Safety & Quality Account 2020-21 | 2021-22 Future Priorities

Safety & Quality Account 2020-2021 2020-2021 REPORT | 2021-2022 FUTURE PRIORITIES

About WSLHD WSLHD Safety & Quality Account

About WSLHD WSLHD Safety & Quality Account Acknowledgement

Western Sydney Local Health District (WSLHD) acknowledges the first people of the land. The overarching Aboriginal nation inWestern 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 dragonflies as they move through their journey of life.

FRONT COVER: Professor Henry Pleass (Senior Transplant and Hepatobiliary Surgeon). Pradeepa Selvaraj, Clinical Nurse Educator, Blacktown Hospital. BACK COVER: Emergency Department Dr Roberto Gennari (Medical Officer). Dr Tony Padley (Anaesthetist).

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About WSLHD WSLHD Safety & Quality Account

Foreword

Western Sydney Local Health District (WSLHD) is committed to providing equitable access to safe, high-quality care, as we strive to be a trusted partner in our community. It is an exciting time for WSLHD as we transform our organisation and develop a new vision to provide safe, high quality and cutting edge care to support our communities in Western Sydney.

In 2020-2021, WSLHD was guided by our Better West Strategic Priorities 2017-2021 of:

• Spending wisely • Information underpins everything we do • Patient experience matters

• Healthy people • Exceptional people • Integrated research, education & clinical care

As part of the journey to achieve our strategic priorities, the resilience of our staff across WSLHD came to the forefront in 2020 and early 2021 as we grew and improved services, increased our commitment to research, looked after our staff and planned for the future of healthcare. Over the past 12 months we have opened the Central Acute Services Building as part of the $1.1 billion dollar Westmead Redevelopment Project and launched Collaborative Commissioning with the Western Sydney Primary Health Network to drive innovation in the way we utilise acute and primary services to respond to the health needs of our community. To support the safety and quality of our services, WSLHD has launched new models of care in our emergency departments to improve the patient experience and in antenatal services to support women. We have focused on strengthening our workplace culture and in 2020 launched the Our People, Our Culture program. We have achieved all of this while continuing to lead projects and strategies in response to the COVID-19 pandemic. We have opened numerous COVID-19 testing clinics across Western Sydney, conducted over 1,000,000 COVID-19 tests and administered over 150,000 vaccine doses. The achievements of WSLHD, would not be possible without the incredible work of the people who make it happen. To all our staff, thank you for being on the frontline and your commitment and dedication to providing safe and high-quality care to all individuals who come through our facilities. The WSLHD Safety and Quality Account is an opportunity to showcase the achievements of WSLHD, our performance against NSW Health indicators and safety and quality standards, and share our aspirations for the next 12 months and beyond to drive continuous improvement and build accountability across the health sector.

GRAEME LOY CHIEF EXECUTIVE WESTERN SYDNEY LOCAL HEALTH DISTRICT

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WSLHD Safety & Quality Account

Contents

01 OUR COMMITMENT TO SAFETY AND QUALITY Creating a positive patient safety culture Shared learning and the drive to improve patient safety

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Partnering with consumers

02 ABOUT WSLHD Our community

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03 OUR CARE AT A GLANCE 2020-2021

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04 SNAPSHOT OF KEY ACHIEVEMENTS 2020-2021 Parenting Plus Program The Blacktown End of Life Communication Research Project

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Australia’s first revived kidney transplant at Westmead Health Precinct

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Aboriginal and Torres Strait Islander Health – Keeping our community safe Multicultural Health Cultural and Linguistic Diverse Community (CALD) Community and Consumer Engagement Program

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05 GOVERNANCE FOR SAFETY AND QUALITY IN WSLHD Clinical Governance Framework 06 NATIONAL STANDARDS AND ACCREDITATION 07 IMPROVING THE PATIENT AND CARER EXPERIENCE How we measure and what we do Snapshot of results for 2020-2021 Mental Health Service YES (Your Experience of Service)

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Patient experience in the COVID-19 pandemic

Patient experience of Telehealth My Experience Matters (MEM) survey Patient Experience Coordinators

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A patient encounter…..

Community and consumer partnership framework 2021-2025

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08 A WORKPLACE CULTURE THAT DRIVES SAFETY AND QUALITY Our Culture, Our Place, Our People What is our cultural ambition for WSLHD?

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Strengthening our culture

Leadership and capability training across WSLHD

Quality Improvement (QI) training

Building WSLHD staff capacity through the Health Literacy Seminar Series

Quality Awards Program 2020

Inaugural Employee of the Year Awards

WSLHD Safety & Quality Account

09 LINKING INFORMATION TECHNOLOGY (IT) TO PATIENT SAFETY AND QUALITY OUTCOMES Streamlining the Perioperative Screening process for Elective Surgery Hospital Acquired Complications (HAC)

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10 WSLHD ACHIEVEMENTS IN 2020-2021 Parenting Plus Program

Australia’s first ‘revived’ kidney transplant at Westmead Health Precinct

The Blacktown End of life Communication Research Project

Multicultural Health Cultural and Linguistic Diverse Community (CALD) Community and Consumer Engagement Program Advanced Life Support (ALS) Team leader training in Virtual Reality (VR) - ALS-SimVR:

