compassion from the staff in their unit. Some of the common themes raised for improvement were inter-hospital transfers and ensuring the patient and families are well informed during this time. All feedback was returned to the respective facility executive team who are developing an action plan to address the items raised by patients. Westmead Foundation have sponsored Therapy Dogs to come to Westmead hospital each week for a year. Two wards will be identified where the therapy dogs would bring most benefit and they will visit each week. This allows staff to build the visits into the ward schedule and to support promotion of the service to patients.

The Framework reaffirms and builds on our approach to support Consumer Representatives and staff to co-design and partner on health care planning, design, delivery, measurement and evaluation of care. PRIORITY 1: We will ensure the numbers, diversity, capacity and capability of a trusting and respectful community of Consumer Representatives to partner with WSLHD staff • 65% of new Consumer Representatives are from a Culturally and Linguistically Diverse (CALD) background or have a disability/ are a carer. • Expressions of Interest (EOIs) to recruit Aboriginal and Torres Strait Islander consumers has commenced for the Aboriginal & Torres Strait Island Community Consumer Council (starting in FY23) • Four new Community Councils were also launched to bring the community perspective and share health resources including COVID-19 information. PRIORITY 2: WSLHD will support staff to develop increased capacity to partner with consumers, with a measurable annual improvement in staff satisfaction and skill in partnership • Consumer Representatives were members of 49 interview panels to interview staff for new roles in FY22. • Consumer Representatives are members of over 40 committees in WSLHD and there were 43 EOIs for new committees or co-design initiatives (Jan-June 22). • Eight Consumer Representatives partnered with Blacktown Hospital to support accreditation, involved in environmental audits and attended ‘What Matters to you’ days to ask, listen and do ‘what matters’ to improve shared decision making. A further three Consumer Representatives are engaged across the District as patient actors and to support newly diagnosed patients. Consumer Representatives were also invited to be judges for the Quality Awards.

Westmead Therapy dogs return to the hospital. Left to right: Erika Marquez (Physiotherapist), Grace Niccol (Occupational Therapist), Louise (Nepean Therapy dogs), Johnson Choi (Physiotherapist), Michelle Lam (Physiotherapist) with Cleo (dog).


Improving the patient carer experience

Consumer Ambassador Program In 2021, the first WSLHD Consumer Ambassador was introduced at Auburn Hospital. Naglaa is the first Consumer Ambassador to partner with a facility in WSLHD. Naglaa is an existing member of the WSLDH Consumer Council, Hospital Community Council and Auburn Hospital Consumer Partnerships Committee with a wealth of valued community and consumer expertise. A Consumer Ambassador provides a consumer face for patients who attend a specified WSLHD hospital, to engage in conversations and other activities which provide feedback on what matters to patients at that hospital. A Consumer Ambassador has experience in the WSLHD health system as a patient or carer, advanced people skills, and is comfortable and skilled in interacting with people from different backgrounds to feed back through hospital systems to facilitate improvements that result in better patient experiences. The Consumer Ambassador program will be expanded in 2022 throughout all WSLHD health facilities and as part of the local Consumer Partnership Committees. PRIORITY 3: Promote social care and health literacy in Western Sydney communities through increasingly deep partnerships with community and consumer leaders in Western Sydney. • New Consumer Partnership Committees (CPCs) were established at Auburn and Blacktown Hospital to ensure effective consumer engagement at a facility level and progress co-design projects (further roll outs for other facilities in FY23). Co-design of welcome packs, information on Patient Entertainment System and reviewing health literate consumer resources were progressed. Consumer templates to feedback on consumer initiatives were co-designed. • A health literacy presentation to the Consumer Council was delivered and consumer health literacy training is planned for October 2022. Health literacy checklists and readability checkers are utilised when developing consumer resources and a Health Literacy Review group was established. PRIORITY 4: Systematically promote the engagement of consumers as research partners across WSLHD • After many interviews with Consumer Representatives over a four-year period up to 2020, the ‘Consumer representative experiences of partnership with health workers in Australia’ was published in the Patient Experience Journal in 2021.

“Thank you for asking me to be a part of the Allied Health first year graduate intern interviews. I enjoyed the experience and having the opportunity to interview the new graduates that will learn from such experienced and caring staff at Westmead. You and the other members of the interview panel made me feel very welcome and a part of the interview process”.

