Living Best Care at Bacchus Marsh / Melton / Caroline Springs

At Western Health, our vision for outstanding patient care is that each of our patients receives ‘Best Care’ from us, every time, everywhere.

It is clear our colleagues at Bacchus Marsh, Melton and Caroline Springs (BM/M/CS) campuses share this vision –  this can be seen in the every day care of patients and in staffs’ endeavours to continually review and improve care.  Click here or on the image to the right to find about what best care means to BM/M/CS staff Katherine, Roshan, Nevine, Candice and Kerryn.

To support and focus the great work of BM/M/CS staff and services to provide and improve care, the Western Health Best Care Framework is being rolled out across all sites.

This Framework is an approach to clinical governance that focuses on care from the perspective of patients and translates this into day-to-day behaviours and systems supporting person-centred, co-ordinated, right and safe care for every patient.  Click here or on the image above to find out what best care means to Bacchus Marsh/Melton patients John, Amie and Michelle.

Putting the patient at the centre of everything we do is also a clear message about living best care from Russell Harrison, CEO.

Click here or on the image  to the right to hear from Russell on what Best Care means for care at BM/M/CS and right across Western Health.

Click on the following tabs to find out what the Best Care Framework looks like and the Patient First, Leadership, Process, Workforce & Improvement systems available to BM/M/CS staff and currently being further developed to support person-centred, co-ordinated, right and safe care. Tab information will be further developed as the transition project progresses.

The Best Care Framework describes care from the expectations of patients and outlines the behaviours of front-line staff, managers & senior clinicians and the executive and board to provide, lead and govern best care. 

Click here to see an interactive model of the framework where you can click on each statement to learn more. 

… developing, implementing and maintaining systems to partner with consumers in planning, design, delivery, measurement and evaluation of care

‘Patient First’ is the central focus of the quality systems described in the Best Care Framework that support staff to lead, drive and create care that is person-centred, co-ordinated, safe and right for clinical needs.

Systems supporting 'Patient First'

Understanding what best care means for patients and listening to how well we’ve done to meet their healthcare expectations is an important part of ‘living best care’. 

Seeking out and learning from patient stories is a key component of ‘Patient First’.

Click here or on the image to read the best care stories of Bacchus Marsh/Melton patients John, Amie and Michelle. 



Western Health promotes and values feedback as an opportunity for consumers to provide the organisation with information about their experience. The detailed and co-ordinated management of consumer feedback assist with governing, reviewing and improving services. Feedback can take the form of a complaint (negative feedback), enquiry (neutral feedback), or compliment (positive feedback).

Western Health encourages all staff to value feedback, and to use the feedback provided by consumers to drive service improvement. Western Health encourages staff to positively approach opportunities to complaints and where possible, to strive for local resolution of the issue(s) in the first instance.

A feedback email address and 1800 phone number have been introduced to support consumers being hard and their feedback addressed in a timely manner. A Redcap Form is also being developed to support consumers to log complaints through the internet.

Refer to the following diagram for the consumer feedback process currently in place at Bacchus Marsh/Melton.



Membership for a Community Engagement Transition Committee has been finalised, with the first meeting held on 10 November 2021.

This Committee is providing to the transition project steering committee on community experience of amalgamation, providing a link to community members and guiding the activities for community engagement to support best care for patients and the wider community.

The committee exists to:

  • Ensure a link between the community and the transition project steering committee
  • Ensure that the amalgamation project is able to respond to needs of communities of Bacchus Marsh, Melton and Caroline Springs
  • Maintain strong connections between project management and former DjHS’s diverse constituents

The ‘Patient Experience during the COVID-19 Pandemic Survey’ is a state-wide initiative designed to better understand the impact COVID-19 is having on patient experiences of care during the pandemic.

Potential respondents are selected from people, 16 and over, who have been admitted to a Victorian public hospital, attended one of Victoria’s Emergency Departments but were not admitted to hospital, or who received services from Victorian public hospital services in relation to antenatal, labour and birth and postnatal care.

