vichealth koori health research and community development...

VicHealth Koori HealthResearch and CommunityDevelopment Unit

Published byVicHealth Koori Health Research and Community Development Unit, Melbourne 2004

Summary of Findings from Hospital Case Studies & Recommendations for Accreditation


FOREWORDI am very pleased to write the foreword of the Aboriginal and Torres StraitIslander Hospital Accreditation Project Community Report.

As the first manager of the Koori Health Unit of the Health Commission ofVictoria in 1982, one of my first challenges was to implement therecommendations of the working party report into Aboriginal health inVictoria.

I started my role in April 1982 under the direction of the Aboriginal HealthResources Consultative Group. This group advised the Government onAboriginal health issues and developed the Aboriginal Hospital Liaison Officerprogram that would be located in hospitals in towns where there was a largeAboriginal population. This was to be the first major step in changing thehospital environment to meet the cultural needs of the Koori community.

The Aboriginal Hospital Liaison Officer recommendation in the working partyreport was for 43 positions but we got 16 positions. It gives me great pleasureand pride that the Aboriginal Hospital Liaison Officers Program is stilleffectively serving Aboriginal people in Victoria and parts of New South Walesalong the Murray River after 21 years.

I have always said, "To be an Aboriginal Hospital Liaison Officer you have tobe a very special person." Several of the officers I appointed are still today intheir positions and will always be special people to me. I would like to see,though, a support framework put in place for these workers that maintainsthe structural changes they work toward. Accreditation would not onlysupport the Aboriginal Hospital Liaison Officers in their role of facilitatingchange but would also provide the accountability needed to sustain it.

There is a continuing trend for hospitals to rely on Aboriginal Hospital LiaisonOfficers to identify Aboriginal patients. Hospitals need to take moreresponsibility for the identification of Aboriginal families using their services.An accreditation process would ensure that systems are in place that wouldallow accurate information to be collected. This would allow for bothhospitals and the community to benefit with identified funds working towardsa better service.

For this to work effectively there needs to be a two-way process of culturalawareness training for hospital staff and an awareness campaign for theAboriginal community.

In closing I enthusiastically commend this report.

KEVIN R. COOMBS OAM

March 2004


CONTENTS

ACKNOWLEDGEMENTS 4

PROJECT TEAM 4

USAGE 4

INTRODUCTION 5

The aim of the project 5

Background 5

HOW THE PROJECT WAS STRUCTURED 6

THE HOSPITAL CASE STUDIES 7

Which hospitals were involved? 7

The findings from the case studies 7

Implications of the findings 10

THE QUALITY FRAMEWORK 12

The structure 12

Applying the Quality Framework 13

Feedback from the hospitals 13

RECOMMENDATIONS FOR ACCREDITATION 14

What is accreditation? 14

Minimum standards 14

The accreditation process 16

Additional accountability requirements 16

A flexible approach to accreditation 17

Involving Aboriginal people in the accreditation process 17

CONCLUSION 19

GLOSSARY 20

APPENDIX I: QUALITY FRAMEWORK 21

APPENDIX II: ROLL-OUT SCHEDULE 25

4 Summary of Findings from Hospital Case Studies & Recommendations for Accreditation

ACKNOWLEDGEMENTSThe project team would like to acknowledge and thank the Steering Committee, and theVictorian Aboriginal Community Controlled Health Organisation for their expertise,guidance and contribution. The team would also like to acknowledge the hospitals thatparticipated. A special thank you to people who provided additional comments.

PROJECT TEAMIan Anderson VicHealth Koori Health Research and Community Development

Unit, University of Melbourne

Angela Clarke VicHealth Koori Health Research and Community Development Unit, University of Melbourne

Russell Renhard Australian Institute for Primary Care, La Trobe University

Shawana Andrews Mental Health Service, Royal Children’s Hospital

Michael Otim VicHealth Koori Health Research and Community Development Unit, University of Melbourne

USAGEAs this project took place in Victoria, the word Koori has been used interchangeably withIndigenous to include all Aboriginal and Torres Strait Islander people.