Consumer Representative

“ Helping and listening to people is not a chore but a passion. I believe everyone should be treated with dignity, kindness and respect. ”


A Workplace Culture that Drives Safety and Quality


A workplace culture that drives safety and quality

Our Place. Our People. Our Culture Our culture program, Our Place. Our People. Our Culture. is in its second year in WSLHD. It is about recognising our shared sense of community, ways of working and our identity at Western Sydney.

By living our culture statement, we can create a positive shared work environment (Our Place) and strengthen our connection with each other and our community (Our People). Our culture statement describes our shared aspiration for how we should all work together and feel coming to work at WSLHD each day. Our areas of focus are on leadership, communication and behaviours across WSLHD. The focus areas are aligned to our Culture Strategy and throughout our culture change journey, we will continue to track our progress through existing measures, such as the People Matter Employee Survey (PMES). Key initiatives for this year have been Manager Capability Program, Coaching & Mentoring Frameworks, Recognition Framework, Our Diversity, Aboriginal Workforce Plan, LGBTQIA+ consultation & Focus group initiatives, review of our Wellbeing & Leadership initiatives.

This is who we are We are a vibrant growing community

This is what we do and the mindset that we bring We are caring and compassionate This is the way we work together We are respecting and connected


LEADERSHIP How we equip everyone to be leaders in our desired culture. This includes building our shared leadership capability and capacity so that everyone is self- aware, empowers others, achieves results, drives innovation, and connects with others across the system.

Our culture starts and ends with us

Change is underway across WSLHD to strengthen our culture.

Visit the intranet to learn more.

2 COMMUNICATION How we create and environment

where everyone feels they are informed, have a voice, and are listened to. This is about how we communicate with each other and ensure that we all know what is happening and what our contribution is.

Our culture statement sets out how we should work together and the way we should feel coming to work each day. Our Culture Statement


We are a vibrant, growing community.

We are caring and compassionate.

How we work with each other so that everyone comes to work knowing it is a place where they fell respected, valued, and engaged. This is focused on how we think and act around each other and on understanding and taking responsibility for the impacts of our actions.

We are respected and connected.


Kylie Telford, ICU Registered Nurse


A workplace culture that drives safety and quality

People Matter Employee Survey The People Matter Employee Survey (PMES) is the NSW Public Sector’s annual employee engagement survey. Within WSLHD the survey is branded as Our Say as part of the Our Place, Our People Culture Strategy. This year, 34% of WSLHD employees completed the People Matter Employee Survey.

WSLHD staff identified the following strengths (% favourable)

Role Clarity & Support

Risk & Innovation


Customer Service

Job purpose & Enrichment Our jobs provide us opportunities to use a variety of skills

We have people at work who care about us

We understand what is expected of us to do well in our job

We feel comfortable raising risks at work with our Manager

Our workgroup considers customers when planning our work






Areas for improvement (% favourable)


Action on Results

Grievance Handling

Communication & Change Management We believe change is managed well in our organisation


We feel Senior managers listen to employees

We are confident our organisation will act on the results of this survey

We receive adequate recognition for our contribution from our organisation

We have confidence in the way our organisation manages grievances






2021 WSLHD People Matter Employee Survey. The results of this survey have led to the development of the ‘Our Recognition’ Framework and ‘Reporting Back’

Reporting back Employee culture is directly linked to patient safety and quality. WSLHD is committed to listening to its employees to improve the employee experience. To achieve this, senior leaders across the District take an action planning approach to review their results and identify potential initiatives before documenting these in a PMES Action Plan. Each facility and service is required to report back each quarter on the actions in place to address the priorities identified out of the PMES. These plans are reported on the Our Place. Our People. Intranet site for staff to access.


A workplace culture that drives safety and quality

Our Recognition Framework WSLHD ‘Our Recognition’ Framework was developed in response to the 2021 People Matter Employee Survey results. The Framework was launched in 2022, and has four parts: • Employee recognition • Peer recognition • Years of Service award • •#KindessWorksHere • Specialty Program and Specialty Events Since the launch of the Recognition Framework, WSLHD has recognised over 2300 staff for Years of Service and recognition categories. Over 1100 peer recognition cards were taken throughout the Culture Roadshow for staff to give thanks to each other.

