Quality of Care 2015

peninsulahealth.org.au
Quality of Care
Report
2015

Contents
1 Welcome from the Chairperson & Chief Executive
1 Fast facts
2 Partnering with our community
10 National standards for quality patient care
11 Governance
16 Preventing infection
18 Medication safety
20 Patient identification
23 Right blood for the right patient
24 Preventing and managing pressure injuries
26 Recognising when a patient’s condition is deteriorating
28 Preventing and managing falls
29 Community dental performance
31 Supporting our community
34 Innovation

Peninsula Health Quality of Care Report 2015
1Welcome
We are pleased to present Peninsula Health’s
Quality of Care Report for 2015.
We hope this important Report will be of interest to you
and will help you to understand more about how our health
service functions. By understanding more about what we
do, we believe that you will become an active partner in all
aspects of yours and your family’s healthcare choices and
decisions.
Quality and safety is the most important aspect of
everything we do. This report outlines the work we have
undertaken to achieve the National Safety and Quality
Standards developed by the Australian Commission on
Safety and Quality in Healthcare. We have introduced
a number of important initiatives over the past year to
improve safety and quality and we believe this work is
making a real difference to the services we provide.
Our success in meeting rigorous quality standards is
testament to the excellent improvement initiatives that we
have introduced to maintain high standards and improve
quality and safety.
This work is making a significant difference to the services
we provide and we hope you enjoy reading about our
progress.
We welcome your input on this Report and invite you to
complete the feedback form attached to the inside back
cover. Your feedback will help us develop this publication
to better meet your information needs.
We are proud of our heath service and the quality of
care we provide. We would like to thank the outstanding
contribution of staff, volunteers and consumer
representatives for their ongoing collaboration and support.
Welcome
Chairperson & Chief Executive
Ms Nancy Hogan
Chairperson
Board of Directors
Ms Sue Williams
Chief Executive Officer
Our population for our catchment includes over 281,787 people
Fast Facts:
It is predicted that:
Frankston population 133,560 people
Mornington population 152,260 people
During the holiday seasons the population can increase by 100,000 people
From 2011-2026 the 75-79 year old age group will grow by 66%
By 2031 the prediction is that the over 70 population will grow by 220%
and the over 85 population by 300%

We are committed to working with consumers to create
a health service that is responsive to patient, carer and
consumer needs.
Our partnerships with consumers are based on mutual
openness, trust, respect, equal opportunity, shared
ownership, and communication.
We have an extensive Consumer Participation Program
and we partner with consumers in a number of ways,
ensuring the consumer/carer perspective is reflected in
the care and service we provide.
The Community Advisory Framework consists of the
Community Advisory Committee and 13 Community
Advisory Groups which represent geographical areas
of our community, some key services and community
groups with specific health needs.
Partnering with our
community
Peninsula Health Board of Directors
Community Advisory Framework
Chief Executive – Sue Williams
Executive Director Community Participation – A/Prof Jan Child
Peninsula Health Community Advisory Committee (CAC)
Alcohol and Other Drugs
(AOD) CAG
Cultural and Linguistic
Diversity (CALD) CAG
Disability CAG Older Persons / Carers CAG
Gay, Lesbian, Bisexual,
Transgender, Intersex
Queer (GLBTIQ) CAG
Aboriginal and Torres Strait
Islander (ATSI) CAG
Mental Health CAG Community Health CAG
Womens CAG
Southern
Community Advisory Group
(CAG)
Westernport (CAG)
Mt Eliza Personal
Assistance Call Service
(MEPACS) CAG
Frankston /
Northern Peninsula (CAG)
Person Centred Care Steering Committee

3Partnering with our community
Highlight story:
For any health service, new buildings and services are
exciting – for both staff and the community it serves. Too
often consumer involvement is limited to brief consultation
at the end of the project, once all the decisions have been
made.
The Frankston Hospital re-development provided not
only new, purpose built facilities but importantly the
opportunity to partner with consumers in building
design and in enhancement of models of care ensuring
continued provision of high quality care. In keeping with
our goal of Person Centred Care and our commitment
to partnering with consumers, the redevelopment
saw extensive consumer involvement at all levels of
governance and decision making and through all stages
of planning and development. The new Emergency
Department and wards were designed and built with
safety and quality considerations at the fore and the
specific needs of staff and consumers considered
at every step.
These elements include:
Dedicated paediatric waiting and treatment areas
Dedicated mental health treatment area including
direct ambulance access to maintain safety and
dignity for acutely unwell patients as well as
minimising disruption for other patients
Individual patient areas to provide positive interaction
between staff, patients and carers and facilitating
patient involvement in individual care
Consideration of lighting and noise levels, in particular
access to natural light to support older patients with
cognitive impairment who are at risk of increased
confusion.
These design considerations were the result of the
extensive consumer consultation with a number of original
options reworked based on the combined feedback of
staff and consumers.
The opening of the new Frankston Emergency Departement in February 2015

4
We follow a model of ‘person-centred care’. For patients,
this means we partner with them to provide excellent care
in a way that they understand and allows them to control
the decisions about their future care.
Person Centred Care is an approach to healthcare that
ensures the planning, delivery and evaluation of care
is grounded in mutually beneficial partnerships among
health care providers, patients and their families.
There is increasing evidence that when health care
administrators, staff, patients and families work in
partnership, the quality and safety of health care
improves, staff satisfaction increases and patient, carer
and staff experience improves.
We have in place a Person Centred Care plan, which was
created by staff, in consultation with consumers. The plan
explains that Person Centred Care at Peninsula Health is
about ‘caring for each other’.
For patients and families this means that we will continue
to provide our excellent care in a way that makes patients
partners in their own care, and ensures that patients
understand and control the decisions about their future
care plans.
Partnering with our community
Person-centred care
Consumer information
Consumers need information that is easy to understand
and up-to-date. We have a well-established Consumer
Information Steering Committee responsible for reviewing
all information produced for our consumers. The
Committee includes consumers who work alongside staff
from across the health service to review all pamphlets,
brochures, health fact sheets and information about
treatment, services or specific health issues.
We welcome consumer representatives on a range of
Quality and Safety committees such as Falls Prevention
and Medication Safety. We also involve consumers in
other key committees and working groups, including
smoking, car parking and in special projects such as
major re-developments.
In 2014, new consumer representative roles were
introduced into Peninsula Health services and previous
patients and/or carers have joined specific teams to
provide recent consumer perspectives on service delivery
and quality improvement activities within these areas.
For staff, this means that we genuinely look out for
and after each other, that we take time to improve our
personal and professional capacity, and apply the values
of integrity, compassion and respect in our day-to-day
work as teams.

Volunteering
Over 800 dedicated volunteers help us provide a
better healthcare experience for patients, carers and
clients across all areas of our health service. We have
a comprehensive Volunteer Orientation and Training
Program, and volunteer coordinators who provide our
volunteers with day-to-day support. Our volunteers range
in age from 18 to 80, come from varied backgrounds
and possess a wealth of work and life skills. Community
Health Volunteer Coordinator Gloria Callery describes
her volunteers as being united in their dedication,
commitment, kindness and their willingness to lend a
hand.
“It is my great pleasure to know and work with each and
every one of them,” Gloria said.
In 2014 we evaluated our volunteer programs and asked
our volunteers to review their role descriptions and tell us
about team highlights, achievements and areas needing
improvement.
Results
174 volunteers provided feedback about their local
volunteer programs
95% of volunteers are either satisfied or highly
satisfied with their volunteer role
satisfied with the support given by the Volunteer
Coordinator/ Community Participation Team.
satisfied with the training/information provided to
them.
Georgina Fraser, our outstanding young volunteer
Community members interested in
Volunteering at Peninsula Health can contact
volunteers@phcn.vic.gov.au for further information.

The Chair of Peninsula Health’s Gay Lesbian Bisexual
Transgender Intersex and Queer (GLBTIQ) Community
Advisory Group, Julian Conlon, won the Outstanding
Individual Achievement by a Volunteer: Supporting
Diversity Award at the 2015 Minister for Health Volunteer
Awards. Peninsula Health’s Chief Executive Officer Sue
Williams said: “Julian is passionate about healthcare for
everyone, bringing humour and warmth, as well as his
own healthcare experience to his work.”
Volunteer Appreciation Day
Our annual Volunteer Appreciation Day luncheon reminds
us how fortunate we are to have such a diverse and
dedicated community of volunteers - the commitment
by our volunteers sets us apart from other healthcare
services.
This year’s luncheon not only provided an important
opportunity for Peninsula Health to say thank you, it
was also an excellent opportunity for all volunteers to
get together and be acknowledged for the fabulous
contribution they make each and every day. At the
luncheon, 11 volunteers were presented with long service
awards for 15 years of service, eight volunteers were
presented with long service awards for 20 years of service
and two volunteers received long service awards for
25 years of service – an astonishing total of 375 years!
Volunteers leading the way
Peninsula Health is extremely proud of its volunteers.
They work tirelessly with our staff to provide excellent care
and support to our community. Over the past six years,
Peninsula Health volunteers have won the Minister for
Health Volunteer Award – a testament to just how great
our volunteers are.
Winners have included:
2010 Pink Ladies Frankston - Outstanding Team
2011 Gus De Groot - Outstanding Individual
2012 GLBTIQ CAG - Outstanding Team
2013 Jenni O’Sullivan - Outstanding Individual
2014 Tai Chi Leaders – Outstanding Team
2015 Julian Conlon – Outstanding Individual
for Diversity Category
In addition, Peninsula Health has been proud to have the
following volunteers recognised in the Victorian Premiers
Volunteer Awards:
2014 Frankston Hospital Pink Ladies Auxiliary –
Outstanding Team
2015 Georgina Fraser – Winner – Outstanding
Young Volunteer
Volunteer Appreciation Day 2015 Long Service Awards.