WSLHD Vaccination Clinic

Baby Steps Program at Auburn Hospital

Dialysis free-time’ through Incremental Peritoneal Dialysis (IncrPD)

11 COVID-19: A NEW CHALLENGE FOR WSLHD Digital Outreach to high school students in a pandemic

Some of our key achievements during the COVID-19 pandemic

Blacktown and Mount Druitt Hospitals (BMDH) COVID-19 Workforce Strategy Plan

All aboard the physiotherapy telehealth service

Conquering the COVID-19 chaos; A communication lifeline

12 IMPROVING HEALTH OUTCOMES FOR ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES IN OUR COMMUNITY Aboriginal Health – Keeping our community safe

41 42 42 43 44 44

Got Ya Back Midiga (Aboriginal child sexual assault prevention program for schools)

Gathering place, healing spirits cultural space Support for Aboriginal People (SAP) Program

Aboriginal Palliative Care Worker

13 TRANSFORMING WSLHD: INNOVATION & REDESIGN FOR SAFETY AND QUALITY Urban woodland for habitat and healing

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Official opening of the Clinical Acute Services Building (CASB) at Westmead Hospital

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Research and Innovation

Using 3D printing aiming to improve spinal surgery at Westmead Hospital

Fishing hooks, hammers and falls: the cost of eye-penetrating injuries in Australia revealed

Improving the safety and quality of emergency nursing care

14 REVIEW OF PERFORMANCE AGAINST 2021-22 NSW HEALTH KEY PERFORMANCE INDICATORS

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15 KEY PROJECTS PLANNED FOR 2021-2022

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REFERENCES

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Our Commitment to Safety and Quality WSLHD Safety & Quality Account 01 OUR COMMITMENT TO SAFETY AND QUALITY

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Our Commitment to Safety and Quality WSLHD Safety & Quality Account

WSLHD is committed to creating an environment which continuously improves the care provided to our community by ensuring the principles of quality, safety and the patient experience underpin everything we do.

CREATING A POSITIVE PATIENT SAFETY CULTURE

We are focused on creating a culture where staff are proactive in engaging with patients and the community to meet our shared safety and quality goals. We promote transparency in reporting and feedback from staff and consumers alike to report near misses, adverse events and incidents. We are achieving this by building capacity, capability and enhancing leadership across WSLHD, as well as embedding safety and quality into our business as usual process. Committees, escalation pathways and structures have been established across WSLHD to support improvement in all safety and quality matters. Risks, near misses and incidents are reported by frontline staff in each facility and service, with significant risks escalated all the way to the Chief Executive and the WSLHD Board. Further work will be undertaken over the next 12 months to strengthen accountability across the District and clearly articulate reporting pathways from our frontline staff to our Executives.

Quality Related Committees

WSLHD Board Committees

WSLHD BOARD

New Interventional Procedures Committee

Audit and Risk

Health Care Quality Committee

Nominations Committee

Drug Committee

Venous Thromboembolism

Research and Development

Safety & Quality Operational Committee

Infection Prevention and Control

Professional Education

Facility Quality & Safety Committee

End of Life

Finance Performance and Assets

Falls Committee

Escalation process including Morbidity & Mortality meetings

Patient Safety agenda items on department/ward meetings

PHOTO: Westmead Emergency Department new colour coded trolleys. Amy Sustek (Reg Nurse).

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Our Commitment to Safety and Quality WSLHD Safety & Quality Account

SHARED LEARNING AND THE DRIVE TO IMPROVE PATIENT SAFETY

PARTNERING WITH CONSUMERS WSLHD works in partnership with community members, consumers and key organisations to plan, deliver and evaluate healthcare, leading to better quality, safety and patient outcomes. Assessing the human experience, understanding the maturity of our organisation (through patient feedback), and working locally with patients and caregivers will allow us to elevate the human experience for everyone. We will use the Elevating the Human Experience Guide to Action and build capacity in WSLHD to include the consumer voice through the every level of the organisation in a systematic, authentic, meaningful part of daily business. Broader linkages across the community provide the mechanism for change at the population health level. The National Partnering with Consumers Standard focuses on supporting patients, carers and consumers to be actively involved in decisions about their care. WSLHD continues to monitor and develop this in multiple ways such as monitoring of patient experience and feedback across all levels of the organisation, consumers as part of the Standards committees and special project working groups, consumer review of WSLHD documentation and patient stories shared from Board to Ward.

WSLHD is committed to providing the best care we can, but we also recognise that sometimes the treatment and care we provide does not meet our patients’, families’ and carers’ expectations or our own expectations. We acknowledge that any incident resulting in harm to a patient is unacceptable and all incidents are reviewed to prevent similar incidents from reoccurring. We continue to review the quality of our performance against state and national standards. Measures such as Hospital Acquired Complications (HACs) and patients’ and carers’ experience data are used to inform safety and quality agendas, identify areas for improvement and highlight areas of excellence.

PHOTO: Westmead Oral Health new students being welcomed. Left to

right: Professor Heiko Spallek (Head of School and Dean), Dr Raul Taliana (Head of Department), Garo Mazmanian (Dental Student), Jacob Wedderburn-Bishop (Dental Student), Rose Mary Nguyen (Dental Student).