Verka Stojanovska (Reg Nurse) and Gildalena Esmundo (Reg Nurse) receiving their 20 year recognition certificates.

The WSLHD Culture Roadshow 2022 The WSLHD Culture Roadshow was launched in 2022 and was an opportunity for staff to have input into the culture we want to create at WSLHD. The roadshow was attended by staff at all levels, business leaders, business partners and guest speakers. There was an opportunity for staff to experience Virtual Reality Meditation sessions, corporate massage sessions, insightful guest speaker sessions and installations from our business partners. The Core Wall photo booth was particularly popular among the staff. Our senior leaders including the Chief Executive, Executive Director of Operations, General Managers, and other senior leaders were present at our roadshows available to answer questions and share insights with our staff.


A workplace culture that drives safety and quality

Staff Member of the Year Awards

Allied Health Professional of the Year –Christine Vo Christine has been recognised by her peers from all professions for her dedication, professionalism and provision of exceptional service delivery to the patients and families of Westmead Hospital. Christine’s work included the Intensive Care Unit (ICU) Communication Vivas at Westmead Hospital, a joint initiative between medical staff and social workers which involves simulation training and an assessment/evaluation process to improve communication and confidence of senior staff in intensive care. Christine has also provided teaching and training on social work practice in COVID times to her peers within Westmead/Auburn Hospitals and the broader social work community through the Australian Association of Social Work and has published practice implications in service delivery within a pandemic environment. Corporate Services Professional of the Year –Katy Martin Katy Martin was awarded the 2021 WSLHD Corporate Services of the Year Award for the dedication to safety and quality in Blacktown and Mount Druitt hospitals. Katy and the team have been described as the ‘backbone of the hospital’ for their day-to-day work in keeping the hospital clean, moving patients throughout and ensuring there is always an adequate supply of PPE and other medical supplies. Katy has been recognised for the excellent management of COVID-19 PPE supplies that supported Blacktown and Mount Druitt hospitals, local aged care facilities, the COVID-19 testing bus, Devitt Street apartment complex, Wentworth point and Qudos Bank Arena vaccination centre. Katy developed mechanisms to ensure effective communication with her team and equal distribution of supplies was maintained during the pandemic to help staff feel safe at work.

Nurse of the Year –Anandhi Murugesan Anandhi joined the Western Sydney Diabetes team as a transitional nurse practitioner in 2019 to coordinate and lead the set up and running of the Mount Druitt Community Health Diabetes Clinic. Anandhi has been involved in a new model of care upskilling GP VMOs together with endocrinologists and helped coordinate the data collection required for the formal evaluation undertaken by the Agency of Clinical Innovation (ACI).

Doctor of the Year –Dr Shopna Bag Dr Shopna Bag was awarded the Doctor of the Year Award in recognition of her leadership in the role of Director of the Public Health Unit in WSLHD. Shopna is an extraordinary leader whose example of expertise delivered with care and compassion has stood out over the past year - particularly throughout the COVID-19 pandemic. Shopna consistently demonstrates a commitment to understanding the local western Sydney community and empathy towards all staff, patients and carers.

Staff member of the year: Multicultural Health–Dipti Zachariah Dipti Zachariah is a leader and community development professional with over 20 years of experience in multicultural health and population health. Dipti is a team leader for the Multicultural Health, Priority Populations Integrated and Community Health team and was awarded staff member of the year at the Multicultural Health Communication Awards in 2021.


A workplace culture that drives safety and quality

2021 Quality Award Winners

Each year WSLHD hosts the Quality Awards to celebrate staff and services who are committed to improving the patient care and health outcomes. The awards are an opportunity to showcase the innovative projects designed by staff that benefit our patients, families, staff and our community. Submissions are aligned to one of seven categories that mirror the NSW Health Innovation awards plus two peak awards chosen by the Chief Executive Graeme Loy and the WSLHD Board Chair Richard Alcock. Selected projects can be entered at a state and national level for further recognition.

2021 Quality Award Winners

Transforming Patient Experience - “Dialysis free time” through incremental peritoneal dialysis. Since June 2019, 95.2% of new patients that started incremental peritoneal dialysis (PD) within Western Renal Services (WRS) and have been screened and offered a new model of care. Minimising discomfort and reducing stress associated with ongoing treatment is a goal for improving the experience of patients receiving dialysis in WSLHD. Eligible patients that have been prescribed PD treatment for increased ‘dialysis- free time’ means less intrusiveness for patients and improved healthcare cost of savings. Understanding that dialysis treatment takes a proportion of time every day, this project has improved shared decision making between patients and treating teams. This project has been rolled out across Blacktown, Mount Druitt and Westmead hospitals has saved patients up to two hours and 15 minutes per day on procedure time.

