Implementation case studies

Barwon Health took a novel approach to enhancing person centred care as part of the Best Care for Older People (BCOP) project – they stopped writing things down. Of course they haven’t stopped gathering information about their patients; it’s just that now they complete all assessments of new patients electronically. Using laptops or iPads, nursing staff are now able to comprehensively assess patients at the bedside, recording all information and making referrals to allied health services as they go.

The decision to embark on changing the way the organisation approached risk assessments came about because of a focus on the principles of person centred care. Staff working on the BCOP project recognised that the paper based system of assessment and referral did not encourage engagement with the patient. It also meant that staff were duplicating information and that information was not always recorded, or recorded in a timely manner.

“It’s all about engagement with that person… [working] in collaboration with that person, and educating them on their risks.”

“To me it was around person centred care – we had this paper based system that we may or may not have filled out, but when we did we just ticked it,” says Sonya Whitehand, a NUM who has been involved in the project from the pilot stage. “What we were asking [the team] to do now was to actually take a device, sit with the person, actually ask them some questions and develop a plan in collaboration with them; so we were asking them to work in a person centred way…”

Barwon Health’s electronic assessment and referral system uses portable devices – laptops and iPads – to enable staff to conduct screening and assessment at the bedside. Once a patient is admitted, a nurse sits with them at their bedside. They log-in uniquely to the system and access the patient’s information, such as their hospital ID and date of birth details. The assessment process involves completing a suite of screens, assessing areas including cognition, falls risk, depression, risk of malnourishment and pressure ulcer risk.

Each screening tool is completed by the nurse with the patient and the system records the answers and the overall scores. Recommendations for action are triggered according to each screens’ outcome, including interventions and allied health referrals. These can then be discussed with the patient at the time and care planning can occur in a collaborative way. Patients also gain more understanding of their risks and what they can do to minimise them.

The system also uses the information entered to generate reports for the patient’s file and automatically populates their electronic medical record, reducing administrative time as information is not being entered multiple times. Hospital administrators are also able to track completion rates and results in real time and use this data for benchmarking and statistical analysis.

Developing and implementing the system was not without its bumps along the way, however. As Karen Heseltine, BCOP Project Manager says, “[when] we decided to go down the electronic route… we didn’t realise actually how long it would take and the journey that we went along really.” The project team found themselves on a steep learning curve as they tried to negotiate the complexities of introducing a new electronic system into the existing health service IT systems. Not only did they need to develop new software components to use for the assessments, but also find a hardware platform on which to run it and integrate the system into the existing systems and the hospital’s wireless network.

Along with the technological issues the team faced, they also needed to convince ward staff who were to use the product that it was a good idea, despite the perception that the new system would take extra time, and the need for many to learn a whole new set of IT skills.

Engaging with staff on the pilot ward from the outset was crucial to achieving this. Staff were asked for their input into the questions, as well as for continuous feedback on the usability of the system in the ward setting. Training was also approached in an ongoing, informal way, allowing staff to take as much or as little time as they needed to learn the new system.

“We were asking them to work in a person centred way…”

Lessons from implementing electronic assessments on the pilot ward and the enthusiasm of the staff helped with the success of the roll out to the broader organisation. The electronic screening and assessment tool is now used across all adult inpatient acute and sub-acute wards in Barwon Health – over 400 beds in total. As well as shifting the focus of assessment from administrative task to patient engagement, it has meant that assessment is now standardised for all adult inpatients.

The project has had an impact beyond that originally envisaged and unexpected new applications and offshoots of the system are continually being discovered. For example, one of the surgical wards has started using the hardware to show patients their x-rays at the bedside. The team is also continually coming up with new ideas for the electronic system, such as using the information to generate discharge summary information rather than this having to be separately created, and having each ward’s journey board become electronic and populated by information from the system.

Other uses for the software are also being developed. One of the most comprehensive is the development of electronic care plans for use by all palliative care teams. The team hope that this electronic care plan will provide the basis for developing similar tools for other settings in the organisation.

No matter what new uses are developed in the future, the focus remains firmly on the patient. Everything that is done is with a view to embedding person centred care into everyday clinical practice by building administrative systems that are time efficient and that engage and involve the patient as a partner in their care. The team also hope that their experience can be used by others to find ways to utilise technology to enhance patient care. As Trish Mant, Practice Development Coordinator, says, “It’s all about engagement with that person… [working] in collaboration with that person, and educating them on their risks.”

If you are walking through the corridors of Northeast Health Wangaratta (NHW), don’t be surprised if you come across staff and patients playing cards together, reading the newspaper or even painting their fingernails. It’s all part of the hospital’s approach to caring for patients with delirium and dementia.

When the hospital was looking at ways it could improve care for older people, they realised there was a need to improve the way patients with dementia and delirium, and associated behavioural problems were being cared for, especially in the acute wards.

Delirium is common in older patients, and can have serious consequences including longer recovery times and functional decline. People with delirium appear confused and sometimes become hyperactive and agitated. Patients with both dementia and delirium are at particular risk of harm.

“I saw a volunteer with a patient the other day and they had a doll and were folding nappies. She was very settled, whereas the day before she had needed [one-on-one care].”