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Our Commitment to Safety and Quality WSLHD Safety & Quality Account

PHOTO: Westmead COVID-19 wards. Dr Helen Tang (Infectious Disease Trainee).

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Our Commitment to Safety and Quality WSLHD Safety & Quality Account 02 ABOUT WSLHD

PHOTO: Left to right seated: Tracy McDonald (Library Manager), Susu Tint (Reg Nurse), Kirk Carbery (Security Officer). Left to right standing: Rene Rivera (Patient Services Assistant), Nirav Thakker (Nurse Manager), Sara Dharmakumar (Reg Nurse).

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About WSLHD WSLHD Safety & Quality Account

WSLHD is one of 15 Local Health Districts (LHDs) in the NSW Health system and serves the second largest and fastest growing population in NSW.

WSLHD provides a range of primary and secondary health care services for people living in the Auburn, Blacktown, The Hills Shire, Holroyd and Parramatta Local Government Areas (LGA) and tertiary care to residents of the Greater Western Region. WSLHD strives to be a leader in contemporary health care delivery in meeting the needs of each individual to improve their health and wellbeing and working in partnership to deliver better health outcomes. Western Sydney is home to a large population comprised of socioeconomic and cultural diversity with: • One of the largest Aboriginal and Torres Strait Islander populations in NSW (2.8%) • An ageing population - it is forecasted from 2016-2026, there will be a 59% increase in people aged 70 years or over and a 54% increase in people aged 85 years and over (ABS 2016 Census) • Cultural and linguistically diverse (CALD) communities - 46.8% of residents were born overseas and 50.3% of people speak a language other than English at home (ABS 2016 Census).

OUR COMMUNITY

Percentage of people who were born overseas 44.3%

Percentage of people who identify as an Aboriginal Person 3% (13,400, majority live in Blacktown LGA) Estimated population 2020 1,054,215 Language other than English 50.3% (71% live in Cumberland LGA)

We are committed to directing more of our resources 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.

PHOTO: Auburn Dialysis

Kickstarter Recipient. Sonia Shalala (Patient),

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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

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About WSLHD WSLHD Safety & Quality Account

Maroota

Gosford >

The Hills Shire LGA

Rouse Hill

Marsden Park

Blacktown LGA

M1

Castle Hill

M2

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1

Penrith

See footnote* e f t te*

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7

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Macquarie Park

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M4

M7

Sydney Harbour Bridge

Parramatta LGA

3

M2

10

r

Cumberland LGA

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Future Western Sydney Airport

Prospect Reservoir

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CBD

Sydney Olympic Park

Parramatta

M7

Bondi >

Liverpool

Sydney Airport

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

M5

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Our Care at a Glance 2020 – 2021 WSLHD Safety & Quality Account

03 OUR CARE AT A GLANCE 2020-2021

163,738 Emergency Department Attendances

151,094 Inpatient Admissions

8,851 Number of Deliveries

18,804 Emergency Surgeries

2,585,621 Outpatient Occasions of Service

28,804 Elective Surgery

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PHOTO: Westmead ophthalmologist Dr Kenneth Lee.

Snapshot of Key Achievements 2021 -2021 WSLHD Safety & Quality Account 04 SNAPSHOT OF KEY ACHIEVEMENTS 2020-2021

PHOTOS: WSLHD Mark McLean, new head of research and education network.

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Snapshot of Key Achievements 2021-2021 WSLHD Safety & Quality Account

Snapshot of Key Achievements 2020-2021

AUSTRALIA’S FIRST REVIVED KIDNEY TRANSPLANT AT WESTMEAD HEALTH PRECINCT Westmead Hospital clinicians with the support of the researchers from Westmead Institute for Medical Research (WIMR) performed the first successful transplant of a revived kidney in Australia utilising a process known as Normothermic Machine Perfusion (NMP). PARENTING PLUS PROGRAM WSLHD introduced the Parenting Plus Program, an innovative, four week program for new parents which embeds health literacy skills into existing community parenting classes. THE BLACKTOWN END OF LIFE COMMUNICATION RESEARCH PROJECT A group of researchers referred to as ‘the Hub’ together with clinicians, developed a multi-component intervention program to improve communication between health professionals, patients and their families about end-of-life care.

PHOTO: Aunty Judith Curry (Marrin Wejali Client). WSLHD Vaccination Outreach Marrin Wejali Aboriginal Centre.

ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH – KEEPING OUR COMMUNITY SAFE In 2020, WSLHD introduced a number of initiatives to keep our Aboriginal and Torres Strait Islander communities’ safe during the COVID-19 pandemic. This included the establishment of outreach clinics and distribution of essential packs with masks, hand sanitiser and information resources about COVID-19 testing and vaccinations. MULTICULTURAL HEALTH CULTURAL AND LINGUISTIC DIVERSE COMMUNITY (CALD) COMMUNITY AND CONSUMER ENGAGEMENT PROGRAM In 2020, the Multicultural Health Services (MCHS) established working groups with our CALD communities to co-design our services and improve access to care and reliable health information. A number of resources have been developed in collaboration with our consumers to improve their health outcomes and enhance our services.

PHOTO: Robert and Angela Gennari celebrated the birth

of their son Leo Gennari born 27th January at 2am at Westmead Hospital.

