Across Australia and internationally, SVHA has a reputation for delivering patient and consumer-focused outcomes, ground-breaking clinical practice and research, and for providing high-quality care to the most vulnerable. Underpinning this reputation is an effective clinical governance strategy to deliver person-centred and high quality health care to patients, residents, and clients, along with their families and carers.

In 2019, SVHA developed a five year strategic plan to support the organisation in its quest to lead the world in safe, efficient, person-centred care. The framework identifies five elements which define the aims of the Clinical Governance team and are encapsulated in the acronym iCARE: Improvement, Clinical Governance, Assurance, Research and Experience.

iCARE
Strategy
EXPERIENCE ASSURANCE RESEARCH CLINICAL GOVERNANCE IMPROVEMENT BUILD IMPROVEMENT CAPABILITY TO ENSURE GROUP WIDE ALIGNMENT OF WHAT GOOD LOOKS LIKE ENHANCEMENT OF STRUCTURES AND SUPPORT THAT ENABLE OUR PURPOSE ALL PATIENTS, RESIDENTS AND STAFF FEEL TRULY WELCOME, VALUED AND SAFE EMBED TRANSLATIONAL CLINICAL RESEARCH ACROSS SVHA DEVELOPING SYSTEMS THAT PROMOTE A CULTURE OF SAFETY AND TRUST SVHA IS RENOWNED FOR ACADEMIC AND TRANSLATIONAL CLINICAL RESEARCH SAFE, EFFECTIVE, INTEGRATED AND HIGH-QUALITY CARE DATA ANALYTICS AND HUMAN ACTION WORK SYNERGISTICALLY FOR CONTINUOUS IMPROVEMENT SAFETY FIRST AND FOREMOST IN EVERYTHING WE DO UNWAVERING FOCUS ON SERVICE AND EXPERIENCE EXCELLENCE VISION PILLAR INTENT OUTCOME To provide the insight,leadership and governance to support SVHA in our quest to lead the world in
Improvement

SVHA aims to put the care and wellbeing of patients, residents and their families at the centre of everything it does. This requires building the knowledge, skills and infrastructure necessary for the consistent delivery of high quality care and continuous improvement.

SVHA is committed to providing clear metrics and actionable insights, investing in continuous improvement capability, and encouraging meaningful partnerships with consumers. Staff are encouraged to lead the change, transforming the experience of our patients, residents, and families in the process.

Success will be achieved when patients, residents and families report they feel welcome, valued and safe at every point in their journey at an SVHA facility.

Clinical Governance

Clinical governance occurs at all levels of an organisation. Every person is involved in the review and improvement of processes for the delivery of care, from the SVHA Board and Group Chief Executive Officer to our divisional and facility CEOs, management teams and general workforce. High quality health care cannot be achieved unless there are robust systems in place to enable oversight of the complex health system consumers and employees find themselves in.

Patients, consumers and the community trust clinicians and health service organisations to provide safe, high-quality health care. SVHA remains committed to ensuring that the right care is provided to the right patient at the right time, achieving outcomes that are aligned to patient and resident expectations and experience.

During 2018/19, SVHA provided care to almost 328,000 patients in its public and private facilities and 1605 residents in its aged care facilities.

With more than 1 million episodes of care provided by SVHA’s facilities each year, the vast majority are safe and effective. However despite having systems in place to ensure reliability of care – and the excellent skills, training and efforts of staff – occasionally things do not go as expected.

When this happens, it can cause distress for patients, families and staff, particularly if the consequence is severe. Creating a culture where staff are encouraged to report incidents is paramount to safety improvement. These incidents are used as opportunities from which to learn and make improvements.

In the last 12 months there have been 45,342 clinical incidents notified across SVHA’s public, private and aged care facilities. Of these, over 95% sustained minimal to no harm with only 0.16% resulting in significant harm or death. This represents 0.5 adverse events per 100 separations compared to the national rate (AIHW 2018) of 5.4 adverse events per 100 separations. Open disclosure is performed on all incidents resulting in any degree of harm, and a systems review, or root cause analysis, is completed on all incidents resulting in serious harm or death.

A sentinel event is an unanticipated event in a health care setting resulting indeath or serious physical or psychological injury to a patient or patients,unrelated to the person’s illness. Total Incidents 43,393 45,342 95.7% 0.16% 3.77% 1,709 77 8 resulted inminimal-to-no harm resulted inserious harm or death sentinelevents1 resulted in somedegree of harm 1
19,235 9,918 16,148 Public Division PrivateDivision Aged CareDivision Incidents by Division

Each year, SVHA’s clinical teams perform thousands of operations and see hundreds of thousands of patients. In 2018/19 SVHA performed almost 18,000 surgical procedures.

A hospital-acquired infection (HAI) is an infection that can either be picked up in a hospital or health care setting, or from outside the environment, brought in by another infected patient or staff member. Across SVHA we monitor HAIs that are commonly found in health care settings, such as Staphyloccus Aureus (SAB), a type of bacteria that can be found on human skin and which is often referred to as ‘staph’ or ‘golden staph’.

St Vincent’s Health monitors SAB infections every month. The national target is for health organisations to have a rate less than two infections per 10,000 patient care days. The rate for SAB across SVHA’s facilities during 2018/19 was 0.55 infections per 10,000, down from 0.72 infections per 10,000 patient care days in the previous year.

SVHA also monitors how often staff wash their hands or use an antiseptic gel prior to providing care to our patients. In 2018-19, St Vincent’s Health’s hand washing compliance was 84.6%. This demonstrates continuous improvement over the last five years, with rates improving from 80% in 2014-15.