Nicola Coats, Best Care for Older People (BCOP) Project Officer and Jonelle Hill-Uebergang, Deputy Director of Nursing at NHW decided to take a three pronged approach to addressing the needs of patients with delirium and/or dementia: they developed a new way of documenting behavioural symptoms in order to provide more effective interventions; they revised the way one-on-one nursing care was provided to high needs patients and they created a library of activities for staff and visitors to use with patients. All these initiatives interrelate and provide a framework for best practice care for older people with delirium and/or dementia.

Patients with behavioural issues or showing signs of confusion were often provided one-on-one care (sometimes called ‘specialling’). Staff providing this care were not always trained in caring for patients with dementia and delirium. It was not uncommon for them to understand their job to be preventing the person getting out of bed, and beyond that having little interaction with them.

The hospital now has a guideline in place for providing one-on-one care. A handbook developed by Nicola is given to all staff providing one-on-one care, detailing information about the signs and treatment of delirium.

Nicola also developed a behaviour chart for use with agitated or hyperactive patients with dementia or delirium. The patient’s level of agitation and pain is documented on an hourly basis, allowing clinical staff to look for patterns in behaviour and adjust the patient’s care to avoid triggers and improve outcomes. The chart also includes information on possible causes for behavioural problems and appropriate interventions, including whether one-on-one care should be provided. The behaviour chart is now used throughout the acute wards.

Patients with dementia and/or delirium, especially if they become agitated or upset, often need to be distracted. The diversional activities library that has been developed is an innovative way of helping to manage patient symptoms while in the unfamiliar environment of hospital and during a severe illness. The idea behind the library is that if an agitated patient is given a task or activity, it can help calm them, by occupying and distracting them. The library includes items such as a toolbox filled with screws, nuts and bolts, realistic looking baby dolls and dogs and cats, games and playing cards, films on DVD and a manicure kit. There are also ‘fiddle mats’ sewn by a volunteer, designed to keep fingers busy with zips, buttons and different textures of material.

Staff, family members and other visitors, and volunteers all have access to the library and are encouraged to find appropriate activities to share with the patient. Knowing about the person’s interests, history and habits helps to find a suitable activity.

Nicola says when they first started introducing it she was unsure whether staff would accept it as a clinical intervention. “I got into work one day and got a call that ‘we’ve got an agitated patient up here in surgical – can you bring up your nuts and bolts’. My heart was in my mouth and I walked up there with my little toolbox and a few other things but it worked. I just said, ‘Bob, these things have got all muddled up here, can you give me a hand sorting them?’ This man had pulled out his IV, was trying to get his catheter out, very agitated – and it worked… the staff see this.”

Family members, friends and volunteers have also found it helpful to have some direction about how to interact with a person who may be behaving quite differently than usual. It can be frightening to see a love one confused and worked up, and being able to use activities to calm a person can be reassuring for both parties. Even under the best of circumstances, having a focus during a visit can be helpful. Playing cards, reading the newspaper or watching a film can pass the time and introduce a sense of normalcy and routine into the hospital stay.

This can also help keep patients calm and occupied, reducing the need for further interventions. Jonelle gives an example: “I saw a volunteer with a patient the other day and they had a doll and were folding nappies. She was very settled, whereas the day before she had needed [one-on-one care].”

"The other day I was in the rehab ward and the unit manager had brought a little motor in because there was a patient there that was an old mechanic and he had started to go into a delirium... He took this motor apart and put it back together… and that kept him on track, as well as medication."

These strategies all work together and all have a person centred approach at their core. Each intervention works best with input from patients (where possible) and their families and carers. Understanding a person’s usual routine, what they enjoy and what upsets them, their background and interests all enhance the effectiveness of the strategies used and work towards ensuring the best possible outcomes for the patient.

Jonelle is full of praise for the way Nicola worked with staff and led by example. “Once Nicola started to educate and give them tools, and give them strategies, they were hungry for it, because they could see it was actually going to make their day easier... She demonstrated that [these strategies] work by practicing them, so people are now using their own initiative.

The success of these strategies, the hard work of staff in championing their use and the dedication of the volunteers who now maintain the resources all contribute to this being an initiative that has now become part of the culture of care at NHW.

Hospitals can be daunting places at the best of times. They are bright, noisy, unfamiliar and crowded. For many older people these factors are compounded by hearing loss, and being unable to hear clearly can make the situation overwhelming. Kaye Gooch, a former patient who sits on the board of the Victorian branch of Better Hearing Australia, says “hearing loss - because it's ‘invisible’ - tends to be overlooked” by staff in hospitals and that this can be a very isolating experience.

The audiology and speech pathology team at Alfred Health’s Caulfield Hospital recognised the risks associated with being ‘overlooked’ and set about improving the experience and outcomes for their older patients who had difficulty hearing. The team recognised that not being able to hear made it difficult for their older patients to understand clinical staff or participate in their care planning, which could have a negative effect on their recovery. As Kaye Gooch pointed out, difficulties with hearing were not always picked up, and other issues such as cognitive decline could be mistakenly blamed. Sometimes hearing loss had not been previously diagnosed; sometimes it had but the issue lay in the person’s equipment or lack thereof. Patients do not always arrive at the hospital with their hearing aids; sometimes hearing aids would be broken, or not working due to a flat battery or need for cleaning. Additionally, in the noisy environment of a hospital, hearing aids do not always work well because of the large amount of background noise.

"At the first try, I asked my dad can he hear my voice, he said 'yes' with a big smile. I couldn't forget this smile! It seems my dad is back to our world. We were happy!"

