Peninsula Health

The Quality and Customer Service Department oversees the monitoring and development of systems that monitor and promote patient safety. This is Risk Management and is the process for determining what, where, when, why and how something could happen that might adversely affect a patient or system outcome and how we work to ensure it does not happen again.  We use a variety of tools and tests, both from within our organisation and from external sources, to gauge how we are performing. 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.

Robust Clinical Governance is the way we ensure we have in place the right people and right systems so that we continue to provide you with the highest standards of care. Clinical Governance is implemented through a framework based on the Victorian Government Clinical Governance Policy Framework which promotes consumer participation, clinical effectiveness, an effective workforce and risk management. 

The Peninsula Health Board Quality and Clinical Governance Committee oversees Clinical Governance at the Health Service. The Committee, chaired by a Board Director and attended by Board Directors, the Chief Executive Officer, Executive Directors and members of the Quality Department, monitors the work of each service within Peninsula Health  to continuously improve quality and safety. Consumers also participate on this Committee and others within the organisation, providing invaluable input into the work we do.

Areas of service and safety monitored by the Quality and Customer Services Department include:

• Infection Prevention and Control is an important Unit that is responsible for monitoring infection prevention and risks to patients and staff, to ensure a safe hospital environment. The Infection Control Consultants provide expert advice and consult on a broad range of activities within the health service. They implement measures to reduce infections and the impact of those infections on patients.  The Infection Control and Prevention Team works closely with all staff to develop guidelines and policies that guide clinical practice,  educate, support and monitor staff in infection control practices including hand hygiene and staff immunisation.

• The Mortality, Morbidity and Major Review Committee reports on patient safety issues to the Board Quality and Clinical Governance Committee. Sentinel events, serious adverse events and deaths are reviewed by the Committee with the assistance of independent audit undertaken by an external medical expert.

• Patient Safety is everyone’s responsibility and the Quality and Customer Services Department monitors care people receive in hospital. The Patient Safety Unit investigates any adverse or near miss events.  Peninsula Health fully investigates these types of events to improve practice and help prevent similar events  from happening again.   

• Victorian Health Incident Management System (VHIMS) is a state-wide system that is monitored by the Quality and Customer Services Department.  This Incident Management System was implemented across the health service in July 2010.  Information provided by the system is evaluated and investigated where required.

• The Consumer Information Steering Committee is newly established and monitored by the Quality and Customer Services Department. Consumers participate as members of this committee.   This committee has been developed to ensure information developed across the health service is clear, relevant, accessible and friendly to the consumer.

• The Quality and Customer Services Department  utilises two avenues to monitor our consumers voice:

1. The Victorian Patient Satisfaction Monitor (VPSM) is an independent body which regularly monitors and reports on patient satisfaction with public hospital services throughout Victoria. This information allows Peninsula Health to compare patient satisfaction against like hospitals and the state.  
2. Peninsula Health seeks ‘on the spot’ feedback from consumers across the organisation by utilising Feedback forms. Our volunteers are available to assist patients with the completion of the forms if required. The internal feedback is analysed by individual departments and wards and is reported to the Board of Directors.

• Customer Relations Service is part of the Quality and Customer Services Department and is responsible for responding to your complaints and concerns.  Complaints and compliments provide an opportunity to better understand how best to improve our services.  Peninsula Health welcomes feedback on the services it provides and works with consumers to resolve their concerns. We encourage our consumers to express their concerns via telephone, Peninsula Health’s website, in writing, in person to the person in charge of the relevant department or program or the Customer Relations manager at customer.relations@phcn.vic.gov.au  

Some other areas the Quality and Customer Service Department manage include:

• Implementation and maintenance of the Patient Charter of Healthcare Rights program throughout Peninsula Health.
• Improvements to the Consent Policy to ensure patients are adequately informed before giving consent to treatment.
• Management of Blood and Blood Product Administration Safety.
• Management, maintenance and development of Clinical and Care Planning Pathways to ensure patients are provided with evidence based best possible care.
• Management of the Redesigning Care Project to embed best practice management into service delivery.
• Management of Medico legal support for issues such as police summonses or subpoenas.

The Quality of Care Report is developed by the Quality and Customer Services Department and provides an opportunity to report to our consumers our achievements in quality and safety, and identify the improvements made to continue to achieve higher standards of care. We invite your feedback on this report. To learn more about our quality systems and services you can view the 2010 Quality of Care Report (2.95 MB).