These wonderful volunteers work side by side with the
Emergency Department staff to ensure that patients’
families and carers are provided with practical assistance,
emotional support and a whole range of services to make
their often traumatic visit more comfortable.
Volunteers get intensive
In 2014 Intensive Care Unit (ICU) staff warmly welcomed
volunteers as new members Intensive Care Unit team.
The volunteers greet visitors as they enter the Intensive
Care Unit, providing practical support and comfort to
family and friends of patients receiving medical attention.
After her first shift in Intensive Care Unit, volunteer Barb
Hamilton said: “It was great to help out where needed
and all the staff were so friendly. I believe the ICU
volunteer program will be greatly appreciated - it is a very
rewarding role.” Dorothea Wagner believes volunteering
in the Intensive Care Unit is the perfect role for her. “After
stepping back from full-time employment, I wanted to do
something worthwhile with my time. My favourite thing
about being an Intensive Care Unit volunteer is the busy
environment and helping people. I especially enjoy being
there as support and help for the relatives of patients,”
Ms Wagner said.
Special thanks
We recognise and thank Clair Duffus and the terrific
volunteers of the Rosebud Hospital and Aged Care
Opportunity Shop, which sadly closed its doors in 2015.
The Op Shop has been raising funds for various projects
and vital equipment in the healthcare and aged services
departments of the Rosebud Hospital since 1997.
We also acknowledge and thank Dawn and Boyd
Standing who established the Rosebud Hospital Garden
Group in 1994. After more than 20 years of tending to the
beautiful gardens of Rosebud Hospital, they packed away
their secateurs and retired from the gardening group.
We sadly said our goodbye to Sue Phillips, long standing
Volunteer and President of the Rosebud Hospital Pink
Lady Auxiliary. Sue passed away suddenly this year and is
sadly missed by staff and patients at Rosebud Hospital.
A milestone
This year we celebrated the 10th anniversary of the
Assistance and Care in Emergency (ACE) volunteer
program in the Frankston and Rosebud Emergency
Departments. This dynamic and dedicated group of 130
volunteers provides an invaluable service to patients
and carers attending our Emergency Departments.
Diversity
Our aim is to meet the diverse health and well-being
needs of everyone in our community in a person
centred, respectful, and responsive way. Peninsula
Health has a strong Diversity Framework, which outlines
our commitment that all people have equal access to
health services and resources within our community. The
Peninsula Health Diversity Plan focuses on the specific
needs of our Aboriginal and Torres Strait Islander peoples,
Cultural and Linguistic Diverse communities, Gay,
Lesbian, Transgender, Bisexual, Intersex and Queers, and
Disability community members.
Disability action plan
We aim to create an environment that recognises
each individual’s needs and preferences. Our Disability
Action Plan 2014-2016 helps us to meet the needs of
people with a disability who use, visit or work within our
organisation. The Plan is monitored by our Disability
Community Advisory Group. Members of this group
partner with service areas across Peninsula Health to
improve healthcare for people with a disability.
Achievements:
Completion of the Disability Action Plan Self-
Assessment Tool by a number of service areas
Linkage with Disability Volunteer Agency to support
increased opportunities for people with a disability to
volunteer
Raising awareness of the specific needs of people
with a disability through International Day of People
with Disability events
A high needs accessible toilet has been included in
the new building at Frankston Hospital.

Multicultural richness
The Cultural and Linguistic Diversity (CALD) Community
Advisory Group includes diverse community members,
representatives from local community services, and
Peninsula Health staff. The group has members who
represent the multicultural richness of our community and
who understand the range of issues that arise in providing
health services for Cultural and Linguistic Diversity
communities. We have a Cultural and Linguistic Diversity
Plan and a new Cultural and Linguistic Diversity Plan
2015-18 is currently being developed.
Interpreter services
When patients are admitted to hospital they can ask to
have an interpreter, if they speak a language other than
English. Referrals to the Interpreter Service have remained
stable over the past 12 months. There were 2,114
referrals for the financial year 2014-2015. The top five
languages requested are Mandarin, Greek, Italian, Auslan
(Australian sign language) and Arabic. The areas requiring
the highest language service support are: Obstetrics
and Ante Natal Clinics, Dental Outpatients, General
Outpatients, Community Health and the Mount Eliza Aged
Care centre.
Peninsula Proud 2015
The Gay, Lesbian, Bisexual, Transgender, Intersex and
Queer (GLBTIQ) community’s Peninsula Health Proud
Midsummer Festival was held in January 2015 Art Show
ran from Tuesday 20 January through to Saturday 7
February. It explored Gay, Lesbian, Bisexual, Transgender,
Intersex and Queer relationships through artwork and
multimedia presentations. The guest speaker was Tony
Briffa, a human rights activist.
Walking together in reconciliation
Peninsula Health’s inaugural Reconciliation Action Plan
was launched last October with representatives from the
Boon Wurrung Foundation, the Peninsula Health Board
of Directors and the Peninsula Health Chief Executive
Officer, Sue Williams. The Reconciliation Action Plan is an
important collaborative document, which outlines how the
entire organisation will make healthcare for Aboriginal and
Torres Strait Islanders more accessible.
Frankston has the highest percentage (42%) of all
Aboriginal and Torres Strait Islanders hospital admissions
in the Southern Metropolitan Region. Frankston and
Rosebud Emergency Departments have the highest
percentage (56%) of Aboriginal and Torres Strait Islanders
presentations to an Emergency Department in the region.
Achievement so far include:
Womin Djeka (welcome) entry panels have been
developed for the new building at Frankston and are
now displayed at all sites across the organisation.
A Welcome to Country and smoking ceremony was
performed by Boon Wurrung Elder for the opening of
the Frankston Hospital Stage 3 Development.
Cultural Safety Training has been conducted in
collaboration with Victorian Aboriginal Community
Peninsula Health Sponsored the Baany to Warrna
Ngargee Water to Water Festival cultural program in
early 2015 at the Briars, Mt Martha.
The BayMob News has been distributed to key
Aboriginal agencies and communities across the
catchment. Distribution has grown to 2000 recipients
this year.
Care coordination and Aboriginal Hospital Liaison
support has been offered to over 800 patients
Reconciliation Action Plan presentations have been
providedacrossallsitesandincorporatedintocorporate
orientation (for all new staff)
A Memorandum of Understanding has been
developed with Boon Wurrung Foundation, traditional
owners for our region.
An Aboriginal and Torres Strait Islander website and
Wirri Girri internal staff newsletter has been created
An Aboriginal Health Policy has been developed
Aboriginal and Torres Strait Islander flags have been
installed at all key sites
Peninsula Health hosted and sponsored National
Aboriginal and Islander Day Observance Committee
and Reconciliation (NAIDOC) Week events
Four Aboriginal trainee positions have been created in
Dental and Aboriginal services.

Overall Hospital
Experience Survey Score
July – Sep 2014 Oct – Dec 2014 Jan – March 2015
State Wide 89.3% 89.3% 87.7%
Peninsula Health 87.7% 85.5% 83.4%
Frankston Hospital 86.7% 83.8% 81.5%
Rosebud Hospital 94.7% 93% 91%
What your feedback is telling us
Consumer feedback card
We also ask our consumers to complete our own Consumer feedback cards to assist us with improving our care delivery,
services and systems. The feedback cards include inpatients as well as outpatient clinics and home services. We have
volunteers at Frankston, The Mornington Centre and Golf Links Road campuses who visit the wards and help patients enter
their feedback on iPad.
An annual Resident and Relative satisfaction survey is undertaken for the Carinya Psychogeriatric Residential Aged Care service
– with a 43% return rate, the survey results included the following responses.
The overall experience score is the response to ‘very good’ or ‘good’ to the patient’s hospital experience. Participation
rate for Peninsula Health was 26% compared to the State-wide participation rate of 29%. Feedback from our service
users is that the Victorian Hospital Experience Survey is a long survey that is not easy to complete. For this reason,
we have continued to focus on the development of our own Customer Feedback card which is used across the whole
health service and which achieves thousands of responses per annum.
Q Does the resident feel happy with the care they receive? 100% agree
Q Does the resident find the staff helpful and supportive? 92% agree
Q Does the resident feel that staff respect their dignity and privacy? 91% agree
Q Does the resident feel they are able to contribute to their ongoing care? 90% agree
Victorian Hospital Experience Survey
The Department of Health and Human Services asks consumers for feedback on their hospital stay via the Victorian
Healthcare Experience Survey for Victorian Hospitals. This Survey covers all health services in Victoria. There are
specific questions for adults and children in hospital; this includes carers and parents of children under eight years of
age at Rosebud and Frankston Hospitals including the Mental Health Service.