Patient Experience survey results have recently been released covering the period ending June 2021. As the image below shows, the care collectively provided by relevant Bacchus Marsh / Melton / Caroline Springs services is strongly reflective of Best Care during this period. Click on the image below to view all patient responses from the ‘Patient Experience during the COVID-19 Pandemic Survey’.

… leading a culture of best care within integrated and outcome focused governance structures

Leadership Systems supporting Best Care

Every single staff member at BM/M/CS —either directly or indirectly, whether clinical staff, non-clinical staff or volunteers—makes a contribution every day to supporting the provision of Best Care and the best experience for our patients. Providing or supporting Best Care when staff are busy and under significant pressure can be challenging, but also very rewarding when they make a positive difference to patients and their family.

Front Line Staff
Best Care is provided by front-line staff (including volunteers) who are engaged in and committed to providing Best Care for each patient, every day, every time. They are at the heart of Best Care, with their practices and behaviours having a direct impact on patient experience and/or patient outcomes.
Staff focused on Best Care are compassionate and respectful, as well as skilled, competent and professional.

What this means to me as a staff member every day is that I:

  • demonstrate person-centred care by communicating with patients and their families and being sensitive to their needs and preferences
  • demonstrate co-ordinated care by being an active team player and looking for ways to do things better
  • demonstrate right care by being competent in what I do and committed to doing my best
  • demonstrate safe care by keeping patients from harm

Click here or on the image to find about what best care means to BM/M/CS staff Katherine, Roshan, Nevine, Candice and Kerryn.

The ‘Keeping You in the Loop meeting’ occurs monthly and is Chaired by General Manager Sandy Schutte.

It was introduced in October 2021 as an opportunity to give staff monthly updates to keep them in the loop of everything currently happening at Bacchus Marsh, Melton & Caroline Springs that affects best care and the staff providing or supporting that care.

A link to join this monthly meeting is distributed via email in the lead up to the scheduled date.



CEO Russell Harrison hosts regular Webinar catch ups to staff across Western Health in the loop about key topics affecting best care across the organisation and the staff providing or supporting that care.  

At least half of the Webinar time is allocated to staff questions.

A link to join ‘Russell’s Webinar Catch Ups’ is distributed via email in the lead up to the scheduled date. 

A link to the recorded Webinar is also distributed via email following the event for those unable to join on the scheduled date.

A key focus of the Bacchus Marsh/Melton transition is to explore, refine and integrate models of best care that are  safe, right, coordinated and person-centred, and to engage staff authentically and continue to build a culture where people are proud to work

To keep BM/M/CS staff up to date on the transition, a dedicated monthly Newsletter commenced in August 2021.

All issues of the Newsletter can be found here or by clicking on the image below.

The Committee structure supporting best care at BM/M/CS is slowly being refined to reflect a Western Health-wide Board and Executive structure, transition activity, and opportunities to support meaningful organisational clinical practice standardisation. The following image is the BM/M/CS Committee structure as at 1 December 2021.

To support the integration of BM/M/CS Clinical Standard Committees integrate with equivalent WH Clinical Committees, a Best Care Boarding Pass is being utilised to record and consider the governance practices active across campuses. 

… maintaining and enhancing the policies, procedures, guidelines and tools supporting the delivery of best care

Process Systems supporting Best Care

The BM/M/CS PROMPT Platform supports staff accessibility to and management of Documents relating to Procedures, Forms, Brochures, Fact Sheets and Patient Information.

Click on the following image to access the PROMPT Platform.

The Western Health Executive have considered and approved a recommendation to adopt PROMPT for the entire organisation. Work to set up a Western Health PROMPT site will commence shortly. The BM/M/CS site will run concurrently with the new Western Health site until 30 June 2022 so staff have access to both PROMPT sites while integration of Documents is undertaken.