First printed in June 2004.

ISBN 0 7340 30207

This work is joint copyright by the VicHealth Koori Health Research and Community Development Unit (University ofMelbourne), Australian Institute for Primary Care (La Trobe University) and the Victorian Department of HumanServices. It may be reproduced in whole or in part for study or training purposes, subject to an acknowledgment of thesource and no commercial use or sale. Reproduction for other purposes or by other organisations requires the writtenpermission of the copyright holder(s).

Additional copies of this publication can be obtained from www.cshs.unimelb.edu.au/Koori/html/publications.htm or from the VicHealth Koori Health Research & Community Development Unit, Centre for the Study of Health andSociety, School of Population Health, Level 4, 207 Bouverie Street, University of Melbourne, Vic 3010.

Tel: (03) 8344 0813 Fax: (03) 8344 0824E-mail: [email protected]

Cover logo designed by Michelle Smith & Kevin MurrayAdditional artwork by Shawana Andrews

5Summary of Findings from Hospital Case Studies & Recommendations for Accreditation

INTRODUCTION The aim of the project

In 2001, the Department of Human Services commissioned the VicHealth Koori HealthResearch and Community Development Unit (University of Melbourne) and the AustralianInstitute for Primary Care (La Trobe University) to jointly carry out the Aboriginal andTorres Strait Islander Accreditation Project with the aim of developing ‘a strategy for theaccreditation of public hospitals in regard to the reporting of Indigenous status and theprovision of hospital services, including discharge planning, for Aboriginal and TorresStrait Islander patients’. This report describes the different stages of the project, anddiscusses the findings and recommendations.

Background

Australian Indigenous people have a fourthworld health status with a 20-year lower lifeexpectancy than that of the mainstreampopulation. In helping to bring about animprovement in the state of Koori health,hospitals play a two-fold role: they providetreatment to patients and they are alsovaluable sources of information. Accurate dataabout Kooris’ use of hospitals is essential forpolicy-making, planning, and serviceimprovement, so in 1993 the VictorianGovernment mandated that public and privatehospitals must identify all Koori patients. Thequestion ‘Are you of Aboriginal or Torres StraitIslander origin?’ was introduced to gatherinformation to:

• monitor changes in the health of the Kooricommunity

• decide on Koori health priority issues andprograms

• obtain adequate resources for healthprograms and health services for Kooripeople

• develop appropriate health promotionprograms and health screening programs

• make sure that mainstream health careservices are providing culturally appropriateand accessible health services for the Kooricommunity. 1

The Indigenous status question provides thedata for another government program - theWeighted Inlier Equivalent Separations (WIES)payment. In January 1999, the Department ofHuman Services introduced a 10% supplementfor hospitals based on the number ofAboriginal and Torres Strait Islander peopleadmitted as inpatients. There was noaccountability structure built into this payment.

1 Department of Human Services 2001, Koori Health Counts, Koori Human Services Unit, Department of Human Services, Victoria.

SUMMARY OF KEY ISSUE

VACCHO supports the release of thereport.

VACCHO makes the following pointsfor discussion, consideration andpossible inclusion:

• VACCHO feels the report does not document the ongoing support issuesof current or future Aboriginal Hospital liaison Officers (AHLO). As part of the 10% WEIS supplement, VACCHO would support an "accreditation package" that including the issue of ongoing professional development of AHLOs. This should include the formation and built-in structural support for an AHLO State network.

• VACCHO would recommend the report including Aboriginal representation on all hospital committees including mandatory Indigenous places on Hospital Boards,as one of the strategies about building relationships with AboriginalOrganisations and Services.

• VACCHO has role to play in both the building relationships with AboriginalHealth Organisations and the coordination of an AHLO network.

RECOMMENDATIONThe feedback from VACCHO isdiscussed, and possibly included in theAboriginal and Torres Strait IslanderHospital Accreditation CommunityReport.

Victorian Abriginal CommunityControlled Health Organisation


HOW THE PROJECT WAS STRUCTUREDThe VicHealth Koori Health Research and Community Development Unit and theAustralian Institute for Primary Care divided the Accreditation Project into four phases:

Phase I Eight Victorian hospitals were studied in regard to their Koori identification practices and provision of services.

