Quality and Safety Highlights Eastern Health 2023-24

Eastern Health seeks to hear the voice of the patient, families and carers in a number of different ways.  Patients, families or carers can: 

• Speak with any staff member or the manager from the area where the experience occurred 

• Call, email or write to the Centre for Patient Experience 

• Use feedback forms in feedback brochures found in patient areas 

• Use the online feedback form on the Eastern Health website 

• Complete the Eastern Health Patient Experience Survey available on discharge 

• Complete the The Victorian Healthcare Experience Survey (VHES) 

There were 18,709 items of feedback received by Eastern Health in 2023/2024. The mechanisms by which feedback was received in the past year are shown in the graph below.  

The Victorian Healthcare Experience Survey (VHES) is one of the ways patients can provide feedback about their experience with Eastern Health. The VHES collects information from a range of healthcare users of Victorian public health services.  The survey is conducted by Ipsos, an independent contractor, on behalf of the Victorian Agency for Health Information (VAHI), a division of the Department of Health (the department).  The table below provides responses from Adult Inpatients at Eastern Health during 2023/24 to the question “Overall, how would you rate the care you received?”.  Eastern Health performed above the state average for three out of four quarters. 

Eastern Health uses feedback from patients to identify opportunities to improve our services and the experience of patients, carers and families. Below are some examples of taking action based on feedback provided by consumers.

In 2023/2024, a partnership of consumer representatives and staff worked together to revise Eastern Health’s Partnering in Healthcare Framework.  Consulting broadly and using co-design principles to develop the Framework provided a valuable opportunity to engage and ensure a Framework that resonates with staff and consumers. The Framework outlines how Eastern Health partners in health care at the three levels of the individual, the program/service and the organisation. The principles within the Framework describe the values and behaviours expected within Eastern Health to support healthcare partnerships, effective communication, shared decision making and health literacy.   Work is underway to ensure a meaningful implementation that raises awareness of the Framework and supports the organisation to embed the principles outlined within the Framework into all our interactions and partnerships with consumers.

Eastern Health is committed to ensuring a safe workplace and to being an inclusive provider of healthcare for all lesbian, gay, bisexual, trans and gender diverse, queer, intersex and queer and questioning (LGBTQIA+) people. The Rainbow eQuality Working Group has supported a number of initiatives including: 

• our biggest ever Eastern Health contingent at the Pride March 2024 

• sponsorship of the Yarra Glen Pride Cup jerseys and stall at this event 

• coordinating communication and acknowledgment of “Wear it Purple Day” and “IDAHOBIT Day” (International Day Against Homophobia, Biphobia, Intersexism and Transphobia) 

• establishment of an Eastern LGBTIQIA+ community of practice. 

This year has also seen the establishment of the LGBTIQIA+ Liaison service to provide support to patients, clients and their families/carers and Eastern Health staff. This service is only the third established service within Australia. 

In 2023/24, the Eastern Health Disability Working Group has continued to undertake work to oversee and support the implementation of actions on the Disability Action Plan.  Eastern Health’s Disability Liaison Officers and the NDIS Navigators have supported the Working Group with key achievements in 2023/24 including: 

• Development of Auslan resources in collaboration with Deaf Victoria 

• In collaboration with TLC Disability services, provision of distraction boxes for child and young people with a disability 

• Facilitated communication and awareness for International day for people with disabilities  

• Community collaboration and consultation with Ability First Australia and Young People in Nursing Home Alliance 

• A reduction in length of hospital stay for people under the NDIS in 2023/2024 compared to 2022/2023. 

Eastern Health has continued to partner with the Aboriginal Community in the eastern region through our Consumer Representatives and Community Elders on the Aboriginal Health Advisory Committee. This Committee meets quarterly and provides regular advice on new initiatives to support Cultural Safety at Eastern Health, including the development of our Aboriginal Cultural Safety Plan.  

In 2024, Eastern Health held its inaugural First Nations Forum, with over 70 staff and community members in attendance. The forum focused on topics identified by the Aboriginal Health Advisory Committee working group, including access to mental health support, support for parents and carers with children with additional needs and accessing aged care support. Eastern Health appreciates the many Aboriginal community organisations that attended the forum to provide information on their services to attendees.  

In March, Eastern Health opened its new Comprehensive Cancer Clinic for First Nations patients in Healesville – nangak warr bagora “caring for you centre”. The Woi-wurrung name was given by Senior Wurundjeri Elder Aunty Joy Murphy. This clinic aims to reduce the travel for Community members to access treatment and will provide a wraparound comprehensive treatment service in partnership with the Aboriginal Health Team. A focus on improving Cultural Safety continues across all of Eastern Health services. In 2023/2024, the First Nations Cultural Safety Lead provided education to our graduate intakes and also supported a review of Cultural Safety at Eastern Health by Blak Wattle Consultancy.  