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Governance of Safety and Quality in Western Sydney Local Health District WSLHD Safety & Quality Account 05 GOVERNANCE FOR SAFETY AND QUALITY IN WSLHD

PHOTO: Cardiologist Dr Peter Fahmy has performed the first watchman FLX device procedure at Westmead Hospital.

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Governance for Safety and Quality in WSLHD WSLHD Safety & Quality Account

Clinical Governance Framework

WSLHD

Governance, leadership and culture

Patient Safety and quality improvement systems

Partnering with consumers

Patient Experience Coordinators

Patient & Carer Experience

Incident Management System

Carer Program

Open Disclosure

Mortality & Morbidity

CLINICAL GOVERNANCE FRAMEWORK

My Experience Matters

REACH

Complaint Management

MCCC

Safe environment for the delivery of care

Clinical performance and effectiveness

Staff Engagement and empowerment

Key Performance Indicators

Clinical Practice Improvement

Quality Awards and Research

Quality Improvement Systems

Quality Practice Audits

Policies & Procedures

Accreditation

In October 2020, the WSLHD Clinical Governance Framework 2020-2022 was published. The framework is modelled on the Australian Commission on Safety and Quality in Healthcare Framework together with the NSW Patient Safety and Clinical Quality Program. The intent of the framework is to assist in identifying areas of priority across our facilities and services, and the structures in place to support improvement in quality and safety across our District.

Clinical Performance and Effectiveness – Clinical effectiveness is measured via a large range of key performance indicators including Hospital Acquired Complications (HACs) and clinical indicators. Various improvement programs and initiatives including: intentional rounding, early mobilisation and safety huddles have been introduced as an outcome of evaluating data and identifying patient safety risks and areas for improvement. Staff Engagement and Empowerment – Promoting programs such as ‘Speak Up for Safety’ and encouraging incidents and near misses to be reported in the Incident Management System (IMS+) contribute to empowering staff and engaging staff in safety and quality conversations at all levels of the organisation. Safe Environment for the delivery of quality care – A range of policies and procedures safeguard the care provided to patients to ensure our services align with evidence-based best practices. Clinical audits and performance data aid in the identification of risks and inform actions needed to improve the delivery of safe, high quality care.

The six components of the WSLHD Clinical Governance Framework 2020-2022 are:

Partnering with Consumers – Within WSLHD we actively seek feedback from patients and consumers to ensure we understand what is important to them and work together to improve the care and services we provide. The “My Experience Matters” platform is one tool we have that provides timely insight into patient experience feedback. This information is used to implement quality improvement activities to improve the experience. In addition we use complaint and compliments data to also inform activities that will improve the experiences of patients, families and carers. Governance and Leadership – The framework articulates a shared vision for safety and quality across WSLHD. It reinforces that providing safe, high quality care that meets the needs of our community is multifaceted and everyone’s responsibility. Patient Safety and Quality Improvement – Patient and staff safety in our health care system is consistently achieved through quality improvement activities, risk identification and mitigation, redesign and research. Currently there are over 50 quality improvement projects registered in the Quality Improvement Data System (QIDS) database and underway across WSLHD.

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National Standards and Accreditation WSLHD Safety & Quality Account 06 NATIONAL STANDARDS AND ACCREDITATION

PHOTOS: Westmead Renal Physician Dr Richard Phoon and Rezek Nametaalla (Patient).

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National Standards and Accreditation WSLHD Safety & Quality Account

All public and private hospitals, day procedure services and public dental practices are required to be accredited to the National Safety and Quality in Healthcare Standards (NSQHS) to ensure the safety and quality of health care provision.

Standard 8 Recognising and Responding to Acute Deterioration

Standard 1 Clinical Governance

Standard 7 Blood Management

Standard 2 Partnering with Consumers

Standard 3 Preventing and Controlling Healthcare-associated Infections

Standard 6 Communicating for Safety

Standard 5 Comprehensive Care

Standard 4 Medication Safety

In preparation for accreditation against the 2nd edition Standards, each facility in WSLHD undertook a comprehensive gap analysis. It was identified that Actions requiring further improvement were comparable across both editions. WSLHD is working collaboratively to implement improvement strategies in those specific areas. To date in 2020-2021, there have been nil “Not Met” recommendations directed to WSLHD.

All facilities, which includes Auburn, Blacktown, Mount Druitt and Westmead Hospitals, Drug Health, Mental Health, and Oral Health Services are accredited against the National Standards Version Two. Integrated and Community Health are accredited under the Aged Care Quality Standards. In 2019, the new NSQHS Standards 2nd edition commenced which consists of eight standards and 148 actions compared to the first edition of ten standards and 256 actions.

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Improving the Patient and Carer Experience WSLHD Safety & Quality Account 07 IMPROVING THE PATIENT AND CARER EXPERIENCE

PHOTO: Westmead cardiac arrest survivor leaving hospital after two months. Chaikel Muksin (Patient).

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Patient experience matters

Improving the Patient and Carer Experience WSLHD Safety & Quality Account

How we measure and what we do

SNAP SHOT of Results for 2020-2021

At WSLHD, understanding our patients’ experiences, celebrating what works well, and identifying where we can improve is essential to our organisation. We have various measurement tools including; the state-wide Bureau of Health Information (BHI) patient experience surveys which measure patient experience across all NSW hospitals and our local real time My Experience Matters (MEM) survey. Over the last 12 months we have worked across WSLHD to improve our feedback services. We have developed clear user-friendly information for patients, families and carers in our feedback brochure. The WSLHD Feedback Framework has also been published to ensure there are clear and transparent systems in place to address what our patients have to tell us.