10 National standards for quality patient care
The Australian Commission on Safety and Quality in Healthcare developed the National Safety
and Quality Health Service Standards in 2013 to improve the quality of healthcare.
The Standards focus on key areas of patient care, and ensure that health services work to
close the gap between current practice and best practice. They help us provide safe quality
healthcare to our community. All Standards ensure that we focus on person centred care
delivered in partnership with our staff and consumers.
The standards cover:
Governance for Safety and Quality in Health Service Organisations
Partnering with Consumers
Preventing and Controlling Healthcare Associated Infections
Medication Safety
Patient Identification and Procedure Matching
Clinical Handover
Blood and Blood Products
Preventing and Managing Pressure Injuries
Recognising and Responding to Clinical Deterioration in Acute Health Care
Preventing Falls and Harm from Falls
National Standards for
consistent patient care

11Governance
Governance
Governance structure
This chart shows the structure for
quality and safety
at Peninsula Health.
We are always striving to meet each patient’s expectations for safe and effective healthcare.
Our health service operates in line with a robust clinical governance system which covers:
Our clinical governance system has been developed with extensive input from our patients and
our community to support our commitment to:
1. Person-centred care (involving you and your family in decisions about your care)
2. Service planning (planning and building for the future)
3. Partnering (working with other healthcare providers to provide the healthcare our community needs)
4. Our workforce (helping staff and volunteers learn new skills, work as teams, and find new ways of doing things)
5. Safety and quality (providing high-quality care and meeting Australian standards for healthcare)
6. Learning, teaching and research (working with education and training organisations, to support research,
and to use the best available research to improve healthcare).
Consumer participation
Risk management
Clinical effectiveness
Effective workforce
Board
Board Community Advisory
Committee
Quality and Clinical
Governance Committee
Quality and Clinical
Governance Management
Committee
Transfusion
Safety
Committee
Drug and
Therapeutic
Committee
Clinical
Handover
Emergency
Management
OHS
Consultative
Committee
ID and
Procedure
Matching
Person
Centred Care
Mortality
and Major
Morbidity
Committee
Falls Steering
Committee
Infection
Control
Committee
Skin Integrity
Committee
RiSCE
Committee
Medication
Safety
Committee
Radiation
Safety
Committee
Recognising and
Responding to
Clinical Deterioration
Committee

12
While the external environment is ever-changing, it is
essential for us to be guided by a broad set of principles,
and by local data, in determining how and where to invest
our finite resources. To achieve the ambitious models of
care outlined in this Plan, access, and service delivery will
need to be continually reviewed across Peninsula Health
in conjunction with local primary care providers and
tertiary and academic partners.
You can download a copy of the Strategic Clinical
Services Plan from our website:
www.peninsulahealth.org.au/about-us/publications.
Person-centred care is at the core of everything we do. It
is with this in mind that we have developed an ambitious
10-year-year Strategic Clinical Service Plan to ensure
that we meet the needs of our community in the years
to come. Whilst we will continue to provide high-quality
care in meeting the needs of our local population, we are
driven by innovation and strategic planning. Our aim is to
become the leading academic and health research facility
on the Mornington Peninsula.
Increasing demand due to the health burdens of age and
chronic disease will affect all Australian communities,
and particularly those on the Peninsula. Constrained
resources and technological and medical advances will
require us to continually improve and refine our models of
care to provide the services to meet this demand.
Governance
Our partnerships
Strategic Clinical Services Plan
2015-2025
The partnerships Peninsula Health has with other organisations and services help us deliver
excellent care to our community. These partnerships allow everyone involved to share
expertise, successes and innovation. Some of our key partners include:
Australian Council on Healthcare Standards
Aged Care Standards and Accreditation Agency
City of Frankston
Department of Health
Frankston Magistrates Court
Frankston-Mornington Peninsula Medicare Local
Monash University
Mornington Peninsula Shire
University of Melbourne
Victoria Police
Ambulance Victoria

13Governance
Improvements in 2014-15
Clinical Risk Register
Our Clinical Risk Register was enhanced to ensure we
regularly report and monitor clinical risks from all our sites
and services. This allows us to better identify, monitor and
take immediate action to manage clinical risks across the
whole organisation.
Electronic Systems
We introduced ‘Prompt’, a specialised web-based
document management system and information sharing
portal for health professionals. Staff can now find the
latest policies and procedures quickly and can view other
health services information. Also in November 2014
we introduced the Emergency Department Information
System (EDIS) – an electronic workflow documentation
system which captures key information when a patient
presents to the Emergency Department. This information
is critical in managing patient access and flows.
Our staff
Having the right staff with the right qualifications, skills and
attitude enables us to provide expert, appropriate and
timely care. It also ensures that patients and their families
are kept informed and involved in decisions about their
care. We have a very strong recruitment and credentialing
system in place, to confirm the qualifications, experience
and competence of all our clinical staff.
Regular checks by the Australian Health Practitioner
Regulation Agency (AHPRA), ensures that all staff are
registered so we can ensure they are in an appropriate
role based on their registration. We monitor compliance
with Police Checks and Working with Children checks for
all new staff.
Growing our workforce
We invest in education and professional development for
our workforce through study leave, our clinical simulation
centre, lectures, journal clubs, library, online resources
and online learning courses.
• We work with other organisations to ensure our
workforce provides skilled, appropriate care.
For example, staff participate in teleconferencing with
other organisations such as the Royal Australasian
College of Physicians, they access tutorial Pod Casts
from the Alfred Hospital and take part in the Cardiac
Conference to discuss case management.
• We have a Simulation (SIM) Centre, which enables
staff to undertake training and assessment for
common events or situations. The Simulation Centre
uses case studies, role-play, simulated patients, and
‘virtual environments’ to support staff education.
Through our membership with the Mornington
Peninsula Clinical Placement Network we have
access to additional Simulation Centre facilities at
the Monash Department of Nursing and free access
to simulation equipment via the Asset Hub based at
Holmesglen College.
• There are now nine qualified Nurse Practitioners who
have worked hard to achieve advanced skills and
extend their scope of practice. We also have four
Nurse Practitioner candidates who are at various
stages in the process of qualifying for registration.
xxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxx

14 Governance
People Matter Survey
In 2014 Peninsula Health participated in the Victorian
Public Sector Commission (VPSC) People Matter Survey.
The Peninsula Health survey demonstrated excellent
response rates and positive results. The outstanding
results prompted the Victorian Public Sector Commission
to select Peninsula Health as one of its case study
organisations for the ‘Creating Great Places to Work’
report. The report found that Peninsula Health has a
strong focus on quality and customer care and builds its
culture on opportunities to learn, open communication,
a supportive approach and reflective practice. Amongst
the positive results, respondents to the survey felt that we
have a culture which supports patient safety.
Sometimes things don’t go to plan -
adverse incidents
Peninsula Health uses the Victorian Hospitals Incident
Management System (VHIMS) - a central, online register
used to report incidents, complaints, consumer feedback,
and quality improvement. When an incident or complaint
is received, it is registered by a staff member, and VHIMS
automatically notifies the relevant staff to ensure action
is taken as soon as possible. The VHIMS rates the
type of incident and its severity. It also links to quality
improvement activities so there is a reduced risk of a
similar incident happening again.
We fully investigate all incidents and adverse events.
Reviews are undertaken of deaths and we aim to identify
any circumstance where care could be improved. The
circumstances surrounding a death are reviewed by
senior clinicians across all clinical areas. If a death is
unexpected or occurs as a result of accident or injury, we
report it to the Coroner. A sentinel event is a very serious
but rare incident not caused by a patient’s illness. In
2014-15 Peninsula Health had no sentinel events.
Strengthening governance to protect
children
Our social workers are dedicated to ensuring that all
staff across Peninsula Health area aware of Victoria’s
Vulnerable Children Strategy 2013-2022. We now have
a Vulnerable Children’s Steering Committee, which acts
to inform, train and resource staff to ensure they have
the necessary knowledge and skills when it comes to
protecting children’s rights and safety.
Our social workers have also been trained in a visionary
approach (developed in the US) to help new mothers
understand the importance of talking to their children,
which in turn directly raises literacy rates amongst
children from vulnerable environments.
Our social workers are dedicated to ensuring that all staff across
Peninsula Health area aware of Victoria’s Vulnerable Children Strategy.

