Best Care at Western Health

We will demonstrate the Western Health values in all that we do… compassion, accountability, respect, excellence, safety.

Click on the statements below to learn more.

 

Person-Centred Care

Person-Centred care involves seeing the person in the patient and providing care that is welcoming, respectful and designed to engage patients in care decisions and management of care.

“I am seen and treated as a person”

Here is a message from Shane Crowe, Executive Director Nursing and Midwifery

 

 

Organisation-wide Systems supporting Person-Centred Care

In line with WH’s ‘Patient First’ approach, consumers are engaged in a number of systems that support the review and improvement of person-centred care.

These include consumer representation on WH committees and working groups aligned with person-centred care, consumer feedback and patient story programs, the use of Volunteers to support person-centred care delivery, and opportunities for consumer engagement in improvement project co-design.

The executive sponsor of person-centred care is the Executive Director of Nursing & Midwifery.

A Person-Centred Care Committee oversees monitoring, review and improvement activity aligned with person-centred care, and provides a reporting line for related clinical committees and working groups. This Committee has consumer representation and reports to the WH Best Care Steering Committee.

A number of WH policies, procedures and guidelines focus the delivery of person-centred care. These are accessible to staff through the WH intranet and undergo review as scheduled or as indicated.

A number of systems exist to support staff to understand and ‘live’ person-centred care in their day-to-day interactions with patients and/or the provision of services.

These include orientation on Best Care, training opportunities for specific clinical practice aligned with person-centred care, clinical supervision, performance development programs, and credentialing and scope of practice processes.

A number of systems exist to support staff to continuously monitor, report and review how we are providing person-centred care. This includes risk management systems such as incident reporting, clinical audit, and the use of in-house and benchmarked indicator data sets.

This information supports the identification and actioning of opportunities to improve the way in which we provide person-centred care.

From a strategic perspective, Western Health identifies objectives and strategies for a three year period relating to person-centred care. 

Person-Centred Care is aligned with the NSQHS Standard on Comprehensive Care and the focus across the Standards on care for Aboriginal Health & Torres Strait Islander patients.

Co-ordinated Care

Co-ordinated care involves providing prompt access to patient services, with a smooth patient journey that is designed to optimise time to care through efficient service provision.

“I receive help, treatment and information when I need it and in a co-ordinated way”

Here is a message from Natasha Toohey, Executive Director Operations

 

 

Organisation-wide Systems supporting Co-ordinated Care

In line with WH’s ‘Patient First’ approach, consumers are engaged in a number of systems that support the review and improvement of co-ordinated care.

These include consumer representation on WH committees and working groups aligned with co-ordinated care, consumer feedback and patient story programs, the use of Volunteers to support co-ordinated care delivery, and opportunities for consumer engagement in improvement project co-design.

 

The executive sponsor of co-ordinated care is the Executive Director of Operations.

A Co-ordinated Care Committee oversees monitoring, review and improvement activity aligned with co-ordinated care, and provides a reporting line for related clinical committees and working groups. This Committee has consumer representation and reports to the WH Best Care Steering Committee.

A number of WH policies, procedures and guidelines focus the delivery of co-ordinated care. These are accessible to staff through the WH intranet and undergo review as scheduled or as indicated.

A number of systems exist to support staff to understand and ‘live’ co-ordinated care in their day-to-day interactions with patients and/or the provision of services.

These include orientation on Best Care, training opportunities for specific clinical practice aligned with co-ordinated care, clinical supervision, performance development programs, and credentialing and scope of practice processes.

A number of systems exist to support staff to continuously monitor, report and review how we are providing co-ordinated care. This includes risk management systems such as incident reporting, clinical audit, and the use of in-house and benchmarked indicator data sets.

This information supports the identification and actioning of opportunities to improve the way in which we provide co-ordinated care.

From a strategic perspective, Western Health identifies objectives and strategies for a three year period relating to co-ordinated care. 

Co-ordinated Care is aligned with the NSQHS Standard on Communicating for Safety.

Right Care

Right Care involves providing appropriate, equitable and effective care for each person.

“I receive care that makes me feel better”

Here is a message from Dr. Narelle Watson, Director Quality, Safety and the Patient Experience

Organisation-wide Systems supporting Right Care

In line with WH’s ‘Patient First’ approach, consumers are engaged in a number of systems that support the review and improvement of right care.

These include consumer representation on WH committees and working groups aligned with right care, consumer feedback and patient story programs, the use of Volunteers to support right care delivery, and opportunities for consumer engagement in improvement project co-design.