Phase IIA review was conducted of national and international literature relating to the identification of, and provision of services to, Indigenous people, the impact of funding incentives on these, and accreditation systems designedto improve identification and services.

Phase III The findings from the hospital and literature reviews were used to develop the Quality Framework. This was structured as a series of questions about policies, procedures and monitoring practices, with accompanying explanatory notes and training sessions.

Phase IV The Quality Framework was given to hospitals from Phase I. The hospitals were asked to evaluate the Quality Framework’s usefulness as an accreditation system. A report of the findings was submitted to the Department of Human Services in November 2002.

Phases I, III and IV will be discussed here in more detail. The results from Phase II areavailable through the VicHealth Koori Health Research and Community DevelopmentUnit.

To date there has been little analysis of the Koori identification process or of the impactthe WIES payment has had on the services provided to Aboriginal and Torres StraitIslander patients. While the accuracy of the Indigenous status data is unknown, it doesappear to depend on two main factors:

• the effectiveness and consistency of hospital administration practices and systems

• the willingness of Aboriginal people to disclose their Indigenous status when usinghealth services.

Against this background, the Aboriginal and Torres Strait Islander Hospital AccreditationProject is a timely and valuable piece of research. It has uncovered problems with theidentification process, and revealed where hospitals could improve their provision ofculturally appropriate services to Koori patients. It has found weaknesses in dischargeand referral procedures, and has identified a need to strengthen the relationshipsbetween hospitals and Koori organisations. The project has highlighted the achievementsof the Aboriginal Hospital Liaison Officers (AHLOs), and has found many examples ofgood practice within the hospital system. Finally, the project has come up with someideas on how to fix the problems, build on the successes, and improve the way hospitalsserve the Koori community.

Which hospitals were involved?

The project team selected eight hospitalsin consultation with representatives of theVictorian Aboriginal community and theDepartment of Human Services SteeringCommittee. The aim of the selectionprocess was to involve a range of hospitalsin relation to size, location and thepresence or absence of an AboriginalHospital Liaison Officer (AHLO). Thehospitals were purposely selected. Arandom sample may have missed examplesof good practice, upon which the QualityFramework would be based, hence the useof Koori community opinion in the finaldecision. Eight hospitals were approachedbut one declined to participate, soanother hospital of a similar size in a ruralarea was found. The following eighthospitals agreed to be part of the casestudy:

• Austin and Repatriation MedicalCentre, Heidelberg

• Mercy Hospital for Women, EastMelbourne

• The Northern Hospital, Epping

• Royal Children’s Hospital, Parkville

• Central Gippsland Health Service, Sale

• Portland and District Hospital

• Mildura Base Hospital

• Southern Health, Dandenong.

The findings from the case studies

Overall

Although the case studies of the eighthospitals revealed some examples of goodpractice there were also some commontrends identified:

• The case study hospitals had no specificpolicy framework designed to directKoori identification, service provision orcommunity involvement.

• There was a generally held view thatthe identification of Koori people was

accurate because patients are routinelyasked the question about theirIndigenous status.

• Whilst Koori cultural and educationalevents contribute to making servicesmore appropriate for Koori people,they were mostly initiated byindividuals and were not driven by anoverall strategy or policy.

• Where hospitals employed AboriginalHospital Liaison Officers (AHLOs), therewas the view that cultural issues werethe business of the AHLO exclusively.

• The discharge process worked wellwhen AHLOs were involved andappropriate referrals were made.

• Few hospitals had strong relationshipswith Koori community organisations.

The project team examined these trends inmore detail and found some specific areasof concern. These are discussed below.

Summary of Findings from Hospital Case Studies & Recommendations for Accreditation 7

THE HOSPITAL CASE STUDIES

The hospital accreditation projecthas highlighted the need forhospitals to be more accountable tothe Koori community about howthey use the WIES money and thatit should be specifically used toprovide training for Liaison Officersor to fund Koori health programs.The project also helped to identifygaps in the hospital system thatneed to be improved (eg supportfor Liaison Officers to provide crosscultural education) to create betteraccess for the Koori community andthat making sure there is goodaccess for Koori families is not justthe job of the Koori workers but allhospital workers.

