Safer Care Victoria Review Update - July 2023
A clinical governance review of Albury Wodonga Health was commissioned by the Chief Executive Officer of Safer Care Victoria and completed in late 2022, with the final report released on the 12 January 2023.
The review used the London Protocol to analyse clinical governance systems at AWH, within the domains of the Victorian Clinical Governance Framework. The review drew on evidence from a wide variety of documents, a site visit, and input from more than 200 relevant stakeholders, including staff and consumers.
It identified strengths and opportunities for improvement in AWH’s clinical governance, resulting in 15 findings for the health service, one dual finding for the Department of Health and AWH, and 54 recommendations.
Action to date
To implement these recommendations the 2023 and 2024 AWH Patient Safety and Quality Action Plan was developed. It describes the specific actions to be completed, the timeline to do so and the expected outcomes or measures to be achieved.
As part of its implementation, AWH and SCV have updates every six months, to discuss progress towards the recommendations. The first of these meetings occurred on Friday 14 July 2023.
During this meeting, SCV very much acknowledged the significant ongoing work being carried out by AWH, along with the organisation's willingness to share progress, insights, and information with SCV.
Progress so far
Action over the past 5 months has resulted in:
- 23% of the actions have been completed;
- 37% of the actions are green, meaning they have been commenced and are on track for completion within the allocated time frame for implementation;
- 34% of the actions are amber, meaning they have been commenced and are works in progress; and
- 6% of the actions are red, meaning they are overdue or have not had sufficient actions completed for the expected completion date.
Some of the completed actions include:
- Workforce Governance Committee established and is meeting on a monthly basis
- Participation in the Hume Region Credentialing project
- Board of Directors orientation program and manual developed and endorsed
- Redesign of Board sub-committees including terms of reference, agenda, and reports
- Recommencement of face-to-face practical learning/training for staff
Commenced and work in progress include:
- Redesign and implementation of the new AWH committee structure – due for completion in November 2023
- Commencement of the PAS project for a single PAS system across AWH
- Review of the employment cycle from recruitment to separation
- PROMPT will be the new Quality Management System for AWH, with implementation expected by December 2023
- Strengthen of the system to prevent occupational violence and aggression.
The action plan is monitored by the Executive Committee on a monthly basis. The action plan progress is presented to the Board Patient Safety, Quality, and Safety Review Committee on a bi-monthly basis, with this last occurring in June 2023.
The AWH Board of Directors will receive the first 6 monthly update report at the July 2023 Board meeting.
Download the 2023 & 2024 Patient Safety and Quality Action Plan in full here