With such a broad array of issues to contend with, an innovative solution was needed. The team took a multi-pronged and multi-disciplinary approach to improving the recognition and treatment of older people with hearing loss at the hospital, utilising the framework and principles of the Improving Care for Older People (ICOP) program. The team looked at practical ways to help patients hear and communicate more effectively during their hospital stay and to refer them for further intervention if complex testing was needed.

This approach included employing a part-time audiologist to provide education to nursing and allied health staff on communication strategies and using and troubleshooting with hearing equipment. The role also included providing assistive listening equipment to patients during their hospital stay.

Personal amplifiers, one of the assistive listening devices introduced, has had a big impact on individuals. These amplifiers are just that – they increase the volume of the sound they pick up. This means they are particularly useful for one-on-one conversations, as one person can speak into the microphone and the volume at which this is heard through headphones can be adjusted by the wearer. Speaking into the microphone eliminates much background noise, unlike hearing aids. There are other advantages to the amplifiers – for one thing they are quite large compared to a hearing aid, making them easier to manipulate for people with limited dexterity. They are also useful when hearing loss had reached a point where aids are of limited use. Privacy for the person with hearing loss is also maintained, as people can speak at normal volume into the microphone and earphones ensure only the wearer experiences a loud volume. They can also be used by a person at the same time as a hearing aid.

For Guang Dong Yu, using a personal amplifier made a huge difference to her father’s wellbeing and quality of life. Prior to his hospital admission, his hearing had deteriorated to the point where he was unable to hear clearly even with a working hearing aid. Guang Dong Yu says that because of this her father had “lost his self-confidence and… started to doubt what other people were saying about him. For example, he thought he might get cancer after I talked to the doctor about something like the weather and did not report to him.” She says he became embarrassed to talk to people and seemed despairing.

Seeing this change in Pat has been, “Joy, pure joy! To see someone hearing, understanding and linking in with it.”

Her father was provided with an amplifier to use while at Caulfield: “At the first try, I asked my dad can he hear my voice, he said "yes" with a big smile. I couldn't forget this smile! It seems my dad is back to our world. We were happy!” says Guang Dong Yu. He was also able to understand doctors and other clinicians and answer their questions; factors which she says helped his recovery. They found the amplifier so useful that on leaving the hospital they bought their own!

The amplifiers have also helped to improve quality of life and communication for some long-term patients with dementia. When a person has moderate to severe dementia, it is easy to assume that their communication difficulties are entirely the result of their condition, however this is not always the case. As Lynda Loughridge, a Registered Nurse working with dementia patients, says of one her patients Pat, “we weren’t quite sure whether she wasn’t understanding what we were saying or wasn’t hearing, and a lot of it was that she wasn’t hearing… When we put the amplifier on her… absolute enlightenment! Now she still has the dementia, but we understand that cognitive level – but she could actually hear what we were saying.”

Lynda says using the amplifier has improved Pat’s quality of life immensely, allowing her to communicate more effectively with family members and staff, and engage with her surroundings, alleviating some of the aggression that has been a symptom of her dementia. For Lynda, seeing this change in Pat has been, “Joy, pure joy! To see someone hearing, understanding and linking in with it.”

For clinicians, patients and their families, this joy of hearing and understanding anew is an experience being repeated all over Caulfield Hospital thanks to the team and the ICOP program.

When a familiar face walked into the shop where Maria Berry was working, she had no idea that striking up a conversation with an old acquaintance would lead her in a new direction.

That old acquaintance was Marie Marotta, then the project officer for Improving Care for Older People in the Hume region. The pair had met many years before, when Marie was a social worker in the hospital where Maria was having a child. Maria and Marie chatted and caught up, and Maria shared some of her recent experiences as carer for her mother while in and out of hospital.

Maria had found her mother’s “hospital experience just horrid.” She felt there had been a lack of communication and that information was uncoordinated and difficult to access. Maria found it particularly upsetting that she had not been notified for some time after her mother had broken her hip while in hospital. Maria saw this as a culmination of a number of adverse events stemming from a failure to practice person centred care.

“Her buzzer had been taken off her because she was ringing the bell too often. And I think the reason why she might have been ringing the bell too often was one, her pain. It still was not under control,” says Maria. “Sometimes I'd walk in and… she hadn't had enough to drink and things like that, so ... there was the pain, there was the urinary tract infection, and all of that, I think, didn’t help the situation with Mum becoming distressed and ringing a bell.”

“She’s a carer, she’s articulate. She’s passionate, she knows how things ought to be for older people in hospital.”

At the time, Alfred Health was developing a video resource on behalf of the Department of Health about improving care for older people in hospital, based on Best Care for Older People Everywhere: The Toolkit ¹. The video resource was part of the sustainability strategy for the project, ensuring the lessons from The Toolkit would be accessible to a wide audience and beyond the period of the project’s funding.

The project advisory group sought the views of clinicians, patients and carers from across Victoria. Others interviewed about their experiences shared similar stories about lack of communication and having their views overlooked. As Marilyn, a patient interviewed in the resource says, “the feeling you get is that you’re not a person at all; you’re just another thing that’s in there, or another condition, that you’re there for them to treat and get better and get home quickly.”