15Governance
Adult mental health service seclusion events per 1,000 bed days – Quarterly data
Aged mental health service seclusion events per 1,000 bed days – Quarterly data
Jan-Mar
2014
Apr-Jun
2014
Jul-Sep
2014
Oct-Dec
2014
Jan-Mar
2015
Apr-Jun
2015
Peninsula Health 0 4.7 0 1.2 0 0.6
State-wide 10.9 10 9.4 8.1 9.7 10.5
Jan-Mar
2014
Apr-Jun
2014
Jul-Sep
2014
Oct-Dec
2014
Jan-Mar
2015
Apr-Jun
2015
Peninsula Health 0 0 0 0 0 0
State-wide 0.9 1 0.7 0.3 0.5 1.6
Best Practice
Our Mental Health Services have been consistent statewide leaders in reducing the number of seclusions for
Mental Health clients. Seclusion is sometimes necessary to protect the immediate safety of an acutely unwell
person or others. This excellent outcome is the result of significant staff training and expert clinical governance.
Health service accreditation
The Australian Council on Healthcare Standards (ACHS)
is the main accrediting body for health services. ACHS
is an independent organisation that assesses health
services against the 10 National Safety and Quality Health
Service (NSQHS) Standards. Our accreditation in 2014
had a favourable review with one recommendation that
consumers should be involved in training clinical staff.
We have responded to this recommendation through
our Person-centred Care Plan, which includes consumer
and carer involvement in the training of clinical staff as a
priority for the next 12 months.
Our orientation program includes the screening our
‘Patient Experience’ DVD. This DVD was developed with
three Peninsula Health consumers who talk about their
experience in the health service.
Consumer stories are incorporated in staff education
programs, in person- centred care workshops, clinical
risk education and operational forums. Mental health
consumer and carer consultants are involved in the
development and delivery of education in our Mental
Health Service.
Department of Human Services
Quality Standards review
In May 2015, our Family Violence Service and Paediatric
Continence Support Service were reviewed against the
DHS quality standards. Both teams work with complex
client groups and constantly work to improve services,
embed practice improvements and ensure documentation
demonstrates the provision of high quality of services.
Both team’s strong commitment to quality care was
reinforced by the accreditation outcome of all standards
being met with no recommendations. Feedback from
the accreditors was overwhelmingly positive with praise
for staff regarding their dedication and commitment to
providing person centred high quality services to our
clients.
Residential aged care accreditation
All residential aged care facilities across Australia must
be accredited by the Australian Aged Care Quality
Agency. Peninsula Health’s residential aged care facilities
are reviewed by the Quality Agency every three years.
In 2015, we met all 44 standards and remain fully
accredited.

16
Our Infection Prevention Committee provides advice
and recommendations across the health service. The
Committee includes a consumer representative and
oversees:
Ongoing improvements in infection prevention and
control across the whole organisation
Monitoring of rates of infection against best practice
and our state and national peers
Implementation and ongoing monitoring of
requirements to minimise the risk for patients
acquiring preventable infections in hospital
Effective management of infections if they occur.
We also have an Infection Prevention and Control team.
This team is responsible for:
Raising awareness of infection prevention in reducing
healthcare-related infections
Developing and implementing the infection prevention
strategic plan for patient safety
Promoting ownership of local responsibility for
prevention of hospital acquired infections
Driving improvements with external mandatory
outcome measures.
Hand hygiene
Patient safety is the foundation of all the infection
prevention activities we do across Peninsula Health.
Our goal is zero preventable harm to our patients from
healthcare acquired infections. The single most effective
strategy to reduce risk of infection is the simple act of hand
hygiene (cleaning our hands).
Peninsula Health has continued to improve its results in
2014-2015 by introducing local ownership of results with
training of local auditors to role model good hand hygiene.
Preventing infection
Preventing infection
We have rigorous systems and processes in place to prevent patients from getting preventable
infections while they are in our care. We also use best practice principles to manage these
infections, should they occur.
The single most effective strategy to reduce risk of infection
is the simple act of hand hygiene
How we compare with our peers (how we perform when we clean our hands doing patient care)
Hand Hygiene audit results for 2014 -15
Frankston
Hospital
Rosebud
Hospital
Department of Health and Human Services
Target
Round 3 - 2014 75% 79% 75%
Round 1 - 2015 80.4% 79% 78%
Round 2 - 2015 81.8% 78.5% 80%

17Preventing infection
Targeting zero for intravenous catheter
related blood stream infections
Staphylococcus aureus, or S. aureus, is a common
bacterium that lives on the skin or in the nose. It is also
called golden staph. In most situations, S. aureus is
harmless. However, if it enters the body through a cut in
the skin, it can cause a range of mild to severe infections,
which may cause death in some cases. 2013-2014
saw a record number of blood stream infections from
Staphylococcus aureus (SABs). Frankston Hospital
reported 26 such infections of which 15 were possibly
related to poor intravenous catheter (IV) insertion and
management practices. These infections can often be
prevented by good aseptic technique and hand hygiene
practices.
In response to the Frankston Hospital results, we
established a Staphylococcus aureus Working Party to
review our practices and develop protocols to address
some of the issues. The improvements now in place
include: a dedicated IV insertion kit; and individual
notification to the treating medical unit and nurse unit
manager of each infection with an in-depth case review
of each IV-related infection to identify potential issues
that need to be addressed. We have been raising
education and awareness levels and we have developed
a credentialing program to ensure that all junior medical
staff and nurses who insert IVs are aware of the aseptic
technique and hand hygiene requirements.
In addition, all IVs are reviewed daily by treating medical
teams and are removed, if action is no longer required.
Nursing staff also review each shift and document if any
signs of infection are developing.
For 2014-2015, there has been a 60% reduction in IV
related Staphylococcus aureus. Ongoing work continues
to target zero Staphylococcus aureus infections over the
next 12 months.
2013 - 2014 2014 - 2015
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Frankston
Hospital
1.50 2.20 2.20 1.50 0.30 0.60 0.90 1.90
VICNISS
Aggregate
1.10 0.90 0.90 0.90 0.90 0.90 0.90 1.10
Staphylococcus aureus bacteraemia infection rates have met the Victorian Healthcare Associated Nosocomial Infection
Surveillance aggregate for 2014-15 (Infections per 10,000 occupied days)
Antimicrobial stewardship
Antibiotic resistant bacteria are an increasing problem
worldwide and are a major threat to patient safety.
Infections with antibiotic resistant bacteria are more
expensive to treat, result in longer hospital stays, worse
outcomes for patients and increased deaths.
“Studies have shown that up to 50% of antibiotic use in
hospitals may be inappropriate,” reports the Head of the
Infectious Diseases (ID) Unit, Dr Peter Kelley.
“We know that the overuse and misuse of antibiotics can
produce antibiotic resistance.
Antimicrobial Stewardship aims to improve antibiotic use,
minimise the emergence of resistant bacteria and the
unwanted side effects from antibiotics,” Dr Kelley explains.
At Peninsula Health, an Antimicrobial Stewardship (AMS)
team monitors antibiotic use and resistance rates. The
team performs twice-weekly rounds at Frankston Hospital
and a monthly round at Rosebud Hospital. Patients are
triaged for review and their antibiotic therapy evaluated
for appropriateness. The team also works closely with
the Infection Prevention and Control unit, which monitors
patients with infections and undertakes audits of
antibiotic usage.

18 Medication safety
How do we do this?
When a patient is admitted to hospital it is vital to obtain
an accurate list of all their current medications including
non-prescription items, herbal or natural remedies, creams,
eye drops, injections or patches to ensure that nothing is
missed or incorrectly prescribed. Over the past 18 months
our medication safety team has worked to strengthen
processes to ensure that patients have an accurate
documented medication history as soon as possible on
admission; and that a current medication chart is accurate
against the medication history.
At Peninsula Health more than 80% of patients now have
a medication history documented within 24 hours of
admission.
Patients can assist this process by keeping an up-to-date
list of all their current medications which can be brought
into hospital, if they are admitted unexpectedly; and
bringing their medications to hospital with them so we can
check the exact medication name, strength and dose to
make sure we prescribe it correctly.
Medication safety
We are required to show how we safely prescribe, dispense and administer the right
medicines to patients and that processes are in place to reduce medication errors. We must
also demonstrate compliance with legislative requirements in terms of medication storage,
monitoring and security.
Director of Pharmacy, Skip Lam -
More than 80% of patients now have a medication history
documented within 24 hours of admission

19Medication safety
Going home
When patients leave the hospital, Peninsula Health staff
aim to make sure that the medication list for each patient
is reviewed and adjusted, if there have been any changes
during the admission, and that any changes are discussed
with the patient or their carer and passed on to their regular
treating doctor.
The Electronic Medication Management System allows
an easy on-screen review of the patient’s medication by
their doctors and pharmacists before giving any discharge
prescriptions. Information is automatically transferred to a
patient’s nominated regular treating doctor.
Pharmacists discuss the discharge prescription with the
patient or their family, and provide medicine information to
patients when they are discharged.
Encourage consumer involvement
Our ‘Speak Up’ program encourages patients to be
informed about their medications and allergies and to work
with us to make sure they take their medicines safely.
This is particularly important at discharge time where we
provide information to ensure the patient is aware of and
confident about any new medications or changes and
are clear about when to seek advice, if they have any
concerns.
We encourage all patients and carers to ‘Speak Up’ to staff
when they are unsure about the medicines they are taking.
Blood clot prevention
We aim to ensure patients are protected from preventable
problems such as blood clots. Blood clots account for
around seven per cent of deaths in hospital patients,
and are among the most common preventable cause of
in-hospital death. Blood clots can also contribute to other
long-term health risks.
Most blood clots form in a vein in the leg and can
sometimes travel to the lungs. The formation of blood clots
and the way they travel through the blood stream is called
Venous Thromboembolism or VTE. Research shows that
anti-clotting medication can help reduce the harmful effects
of VTE for many patients.
Our computerised electronic medication management
system prompts clinicians to review a patient’s risk of VTE
and to prescribe preventative medication.
In February 2015, the Medication Safety team ran a VTE
awareness week to promote this important issue to clinical
staff and patients. The most recent auditing indicates a
strong commitment to VTE prevention with high rates of
appropriate VTE preventative medication being prescribed
– the overall result for 2014 was 87%.
Medication monitoring and planning
The computerised electronic medication management
system allows clinical pharmacists to review new
medication orders daily.
This system can quickly identify orders which require
further review; for example new orders for drugs which may
have interactions with other medications, and medications
which require special monitoring or care in prescribing in
specific groups of consumers.
The system also allows for immediate onscreen checking
of test results to confirm appropriate medication
management.