Brooke Nam

Aboriginal Family Support Worker –Royal Children’s Hospital


Accuracy of the data

The data collected by hospitals, includingIndigenous status, is known as theVictorian Admitted Episodes Data (VAED).The case studies found some commonfactors that help explain why the data isinaccurate:

• The question about Indigenous status isnot always asked when patients areadmitted.

• Kooris do not always choose to identifythemselves at admission. Ifadministration staff do not understandwhy they are collecting the data anddo not explain to patients why thequestion is being asked, Kooris may bereluctant to identify themselves.

• Admissions staff do not always reviewinformation sent in advance with thepatient upon admission.

• There are no specific systems in placefor Kooris to be identified after theadmission process at a later stageduring their hospital stay.

• Clinical staff rely on AHLOs to telladministration staff about a patient’sKoori status when it has not beenrecognised on admission.

• A number of Koori identifications relyon the AHLO. Because AHLO positionsdo not allow for 7-day, 24-hourcoverage, some Koori people areunlikely to be identified, particularly ifthey present in emergency after hours.

• Some Koori people choose not toidentify themselves as Koori but receiveservices from the AHLO. They are thenincluded on the statistics provided tothe Department of Human Services bythe AHLO, but do not appear in thehospital administration’s data.

• A baby’s Indigenous status may not beidentified because the hospital fails toinquire about the baby’s father. Of theeight hospitals studied, only onematernity service asked about theAboriginality of the father.

The accuracy of the Koori identificationprocess remains unknown. It is difficult toestimate the percentage of under-reporting due to a failure to ask thequestion about Indigenous status versusunder-reporting due to people choosingnot to identify themselves as Koori.

Information technology systems

The case studies found that the accuracyof the Indigenous status data iscompromised when different computersystems within the hospital areincompatible with each other. If a person’sstatus is indicated on one system, there isno guarantee that it will becommunicated to the other systems. Thismay lead to inaccuracies in the PatientMaster Index (PMI), the main record ofpatient information.

Other problems with the hospitals’information systems were identified:

• There is no way of recording when aKoori person is identified in the system,if this is done after they are admitted.

• The PMI only allows for a ‘yes’ or ‘no’response to the question ‘Are you ofAboriginal or Torres Strait Islanderorigin?’ If a patient is unable to answerthe question during admission, hospitalstaff generally select ‘no’, furtherincreasing the proportion ofunidentified Koori patients.

Providing appropriate services in anappropriate cultural context

‘It doesn’t matter if people are black,white or any other colour, they all get thesame treatment.’

This quote reflects an attitude shared bymany staff throughout the hospitalsystem, and helps explain why Kooripatients are not receiving the mostappropriate service. It is well documentedthat Koori people have longer thanaverage lengths of stay in hospital, andare more likely to suffer from multiplemedical conditions than the non-Aboriginal population. These factorsindicate that a difference in treatmentmay be required.

Longer hospital stays mean that Kooripatients may be separated from familyand community for longer periods.Hospital staff should be sensitive to issuesthat may arise from this situation. Morecomplex health problems among Kooripatients mean there is a greater need forcoordinated treatment between hospitaldepartments. Hospital staff should ensurethat patients are fully informed andconsulted about the range of treatmentsthey may be receiving. AHLOs or Kooricommunity services should be available to


assist patients who choose to receivetreatment from Koori health servicesrather than mainstream health services.The referral process should also offerpatients a choice of mainstream and Koorihealth services for ongoing treatment ofmultiple medical conditions afterdischarge from hospital.

While it is appropriate, and desirable, thathospitals deliver a uniform quality ofclinical treatment, other factors mayimpact on a patient’s medical condition.Recognition of a Koori person’s culturalneeds may improve uptake andmaintenance of treatment, which is criticalfor long-term health. For hospital staff toprovide culturally appropriate service toIndigenous patients, they must haveeducation, skills and access to informationabout local Koori services andorganisations. There was little formaltraining for staff in these matters at any ofthe hospitals in the case study.