The film features clinicians, patients and carers from across Victoria talking about care of older people in hospital and preventing functional decline. The emphasis is on person centred care and what that means, both for those working in hospital and for patients receiving care. The importance of being treated with dignity and being seen as a person are themes continually raised by consumers and carers in the film. Communication is also a key theme, and the difference good communication between staff and patient and their carers can make to a person’s experience and recovery.

For Maria, sharing some of her experiences of her mother’s hospital care was in many ways a difficult experience, but ultimately rewarding. As Maria says, “it ignited this passion… to be part of a community that says this is not right.” This new found passion has led Maria on a journey to become deeply involved in improving care for older people across the health sector.

Following her involvement with the Alfred Health film and with encouragement from Marie, Maria contacted Catherine O’Connell, Executive Director of Clinical Operations at Albury Wodonga Health. Catherine asked Maria to address the Acute Care Board about her mother’s care and the need for a more person-centred approach.

Catherine also invited Maria to become a representative on the health service’s Consumer Advisory Committee. The Consumer Advisory Committee works collaboratively with the health service, integrating the perspectives of consumers into the practice of the service. Maria has found her involvement to be valuable and rewarding, but has not stopped there.

Maria has also become involved with the Health Issues Centre, an independent organisation advocating for improvements to the health care system from a consumer perspective. She is also working with Social Connections, a project Marie is coordinating as part of the Hume Integrated Aged Care Plan, as a consumer representative on the project’s advisory group.

Full of ideas and passion, Maria continues to have new ideas about ways to improve older people’s experience of the health and aged care systems in her region. She is constantly making new connections with people she meets and finding new avenues to advocate on behalf of older people.

As Marie says, “She’s a carer, she’s articulate. She’s passionate, she knows how things ought to be for older people in hospital.” Uncovering these talents has been another lasting legacy of the project.

1. The current edition of this resource is Older people in hospital.

It seems self-evident that being around nature makes us feel calmer and more relaxed. In fact, numerous studies have shown the therapeutic benefits of spending time outdoors. For those with dementia, it would seem all the more important to have access to a calming outdoor space, and yet it rarely happens within hospitals.

Western Health’s (WH’s) Dementia Assessment and Management unit at Sunshine Hospital did have an outdoor area for patients, but it was little used having developed in an ad hoc way and didn’t have protection from the weather. When the Best Care for Older People (BCOP) project completed its environmental audit of the hospital, they saw a need for the area to be redeveloped into a space specifically designed with the needs of those with severe dementia and their families in mind.

This patient group often stays for a significant amount of time in the unit, and most of these patients also exhibit behavioural and psychological symptoms of dementia (BPSD). The project aimed to create a space based on the latest evidence that would help improve mood, social interaction, sleeping patterns, spatial orientation and provide opportunities to participate in meaningful activities.

The garden features different spaces to allow for reflection, activities or interaction, depending on need and inclination.

Realising such grand ambitions was not going to be cheap! Aware that their vision was beyond their means with existing funding, the BCOP team sought to gain support from WH’s impressive community and volunteer support base.

First up, they approached the Western Health Foundation for funding. They were provided with an impressive $100,000 from the Sunshine Hospital Auxiliary and Opportunity Shop, which is run by a dedicated group of volunteers. Next they partnered with Paul de la Motte, President of the Horticultural Therapy Association of Victoria and a Holmesglen TAFE manager, whose expertise was invaluable in planning and installing the garden. Partnering with the Engineering Department of WH was also instrumental to the success of the project, as well as having the ongoing benefit of an understanding between the two groups about how the other operates and what is important to their work.

Opened in 2013, the garden features different spaces to allow for reflection, activities or interaction, depending on need and inclination. There are raised garden beds containing vegetables and herbs, encouraging patients to reminisce through access to familiar smells and sights. An undercover barbeque area is frequently used for communal meals. The garden also has various defined spaces within it, such as a ‘tranquility area’ where patients and visitors can have some seclusion and privacy. Other areas are designed with patients’ former lives in mind – such as a ‘bus stop’ where patients often enjoy waiting, and a Mediterranean section with mosaics and plants from the region. Seating is available throughout so that groups or individuals can find their own space within the larger area.

The success of the garden has inspired the redevelopment and creation of other garden spaces within the hospital, including redeveloping another outdoor space for the geriatric assessment and management unit (GEM) and planning a garden for the palliative care unit.

The students consult with staff, patients and families as part of their project planning, giving them an understanding of the needs of patients with dementia and a chance to interact with them, breaking down some of the barriers between the groups.

The ongoing dedication of volunteers and nurturing of community partnerships has been essential to the success of the project. The therapy garden, as well as the GEM unit’s outdoor space, is tended by a group of volunteers who maintain the plants and continuously work to improve the garden. Other community groups also help with maintaining and improving the garden, including primary school students, gardening clubs and staff from a local Bunnings hardware store.

WH also has a partnership with a local high school, Copperfield College, whose students undertake projects as part of their VCAL work. Up to 50 students work in small groups on defined projects with the help of a mentor. Projects have included making furniture and artworks, and a group is currently working on creating a workbench (inspired by men’s sheds) for patients in the garden. The students consult with staff, patients and families as part of their project planning, giving them an understanding of the needs of patients with dementia and a chance to interact with them, breaking down some of the barriers between the groups. In fact, this side of the project has been so successful that it has been recognised by WH with an excellence award.