Engaging with external partners to build our organisational cultural competency and strengthen self-determination continues to be a priority. A group of senior leaders attended the first Cultural Immersion for our team at Coranderrk, guided by Uncle Dave Wandin and Jaquie Wandin at Coranderrk in December 2023. Arabena Consulting and Karen Milward Consulting have supported the Eastern Health Board and Executive with a cultural orientation workshop and review of cultural competency of the organisation in April 2024.  

The Reconciliation Action Plan Committee, which includes Community Elders Uncle Thompson and Aunty Lucia Baulch have met regularly to oversee the implementation of Eastern Health’s Innovate Reconciliation Action Plan. The majority of actions have been complete and are on track for our first Innovate RAP and planning is now underway for our next Reconciliation Action Plan. Eastern Health continues to strengthen self-determination and governance and is pleased to announce the appointment of a new First Nations Board member, Joe Morrison to the Eastern Health Board in July 2024. 

[Picture – Aboriginal Health Advisory Committee at the First Nations Forum March 2024] 

[Picture – Smoking ceremony at the opening of the nangak warr bagora Comprehensive Cancer Service for First Nations patients at Healesville Hospital 2024].

• Reviewing consumer information and education resources 

• Presenting at Deakin Study Day Clinical Governance Course  

• Membership on many new committees and working groups including  

• Peripheral Intravenous Cannula (PIVC) Governance group  

• Overall Rating of Care (Patient Experience) Working Group  

• Interview panels for recruitment 

• Planning forum for Clinical Deterioration Committee Direction  

• Partnering in Healthcare Framework consultation and workshop. 

In 2023/2024, Eastern Health held two in person Consumer Forums:

• At the November 2023 forum, Eastern Health presented ‘service awards’ certificates and badges for the first time in acknowledgement of consumer representatives who had been volunteering for over 5 years and 10 years. 

• The June 2024 Consumer Forum titled – ‘Consumers and Community Together’ was planned by a working group of staff and consumer representatives.  It was the first time community stakeholders and Eastern Health volunteers were invited to the Eastern Health event, which traditionally was only open to Eastern Health consumer representatives, Board, Executive and staff. 70 people attended the forum, and the feedback was very positive.

This project aimed to provide patients with clinical support tools that they could access in their own time that would: 

• Improve consumer experience
• Ensure timely access to information 
• Allow patients to revisit information as required 
• Ensure equitable provision of education materials.

The ‘Having Surgery at Eastern Health’ digital patient education resource is available on the Eastern Health website for patients to use before and after surgery.  It includes: 

• Education videos 

• Interactive learning content 

• Patient stories 

• Frequently asked questions 

• Hospital navigation advice (such as carparking, public transport and site maps) 

• Checklist e.g. packing a hospital bag 

Eastern Health’s Mental Health and Wellbeing Program is reforming services to ensure alignment with the recommendations from the Royal Commission into Victoria’s Mental Health System. 

The Mental Health and Wellbeing Act 2022 (The Act) was a key recommendation of the Royal Commission into Victoria’s Mental Health System and came into effect on September 1, 2023.   The Act outlines how we communicate and provide treatment to people with mental illness, as well as a person’s right to make decisions about their care.  The Act promotes voluntary treatment in preference to compulsory treatment wherever possible with the aim of promoting a person’s recovery and full participation in community life.  The Act promotes communication between practitioners and people with mental illness, their families, carers and supporters, to support people receiving mental health care to understand their rights and make decisions about their care and treatment. 

At Eastern Health, we are working across the service to ensure the principles of the Act are embedded into our service to promote good mental health and wellbeing in our emergency departments, hospital and mental health and wellbeing services.    We have seen the following improvements: 

• Significant reduction in the number and duration of seclusion episodes for consumers in our inpatient mental health units. 

• Implementation of the opt-out system for independent consumer advocacy in all inpatient units. 

• Implementation of a process to facilitate an internal second opinion for consumers concerned about their diagnosis and treatment.  This has reduced the waiting times for consumers seeking a second opinion, which previously was conducted by an external service.   

• Formal processes implemented to ensure that when a person has an Advance Statement of Preferences in place, our service makes all reasonable efforts to give effect to the statement. 

An incident is an event or circumstance which could have resulted, or did result, in unintended or unnecessary harm to a person receiving care. All staff are encouraged to report all incidents that occur as part of our commitment to a culture of safety.

Each incident is rated according to degree of harm and changes to the level of care and treatment required as a direct result of the incident. Each incident is assigned a rating between 1 and 4, 1 being the most serious outcome to 4 where no harm has occurred but was a near miss. This severity rating informs follow up of both the individual incident and system issues identified. 

All reported incidents are initially reviewed by the manager of the location where the incident occurred. There is an immediate assessment of safety and care of those involved and any identified concerns are addressed. Information is gathered from staff, patients and visitors at the time of the event to get a thorough picture of what has occurred. 

All incident reviews apply the following key principles: 

1. Determine the timeline of events leading up to an including the incident 
2. Identify if there are any issues/ variations from expected practice 
3. Identify what may have contributed to the issues. 
4. Consultation and communication with the patient/family to ensure a collaborative and informed process. 