20 Patient identification
Patient Identification and Procedure
Matching Week
Patient identification
We are required to correctly identify each patient whenever they receive care from us, and to
correctly match them to the treatment they are set to receive. This ensures that staff know exactly
who everybody is, particularly before a patient is about to undergo a procedure, test or operation.
We have a number of policies and procedures in place,
which outline our organisation-wide ‘Patient Identification
System’. Staff are required to check and verify their patient’s
identity against three approved identifiers – the first is the
patient’s full name, the second is the patient’s date of birth,
and the third is the unique hospital identification number that
is generated by our computer system. This helps us check
that the right patient is receiving the right treatment. These
three identifiers must be checked with the patient at various
times during their care including at the point of handover,
transfer, drug administration or discharge.
When you are admitted to hospital, a patient identification
(ID) band is applied to assist with this identification.
A white band is used for patients with no known
allergies
A red band is used for patients with an allergy.
Any incidents of incorrect patient identification and
procedure matching are reported through the Victorian
Information Incident Management System (VHIMS) and
escalated to the appropriate senior staff member to
investigate the cause. Incidents are also reported to the
Patient Identification and Procedure Matching Committee
for monitoring and recommendations on improvements.
We also fully inform patients and carers.
Peninsula Health holds a ‘Patient Identification and Procedure Matching Week’ twice
a year to remind staff of their responsibilities in ensuring they provide the right care to
the right patient at all times. Failure to correctly identify patients may result in errors
with medications, transfusions, diagnostic testing and the patient receiving the wrong
procedures.
During Patient Identification and Procedure Matching Week both consumers and staff
are engaged in a number of activities including crossword and quiz competitions, poster
and slideshow displays as well as daily emails and desktop image reminders, tips and
important key points. The May 2015 campaign involved posters being placed in all
clinical areas with the key message: ‘Although we may know who you are, we still need to
ask you three identification questions, help us, help you, be safe.’

21Patient handover
Patient handover
Patient handover, or clinical handover, is the transfer of professional responsibility and
accountability for some or all aspects of care for a patient, or group of patients, to another
person or professional group on a temporary or permanent basis.
The process of handover happens many times while
patients are in our care. For example when the morning
staff go home, and the afternoon staff take over; when a
patient moves from one ward or site to another; or when
our health service hands over to the patient’s General
Practitioner (GP).
We are strongly committed to developing Clinical
Handover processes at Peninsula Health that include the
patient and their family. We know that patient and family
involvement in handover will assist their understanding of
all aspects of their care.
Handover survey results
In January 2015, a Patient Survey took place for both
Acute (Frankston and Rosebud) and Sub-Acute (Golf
Links Road and The Mornington Centre) Services to look
at the patient’s perspective of the Bedside Handover
process.
Patient Survey January 2015
Nursing Shift to Shift Bedside Handover
Acute
58 Patients surveyed
Sub Acute
61 Patients surveyed
Communication between nurses at the end of a shift and the start of another is vital to ensure care is appropriate.
Bedside handover involves the transfer of important and relevant information to assist care coordination. Bedside
handover must involve the patient and if appropriate their family or carer.
Did the nursing staff do the handover at your bedside? 91% agreed 59% agreed
Did the nurse explain the bedside handover to you? 79% agreed 64% agreed
Did you feel your privacy and confidentiality were
respected during the handover?
96% agreed 95% agreed
Was the new nurse introduced to you? 98% agreed 87% agreed
Were you given the opportunity to ask questions
or clarify information with the nurse?
93% agreed 95% agreed
Nursing handover
Our Nursing Clinical Handover Working Group has
developed a set of five principles to guide staff in giving and
receiving an effective nursing handover.
These principles aim to improve communication between
health professionals and the patient, and are in place across
our health service.
They are:
The patient and/or their family should be given the
opportunity to participate in clinical handover at least
once in a 24 hour period
Handover is brief and structured with well-defined criteria
for the content in bed-based services
Handover involves observing the patient
Handover includes a review of the patient’s clinical
information and discussion about their risk assessment
Handover includes review of the patient’s immediate
environment, including safety considerations on each ward.
Nurse Unit Managers have educated and upskilled nurses on
each ward to implement these handover processes with a view
to making sure all nurses as well as the patient know what is
happening for the patient.

22 Patient handover
Penny Ritchie is wearing the
glasses and the other Nurses
Robyn Edgecumbe and Penny
Ritchie with patient Maureen
Spencer during a handover.
Nursing handover in acute mental
health
Our acute Inpatient Mental Health Unit is undertaking
research with Monash University to evaluate our nursing
handover system as part of our recovery-oriented service
delivery. Under this handover arrangement, greater
emphasis is placed on ensuring that clients are involved
during the change of shift handover. The study aims
to establish guidelines to inform nursing handover and
enhance quality and safety of care outcomes of the
Adult Acute Mental Health Inpatient Unit.
Redesigning handover processes
Our medical staff have also been involved in redesigning
the clinical handover process. In 2015, junior medical staff
worked to improve Clinical Handover between morning
and afternoon shifts for medical staff and to standardise
the process for clinical handover between Junior Doctors.
The project group identified clinical handover for medical
staff in the afternoon as having inconsistent processes,
leading to a risk of communication errors. The clinical
handover process was improved and a structured
afternoon clinical handover for medical staff was
established as well as afternoon medical staff clinical
handover occurring in one location for Medicine, Surgery
and Paediatrics patients.
Communicating with local GPs
Dr Joanne Newton and Jennifer Sidwell are our General
Practitioner Liaison team.
Dr Newton also works as a local GP and Ms Sidwell
is a registered nurse. “Our job is to facilitate two-way
communication between local General Practitioners and
Peninsula Health. We keep General Practitioners up to
date on the health services and systems, we look at
referral and discharge processes, and we look at services
where we have shared care with General Practitioners,”
said Dr Jo Newton.
One of the main ways we provide information to our
local General Practitioners is by the extensive Peninsula
Health General Practitioners Liaison webpage. The
General Practitioners Liaison Unit has also reviewed
other pathways to care for patients with complex health
problems. Last year Anorexia Nervosa pathways were
developed with our Mental Health Services team and
Monash Health.
These pathways can be found in the Mental Health
Services section of the General Practitioner Liaison Unit
webpage, visit:
www.peninsulahealth.org.au/health-professionals/gp-liaison.

23Right blood for the right patient
Right blood for the
right patient
In the past 12 months the Australian Red Cross Blood Service has collected 1.3 million lifesaving
blood donations through 78 donor centres and 31 mobile van donor units. We are committed to
ensuring that patients who receive blood and blood products do so appropriately and safely.
We have a number of systems in place to ensure we use
blood and blood products safely and efficiently. Many of our
staff work to ensure the safe and effective delivery of blood
and blood products (often referred to as transfusion). People
involved in the process include:
Patients and their carers
Doctors and nurses
Dorevitch laboratory staff
Non-Clinical workforce such as patient service assistants
Managers in health service organisations
Health service senior executives
Meeting our obligations
We are a signatory to the Australia Blood and Blood
Products Charter. Developed by the National Blood Authority,
the Charter aims to ensure blood and blood products reach
all patients in need.
The National Blood Authority is the sole supplier of fresh
blood products in Australia and the Authority sets out
strict conditions to ensure safe prescription and use of this
precious resource.
By signing the Charter, we have agreed to meet strict criteria
to manage blood and blood product use.
Safe practice
Peninsula Health employs two Transfusion Clinical Nurse
Consultants (Specialist Nurses) who are responsible for
ensuring that:
Patients who receive blood and blood products do so
safely
Our staff are kept up to date with safe transfusion
practice.
We also have a Transfusion Safety Committee, which
includes a consumer representative. The Committee
oversees the development and review of best practice
policies and guidelines in safe transfusion practice to
support our clinical staff. Extensive auditing is carried out to
ensure that the guidelines are complied with and to allow
the transfusion team to identify where further education is
required.
Promoting the safe use of blood
products
We ran a Blood Transfusion Awareness week and a
Blood Transfusion Education week in June 2015
The Australian Red Cross Blood Service presented
education sessions to our nursing and medical staff
Our Transfusion Clinical Nurse Consultants work
with treating teams to ensure our consumers receive
information about their blood transfusion.
Blood wastage –
how do we compare?
Blood wastage 2014 - 2015
National average
4.5 %
Victorian average
3.8 %
Peninsula Health
2.4 %
Blood and blood products are very precious. We run continual hospital-wide campaigns to promote best practice
use so this valuable resource is not wasted. Our goal is to see a continual decline in blood wastage each month.
For further information about blood transfusions, visit: www.mytransfusion.com.au

24 Preventing and managing pressure injuries
Preventing and managing
pressure injuries
A pressure injury is an area of skin that has been damaged because of pressure or rubbing
(sometimes called bed sores). These injuries can be painful, difficult to treat and can lead to
longer stays in hospital. Patients of all ages can develop pressure injuries while in hospital.
We are committed to preventing patients from developing pressure injuries and effectively
managing pressure injuries when they do occur. Skin Integrity and pressure prevention policies
are governed by best practice and the Skin Integrity Clinical Nurse Consultant along with the
Skin Integrity Steering Committee monitor pressure injury data and compliance to our policy.
Reducing the risk of pressure injuries
Guided by world-recognised Pressure Risk Assessment tools, we:
monitor patients’ skin hygiene and keep skin dry using appropriate skin care products, particularly if
there are continence issues.
ensure patients have a healthy diet or supplements to assist skin repair
use pressure relieving beds, mattresses and other appropriate equipment for patients with fragile skin
monitor and track improvement of wounds
reposition patients frequently to relieve pressure
ensure patients are aware of pressure risks
encourage them to reposition and protect themselves where they can.
How are we doing?
We regularly record fewer developed pressure injuries than similar hospitals and we are favourable lower than the State average.
Australian Council of Health Care Standards (Second half 20140) hospital wide indicator data for
Peninsula Health per 1000 bed days for ‘Inpatients who develop one or more pressure ulcers’
Second Half 2014 Peninsula Health Other like hospitals
Frankston Hospital 0.10% 0.14%
Mornington Centre 0.03% 0.96%
Rosebud Hospital 0.47%* 0.11%
*What does this refer to???