WSLHD Inpatient 1752 total surveys: Patient experience rated at

90% satisfaction

PATIENT EXPERIENCE IN THE COVID-19 PANDEMIC

MY EXPERIENCE MATTERS (MEM) SURVEY Our MEM data is reported at a facility and unit level to identify

Since early 2020, WSLHD has implemented surveys to capture patients’ experiences of telehealth support for patients isolating at home during the COVID-19 pandemic. In the COVID-19 testing stations, surveys have aided in troubleshooting issues quickly. As a result of feedback, signage at testing stations was improved to ensure easy access. Surveys have also provided the opportunity for members of the public to give compliments to our staff. A patient experience survey was also developed in the COVID-19 Vaccination Hubs. This has provided valuable insights and improvements into access to interpreters, information about how the shuttle bus system operates, with a huge number of compliments received about the staff. In April 2020, 499 surveys were completed in the COVID-19 Vaccination Hub, and over 3,000 surveys completed in May 2020. As our clinics adapted outpatient services to respond to the pandemic and implement telehealth options for clinic appointments, we updated the existing outpatient survey to include questions on patients’ experiences of telehealth. Results have indicated overwhelmingly positive experiences, with patients appreciating the option to communicate with their clinician virtually and not always having to travel to our facilities. Over 2,000 surveys were completed in January 2020 - May 2021. PATIENT EXPERIENCE OF TELEHEALTH

WSLHD Outpatient 1473 total surveys: Patient experience rated at

and inform improvement strategies. Currently there are 72 active surveys on the platform including the Inpatient Outpatient, Carer, Community and Emergency Department surveys as well as multiple special project surveys. Over 42,000 patients have provided feedback since we implemented the MEM platform in 2017. The number of responses increases each year.

92% satisfaction

Mental Health Service YES (Your Experience of Service)

Inpatient Services 1580 surveys returned: Patient experience rated at 73% satisfaction

Ambulatory (Community) Services 945

surveys returned: Patient experience rated at

94% satisfaction

PHOTO: WSLHD Qudos

Vaccination Centre. Mary Salib getting vaccinated.

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Improving the Patient and Carer Experience WSLHD Safety & Quality Account

PATIENT EXPERIENCE COORDINATORS Patient experience is the number one priority for a new team of experts called the Patient Experience Coordinators who joined hospitals across WSLHD. The Patient Experience Coordinator role was introduced across all our emergency departments in 2020. WSLHD has seven Patient Experience Coordinators working across WSLHD emergency departments. Their primary function is to improve every aspect of interaction with our services and to create an environment that makes patients, carers and their families feel welcomed, safe, cared-for and empowered. They actively engage with patients in the emergency department to keep them updated, address concerns and follow up with anything they may be waiting for such as test results or discharge paperwork. The Patient Experience Coordinators have had a positive impact on the experiences of the patients, families and carers within the Emergency Department (ED) with a decrease

in patients who ‘did not wait’ (left the ED before medical assessment completed) and incidents of aggression within our facilities’ ED. The Patient Experience Coordinators also work closely with other staff in the department to understand any new or ongoing issues, and have de-escalation training in the event of any patient/ visitor agitation. From July 2020 when the program started to May 2021 over 7,000 patients have completed the My Experience Matters Survey in Emergency Departments providing valuable feedback about the program. Feedback about the service is overwhelmingly positive from both patients and staff. “Not all heroes wear capes. Some work in hospitals. Thanks a lot for taking care of me today. I spent eight hours in emergency including maximum time in waiting room. Special thanks to the Patient Experience Coordinator and Nurses. Comment from patient Westmead Emergency Department November 2020.”

A Patient encounter….. The following story is told in the words of Thavashanie Govender a Patient Experience Coordinator at Blacktown Hospital Emergency Department. ‘A patient presented with her partner having an active miscarriage while walking into the hospital. As I noticed the patient was bleeding while being screened to enter I brought a wheelchair to her, asked her to sit and took her straight into the triage area. I bypassed the administration process and took the patient directly to the triage nurse as I could see the patient was in active miscarriage. I took the partner to the admin desk and got the patient registered. While this was not the correct process for the admin team, I explained that the partner will provide the details and then took him back to be with the patient. The nurse immediately offered patient sanitary stock and got her comfortable. The patient thanked me for keeping her dignity and not leaving her to sit in a waiting room full of other people watching her going through a miscarriage. I only did my job. I see my role as an opportunity to assist our clinical team in providing that added layer of care to our patients for all their non-clinical needs, food, water, blankets, hygiene packs, quick aids such as gauze to cover a bleeding wound on a teenager who has tried to self-harm themselves. Providing access to information for a variety of services such as, access to an Aboriginal Health Worker, community drug and alcohol, women's health, social work, transport and taxi services to name a few. It is times like this coming to the aid of our patients and ensuring they are receiving dignified, timely care while in the care of our health system, I understand what an honourable position I hold with the patient and their journey in the health system. A little kindness goes a long way and sometimes just listening to a person, showing small acts of kindness, elevates their experience and demonstrates that our organisation cares for their wellbeing.’ Thavashanie Govender: ED Patient Experience Coordinator, Blacktown Mount Druitt Hospital.