The executive sponsor of right care is the Director of Quality, Safety & the Patient Experience.

A Right Care Committee oversees monitoring, review and improvement activity aligned with right care, and provides a reporting line for related clinical committees and working groups. This Committee has consumer representation and reports to the WH Best Care Steering Committee.

A number of WH policies, procedures and guidelines focus the delivery of right care. These are accessible to staff through the WH intranet and undergo review as scheduled or as indicated.

A number of systems exist to support staff to understand and ‘live’ right care in their day-to-day interactions with patients and/or the provision of services.

These include orientation on Best Care, training opportunities for specific clinical practice aligned with right care, clinical supervision, performance development programs, and credentialing and scope of practice processes.

A number of systems exist to support staff to continuously monitor, report and review how we are providing right care. This includes risk management systems such as incident reporting, clinical audit, and the use of in-house and benchmarked indicator data sets.

This information supports the identification and actioning of opportunities to improve the way in which we provide right care.

From a strategic perspective, Western Health identifies objectives and strategies for a three year period relating to right care.

Right Care is aligned with the NSQHS Standard on Clinical Governance

 

Safe Care

Safe care involves the design and delivery of care and services to minimise the risk of patient harm.

“I feel safe”

Here is a message from Dr. Paul Eleftheriou, Chief Medical Officer

Organisation-wide Systems supporting Safe Care

In line with WH’s ‘Patient First’ approach, consumers are engaged in a number of systems that support the review and improvement of safe care.

These include consumer representation on WH committees and working groups aligned with safe care, consumer feedback and patient story programs, the use of Volunteers to support safe care delivery, and opportunities for consumer engagement in improvement project co-design.

The executive sponsor of safe care is the Chief Medical Officer.

A Safe Care Committee oversees monitoring, review and improvement activity aligned with safe care, and provides a reporting line for related clinical committees and working groups. This Committee has consumer representation and reports to the WH Best Care Steering Committee.

A number of WH policies, procedures and guidelines focus the delivery of safe care. These are accessible to staff through the WH intranet and undergo review as scheduled or as indicated.

A number of systems exist to support staff to understand and ‘live’ safe care in their day-to-day interactions with patients and/or the provision of services.

These include orientation on Best Care, training opportunities for specific clinical practice aligned with safe care, clinical supervision, performance development programs, and credentialing and scope of practice processes.

A number of systems exist to support staff to continuously monitor, report and review how we are providing safe care. This includes risk management systems such as incident reporting, clinical audit, and the use of in-house and benchmarked indicator data sets.

This information supports the identification and actioning of opportunities to improve the way in which we provide safe care.

From a strategic perspective, Western Health identifies objectives and strategies for a three year period relating to safe care. 

Safe Care is aligned with the NSQHS Standards on:

  • Infection Prevention
  • Medication Management
  • Deteriorating Patient
  • Blood Management

        

Best Care Governance

A number of quality systems support the governance of Best Care.

These systems are grouped under five headings – Leadership, Process, Workforce, Improvement, and as the central point ‘Patient First’.

Here is a video from Russell Harrison, Chief Executive Officer on Best Care

At Western Health we are committed to high quality care that is safe, person-centred, right and co-ordinated – we are committed to Best Care.

To provide Best Care for patients, we must constantly put them first, listen to them and their families and constantly review, enhance and improve how we deliver care.

The Best Care Framework outlines how Western Health – in partnership with our patients and their families; building on the strengths of our clinical and health support staff; and supported by managers, the Executive and the Board – continues to strive for our Vision for Best Care.

(Click on this link to access the Best Care Framework document)

This Vision (see graphic below) has been developed following consultation with patients and their families, staff leaders, clinicians, Executive and the Board and identifies how we wish to develop as an organisation over the coming years. The vision has a clear focus on our patients experiencing care that is personal, co-ordinated, safe and right for their clinical needs.

Every single staff member at Western Health – either directly or indirectly, whether clinical staff, non-clinical staff or volunteer – makes a contribution every day to supporting the provision of Best Care and the best experience for our patients.

Delivering Best Care within the complexity of our health system is not always easy. It requires people to be clear about what they need to achieve, it requires each of us to strive for excellent communication with our colleagues and with patients and their families, and it requires a commitment to wanting to achieve a high quality outcome even when we are busy and under significant pressure.

Our values at Western Health of compassion, accountability, respect, excellence and safety (CARES) are the foundation on which Best Care is set.