25Preventing and managing pressure injuries
Rosebud Pressure Cushion Project
In 2015, Rosebud Hospital implemented the Rosebud Pressure Cushion Project in response to a spike in
pressure injuries. This initiative has resulted in supported foam cushions being available to every bed in Rosebud
Hospital. The project is based on the outcome from a study from St Vincent’s Hospital, which found improved
outcomes and decreased pressure injuries following this intervention.
How we ensure we provide
the best care
Our Skin Integrity Steering Committee, which includes
a consumer representative, monitors and oversees
the prevention and management of pressure injuries
and wounds.
Each clinical area has a nurse that receives additional
training in Skin Integrity. These Portfolio Holders aid
best care for pressure prevention and wound care.
We have added a formal questioning process to our
ongoing Skin Integrity audits – ‘Is the patient aware
of pressure risks?’ This allows a simple interaction to
raise awareness of pressure prevention and allows
education and/or update for the patient of their
pressure prevention care. For example, the patient
may be reminded to initiate small positional moves
which are very effective when full body repositioning is
not always required.
Access to pressure relieving equipment including a
variety of specialty mattresses and cushions are in
place across the health service.
Staff undertake regular and comprehensive skin
checks of patients in our care.
Development of a ‘Wound Awareness Week’, which
provides information regarding the needs for pressure
prevention and wound care and management for the
community.
WHO LOOKS
AFTER WOUNDS
AT PENINSULA
HEALTH?
MEDICAL
NURSING STAFF
PODIATRY
Managing all needs
for foot care
OCCUPATIONAL
THERAPISTS
PHYSIOTHERAPISTS
WOUND NURSES
DIABETES
NURSES
Having well controlled
Diabetes helps with
wound healing
DIETITIAN
Good nutrition helps
wounds heal
HOSPITAL
IN THE HOME
(HITH)
You may be cared for
in your home if you
have a wound

26 Recognising when a patient’s condition is deteriorating
Recognising when
a patient’s condition is
deteriorating
Peninsula Health aims to provide the most suitable care to patients when they need it.
It is very important to recognise the warning signs when a patient’s condition is deteriorating
and to act quickly to give them the best possible outcome.
Peninsula Health has a range of processes and systems in place to support doctors and
nurses to measure patient observations and to rapidly increase the care provided when a
patient’s condition is deteriorating.
An important part of this response is clear communication with patients, families and carers.
Bernadette and one of her
many patients.

27Recognising when a patient’s condition is deteriorating
Our ‘Recognising and Responding to the Deteriorating
Patient Policy’ is a practical guide for staff. It is based on
best practice, and tells staff how to call for help for any
patient whose condition is getting worse.
The ‘Recognising and Responding to Clinical
Deterioration Committee’, which includes a consumer
representative, advises staff on best practice and
monitors our outcomes to improve practice.
Across all sites, a ‘Code Blue’ call system is in place to
facilitate additional expert staff to attend a deteriorating
patient. Code Blues are often called for cardiac arrests or
respiratory arrests.
A Medical Emergency Team (MET) call system is also in
place to facilitate increased support and review when a
patient starts to exhibits the first signs of deterioration.
A rapid response when time is critical
At the Frankston and Rosebud Hospitals, a Rapid
Response Team is in place to help staff manage all
medical and cardiopulmonary emergencies.
This team is made up of doctors and specialist nurses
who respond to calls from clinical areas when staff are
concerned. At our sub-acute sites (The Mornington
Centre and Golf Links Road), a Senior Nurse Response
Team monitors deteriorating patients’ condition.
How are we doing?
All Code Blue and Medical Emergency Team calls are
reviewed in order to provide feedback to staff involved
about what went well and what we can improve.
An education package is available for all clinical staff to
ensure they understand and can effectively apply the
correct processes to manage clinical deterioration.
Over the last year, we have seen a decline in the number
of Code Blues called as a result of cardiac or respiratory
arrest.
This indicates that clinical deterioration is being
recognised quickly, before it progresses to a life-
threatening situation.
Our systems enable doctors and nurses to:
Measure and record patient observations
Increase the level of care when we see a patient’s condition getting worse
Respond rapidly to manage a patient’s worsening condition in the most effective way
Communicate clearly with patients, families and carers.

28
Let’s prevent falls
Instead of reviewing patients after they had a fall,
Peninsula Health treating teams look at what can be
done to prevent the fall in the first place. One example
of a strategy developed to prevent falls is the ‘Pre-Falls
Huddle’. A ‘Pre-Falls Huddle’ is implemented for patients
identified on admission as having a very high risk of falls.
Once a patient is identified as a very high falls risk, the
multidisciplinary team meets with the patient to discuss
circumstances that have led to previous falls. The patient
is asked to contribute to strategies to reduce the risk of a
fall occurring whilst they are in hospital.
Other risk factors, such as low vitamin D levels or not
wearing eyewear, are also discussed with the patient.
The agreed strategies are documented on a chart at the
patient’s bedside for the staff, patient and family members
to read and be aware of.
The ‘Falls Huddle’ initiatives have highlighted to our
patients that they are an important member of their
healthcare team, and an active team member in reducing
their risk of having a fall, whilst in hospital or at home.
Peninsula Health has a best practice falls prevention
program to reduce falls in inpatient areas, and also reduce
risk of falls for older people in the community. Falls are
best prevented through a range of strategies that are
determined after an individual assessment. It is important
to understand the reasons the falls might be happening,
to then work at the best strategy for prevention.
A consumer’s perspective
Lorraine Burt
“I attend the Falls Steering
Committee monthly as the Consumer
Representative. This gives me the
benefit of understanding how the
organisation goes about implementing
new falls prevention strategies, including
extensive discussion at meetings and
development of written policies and
procedures.
I was also involved in the trial of a
‘noodle’ mattress at The Mornington
Centre to reduce the incidence of rolls
out of low-low beds. I found the process
very interesting and was very impressed
by the knowledge and commitment of
the physiotherapist, Peter Hough.
I can see how the staff are taking every
opportunity to reduce the risk of patients
sustaining falls and injuries.”
Preventing and managing falls
Preventing
and managing falls
We continue to strive to reduce the number of patients who fall in hospital. Our policy on falls
prevention and management is based on best practice and is regularly reviewed by the Falls
Steering Committee, and modified to reflect any changes to current best practice.
The Falls Steering Committee takes a multidisciplinary approach with representatives from
Acute, Sub-acute, Mental Health, Transition Care and Community settings as well as a
consumer representative. We use the VHIMs system to capture any falls that do occur across
the organisation both in hospital and in our community settings.

29Community dental performance
Community dental
performance
Peninsula Health has continued to expand its award-winning dental service. The Community
Dental Program includes multidisciplinary dental teams providing public dental services and
some private services, across three Peninsula Health sites and numerous outreach posts.
It delivers services from 23 fixed chairs (11 at Frankston, six at Rosebud, four at Hastings, and
two at Carrum Downs) and has two portable chairs to provide outreach services to schools,
aged care facilities, disability services, mental health services and community facilities. The
Community Dental program has a strong focus on providing easy referral pathways into care
and is focused on engaging with vulnerable and/or high risk communities.
We have continued to expand our award-winning dental service
throughout 2015.

30 Community dental performance
We are very pleased that in 2014-15, Peninsula Health performed better than the state average against the
majority of indicators.
The safety of clients and staff is a top priority for the Community Dental Program, which follows strict infection
control guidelines for all dental procedures and places a high priority on continuous improvement and education
for staff. Annual competency training in infection control has been enhanced to maintain current knowledge and
high standards for all staff.
In 2014-15, the Community Dental Program provided 29,466 courses of care to
18,959 individuals. Of this, 53% of clients were from an identified priority group
(pregnant women, people with a mental illness or disability, children, people at risk of
homelessness, people from an Aboriginal or Torres Strait Islander background, refugees
and asylum seekers, youth in custodial care).
Performance Indicator Peninsula Health State-wide
Restorative retreatment
within 6 months - Adults
4.2% 4.7%
Restorative retreatment within 6 months - children 5.7% 6.8%
Unplanned return within 7 days subsequent to routine
extraction
0.9% 1.2%
Unplanned return within 7 days subsequent to surgical
extraction
2.7% 3.4%
Extraction within 12 months of commencement of root canal
treatment
7.3% 6.9%
Denture remakes within 12 months 1.2% 2.5%
Preventive sealants retreatments within 2 years - children 2.3% 2.8%
Root treated baby teeth extracted within 6 months - children 2.9% 4.7%
Triage Compliance for priority one clients 94.6% 85%

31Supporting our community
Supporting our community
Discharge Information
It is our priority to ensure patients and their GPs are
made aware of the care provided to a patient who
has been in hospital. This helps to ensure patients are
well managed once they are discharged from hospital.
Through the Clinical System we can automatically send
a discharge summary for an Emergency Department or
Inpatient attendance by secure messaging email or fax.
GPs who are not set up to receive discharge summaries
electronically receive them via mail. We have worked with
the doctors to have electronic secure messaging as the
preferred method of distribution as it provides
the timeliest solution.
As a result of this work, we have continually met the
Department of Health and Human Services target of
80% for discharge summaries completed within 48
hours of discharge from the health service. These audits
are conducted monthly and are fed back to the relevant
governance groups and doctors.
Residential aged care capacity
building
There has been a 24% increase in the number of
Residential Aged Care beds in our catchment between
2013 and 2015. These new beds are the result of
additional Residential Aged Care Facilities being built or
extended.
ACP is a way to let your family and doctors know how you want to
be cared for if you become unable to make decisions for yourself.