The most serious incidents are reviewed by a panel of clinicians, service providers and consumers.   

Sentinel events are unexpected events that result in death or serious harm to a patient while in the care of a health service. Eastern Health notified Safer Care Victoria (SCV) of 7 sentinel events during 2023-2024. 

1. Graphic demonstrating incidents numbers with and without harm INSERT GRAPH

2. Incident numbers by month:

• An average of 1784 patient incidents are reported each month. 
• Of these incidents, 406 on average, resulted in a level of harm that ranged from minor to more serious. 

3. The three main incident types where harm has been experienced by a patient are: 

• Falls (4187 in 2023-2024) 

• Behaviours of concern* (7578 in 2023-2024); and 

*Behaviours of Concern are behaviours that people engage in which are unsafe and/or distressing to the person and/or others. This may include someone harming themselves, other people or things. These behaviours can be very stressful and upsetting. These behaviours can seriously hurt people. 

• Medication related incidents (3213 in 2023-2024).  

4. Improvements

The primary purpose of incident review is to understand how and why the incident occurred and to identify ways of preventing recurrence. Often on review of multiple similar incidents a theme is identified which then contributes to changing processes or procedures. 

Incident numbers are increasing each year, with the reason for this explained by expansion of services, therefore increased numbers of consumers and patients coming through the health system. The percentage of harm has remained stable. The graph below shows the average incidents each month, and those incidents where harm occurred. Reporting of incidents is also increasing due to the safety culture that has evolved over time.  

SDC is a legal obligation for Victorian Health service entities to ensure that patients/clients/residents and their families or carers are apologised to and communicated with openly and honestly when a SAPSE has occurred. It builds on the Australian Open Disclosure Framework currently utilised for all cases of adverse patient safety events including near misses. Communicating in this way helps patients, families and carers to understand the impact of adverse events and facilitates the building of a relationship of trust between them, their clinicians and the organisation. 

• a written account of the facts regarding the SAPSE 

• an apology for the harm suffered by the patient 

• a description of the Eastern Health’s response to the event 

• the steps that Eastern Health has taken to prevent re-occurrence of the event. 

From 1 July 2023 until 30 June 2024, Eastern Health reviewed 66 SAPSE and of these 42 consumers accepted the SDC process and 24 declined.  Following completion of the SAPSE process, consumers are invited to complete an evaluation survey. The feedback received is mostly positive and patients/families are grateful to be included in the review of their clinical incidents.

Eastern Health demonstrates its commitment to excellence through external accreditations against a wide range of industry standards, including the National Safety and Quality in Healthcare Services (NSQHS) Standards, Aged Care Quality and Safety Standards, General Practice (GP) Accreditation Standards, Diagnostic Imaging Standards and Pathology Standards.  

The primary aim of these accreditations, undertaken by independent accrediting agencies, is to protect the public from harm and to improve the safety and quality of health care provision. They require Eastern Health to develop ways of working that reduce harm and improve care. 

Eastern Health was fully re-accredited by the Australian Council on Healthcare Standards (ACHS) against the NSQHS Standards in 2023. The organisation is now prepared for a short notice assessment, where the hospital receives 24-hour notice that our service will be assessed. The introduction of short notice assessments will improve the accuracy of the assessment process and better ensure that the assessment outcomes reflect day-to-day practice. Since the last assessment, we have actioned recommendations received to improve clinical handover and communication with patients and families through communication boards on the wards, improved documentation of medication history and continue to enhance training opportunities for staff.   

A range of Eastern Health’s services are accredited by the Australian Aged Care Quality and Safety Commission, including our two residential aged care homes – Monda Lodge and murrenda Residential Aged Care Home and the Transition Care Program. murrenda was re-accredited by the Commission in July 2023 for another three years within 9 months of its opening and transferring of three existing Eastern Health homes into one purpose-built state of the art home. 

**N.B. CARPS is the electronic task management system in place at major Eastern Health campuses for allocation of cleaning and PSA tasks.  

As a result, the following outcomes were achieved: 

In partnership with the Department of Health and Institute of Healthcare Improvement, Eastern Health’s Box Hill campus recently completed an 18-month project aimed to improving the timeliness of emergency care by improving the efficiency of how the patients move throughout the hospital.

The Timely Emergency Care Collaborative (TECC) provided an opportunity for 14 Victorian public health services and Ambulance Victoria to partner and share challenges, improvements and progress across the project timeframe.

Targeted improvement initiatives that occurred during the TECC project included improving the movement of patients through emergency department and on the wards to ensure there was room for new patients, as well as improving the time in which patients were moved from an ambulance into the emergency department.

As a result, at of 30 June 2024, Box Hill campus demonstrated a reduction in the time consumers spent in emergency awaiting care, an increase in the number of patients that were discharged from hospital in time for brunch and an improvement in the time it took to get consumers off the ambulance and into the emergency department. These improvements helped to ensure new consumers presenting to the hospital were able to get the care they needed much sooner.