Patients and staff when asked about their expectations identified four essentials in order for the care provided to be “Best Care”:

  • Genuine listening to, understanding of, and respect for patients, their carers and staff
  • Co-ordination of teams and processes
  • Improving their health
  • Provision of care in the safest manner feasible for patients and staff

To ensure that we can provide the best care, we need to translate these expectations into day-to-day behaviours and priority actions to improve point of care clinical practice and systems supporting person-centred, co-ordinated, right and safe care for every patient, every time, everywhere.

Everyone has a role in the Vision of delivering Best Care at Western Health. Let’s see what we can do together.

… 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 Western Health’s Best Care Framework that support staff to lead, drive and create care that is person-centred, co-ordinated, safe and right for clinical needs.

Patient First focuses on consumer partnerships to support planning, design, delivery, measurement and evaluation of care.

In line with the Safer Care Victoria (SCV) 2019 ‘Partnering with Healthcare’ framework, five focus areas have been developed for Patient First to help us identify and bring together systems and improvements across Western Health that may bring real benefits to a positive patient experience.

These focus areas were identified through extensive consultation by SCV with consumers, health professionals and community members. Western Health has adopted these focus areas and adapted consumer goals to align with our Best Care Framework focus on Patient First.

The five focus areas of ‘Patient First’ are:

              • Working Together …           I am included as a respected partner in reviewing and improving healthcare
              • Shared Decision MakingI am supported to make informed decisions about my healthcare
              • Personalised & Holistic …   I receive personalised care that is informed by the experiences of others and supports me as a whole person
              • Equity & InclusionI receive care that is considerate of patient diversity and promotes inclusion
              • Effective CommunicationI receive high-quality information that I can readily understand and act upon

Systems

In line with WH’s ‘Patient First’ approach, consumers are engaged in a number of systems that support the provision, review and improvement of care that is person-centred, co-ordinated, safe and right for clinical needs.

These include:

  • Engaging consumers in partnership opportunities
  • Co-designing care and service improvement with consumers and families
  • Identifying and enhancing key staff-patient communication and decision-making points across the patient journey
  • Incorporating consumer views and experiences into training and education
  • Using patient stories and feedback data to inform care and service delivery improvements
  • In consultation with consumers, improving the cultural safety of vulnerable patient groups
  • Engaging consumers in the development of clear written information
  • Providing different ways for consumers to provide feedback about their experiences in healthcare

Improvement

Developing, implementing and enhancing systems to support ‘Patient First’ is a shared responsibility across all of the areas of Western Health.

A ‘Patient First’ Committee brings together and supports system improvement designed to bring real benefits to a positive patient experience. Membership of this Committee includes staff who have specific roles regarding consumer partnerships, as well as those with a special interest in this area.

From a strategic perspective, Western Health identifies objectives and strategies for a three year period area against our grouped quality systems supporting Best Care.

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

 

A range of operational systems are in place to support Best Care Leadership. These focus on:

  • Promoting a culture of Best Care
  • Using a Best Care Framework
  • Maintaining a Committee structure to support Best Care
  • Considering Best Care in business decision-making
  • Providing opportunities for leadership development to support Best Care

From a strategic perspective, Western Health identifies objectives and strategies for a three year period area against our grouped quality systems supporting Best Care. An annual WH Best Care Action Plan identifies implementation actions against the documented strategies. This Action Plan informs and is informed by the annual Western Health Business Planning Process.

The following is the organisational objective and strategy identified against Best Care leadership for the period 2017-20.

A new three year strategy will be developed in line with and informed by the development of Western Health’s new strategic plan in 2020.

 

Organisational Objective Organisational Strategy We will know if we are successful by …
By the end 2019/20, clinical practice at the                front-line will be enhanced by the practical application of Best Care Implement ‘Live Best Care’ initiatives to relate Best Care to the provision and ongoing improvement of clinical practice at the front line Front line staff being able to describe enhancement to clinical practices aligned with the Best Care goals of person-centred, co-ordinated, right and safe care

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

A range of operational processes are in place to support our workforce to provide Best Care. These focus on:

  • Translating externally set standards and the best available evidence into process and practice that supports Best Care
  • Maintaining current, best care related policies, procedures & guidelines
  • Ensuring availability of comprehensive accurate and integrated healthcare records
  • Securely sharing accurate clinical information with authorised clinicians
  • Supporting clinicians to use the best available evidence
  • Monitoring & managing variation in clinical practice

From a strategic perspective, Western Health identifies objectives and strategies for a three year period area against our grouped quality systems supporting Best Care. An annual WH Best Care Action Plan identifies implementation actions against the documented strategies. This Action Plan informs and is informed by the annual Western Health Business Planning Process.