The Bacchus Marsh/Melton Document Tracking Process supports the development and review of Documents relating to Procedures, Forms, Brochures, Fact Sheets and Patient Information.

This process has been revised to align with the Transition Management Structure and to reduce the number of steps required to authorise new or reviewed Documents. The revised tracking process is described in the image below – click on the image to access a pdf version of the flow.

The Document Tracking Record (DTR) has also been revised to reflect the flow. The DTR can be accessed by clicking here or via PROMPT by following the link through ‘search Policies & Procedures’ on the intranet. Document templates have been updated and now include a Western Health logo, with the exception of the MR Form template. Any pending DTR submissions using the previous template will be converted to the new form by the Quality Team and follow the new authorisation flow.

In line with Western Health process, review and generation of organisation-wide policies which cover all campuses (including BM/M/CS) will be undertaken at Executive level, with authorisation at Board level. Organisation-wide policies will be made available in PROMPT, with reference to any specific BM/M/CS systems/services highlighted in these documents. Western Health and BM/M procedures will slowly be integrated over the Transition period in consultation with key staff across all sites.

BM/M/CS services participate in a number of accreditation programs that review processes, performance and improvement against externally set Standards supporting best care. 

Below is a list and status of involvement in current accreditation programs.

… recruiting and supporting a workforce with the right qualifications, skills and supervision to provide best care

Workforce Systems supporting Best Care

Supporting the wellbeing of staff is an important part of being able to provide best care.

When we take care of our wellbeing we feel fulfilled, develop resilience and tools to overcome challenges, and make the most of life.

Connection, community, learning, being active, practicing mental and spiritual fitness, and eating well are just a few examples of what wellbeing encompasses.

Click here or on the images below to find out more about Western Health’s ‘Wellbeing & Support’ tools and initiatives. This includes practical information and the Virtual Tea Room.  

WeLearn is available to all staff across Western Health and is a great training resource. Until Bacchus Marsh/Melton IT systems are integrated, please use the following steps to access WeLearn

  • Access WeLearn using Google Chrome.
  • The link is:
  • Select ‘non-employees’
  • Username: your djhs email address e.g.
  • Password: Welearn123
  • You will be prompted to change your password on initial login.
  • Please see here for an instructional video: INSTRUCTIONAL VIDEO
  • For further assistance with WeLearn please email the WeLearn Helpdesk:

All previous training records from the DjHS Online Education Portal will be securely stored but not yet visible on WeLearn. All previous training history will be merged once we have permanently migrated to WeLearn.

The competencies that cannot be accessed through the WeLearn platform can be accessed using the quicklinks below. For compliance monitoring please email your certificates from these courses to and your manager.








(EMPOWIR) is an element of Western Health Positive Workplace Strategy.

Western Health has developed a strategy for sustaining a positive workplace across all sites. The strategy was established to strengthen and maintain a positive workplace environment where all employees and volunteers feel safe, are enabled to work to their full potential ensuring Western Health offers their patients the best possible care outcomes.

We aim to create the best environment for our employees, volunteers and our patients who count on us every day to provide compassionate and respectful care for them.

EMPOWIR is a tool that has been developed to enable every volunteer and employee to access advice to achieve an informal and ‘no blame’ resolution or outcome in the event they have been subject to, or have witnessed some type of inappropriate workplace behaviour or interaction.

Find out more about our Positive Workplace Strategy at

October 2021 marked the launch of our new Nursing & Midwifery microsite.

This  is a new resource to keep our nurses and midwives at all sites across Western Health updated and allow for easy access to tools, information and documents to support best care and the personal development and wellbeing of our nursing & midwifery workforce.

The microsite will be frequently updated, with information relevant to nurses and midwives – so be sure to check it out and come back often!

Click here or on the image to access this site.