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Improving the Patient and Carer Experience WSLHD Safety & Quality Account

COMMUNITY AND CONSUMER PARTNERSHIP FRAMEWORK 2021-2025 In 2021, WSLHD released our new Community and Consumer Partnership (CCP) Framework 2021-2025. WSLHD has a strong commitment to strengthening partnerships with our consumers and achieving shared goal of delivering safe, high-quality, and patient-centred care to the community.

PHOTO: Consumer

representatives visit Westmead

Hospital before the COVID-19 outbreak.

The CCP Framework 2021-2025 sets clear goals which WSLHD is committed to achieving, including: • Recruitment of consumers that are reflective of our diverse local communities and providing training and skills to equip them as a WSLHD consumer representative • Supporting increased partnership opportunities between staff and consumers • Promoting social care and health literacy in our communities in partnership with community and consumer leaders • Promoting the engagement of consumers as research partners across WSLHD.

The CCP framework builds on the realised goals of the 2015-2020 framework, in which WSLHD achieved: • Increased consumer and community involvement in our committees • Strengthened relationships with key organisations and communities across WSLHD, including the Western Sydney Primary Health Network, the Western Sydney Community Forum and the Parramatta Koori Interagency • Improved systems to strengthen and understand consumer engagement, including the continued usage and promotion of the My Experience Matters platform. We understand the importance of consumer feedback in understanding what is important and in shaping safety and quality initiatives.

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A Workplace Culture that Drives Safety and Quality WSLHD Safety & Quality Account 08 A WORKPLACE CULTURE THAT DRIVES SAFETY AND QUALITY

PHOTO: Westmead orderly Sarah Niblock has been working at WSLHD May 2021.

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Exceptional people

A Workplace Culture that Drives Safety and Quality WSLHD Safety & Quality Account

Our Culture, Our Place, Our People.

WSLHD is a vibrant and growing community and we have great aspirations for our culture. We want to be a workplace of care, compassion, connection and where our people want to come to work and feel fulfilled. We are transforming our organisation and developing a new vision to provide the safest, highest quality and cutting edge care to the community of Western Sydney. In 2020 we launched the “Our Place. Our People” to further strengthen our workplace culture. This program is about recognising our shared sense of community, ways of working and identifying as WSLHD. The aim of the program is to promote a workplace culture where people feel safe, respected and supported to deliver world-class healthcare to our community.

We are a vibrant, growing community

We are respected and connected

We are caring and compassionate

Our Culture We're working to further strengthen our culture – what we believe, how we behave and the mindset we bring to work.

Our Place

Our People We all want to work in an environment that fosters collaboration, openness, respect and empowerment.

Everyone wants to work in a place where they can feel safe and be at their best.

WHAT IS OUR CULTURAL AMBITION FOR WSLHD? Our culture statement describes our shared aspiration for how we should all work together and feel coming to work at WSLHD each day. It celebrates what makes us unique and guides the way we behave and make decisions. It applies to every individual and every team at WSLHD.

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A Workplace Culture that Drives Safety and Quality WSLHD Safety & Quality Account

STRENGTHENING OUR CULTURE Our Safety:

Recognising the strain and stressors work can place on our staff. The ‘Our Place, Our People’ program aims to ensure the physical safety of staff at all times in addition to ensuring that staff have access to resources to assist in maintaining emotional and mental wellbeing. Investing in Culture Ambassadors: Any employee of WSLHD is encouraged to be a Culture Ambassador and join a community of like minded colleagues who: • Get involved and promote the CORE values, aspirations and initiatives of WSLHD • Are an advocate for positive change and promote the values and ideals WSLHD aspires to • Promotes conversation, collaboration and feedback helping to build a vibrant WSLHD community. To date we have 62 Cultural Ambassadors and we continue to grow this group weekly. Our Leaders: The integral role a leader plays in shaping the culture of our organisation is acknowledged. WSLHD is establishing a leadership framework to identify and support the development and skills of our leaders through coaching, mentoring and communities of practice. Our Stories: Promoting the voice of our staff and community alike and sharing in achievements and reflections is an important driver of safety and culture alike. WSLHD is committed to strengthening the voice of our people and ensuring they are heard.

PHOTO: Westmead Multicultural

Integration and Culture Project. Associate Professor Nirmala Pathmanathan

(Director Breast Cancer Institute).

LEADERSHIP AND CAPABILITY TRAINING ACROSS WSLHD

We are committed to enhancing the capability of our staff to have the skills and knowledge to deliver safe and high quality care now and into the future. We want to develop strong compassionate leaders to create confidence amongst all staff and to encourage a professional and positive environment. WSLHD provides opportunities to staff to lead sustainable system improvements and patient safety initiatives, work more effectively with available clinical information and resources, and develop a patient-centred care culture which includes speaking up for safety and quality.

PHOTO: Left to right: Dr Jessica Xiong, May Ng, Dr Kenneth Lee, Freda Vosdoganis, Francil Ubana, Lorraine Reyes, Molly John.