The following is the organisational objective and strategy identified against Best Care process for the period 2017-20.

A new three year strategy will be developed in line with and informed by the development of Western Health’s new strategic plan in 2020.

 

Organisational Objective Organisational Strategy We will know if we are successful by …
By the end 2019/20, WH’s application and the independent assessment of version 2 of the National Standards for Safety and Quality will improve clinical processes supporting Best Care Plan and implement a transition from version 1 to 2 of the National Standards On independent assessment (accreditation), compliance with version 2 of the National Standards

 

A range of workforce management related operational systems are in place to support our staff to provide Best Care. These focus on:

  • Supporting the workforce to understand their role and responsibilities for Best Care
  • Appropriately orienting and training the workforce to provide Best Care
  • Ensuring clinicians are appropriately credentialed and work within agreed scope of practice
  • Routinely reviewing individuals’ performance in provide Best Care
  • Providing supervision to clinicians to provide Best Care

From a strategic perspective, Western Health identifies objectives and strategies for a three year period area against our grouped quality systems supporting Best Care. An annual WH Best Care Action Plan identifies implementation actions against the documented strategies. This Action Plan informs and is informed by the annual Western Health Business Planning Process.

The following is the organisational objective and strategy identified against a Best Care workforce for the period 2017-20.

A new three year strategy will be developed in line with and informed by the development of Western Health’s new strategic plan in 2020.

 

Organisational Objective Organisational Strategy We will know if we are successful by …
By the end 2019/20, improved organisational capability and positive workplace will enhance the provision of Best Care Plan and implement the 2018-2020 WH Best People Roadmap Improved measures in the annual People Matter Survey

 

A range of operational systems are in place to support our workforce to engage in Best Care improvement activity. These focus on:

  • Utilising purposeful information collection from audits, indicators and incidents to analyse, share and respond to identified risks and opportunities to improve Best Care
  • Supporting improvement activity to maximise positive impact on patient care and outcomes
  • Reporting and recognising Best Care Improvement activity

From a strategic perspective, Western Health identifies objectives and strategies for a three year period area against our grouped quality systems supporting Best Care. An annual WH Best Care Action Plan identifies implementation actions against the documented strategies. This Action Plan informs and is informed by the annual Western Health Business Planning Process.

The following is the organisational objective and strategy identified against Best Care improvement for the period 2017-20.

A new three year strategy will be developed in line with and informed by the development of Western Health’s new strategic plan in 2020.

 

Organisational Objective Organisational Strategy We will know if we are successful by …
By the end 2019/20, measurable clinical practice improvement within WH will be supported by a systematic and consistent org-wide approach to improvement Establish the ‘Western Way’ – a systematic and consistent org-wide approach to clinical practice improvement A visible ‘Western Way’ with measurable clinical practice improvement and positive feedback from staff

 

 

 

 

 

 

Our Quality Systems are aligned with the NSQHS Standards on Clinical Governance and Partnering with Consumers

   

 

Adapted from the Victorian Safer Care Victoria Organisational Strategy for Improvement Matrix (OSIM), the Western Health Quality System Capability Matrix (QSCM) is an in-house capability measurement tool designed to help Western Health identify, measure and monitor organisational quality system capability accelerators and barriers.

It is structured around the following WH Best Care governance domains:

  • Process: Organisational systems and structures
  • Workforce: Workforce capability and development
  • Improvement: Results and system impact
  • Leadership: Culture and behaviours

The Live Best Care learning package includes 17 questions on the ‘Systems Supporting Best Care’ and the 2019 responses provided by staff have been used to inform the QSCM self assessment and provide a current maturity score and current maturity level for Best Care at Western Health. The Best Care Maturity Assessment will be used as a basis for future action plan development.

Reviewing the results of the Western Health QSCM for Best Care, the current maturity score for Best Care was assessed as 3.8 out of 5, and current maturity level was assessed as 3 – Refining. Striving for excellence, Western Health’s target maturity level score for 12 months time was assessed as 4.7 and target maturity level for 12 months time was 4 – Consolidating.

‘Patient First’ is the central focus of the quality systems described in Western Health’s Best Care Framework that support staff to lead, drive and create care that is person-centred, co-ordinated, safe and right for clinical needs. Patient First focuses on consumer partnerships to support planning, design, delivery, measurement and evaluation of care.