32 Supporting our community
provide assistance with advance care planning for people
living in the Frankston-Mornington Peninsula region.
Peninsula Health provides a free interactive toolkit for
making an Advance Care Directive, visit:
peninsulamodel.org.au/advance-care-planning-tool
or to make a Medical Power of Attorney, visit:
peninsulamodel.org.au/medical-enduring-power-attorney
Supporting people to stay in their
homes
The Peninsula Health Hospital Independence Programs
includes a number of services, all of which aim to support
you in your own home. These programs include the
Hospital Admission Risk Program, Post-Acute Care, and
Subacute Ambulatory Care Services. These service work
with key community providers such as GPs, residential
care facilities and home and community care providers to
provide safe community care.
The Hospital Admission Risk Program (HARP)
provides care coordination and allied health support
to patients who have been attending hospitals
frequently and those at a high risk of presenting to the
Emergency Department.
Residential in-reach service that supports up to
40 residential aged care facilities across Frankston
and the Mornington Peninsula by providing rapid
assessment and management of acute medical
conditions that would otherwise result in a resident
presenting to hospital.
The Post-Acute Care Program provides patients with
immediate access to community support within the
first month after discharge.
In 2014, achievements include:
The Hospital Admission Risk Program saw 670 clients
and avoided presentations to hospital by 41% and
reduced Length of Stay by 45%
The Residential In-reach service prevented
approximately 100 admissions to hospital per month
from Residential Aged Care Facilities
Post-Acute Care supported an average of 250
patients per month at home, providing care such as
nursing and home care
The Response Assessment Discharge Team based
in the Emergency Department prevented on average
102 admissions to hospital per month and supported
80% of all clients seen to be safely discharged home.
In order to build the capacity of staff from these facilities
to provide care to their clients, we developed the
Residential Aged Care Empowerment Program.
The Program enables staff from local Residential Aged
Care Facilities to access standardised patient assessment
education to improve clinical knowledge; improve clinical
handover skills; and improve communication with medical
providers. This project has significantly improved the
ability of Resident Care Facilities to manage the health
needs of residents onsite and has reduced ‘avoidable’
presentations to the Emergency Department for these
residents.
Stroke care at home
The Stroke Detours Program enables people who have
had a stroke to be cared for in their home. Clients
receive intensive home-based rehabilitation from a
multidisciplinary team, which comprises physiotherapy,
occupational therapy, speech pathology, nursing, allied
health assistant and social work. Clients are also
reviewed by the rehabilitation physician at the weekly
medical clinic.
To ensure that the therapy provided is effective, the
Stroke Detours Program carries out a number of outcome
measure assessments.
These include:
Functional Independence Measure – which measures
independence in activities of daily living, and the
Quality of Life Measure
Stroke Impact Scale – which measures the impact
of the stroke on the person’s functional skills.
As a result of this program, on average, clients have
shown an improvement of 14.5% on the Functional
Independence Measure, 13% on the Quality of Life
Measure and 17.3% on the Stroke Impact Scale.
Advance Care Planning
Advance Care Planning (ACP) provides a process for
you to document your preferences about future medical
treatment and health care. Our policy for ACP guides
high-quality end-of-life care across the health service.
ACP is a way to let your family and doctors know how
you want to be cared for if you become unable to make
decisions for yourself. It is about planning for a time when
you may be very sick or frail. The ACP is a free service to

33Supporting our community
The PACER program was introduced in Rosebud in
November 2014. There, the team responded to a total
of 103 events up to July 2015. Of the 103 events, only
24 of these clients required transport to the Emergency
Department. This resulted in a saving of 79 trips to the
Emergency Department by Ambulance and Police.
Alcohol and drug services reform
We used the recent reforms to state-funded alcohol and
other drug (AOD) treatment services provided Peninsula
Health as an opportunity to implement a new model of
AOD service delivery in partnership with the Frankston
and Mornington Peninsula Medicare Local and Youth
Support and Advocacy Service.
The new service model means that individuals in the
Frankton-Mornington Peninsula region seeking state-
funded AOD services complete an assessment with
a senior AOD clinician. The clinician then works in
partnership with the client and other agencies to develop
a recovery plan.
In addition to improving the current service model, a
health-sector-wide alliance of organisations (the Alcohol
and Other Drug Alliance), is leading a number of key
actions including assessing the changing trends in alcohol
and drug use, and developing a program of service
redesign to match our at risk communities.
This redesign work is being undertaken in collaboration
with community pharmacists, Monash University, the
Chisolm Institute, GPS, local traders, consumers, and
the University of Melbourne. This re-design work is a key
platform for ongoing alcohol and drug service reform,
and for the development of a centre for excellence for
addiction management.
Transition Care Program
The Transition Care Program provides short-term
restorative therapy to clients following their hospital
stay. The Transition Care Program operates 50 beds in
a private residential care setting along with 15 home-
based places where therapy is provided in the client’s
own home. During the past year, the Transition Care
Program undertook an open tender for the provision of
50 Transition Care Program residential care places. The
successful applicant was the Regis Group. As a result,
all 50 Transition Care Program residential care beds are
offered at Regis Shelton Manor located in Frankston.
For 2014-15, Peninsula Health’s Transition Care Program
discharged 44% of its client to their home. This is higher
than most other Transition Care Programs across the
state, and a great outcome for older people wanting
to return home after hospitalisation. On average, the
Transition Care Program clients stayed with the program
for 47 days compared to the State average of 62 days.
In addition to this, Peninsula Health’s Transition Care
Program beds were occupied 93% of the time compared
to the State average of 89%.
The Police, Ambulance and Clinician
Early Response (PACER) team
The Police, Ambulance and Clinician Early Response
(PACER) team is a multi-disciplinary team (mental health
nurses, allied health clinicians and Victoria Police) aimed
at providing early intervention and assessment for mental
health crisis-situations in the Frankston- Mornington
Peninsula catchment. The PACER team operate seven
days a week and are based at the Frankston Police
Station.
The client is at the centre of the PACER service model,
with staff typically responding to individual crisis. Placing a
mental health clinician in the peak of the crisis means that
in most cases, mental health clinicians and Police working
together are able to diffuse the situation and treat and
support clients in their own home. Importantly this also
avoids the need to transfer the person to the Emergency
Department by Police or ambulance.
PACER evaluation data for Frankston shows that since its
commencement in April 2014, the team has responded to
a total of 656 events. Of the 656 events, only 21 of these
clients were transported to the Emergency Department,
which has resulted in a saving of 635 trips to the
Emergency Department by Police.

34
These innovative inpatient facilities have been bustling since
their opening and we have received excellent feedback
from our patients and families about the excellent amenities
and care.
New outpatient facilities
The old Emergency Department at Frankston Hospital has
been transformed into a state-of-the-art outpatient facility
with more than 20 consultation rooms and treatment areas to
provide a range of outpatient services including:
Outpatient services for women and children include ante-
natal care, birthing classes, Paediatric appointments, and
gynaecological services.
Orthopaedic outpatients for elective patients, post-
operative patients and emergency patients.
A range of other outpatient clinics designed to ensure
patients can be reviewed by specialist services.
Innovation
Innovation
Frankston Hospital expansion
A landmark $81 million expansion at Frankston Hospital was officially opened by the Ministerfor Health the Hon Jill
Hennessy MP in February 2015. The new building includes a newEmergency Department and 92 new beds in three
state of the art wards. The new facilities provided a major health boost with our Emergency Department being one of
the busiest Emergency Departments in Victoria. The new four-storey addition to the hospital was delivered on time and
under budget. The new Emergency Department is more than double the size of the previous emergency department.
This significant development to Frankston Hospital was
designed to address the acute health needs across the
fast-growing Mornington Peninsula region. Not only are the
facilities and equipment amongst the best available, the
quality of care from a patient’s perspective remains at the
heart of this service. Prior to its opening, significantwork
was undertaken with consumers, volunteers and staff
to ’road test’ the building and the new models of care
to ensure we were opening a contemporary service
that met the needs of our community. The Emergency
Department comprises 49 general treatment cubicles as
well a specialist treatment rooms and consultation areas
for Paediatrics, Mental Health and Immunocompromised
patients (patients whose immune system is weakened
because of illness or medication).
Above the new Emergency Department level are a further
three levels, each housing new wards for surgical and
cardiac patients.
The new Outpatients facility was opened in August
by the Minister for Health, the Hon Jill Hennessey.