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A Workplace Culture that Drives Safety and Quality WSLHD Safety & Quality Account

WSLHD offers a range of training programs all designed to improve the calibre of leadership across the District.

Training Numbers: IMS+

100% staff have notifiable access with refresher training continuing for all new and existing managers. >150 senior staff across all disciplines have been trained and have access to shared databases. More than 50 quality improvement projects are currently registered in QIDS. >200 staff across all disciplines have been trained and utilise this modality.

These include but are not limited to:

• Nursing and Midwifery Leadership pilot program – the program seeks to orientate, support and develop new Nursing Unit Managers (NUM) and Midwifery Unit Managers (MUM). The program focuses on developing knowledge, understanding and skills around core technical components of a NUM and MUM role. • Clinical Leadership Program – the program seeks to enhance the capacity of clinicians to lead sustainable system improvement and patient safety initiatives. • Senior Medical Officer Leadership Development program – the program is designed to equip senior medical leaders with relational capabilities of effective leadership. QUALITY IMPROVEMENT (QI) TRAINING In 2020-2021, WSLHD increased training for our staff on utilising quality improvement tools, clinical data, and incident information management systems. Structured education and training programs addressing Quality Improvement Data System (QIDS), Quality Audit Reporting System (QARS) and the incident management system (IMS+) have been implemented.

QIDs

QARS

BUILDING WSLHD STAFF CAPACITY THROUGH THE HEALTH LITERACY SEMINAR SERIES Bi-monthly health literacy research seminars were introduced to build capacity within the district to improve health literacy and health outcomes for our patients and consumers. A strong Health Literacy Hub Community of Practice has been developed with 1,500 members currently registered and regularly attending health literacy seminars.

We Recognise and Celebrate the Work of our Staff!

QUALITY AWARDS PROGRAM 2020 The annual WSLHD Quality Awards program acknowledges the creativity and innovation of our staff. In 2020 fifty two submissions were received.

WINNERS OF 2020 WSLHD QUALITY AWARDS INCLUDE:

Delivering Integrated Health Care – Pathways to Community Living Initiative (Mental Health Services) The aim of this program is to support people with severe and persistent mental illness who have had stays in hospital for twelve months or more. 110 patients have transitioned back into the community which would have equated to a length of stay of >555 years.

Transforming Patient Experience: Just Ask It (Auburn Hospital) The aim of this project was to increase the identification of Aboriginal and Torres Strait Islander patients presenting to Auburn Hospital. There was an increase of 62% in identification from 2017-18 to 2019-20 (YTD) of patients of Aboriginal and/or Torres Strait Islander backgrounds patients presenting to ED.

PHOTOS: Left: Just Ask It Project Team (left to right): Auburn Hospital surgical ward nurse unit manager Riki Richards, WSLHD Aboriginal training coordinator Kristy Kendrigan, outpatient nurse unit manager Tanja Nietlisbach, nursing and midwifery director Kate Murphy, acting Quality and Accreditation manager and project lead Sally Henderson, Aboriginal liaison officer Narelle Holden and administration manager Lidiya Malinov. Right: Delivering Integrated Health Care Luisa Albornoz - Pathway to community living winner 2020.

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A Workplace Culture that Drives Safety and Quality WSLHD Safety & Quality Account

WINNER OF THE BOARD CHAIR AWARD: Patient Safety First – Keeping Clozapine Patients Safe during COVID-19 (Mental Health Service) The aim of the program was to ensure the Clozapine service to 179 consumers continued during the COVID-19 lockdown. In 2020 Blacktown Clozapine Strategies such as clinical reviews via telehealth and delivering medication to consumers’ homes utilising COVID-19 safety protocols were instituted. 80% of the consumers reported that they were ‘very satisfied’ with the service. The aim of this program dubbed the ‘COVID STREET FIGHTERS’ by local media, was to work collaboratively with external partners. COVID-19 testing and flu vaccination targets were exceeded achieving almost 100% COVID-19 testing for eligible clients and almost 100% vaccine coverage for the estimated homeless population within the WSLHD catchment. WINNER OF THE CHIEF EXECUTIVE AWARD: Supporting Our Teams – Workplace Wellness in the Time of COVID-19 and Beyond (People and Culture) The aim of this program was to ensure all staff felt informed, supported, focused and valued. This translated into a number of initiatives requiring exceptional collaboration and partnerships within our directorate, across the district and with external partners. Keeping People Healthy – COVID Street Fighters (Youth Health)

A Safe and Healthy Workplace – Contain the Contagion! A Clinical Mission to Eradicate Transmission (Integrated and Community Health) The aim of this project was to ensure staff were well informed to ensure safe ‘donning and doffing’ of Personal-Protective-Equipment (PPE) required for COVID-19 precautions during a home visit. Staff evaluated the video developed: with 93% of nurses reported increased feelings of safety and 95% reporting an improved knowledge of PPE application. Innovation and Research – PPE Predict (Infection Prevention and Disease Control) The aim was to develop a best-practice, data-driven predictive model for PPE use and burn rates for WSLHD. This information informs the level of PPE required to return to full clinical services locally. Westmead Hospital’s results and approach were able to be applied at a state level to inform wider PPE needs and has been adopted by the NSW Ministry of Health. Education and Training – Flipping COVID Facedown (Physiotherapy Department, Blacktown & Mount Druitt Hospitals) The aim of this program was to increase medical staff confidence, clinical skills and familiarity with diabetes management. Medical staff completed a two week intern placement with the service. A pre and post-attachment survey was undertaken demonstrating improved competency of interns in the management of diabetes.