In line with the Safer Care Victoria (SCV) 2019 ‘Partnering with Healthcare’ framework, five focus areas have been developed for Patient First to help us identify and bring together systems and improvements across Western Health that may bring real benefits to a positive patient experience:

Working Together …  I am included as a respected partner in reviewing and improving healthcare
Shared Decision Making … I am supported to make informed decisions about my healthcare
Personalised & Holistic …   I receive personalised care that is informed by the experiences of others and supports me as a whole person
Equity & Inclusion … I receive care that is considerate of patient diversity and promotes inclusion
Effective Communication … I receive high-quality information that I can readily understand and act upon

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The Best Care Committee structure is imbedded within and supports the overall Western Health Committee structure, designed to support governance against WH’s five Strategic Aims.

The peak clinical governance committee is the Board, with quality care monitored by the Board Quality and Safety Committee and operationalised by the Best Care Steering Committee and reporting Committees covering the four Best Care domains. Each Best Care Committee has an Executive sponsor.

Divisonal Quality and Safety as well as M&M Meetings feed into the Best Care Committee structure, while operational meetings from ‘ward to board’ inform the focus and activity of groups within this structure.

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Education & Learning is committed to high quality, safe and person-centred patient care – we are committed to Best Care.

To provide Best Care, Education is committed to offering staff programs that continually develop their capabilities and skills.

Western Health aims to provide  work based education and training for staff, students and external applicants which will support excellence in practice and career progression opportunities. We are pursuing multi-disciplinary approaches, patient-centred care and lifelong learning.  

All programs utilise the services of suitably qualified and vocationally experienced educators and clinicians.

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The Live Best Care Improvement Framework provides a systematic, organisation-wide approach to quality improvement, and sets out how this can be achieved  by building individual and organisational capability.

It ensures that continuous improvement can be achieved across the Best Care domains.

The framework includes the process steps required for carrying out an improvement project.

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Incident management is an integral component to Western Health’s quality and safety system. 

A clinical incident is when harm occurs to a patient, or could have occurred to patient, while they are receiving care from a health service, Western Health in this case.  Examples include but are not limited to falls, medication errors, pressure injuries, and hospital acquired infections.
 
We report clinical incidents so that we can learn from them and put strategies in place to minimise the risk of them happening again.
We also collect data about them so we can learn what is happening across the health service.
 
This collection is done through a secure data storage program, Riskman.  The Department of Health and Human Services mandate that all public health services in Victoria use Riskman to report and record incident data.

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The Western Health Policy and Procedure/Guideline Framework assists the organisation to establish leadership, responsibility and accountability through clearly structured, articulated and accessible policies, procedures/guidelines.

​The details of the Policy and Procedure/Guideline Framework are outlined in the associated ‘Corporate and Clinical Policies’ policy and ‘Policy & Procedure/Guideline Framework – Operation’ procedure.
 
Western Health policies set our organisation’s expectations and boundaries within which staff are expected to act when performing duties and making decisions. They establish areas of authority and regulate organisation-wide consistency.
 
Western Health procedures represent an implementation of policy by supplying a more specific guide to action.  Whilst procedures may be tailored to suit local requirements, they must reflect the policy under which they sit.  Procedures within Western Health can be organisation-wide (ie practice is multidisciplinary and takes place across multiple divisions/departments), divisional (ie practice takes place within or involves a single division/department or profession) or take the form of clinical practice guidelines.  These guidelines are a distillation of current evidence and opinion on best practice.

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WH has a documented Risk Policy and Risk Management Framework. The Framework is refreshed annually. WH’s approach to risk management maps to the International Standard ISO 31000:2009.

​Risk management processes are supported by ongoing risk assessment and mitigation activities at various levels of the organisation’s operation:

What do we do when things go wrong around here? – routine operational systems supporting risk identification & mitigation
 
Strategic Risk Profiling – identifying and mitigating a small number of threats or opportunities against WH’s Strategic Aims that may materially affect the health of the organisation.
 
Operational Risk Profiling – using the annual business plan and operational reporting processes to drive the identification and mitigation of threats or opportunities that may materially affect operations
 
Clinical Risk Profiling – using the National Standards for Quality & Safety to guide clinical risk identification and mitigation. 
  
Project Risk Profiling – identifying risks & mitigations for significant projects in business cases and change management plans​

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Clinical practice and health outcome variation monitoring is a critical component of the cycle of monitoring, improving and evaluating our provision of Best Care and supporting care that is person-centred, co-ordinated, right and safe for every patient, every time, everywhere. 

Western Health systematically monitors the quality (appropriateness and effectiveness of health care) by routinely collecting, analysing and reporting health-related information.

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