… continuous monitoring, assessment and reporting of best care

Improvement Systems supporting Best Care

The aim of risk management within Western Health is to  support best care by preventing or reducing harm to patients, staff and others as a result of services provided. Staff at BM/M/CS identify and manage risks to best care and service delivery as part of their everyday work. However, sometimes risks can’t be immediately managed and a planned approach is required. 

An Operational Risk Register is designed to capture and support the planned management of risks to the day-to-day delivery of best care and services.

General principles for identifying suitable risks for the Operational Risk Register include:

  • They have the potential to significantly impact day-to-day operations/directly impact on patient care or service delivery
  • They are specific to aspects of operational delivery of care/services and need to be mitigated in the short-term
  • The is value add in formally, recording, assessing, planning mitigation and tracking these risks
  • They can be mitigated as part of operational management
  • They may be informed by incident(s) but are not individual incidents
  • They are operational challenges that ‘keep you awake at night’

Riskman at BM/M/CS includes a Operational Risk Register module. The BM/M/CS Risk Register can be accessed through staff’s Riskman log-in, accessible through this link.  Click on My Workspace, New, Risk Entry to enter a new risk or update an existing risk. 

The Quality Team are available for assistance in using the Risk Register:

Currently, this Risk Register is not well utilised. BM/M/CS staff will be consulted to see how they can be supported to use a Risk Register and risk management processes to help the ongoing review and improvement of best care. 

Transition activity is yet to commence on utilising one Risk Register covering all of Western Health.


Incident management is an integral part of providing Safe Care at Western Health. All staff are encouraged to report clinical, staff and facility incidents so we can learn from them and put strategies in place to minimise the risk of them happening again. At Western Health, incidents are reported and acknowledged without fear of blame or retribution.

The current incident review process at BM/M/CS is summarised in the following graphic.

Riskman at BM/M/CS includes a module to report and follow-up patient, staff and facility incidents. This Incident Management module can be accessed through staff’s Riskman log-in, accessible through this link

Click on My Workspace, New, Incident Entry to enter a new incident or update an existing incident. 

The Quality Team are available for assistance in using the Incident Management module on Riskman:

A plan is being developed to transition to one Riskman Incident Management system for all of Western Health. This is a big task that includes a Riskman upgrade, and will take several months. 

In the meantime, training is available to update staff knowledge on general incident reporting and follow up. If you missed the Riskman refresher training sessions held in November, email to organise a session for yourself and/or your team.  

In addition, BM/M/CS have adopted some of Western Health templates for the review of incidents, including for serious incidents covering PPH and perineal tears.


Improvement and innovation is alive and well at BM/M/CS. It is visible in the day-to-day efforts of staff to improve care and services and how staff have embraced new care and service opportunities, including for example providing a vital COVID testing service for the community.

Currently, Riskman at BM/M/CS includes a Quality Improvement Register to support the planning and reporting of improvement activity.

The Quality Improvement Register can be accessed through staff’s Riskman log-in, accessible through this link. Click on My Workspace, New, Risk Entry to enter a new risk or update an existing risk.  The Quality Team are available for assistance in using the Quality Improvement Register:

Currently, this Register is not well utilised. BM/M/CS staff will be consulted to see how they can be supported to use a Quality Register and improvement methodology to help the ongoing review and improvement of best care. 

Transition activity is yet to commence on utilising a common methodology supporting ongoing quality improvement activity across Western Health.

Drawing heavily from the excellent BM/M/CS MAP Report, a new Performance Dashboard has been developed. This monthly dashboard is set against the elements of best care – person-centred, co-ordinated, right and safe care and is discussed at the newly implemented Bacchus Marsh/Melton Quality & Safety Committee meeting. These discussions inform performance reporting on best care at Bacchus Marsh/Melton at the wider Western Health operational level. 

Following discussion with the Department of Health, quarterly BM/M/CS performance reports and patient satisfaction survey reports have been added to Western Health reports. These are reported on at WH executive and board level meetings.