WINNER OF THE PEOPLE’S CHOICE AWARD: Newborn Education and Skills Training - NEST (Auburn Hospital Maternity Services with Westmead Hospital Neonatal Intensive Care).

This skills training program aimed to build the capabilities of staff in procedures including; airway management, nasogastric tube insertion, urinary catheterization, intubation, defibrillation and paediatric assessment.

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A Workplace Culture that Drives Safety and Quality WSLHD Safety & Quality Account

Inaugural Employee of the Year Awards We held our inaugural Employee of the Year Awards in 2020. Four individuals who made an exceptional contribution to WSLHD were recognised.

ALLIED HEALTH – Samantha Tate , A/Head of Podiatry, Westmead Hospital. Samantha has worked tirelessly to address a number of risks both clinical and enterprise in nature.

DOCTOR – Dr Alpha Tung , Head of Anaesthesia Department, Auburn Hospital. Dr Tung has been essential in assisting the executives in developing a COVID-19 response for Auburn Hospital.

CORPORATE SERVICES – Rory Dunlop , Cleaner, Blacktown Hospital. Rory takes a high level of pride in his work and has displayed qualities that are to be commended with his engagement of staff and patients.

NURSING – Pradeepa Selvaraj , Clinical Nurse Educator, Blacktown Hospital. Pradeepa makes sure patient safety is a number one priority and she ensures that all efforts are put in place to achieve this.

WE ALSO ACKNOWLEDGE OUR UNSUNG HEROES! WSLHD is extremely proud of the endless dedication and commitment of our staff to support communities. Many of our staff have been recognised for their contribution in research and response to the bushfires, floods and various other emergencies. We salute you!

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Linking Information Technology (IT) to Patient Safety and Quality outcomes WSLHD Safety & Quality Account 09 LINKING INFORMATION TECHNOLOGY (IT) TO PATIENT SAFETY

& QUALITY OUTCOMES

PHOTOS: Westmead JMO receiving new computer. Left to right: A/Professor Naren Gunja (Chief Medical Information Officer), Theodore Iannuzzi (JMO).

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Information underpins everything we do

Linking Information Technology (IT) to Patient Safety and Quality Outcomes WSLHD Safety & Quality Account

Health information technology (IT) is an essential tool for improving healthcare quality and safety.

HOSPITAL ACQUIRED COMPLICATIONS (HAC) A hospital-acquired complication (HAC) refers to a complication for which clinical risk mitigation strategies may reduce (but not necessarily eliminate) the risk of that complication occurring. HAC data is collected regularly within each facility and service and is used to drive improvements across WSLHD. The positive outcomes of improvement activities are identified via an overall decrease in the rate of HACs occurring across WSLHD. A District-wide approach has been undertaken to address harm from fall and hospital acquired pressure injuries. Strategies to reduce harm from falls include: • Intentional Rounding –a proactive, multidisciplinary activity designed to improve awareness of the clinical and personal needs of the patient • Safe and Early Mobilisation - engages the multidisciplinary team to identify, assess, plan and manage functional ability to safely mobilise patients • Recognition of Cognition and Patient Education – engages the multidisciplinary team to prevent, identify, plan, treat and manage delirium and altered cognition. Strategies to reduce pressure injuries include: • Pressure Injury Prevention Bundle – this model of care involves a safer microclimate for skin integrity reducing the incidence of incontinence associated dermatitis and reducing shear and frictions • Intentional Rounding - a structured process of regular checks are conducted with individual patients using a standardised protocol • Documentation and Staging – roll out of an education package to ensure accuracy and consistency in effective staging and documentation • Pressure Injury Prevention Plan in the electronic Medical Records (e-MR) - improves compliance with the completion of pressure injury risk assessments and prevention plans.

WSLHD utilises health IT to improve the safety of our services by reducing errors and clinical variation, improving compliance to practice guidelines and identifying areas for improvement. WSLHD collects health information to inform care and ensure appropriate treatment is provided to patients. Data is used to monitor performance and deliver innovative care. STREAMLINING THE PERIOPERATIVE SCREENING PROCESS FOR ELECTIVE SURGERY The aim of this program, which used a telehealth application, was to streamline the perioperative screening process for elective surgery ensuring that 100% of patients receive appropriate pre- assessment prior to surgery. This resulted in the patient’s baseline health being optimised prior to the surgery. As a consequence of the implementation of this program numerous positive outcomes were generated and include: • <2% cancellation Day of Surgery (which meets the state-wide key performance indicator) • Less pressure to meet the volume of face-to-face clinic appointments required which was reduced from 35 per day to 20 per day on average • Improved resource vs demand management • Reduction in patients who did not attend (DNA) face-to-face clinic appointments with telehealth now utilised within the screening criteria increasing patient attendance • Fewer post-operative complications reported at surgical services and Anaesthetic Morbidity and Mortality meetings where complication due to inadequate pre-assessment processes.

PHOTOS: Left: Nelson Ubera (NUM Renal) Right: Westmead Eye Clinic.

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