Others who volunteer and spend time in the garden also experience this same increase in understanding, something the BCOP project managers see as an added bonus of the program. “They’ve purely volunteered I think to maintain and develop the garden, but slowly just through informal connections with patients… they’re starting to interact with patients in their own way,” says Amy Parker. Kate Mangion agrees, and adds, “Because you’ve got the right people in those roles it’s a natural evolution”.

In a packed seminar room, clinicians from Northern Health listened intently to nearly a dozen presentations on practical projects implementing the principles of the Best Care for Older People Everywhere: The Toolkit (The Toolkit)². What made this day different from many other study days, however, was that the presenters were also clinicians from Northern Health. Most had never previously undertaken project work, or presented to such a large audience. This was one of the outcomes of Northern Health’s (NH’s) Staff Capacity Building Initiative.

The initiative provided successful applicants from NH’s clinical staff with training in project management, leadership and presentation skills. Those undertaking the program then used these skills to develop and implement a project in their clinical area based on the domains and principles of The Toolkit. A Project Mentor was also available to help throughout the period.

Applicants were from a variety of allied health and nursing roles. Most were ward staff who had not previously had the opportunity to do this type of training or project work. Projects undertaken were quite diverse, from no lift techniques to be used with resistive patients, to trialling an exercise group in a secure dementia unit, to reducing falls in a short stay unit.

"If we know the name of their football team or their granddaughter’s name it can help calm them – it doesn’t always work, but when it does work it’s really, really good."

One participant was Jan Thomas, an experienced Enrolled Nurse in a secure dementia unit. Jan undertook a project to revise The Key to Me, an information form about the background and personal preferences of dementia patients, and champion its use. She initially thought taking on the project “was out of my depth, but I like to push myself… so I thought I’d give it a go.” Her project involved developing a questionnaire and distributing it to staff and some family members of patients about what they would like to see from the new form. She simplified and shortened the existing document to make it more relevant and easier to use. Involving staff and family also helped foster a sense of ownership.

Jan found the process challenging, but ultimately rewarding. She says having information about a person with severe dementia can often help to manage some of the behavioural and psychological symptoms of dementia. “If we know the name of their football team or their granddaughter’s name it can help calm them – it doesn’t always work, but when it does work it’s really, really good.”

The program also had a personal impact on Jan. She says it was valuable creating connections with staff members outside of her area, and has also sparked a desire to undertake further education. Having the support of her team and finding others who are continuing to champion the use of the form have been other bonuses of her involvement.

Angela Ruzzene, a Clinical Nurse Consultant who coordinated the education program, says that several of the projects are having an ongoing impact at the ward level, such as a delirium screening tool that was introduced in a dementia ward. Others are having an impact more broadly through the organisation. Perhaps the widest reaching of these is nurse rounding for falls prevention. Nurse rounding involves each patient being regularly checked by a nurse and asked several basic questions about their needs, such as whether they need to use the toilet, whether they have pain and whether they need to be repositioned. This was piloted by one participant as her project and is now being refined and will be rolled out across the organisation.

"I’ve been nursing for a long, long time and sometimes you forget that [patients] had lives, they’re not just a patient… I think that did me the world of good."

While some projects are having a lasting and tangible impact, the initiative was not without its challenges. Recruiting staff, particularly ward-based nurses, was challenging, and not all who undertook the program were able to complete it. The program required a detailed application, support from the participant’s manager as well as a significant time commitment, factors which Angela thinks may have limited the number of applications. Some projects participants began were too large scale and ambitious to be realistic and some were constrained by the need for costly equipment purchases.

Nonetheless, Angela says the initiative has had a positive impact in spreading the principles of person centred care and of The Toolkit. She says the most successful projects were those that were small scale, contained and had tangible results. In many cases these projects have continued to have an impact and the participants continue to champion them. For several, being involved in the initiative has also led to moving into a more senior role within the organisation. Others have been able to utilise their new skills in their current roles.

However, the most lasting impact may be the way the program allowed those involved to see their role, and their patients, in a different light. As Jan says, “I’ve been nursing for a long, long time and sometimes you forget that [patients] had lives, they’re not just a patient… I think that did me the world of good.”

2. The current edition of this resource is Older people in hospital.

It seems obvious that when you’re not well, you will probably eat and drink less – after all you’re not doing much, and you may not have much of an appetite. In fact, it is important to eat and drink as much if not more that you would normally in order to recover in the quickest time possible. Under-nutrition can cause wounds to heal more slowly, increases the risk of complications and of infections and can lengthen the hospital stay. Adequate nutrition and hydration is particularly important for older people. In fact, food and drink are as important to getting well as medicine!

Even when the importance of nutrition is recognised, it doesn’t always mean a person will get an adequate amount. In fact, many older people will be malnourished when they are admitted to hospital or will become so during their stay. While loss of appetite and feeling unwell account for some of this, there are many other reasons that patients may miss meals or not finish them. They may be asleep when the meal is brought and not woken up, they may be unable to open the packaging, or they may not be able to cut up the food themselves. Others may be unable to feed themselves or sit themselves up in order to eat. All of these factors can contribute to patients being undernourished while in hospital.

Staff got a sense of what it's like to be unable to eat their meal through roleplaying scenarios like trying to eat while lying on a table.

Goulburn Valley Health recognised the importance of helping ensure patients were able to eat and drink at mealtimes and that not everyone who needed assistance was getting it. They also realised that the number of malnourished patients being admitted to the hospital was not being fully counted. So they embarked on a process to change this.