Assurance

The St Vincent’s Clinical Assurance and Reliability Program (SCARP) was introduced in 2017 to provide the Board, divisions, facilities, clinicians, and the public with assurance, transparency, and visibility of the clinical care provided across the organisation, in accordance with evidenced-based guidelines.

SCARP assessments – which are carried out in collaboration with local clinicians – are key to identifying any discrepancies which in turn informs improvements and assurance. The assurance process is integral to maintaining health care accreditations and jurisdictional licensing.

In 2018-19, SVHA completed two full SCARP assessments against standards for the management of Acute Coronary Syndrome and Acute Stroke.

Acute Stroke (AS) is one of Australia’s biggest killers and leading causes of disability. The degree of damage caused by a stroke is dependent on the amount of time brain tissue is denied blood supply. The ‘time is brain’ concept means that avoiding delays in diagnosis and treatment of stroke is a priority.

SVHA’s SCARP assessment of AS was carried out in the following way:

  • 453 patient records were found to meet the AS assessment selection criteria. A detailed analysis of the records followed, including a review of reports from multiple clinical information systems, along with validation of data with chart review of each episode of care.
  • The assessment was completed against the Australian Commission on Safety and Quality in Health Care’s Acute Stroke Clinical Standards.
  • The assessment subsequently found:

  • 100% of patients arrived at an SVHA hospital within the 4.5 hr time window required for thrombolysis, which is the breaking down of blood clots using medication. The national average is 36%.
  • 22% patients at St Vincent’s Hospital Sydney received thrombolysis (national average 13%).
  • Between 60-80% of patients received thrombolysis within 60 minutes or arrival at an SVHA hospital (national average 30%).
  • 100% of SVHA patients received imaging within two hours (as an inpatient) and one hour (in ED). The time critical benchmark is 4.5 hours.
  • At St Vincent’s Sydney public and private hospitals, between 95 and 100% of patients were treated in a designated stroke unit.
no. of patients who reached an SVHA hospital in the for thrombolysis 4.5hr window 100% Use of thrombolysis 22% 8% Increased atSVHS atSVHM no. of patients who Received thrombolysis within 60 minutes 60% 80% on Arrivalat an SVHAHospital atSVHS atSVHM

In recognition of the SCARP team’s work in this area, St Vincent’s Hospital Melbourne won the SVHA Clinical Innovation Award in 2018 for their project ‘simulation training to improve code stroke performance’.

RESEARCH

SVHA is creating an organisation-wide research strategy, creating a network that can address areas of critical importance to clinicians and communities.

The first national networks will be established in palliative medicine, orthopaedics, comprehensive cancer care, and Mission-related areas including homelessness, drug and alcohol addiction and prisoner health.

SVHA will develop national approaches to:

  • Ensure all patients will be offered the opportunity to participate in clinical trials and studies that aim to improve health care for all Australians into the future.
  • Simplify and facilitate collaboration with other organisations on policies related to intellectual property and commercialisation.
  • Deliver IT solutions to assist with leveraging health-related data to improve patient care and health services.
Experience

SVHA is strongly committed to a patient-centred health care system and conducts dual processes for measuring patient experience.

The first is a biannual survey which provides trend data going back to 2014. It also allows us to benchmark our performance against similar feedback to 89 Australian and 2,790 international comparison hospitals.

SVHA’s most recent results indicate that 70% of all patients rate its hospitals 9 or 10 out of 10. This is above the Australian benchmark of 65.5%. In SVHA’s private facilities, 70.1% of patients give a rating of 9 or 10 out of 10 (Australian benchmark, 69.3%); in the public facilities, it’s 69.5% (Australian benchmark, 59.2%).

The second measure is a real-time SMS survey sent to all patients within 48 hours of discharge, providing what’s known as a Net Promoter Score (NPS). The NPS is used globally to measure customer experience and is based on the answer to a single question; “How likely are you to recommend our facility to a family or friend?”

SVHA’s NPS for August 2018 was 72%. SVHA has established an ambitious goal to improve its NPS score to 80% by 2025.

SVHA’s Inspired to Care program embeds the three principles of person-centred care – ‘we feel welcome’, ‘we feel valued’, and ‘we feel safe’ – across the organisation, uniting staff in a shared aspiration. The program supports facilities to embed the person-centred care principles and provide a consistently positive care experience to every patient and resident.

Inspired to Care underwent review during the year which resulted in a new strategy for the initiative, placing the Net Promoter Score at the centre of the program so the organisation can prioritise the consumer experience when designing and delivering services.

The goal of the new Inspired to Care strategy is to amplify the voice of our patients, residents, and families, and empower our staff to consistently deliver and improve on the quality of their care.

Ethos

SVHA’s Ethos program aims to embed safe, respectful and professional behaviour across the organisation. Launched at St Vincent’s Hospital Melbourne in July 2017, Ethos has since been rolled out to St Vincent’s Private Hospital Melbourne (June 2018), St Vincent’s Hospital Sydney (November 2018), St Vincent’s Private Hospital Sydney (November 2018), the Mater Hospital (July 2019), and St Vincent’s Private Hospitals Northside and Brisbane (September 2019). The program will be launched at St Vincent’s Private Community Hospital Griffith and St Vincent’s Private Hospital Toowoomba by the end of 2019. The program currently reaches over 15,000 staff.

As at August 2019, there have been a total of 1,134 staff messages submitted to Ethos: 49% resulted in feedback to individual staff asking them to reflect on expected standards of conduct, while 51% resulted in feedback providing acknowledgement and recognition.

During 2019, the Ethos program underwent an independent review, which made 18 recommendations designed to improve the program based on feedback from staff, all of which were accepted by the St Vincent’s Ethos Steering Committee.

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