35Innovation
Chronic Disease (including prevention
and management)
Mental Health (including alcohol and other drugs,
youth, and homelessness)
Vulnerable Children and Families.
For more information, visit: www.peninsulamodel.org.au.
New technologies
At Peninsula Health, we foster innovation that enhances
patient care, introduces evidence-based clinical practice
and promotes better health service delivery to our patients.
We work closely with our doctors, nurses, allied health
professionals, managers, consumers and our Clinical
Networks.
Recent introduction of new clinical innovations to
Peninsula Health include:
Eye Connect
In partnership with the Royal Victorian Eye and Ear Hospital
(RVEEH), Peninsula Health will be the first Health Service to
utilise EyeConnect, a telemedicine device that will connect
the Emergency Department at Peninsula Health and RVEEH.
The device will enable prompt review and management
of Peninsula Health patients by RVEEH staff, potentially
avoiding the patient needing to travel to RVEEH for review.
Xiaflex injection to treat Dupuytren’s Contracture
This is a new treatment option for patients who suffer from
Dupuytren’s Contracture (a condition in which there is fixed
forward curvature of one or more fingers, caused by the
development of a fibrous connection between the finger
tendons and the skin of the palm). Studies have shown
that the success rate of the treatment is high in appropriate
patient groups.
Lucas II
Lucas II is a machine that provides consistent chest
compression from outside of the body. This machine will be
used at Peninsula Health for specific patients in Emergency
Department.
Bronchial Thermoplasty
Bronchial Thermoplasty helps to treat a small group of
asthmatic patients who do not respond to current asthma
medications. Our doctor received further training in
Germany and invited an international expert to Peninsula
Health to ensure that we are providing a quality service.
This redevelopment provided an opportunity to review
the model of care for outpatient services moving into
the new area. The review identified a number of service
improvements and changes to the model of care:
A self check -in and patient tracking system was
introduced. With this system clinicians save time walking
between the consulting room and the
waiting room thereby improving patient flow and
reducing waiting times. The system also allows reports
to be generated about the patient journey, which will
support further refinement of the model of care over
time.
A dedicated wound review clinic was established in
recognition that a number of patients were waiting
unnecessarily to see a consultant for care that could be
provided more rapidly and equally effectively
by nursing staff.
Co-location of clinics with existing synergies (e.g.
fracture clinic and physiotherapy clinic; paediatric
clinics and young adult diabetes clinics) to improve
opportunities for teamwork in patient care and minimise
the need for patients to walk between physical areas of
the hospital or return multiple times to receive care.
Consumer representatives participated in the
redevelopment group working on models of care and
the physical building of the new space.
They also participated in the working party to select the
check-in and tracking software from a variety of vendors
to ensure custom built features met consumers’ needs.
The Peninsula Model
The Peninsula Model for Primary Health Planning – the
Peninsula Model – is a partnership between key health and
community service organisations, government departments,
consumers, carers and communities within the Frankston-
Mornington Peninsula catchment area.
Working collaboratively and based on a population health
approach, the model wraps the collective effort of providers
around agreed health priorities to address service gaps
for the catchment.
Coordinated by the Frankston Mornington Peninsula Primary
Care Partnership, the Peninsula Model priorities have been
determined by population health data and include:
Aboriginal Health
Ageing

36 Innovation
CarePoint Trial
The CarePoint program is a partnership project between
the Victorian Government and Medibank Private to trial a
two-year integrated care program for 2,200 insured and
uninsured Victorians with chronic and complex conditions
and a history of multiple hospitalisations. Peninsula Heath
has partnered with CarePoint to deliver the pilot in the
Frankston-Mornington Peninsula region.
CarePoint aims to provide evidence-based preventative
care in the client’s home, improve health outcomes
for enrolled clients and reduce the need for costly
hospitalisations. The CarePoint trial will take place over
2014-17 with the independent evaluation anticipated to
be completed by the end of 2017.
Mount Eliza Personal Alarm Call
Service (MEPACS)
Peninsula Health operates a personal alarm call service
(MEPACS) which provides home monitoring services to
28,000 public and 4,000 private clients across Victoria
and southern New South Wales. This service is provided
with strong technical support from NEC and during the
last 12 months, we have collaborated with CSIRO to
evolve this technology and develop a service to care for
patients with chronic heart failure in the home.
The Chronic Heart Failure (CHF) technology provides
an internet-based solution that collects a patient’s daily
weight using a Bluetooth-enabled digital scale and
transmits the information to Peninsula Health’s MEPACS
Service staff and CHF nurses, which allows a proactive
response to a patient’s changing condition in accordance
with clinical protocols to prevent hospitalisation. This
innovative technology and care solution aims to better
manage chronic disease in the community. We are
currently exploring how the technology can be used
to manage other chronic conditions including Falls,
Dementia and Chronic Obstructive Airways Disease.
Rosebud Hospital medical imaging
A new medical imaging area has been operating at
Rosebud Hospital since December 2014. The community
raised an impressive $1.9 million for the medical imaging
area , complete with CT scanner, Ultrasound machine
and expanded x-ray facilities at Rosebud Hospital. The
new facilities at Rosebud have significantly reduced the
number of patients who would otherwise need to be
transferred to Frankston for CT scans.
Medication safety with technology
Peninsula Health has traditionally been a leader in
embracing technological solutions to improve medication
safety in a number of areas. Medications administered
intravenously have the greatest potential for serious harm
from medication errors.
At Peninsula Health, this risk is mitigated through the
introduction of smart technology to prevent doses being
too high or too low. Peninsula Health was one of the first
Australian hospitals to implement smart pumps in 2008.
The pumps pre-set safety limits within the machines drug
library (Guardrails®
) and alerts users if the concentration or
infusion rate is outside these limits.
This has been implemented as a medication safety
initiative to reduce clinical errors, acting as a double check
at the bedside. At Peninsula Health, using Guardrails®
is
mandatory and audits have consistently shown over 90%
compliance.
CLOVER Clinical System
Peninsula Health has been pioneering the use of clinical
information systems in Victoria, implementing electronic
workflows in the move to a fully electronic health record.
One of the major planks of this work was to implement
Electronic Medication Management (EMM) to reduce
medication errors, which remain the second most
common type of medical incident reported in hospitals.
Electronic Discharge Summaries and Radiology
and Pathology ordering and viewing have also been
implemented across all Peninsula Health sites.
Our award-winning CLOVER system has led to:
a decrease in medication errors.
no medication errors due to legibility issues.
improved documentation of allergy status.
GPs, in addition to the inpatient wards, are now
receiving e-discharge summaries from the Emergency
Departments and acute Mental Health units.
improved electronic discharge summary completion
rates
no incidences of lost drug charts
enhanced pathology and radiology efficiencies.

What do you think of this report?
Your feedback is important to us as it helps us develop our next Quality of Care Report. Please answer the questions below and return
the form to a Peninsula Health staff member or place it in the feedback box at the main reception or on a ward. You can also leave your
feedback on our website at www.peninsulahealth.org.au, or post this form to Quality Department, Peninsula Health, PO Box 52,
Frankston Vic 3199.
1. What did you think of the information in this report? (please circle)
Poor 1 2 3 4 5 Excellent
2. What did you think of the presentation of the report? (please circle)
Poor 1 2 3 4 5 Excellent
3. Is there any other information you would like to see in the Quality of Care Report?
Sharing our improvements with the
community
The Department of Health of Human Service’s 2014-15
policy and funding guidelines require all Victorian health
services to publish an annual Quality of Care Report for
the financial year 1 July 2014 to 30 June 2015.
Distributing our Report
This Quality of Care Report is made available to
patients, clients, visitors, healthcare partners, local GP
clinics, and community leaders. Copies are available in
our reception areas.
You can read the Quality of Care Report on our website
at www.peninsulahealth.org.au.
We value your feedback on the Quality of Care Report
2015. Please fill out the feedback form and send it to
us. You can also email your comments to:
customer.relations@phcn.vic.gov.au.
Tell us what you think
Please tell us about your concerns or satisfaction with any
Peninsula Health services. You can do this by telephone,
on our website, in writing, or in person to the Customer
Relations Manager or the person in charge of the relevant
department or program.
Complaints and compliments from patients, carers and
families help us understand how we can best improve our
services.
To pass on a complaint or compliment
Phone Customer Relations on (03) 9784 7298
or email customer.relations@phcn.vic.gov.au.
Customer Relations
PO Box 52
FRANKSTON VIC 3199
Information about our services and programs Phone
Corporate Community Relations on (03) 9788 1501
or email corporate.relations@peninsulahealth.org.au.
Or visit our website at www.peninsulahealth.org.au.

We acknowledge and pay respect to the traditional people of this region,
known as the Myone Buluk of the Boon Wurrung language group of the
greater Kulin Nation. We pay our respects to the land this organisation
stands on today. We bestow the same courtesy to all other First Peoples,
past and present, who now reside in this region.
Peninsula Health
ABN 52 892 860 159
2 Hastings Road (PO Box 52)
Frankston Vic 3199
Tel (03) 9784 7777
Callers outside the Melbourne
Metropolitan Area
Tel 1800 858 727
peninsulahealth.org.au

Quality of Care 2015

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