The approach was two pronged: ensuring every patient was screened on admission using the Malnutrition Screening Tool (MST), identifying those who were malnourished or at risk, and introducing red trays for patients who needed assistance to eat their meals. The MST also identified those needing meals assistance, and the level of assistance they needed.

In order to have an impact, they first needed to identify the scale of the problem. To do this an audit was conducted to see how many patients were sitting up for meals, could reach their tray, were given assistance if needed and were finishing their meal. The audit showed there was room for improvement on all the measures, and that around 20 per cent of those who needed assistance weren’t receiving it.

Having identified the need, the next challenge was to get everyone on board – not just the clinical staff, but also the catering staff, the patients, and their families and carers. For Lisa Pearson, Best Care for Older People (BCOP) Project Officer, and Wendy Swan, Manager Nutrition and Dietetics, this involved a lot of consultation to get it right. It was important that the trays would work with the existing catering equipment and systems – finding the right trays was “a project in itself” says Wendy.

One of the keys to the success of the initiative was involving the catering staff from a very early stage. Denise Maloney, Manager Hotel Services says that the fact that members of the catering staff had input in to the process of developing and implementing the system, as well as understanding why it was being done, made a big difference. “I think it’s imperative that you do [that], because at the end of the day they’re the people actually handing out the trays,” she says.

The next step was educating staff about the trays and the MST. Catering staff were educated about how to respond to patient queries about the new trays. A staff event was also held to launch the red tray system and the MST. Staff got a sense of what it’s like to be unable to eat their meal through roleplaying scenarios like trying to eat while lying on a table. A sense of fun and ownership helped the new system to gain acceptance. The system has also been designed so that any member of staff can flag that a patient requires a red tray.

Information brochures were developed for patients and their families and carers. These explained why red trays had been introduced and what they meant, as well as tips on how to maximise nutrition while in hospital. Each person who received their meal on a red tray was also given a flyer that briefly explained why their tray looked different and why it is important to eat and drink enough when in hospital. A video about nutrition and the red trays was also made for patients and families, and was provided in English, Arabic and Turkish.

The system has now become part of usual practice in the hospital, and is also being rolled out to the health service’s satellite campuses, as well as to local small rural health services. Patients and families are also accepting of the system, with many wondering why “no-one thought of it before”. Many have indicated they feel less anxious if they are unable to be at the hospital during meal times.

The mealtime audit was repeated several months after the trays were introduced and found improvements on almost all the measures. Significantly, the proportion of patients who needed help and didn’t receive it had dropped to just five per cent. The catering staff have also noticed a difference through their own waste monitoring, particularly a reduction to the number of meals returning to the kitchen untouched. “It was going unnoticed,” says Denise, “but now the red trays have certainly flagged it… it’s certainly increased the amount of patients eating their meals.”

There is always room for further improvement, of course, and Wendy says that there is a continual need not to just make sure patients have assistance, but to make sure that it is timely and adequate also.

It takes courage to admit that you got it wrong, and courage to try to set things right. The Royal Melbourne Hospital (RMH) is a highly respected institution and prides itself on the quality of care provided to patients. However, even in the best organisations, sometimes things happen that are not ideal. It is how we respond that makes the difference – do we ignore them and hope for the best, or do we admit our faults, examine our mistakes and try to learn for the future.

When the hospital received a complaint from an elderly patient’s daughter, it followed best practice and responded to and addressed her concerns. Usually, that is where the story would end, however, this time they decided to go further. They saw an opportunity to document the experience for a wider audience within the organisation and to use it as a teaching and learning tool. Thus the journey of making Lola’s Story, and with it a new approach to listening to patients, began.

"We are not just talking about a bunch of figures or graphs on paper - these are real people that have real experiences with us."

Lola had been a patient at the hospital. An elderly woman, she had communication difficulties following a stroke and was quite frail. Her daughter spent a great deal of time with her at the hospital and felt that her mother was overlooked by staff who didn’t make the time to try to understand her needs or what she wanted from her care. She also felt there was a lack of communication between staff and Lola’s carer’s (herself and other family members) and that there was no interest shown by staff in initiating or pursuing conversations about Lola’s care.

The complaint came to the attention of senior staff within RMH. There had been discussions within the executive leadership for some time about ways that patient stories could be utilised constructively to improve practice. Sharon McGowan, Executive Director of Communications and Community Relations, Associate Professor Denise Heinjus, Executive Director of Nursing Services and Allied Health, and Liz Cashill, Consumer Liaison and Integration Manager had all seen the way patient stories had been utilised elsewhere, in Australia and internationally.

They had used patient stories at some committee meetings, but wanted to reach a wider audience. In order to do this they made a conscious decision to move away from seeing the recording of such a story in terms of risk. Instead they saw it as an opportunity – to acknowledge a failure to provide person centred care and to use it to inform better practice in the future.

Part of the decision to film the story stemmed from the situation itself. Lola’s daughter was an experienced aged care professional, with a robust understanding of best practice in the area of caring for older people. Most importantly, perhaps, she was keen to work towards creating something positive from her mother’s experience. As Sharon says, “we had clearly a very detailed complaint, clearly a very articulate carer, and somebody that wanted to help us change things.”

