At Peninsula Health we ensure the quality of what we do by constantly and consistently measuring how we are performing. We use a variety of tools and tests, both from within our organisation and from external sources, to gauge how we’re doing. Then we respond to the information by extending what works well and finding new and better ways to manage activities that are not as efficient or successful as we would like.
One of our basic means of monitoring performance is through what we call our Quality and Clinical Governance Framework. This consists of the Board Quality and Clinical Governance Committee and Subcommittees that keep an eye on everything that we do to ensure we deliver safe, high quality services. They also challenge the way we do it, which drives continuous improvement across the health service.
The Peninsula Health Quality and Clinical Governance Committee of the Board of Directors is the main committee, which reviews performance and is chaired by a member of the Board. Feedback from consumers is reported every eight weeks to the committee. This includes complaints as well as compliments. The Quality and Clinical Governance Committee is also the place where we review how we are meeting the targets we have set for our work and our services. These targets are known as Key Performance Indicators, or KPIs. KPIs are set by the CEO and Executive as a way of monitoring key areas of risk and setting targets for improvement in what we do and how we do it.
At Peninsula Health we want to identify potential risks in clinical care and intervene before errors and accidents can happen.
We have a specific Unit dedicated to managing patient safety. The Patient Safety Unit (previously Clinical Risk Unit) commenced in 1999, before any other hospital or health service in Victoria. This unit monitors, reviews and investigates incident reports, adverse events (incidents that result in harm), Sentinel Events (the most serious of adverse events which must be reported to the Department of Human Services), and contributes to quality improvement activities within the health service.
Peninsula Health has three committees whose prime concern is monitoring and improving patient safety:
Patient Safety Committee
The Patient Safety Committee is responsible for making Peninsula Health hospitals and facilities safe for our patients and visitors.
In this committee, we discuss patient incidents that have been reported and ways in which we can prevent such incidents recurring. It is also the place where we focus on the key areas of patient safety improvement.
Mortality Review Committee
The Mortality Review Committee reviews all unexpected deaths that have occurred at any of our sites. We thoroughly review all such events to ensure that we have acted appropriately and put in place changes to procedures where required.
We take this very seriously and liaise with the State Coroner’s Office as required.
Infection Control Committee
The Infection Control Committee is responsible for minimising transmission of infectious disease to patients during their time with us. We have an excellent record in this regard but the Committee takes its job very seriously.
The three committees have representation from senior management, senior medical, nursing and allied health staff, and the Patient Safety Unit.
These committees report to the Board’s Quality and Clinical Governance Committee so that the Board receives information and ideas about patient safety.
Recent achievements in patient care quality and safety:
- We became participants in the Blood Matters Breakthrough Collaborative which aims to improve blood transfusion practices and the handling and prescribing of blood products.
- We appointed a Falls consultant and a Skin Integrity Nurse to look for ways of protecting patients and clients against falls and pressure area sores respectively.
- We became participants in the Medication Safety Breakthrough Collaborative which aims to improve prescribing practices and the safe use of medication.
- There has been greater clinician cooperation in reporting adverse events. This has been achieved through continuous liaison with the Patient Safety Team and through the implementation of new policies and procedures.
- We improved the discharge process to be sure that all patients have follow-up appointments and are notified about them.
For more information download a copy of our most recent Quality of Care Report.