Delivering Integrated Health Care - COVID-19 care in the community Built on existing partnerships of the integrated chronic care program, this service provides care for low- to-moderate risk COVID-19 positive patients whilst they recover in their home. This project focused on building capacity in clinical teams and innovating new pathways for COVID-19 patients to access high-quality care in their home rather than hospital. GPs, pharmacists, medical and nursing staff were heavily utilised to provide care to over 400 patients through this model. A COVID-19 patient experience survey demonstrated an average of 91% satisfaction rate for this service with 72% stating they felt supported at home and did not need a hospital and 86% felt as though they were treated with kindness and respect. This program has since been expanded and branded as the inTouch model.

Patient Safety First – “I hear you”

49 Integrated Chronic Care Program (ICCP) together with COVID-19 drive- through clinic staff were educated in health literacy and teach-back techniques to help improve the communication of information to consumers. The two-hour education program included simulation and theory-based education on how to effectively communicate in plain language, using evidence-based health literacy techniques. Clinician confidence and the ability to re-explain information as required rose from 70% pre-training to 100% post-training, achieving an overall result of 100% competency within 6 months of running the program.


A workplace culture that drives safety and quality

Keeping People Healthy - Conquering the COVID Chaos, A communication lifeline WSLHD’s Population Health team worked collaboratively to design and deliver a new communication model with the capacity to respond quickly to ongoing and emerging public health information needs. The new model included the establishment of a local rapid response network consisting of 1,660 contacts and a new community website for local wellbeing resources, accessed by 9,783 users. Community members were able to access tailored resources including testing information for Aboriginal communities, a children’s testing story book and fact sheets for older adults.

Innovation and Research - All aboard the physiotherapy telehealth service

During 2020, physiotherapy telehealth services were rapidly implemented due to the escalation of COVID-19. During this time, a program was designed to capture the experience of physiotherapists and patients using the telehealth outpatients service in a tertiary facility. Between June and October 2020, 123 patients and 18 physiotherapists used the telehealth service and received a 93% satisfaction rating. Physiotherapists reported an overall positive experience with the telehealth service, noting it was particularly useful for continuity of care for patients and ability to stay connected with during the pandemic. This service will remain as part of business as usual moving forward.

Best of West event 2021. Left to right: Kin-ja Kim (Health care interpreter), Angela Bishop (TV presenter/guest speaker), Yulita Luck (Health care interpreter)

People and Culture - Virtual Connect - Oral Health Clinic Interpreting Oral Health, Health Care Interpreter Services and Biomedical Engineering collaborated to re-design

Education and training - Network 5 – Emergency Medicine Journal Club Network Five – Emergency Medicine Journal Club is a podcast launched by four registrars and one staff specialist from the Westmead Emergency Department. The podcast is the first of its kind in Australia, inviting different specialists as monthly guests to discuss the latest research within their fields and discuss matters across a range of topics including challenges faced by women in medicine. The podcast provides emergency trainees access to regular, interactive medical education and its user-friendly format helps staff to engage with research and relevant clinical discussion. To read more, please visit: The Pulse: Network Five - Emergency Journal Club Best of West event 2021. Left to right: Dr Kit Rowe (Medical Officer), Dr Samoda Mudalige (Medical Officer), Dr Pramod Chandru (Medical Officer)

healthcare delivery during the pandemic. In 2021, dental patients were able to utilise innovative tablet stands and mobile devices to access oral health interpreter services using the MyVirtualCare platform. This project leveraged virtual care technology to enable 2,157 video sessions and a further 3,812 phone call sessions for both ad hoc and booked patients requiring acute Oral Health care. The interpreting sessions were offered in 47 languages for Culturally and Linguistically Diverse (CALD) consumers and allowed for the safe delivery of care for staff and consumers during the COVID-19 pandemic. This project has successfully been integrated into Oral Health’s business as usual care and will continue to support the local community into the next financial year.


Made with FlippingBook - Online magazine maker