The process of filming and showing Lola’s Story has also been a learning experience for the team involved. While they all feel there are things they would have done differently with hindsight, a lot has been learned from the process and this has informed subsequent use of patient stories and other strategies to embed patient centred care into practice.

The experience producing and sharing Lola’s Story has given impetus to using patient stories further within RMH. A second patient story, Florence’s Story has been filmed, and is now used for staff training. As well, the hospital is continually expanding the contexts where patient stories are shared verbally. They now open all quality committee meetings and Board of Directors meetings with a patient story.

Patient stories are just one of a raft of strategies being used by RMH to put patient experience front and centre, and ensure that person centred care is delivered across the organisation and by all staff, all the time. All staff are required to complete an online training package on Partnering with Consumers and Person Centred Care. Other training resources include Florence’s Story, as well as videos on person centred care and on providing health care to the ATSI community.

The hospital has also been surveying patients after discharge about their experience of the hospital and its care. The survey is sent by email to all patients who provided an address. The hospital has also implemented the Partnerships in Care Strategy, endorsed in early 2014. The strategy is multi-pronged and aims to empower consumers as well as build workforce capacity.

These strategies all form part of a concerted organisational push to ensure that person centred care is something that is central to clinical practice in every profession and every occasion of care. Ultimately it is about remembering what a hospital’s performance is actually about . As Sharon says, “we are not just talking about a bunch of figures or graphs on paper – these are real people that have real experiences with us.”

If you are a patient at St Vincent’s Hospital Melbourne, you will find yourself sitting in a very comfortable chair. Thanks to the Best Care for Older People (BCOP) initiative, every patient chair at the hospital is now equipped with a custom designed pressure relieving cushion. The initiative is reducing the incidence of pressure injuries via a preventative health approach.

Pressure injuries are largely preventable. They are painful, difficult to treat, costly and can have severe adverse consequences for those experiencing them. However, they still occur in hospitals every day.

"Even if there's one person we prevented from a pressure injury, then it's worth it."

The use of pressure relieving equipment, such as pressure reducing cushions and heel wedges has been shown to reduce the likelihood of pressure injuries forming. However, preventable injuries can often occur because appropriate pressure relieving equipment is not available unless a patient is deemed high risk or has already sustained an injury. Additionally, staff are not always aware of when or how to use the equipment available, or how to monitor patients’ skin integrity.

St Vincent’s Hospital Melbourne was no exception. An audit revealed that 92 per cent of inpatient units did not have sufficient pressure-relieving devices available. Equipment was hired when needed, a costly and inefficient exercise.

The innovative approach to preventing pressure injuries taken by St Vincent’s came about organically. Natalie Newman, a BCOP Project Officer and Amber O’Brien, an Occupational Therapist, met to discuss a project to help nursing staff decide when and what type of pressure relieving cushions to provide to patients. As they explored the types of cushions available, they decided they needed to further understand the impact of extended unsupported sitting and the pressure relieving devices available.

Natalie and Amber mapped the pressure on the sacral area for a person sitting on a standard hospital chair using an image mapping system. The results were surprising, clearly showing very high areas of pressure particularly on the sacrum. Mapping the pressure areas while using available cushions showed that none were right for the job. Not content with this, they set about designing their own. Collaborating with patients, infection control and an external manufacturer they came up with a suitable design. The new cushion reduced pressure by a massive 65 per cent.

Realising the potential impact of such a huge reduction in pressure, they decided that all patients, not just those deemed at high risk, would benefit from access to this equipment. “Once we realised that everyone could benefit from these cushions, then we ran with it and it turned into an organisational strategy” says Natalie.

With funds available through BCOP, 560 of the custom designed pressure cushions, as well as 200 heel wedges, were purchased and the pair set about introducing them to every acute and sub-acute inpatient ward. The approach meant that all patients sitting out of bed would be on a pressure relieving cushion at all times, no matter how low risk they might be. High risk patients would still be referred for assessment by Occupational Therapy and further interventions introduced if necessary. All wards were also provided with enough heel wedges for patients confined to bed for long periods.

Crucial to the success of the roll out was the extensive education campaign – over 500 staff attended tutorials on the preventative approach to pressure injuries and the use of the cushions. In addition, over 750 educational posters were distributed, and all inpatient units were provided with an information pack about the cushions, including infection control, maintenance and ordering. This comprehensive approach meant that the roll out went smoothly with everyone understanding the purpose and requirements of the new practice.

The approach to pressure injury prevention has become part of daily clinical practice at SVHM. The ongoing responsibility for maintaining the initiative has been taken up by the Occupational Therapy Department and the Nurse Unit Managers of each ward. Occupational Therapy staff now work with Nurse Unit Managers to assess the condition of the cushions and replace them as necessary. They are also champions of the policy and work to ensure it remains standard practice throughout the hospital. The Occupational Therapy Department even keeps a supply of cushions for patients to purchase and use at home.

This groundbreaking approach to preventing pressure injuries has already shown impressive results. Just six months after the roll out was completed, pressure injuries of all types were reduced by 34 per cent. Not only that, but the severity of the injuries that did occur were reduced across the board.

Recognition of the effectiveness of the initiative has come from far and wide. St Vincent’s Health Australia awarded the project a Quality Award in 2013 for Exceptional Care – A culture of no harm. Several other organisations have also expressed interest in adapting the initiative for their own use.

Not only that, but the custom designed pressure relieving cushions developed by SVHM have proved very popular with other healthcare providers, due to the evidence based development process. They have been so effective that their manufacturer has now made them their standard.

Perhaps, however, the worth of the initiative can be gauged more simply - as Natalie says, “even if there’s one person we prevented from a pressure injury, then it’s worth it.”

When most of us think of hospital, we think of a place you go to get better – either because you’re very sick or injured. Historically, this has been the main role of the hospital – the treatment of acute disease and trauma – but it is no longer the case.

As the population ages and the nature of healthcare changes, hospital admissions are increasingly about treating chronic conditions, often at the times when they flare up. This has meant a significant shift in approach for hospitals and clinicians. Some have taken longer to realise this change, and some have been resistant to accepting it, but others have seen these changes as an opportunity to create new ways of providing services and new models of care that meet the needs of this predominantly older hospital population.

This philosophy is what underpinned the Council of Australian Governments Long Stay Older Patients Initiative (COAG LSOP) in Victoria. The COAG LSOP ran initially from 2006 to 2010, and was then extended to 2013. In Victoria, the program has been implemented by the Department of Health and Human Services (DHHS) as Improving Care for Older People (ICOP), building on work that had been ongoing since the development of the 2003 policy of the same name. In the second stage, from 2010 to 2013, 35 public health services across the state participated in the initiative, including all metropolitan health services. These health services implemented a huge range of innovations and changes to improve the care of older people in hospital.

Health services were funded to make changes in a range of areas. They were asked to make improvements to the physical environment that would facilitate better outcomes for older people. One of the most popular improvements was purchasing clocks for patient rooms, especially those showing date and day as well as time. In fact over a thousand clocks were bought! Other improvements included improving chairs and signage, buying pressure care equipment like cushions and heel wedges, through to creating garden areas for older patients and patients with dementia.

Policy development was another focus of the program, namely including ICOP principles for minimising functional decline into policies and clinical guidelines. In fact almost all participating hospitals had developed and implemented an organisation wide policy on minimising functional decline by the end of the initiative.

Health services were also asked to provide professional development to improve their workforce’s ability to best care for older people. A range of education programs were delivered, ranging from lunchtime seminars to vocational qualifications.

Of course, all this policy and knowledge has to be translated into practice, and embedding the evidence into models of care was perhaps the biggest focus of the program. The ways health services went about this, the areas on which they focused and the approaches taken were greatly varied – many examples of innovation can be found within these case studies. All have contributed to our knowledge of what works in minimising functional decline and what can be implemented to improve care for older people.

Underpinning all this work was the principle of person centred practice, which is putting the patient at the centre of their care. Health services showed great innovation and creativity in how they went about promoting and educating on this concept and working towards it being embedded in usual clinical practice.

Implementing such culture change needs leadership to be successful. As Chief Executive of Eastern Health, Alan Lilly has prioritised the patient experience. His recognition that older people are the major users of the health service – he estimates that people over 70 make up at least 40 per cent of their patients – puts their experience front and centre. Using patient feedback to work out priorities for changes has led to improvement like the roll out of staff name badges that can be easily seen by patients and visitors.

Eastern Health now compiles a list of the top 12 priorities for the year, from the patients’ perspective. Ultimately, what comes out as being most important to patients is communication and feeling listened to by staff, says Alan.

Sue Race, Divisional Director of Subacute and Aged Care Services at Western Health (WH), has championed the principles of ICOP since working on the original policy Improving care for older people: a policy for health servies in 2003. She finds it particularly rewarding to have seen a culture shift occur within Western Health during that period, so that the ICOP principles are now embedded into everyday practice across the organisation. She says that having the principles embedded into the clinical governance structure at WH has been essential.

Eastern Health's CEO says they now compile a list of the top 12 priorities for the year, from the patients' perspective. Ultimately, what comes out as being most important to patients is communication and feeling listened to by staff.

Kate Mangion, Manager Communications and Partnerships, division of Subacute and Aged Care Services at WH, who worked on the ICOP project, agrees. “There’s high level governance and really high level support [for this work], and I think it’s great that now we’re seeing so many different people involved in leading all this work,” she says.

This new way of working is spreading through health services as more and more clinicians who were involved in the program champion its ongoing importance. Kate Allen, Nurse Unit Manager of the Geritatric Evaluation Management ward at St Vincent’s Hospital Melbourne worked on the ICOP project there. She says that there are people who worked on the project in positions throughout the organisation. “We all approach our work with our headspace changed,” she says, “and this approach influences others and the message keeps spreading.”

Nicole Doran, Manager Ageing and Complex Care at DHHS, has played a key role in overseeing the implementation over the past decade. Nicole is proud of Victoria’s role in leading the way in best care, and says “these implementation case studies are just some of the many good news stories across the State.” She also stresses that this has only been possible because of the commitment and collaboration of health services, DHHS, the National Ageing Research Institute and a host of experts in their field, to improve outcomes for older people.

Indeed Best care for older people everywhere: The toolkit, affectionately known throughout health services as The toolkit, and the Improving the environment for older people: An audit tool are two tangible resources developed during this period to support health services make evidence based changes.Nicole’s hope is that The toolkit, now in its third edition as this new web based resource Older people in hospital, will retain the existing audience and attract a new audience, not only within Australia, but also internationally. As she says, “that alone is a legacy in itself.”