In most of the hospitals, the informationflow between clinical, support and AHLOstaff relied upon established relationshipsand was not supported by formalprocedures or guidelines. Staff who don’thave these established relationships (e.g.agency nursing staff) will therefore not beaware of the common practices.

A requirement for being able to provideculturally appropriate services is that apatient’s cultural background be known.However, the case studies confirmed whatwas already well documented and widelyknown by Koori health workers – manyKoori patients choose not to identifythemselves because they do not feel thatthe hospital environment is ‘culturallysafe’.

A ‘culturally safe’ place is one that isculturally affirming for Kooris and wherecultural matters are respected. Developingan inclusive and empowering environmentthat filters all levels of hospital servicedelivery is a concept that was notaddressed or fully understood by mosthospitals in the study.

In hospitals without an AHLO, creating a‘culturally safe’ environment was found tobe a low priority, and did not go beyonddisplaying posters and incorporating Kooriissues within a multicultural framework,rather than addressing Koori issuesindependently.

Those hospitals with an AHLO appearedmore pro-active in changing the hospitalenvironment to create a positive culturalcontext. Some of their initiatives included:

• Organising cultural events. Althoughthese events were ad hoc and not partof an overall strategy or specific policyframework, they helped create a betterlevel of understanding among hospitalstaff about issues facing Koori families.

• Promoting professional developmentand cross-cultural training as a keystrategy to initiate change and enhanceunderstanding.

• Developing an area in the hospital thatis identified as ‘Koori space’.

• Establishing links with local Kooricommunity services and organisations.Even in these cases, however, there arefew formal arrangements to ensure thecontinuity of relationships. Maintainingthese relationships seems to depend onthe initiative of the individualsinvolved.

Mildura has a very strong andcommitted group of Kooris whoover the years have built up andmaintained a very good workingrelationship with mainstreamservices. Together we have beenable to streamline referrals andappointments between Koori andmainstream services better thananywhere else that I’ve seen.However, we do believe that allhospitals need to be accountable totheir local Aboriginal Community onhow the WIES money is being spent,as there are no currentrequirements that have to be metby hospitals from governmentfunding. As a Community we haveno idea where the hospital isspending this money and believethat we should be consulted onhow it is spent to improve localAboriginal health.

Ken Knight

Manager - Mildura AboriginalHealth Service

Summary of Findings from Hospital Case Studies & Recommendations for Accreditation10

Appropriate referral

The case studies found that most hospitalshad no protocols or procedures to helpstaff make appropriate referrals for Kooripeople. In hospitals with an AHLO, thedischarge process does work well whenthe AHLO is involved. Unfortunately, itwas found that clinical staff sometimesmake discharge arrangements withoutconsulting the AHLO.

The hospitals involved in the study do notcollect information about referrals into orout of the facility beyond what is requiredfor funding accountability purposes.Consequently there is no data that profilesthe referral patterns for Koori patients.

Apart from some attempts by the AHLOs,none of the hospitals in the studymaintain a centralised database of Kooricommunity organisations and services towhere discharge referrals can be made.Clinical staff need access to thisinformation if they are to make culturallyappropriate referrals. This is particularlyimportant in the bigger metropolitanfacilities where there are more referraloptions.

Implications of the findings

The findings of the case studies indicatethat the hospitals would benefit from asystematic management focus on Kooriidentification, service provision anddischarge planning. Without executive-level policies, the hospitals often rely onindividuals, such as AHLOs, to correctlyidentify Koori patients and provideappropriate services and referrals. Hospitalpolices should cover administrative andstaff development issues, and alsoencourage cultural events and betterrelationships with local Kooriorganisations.

The case studies revealed some instanceswhere individuals and departments areworking together to develop effectiveprocedures. These models of good practiceshould be formalised within a policyframework and adopted throughout theorganisation.

Technical issues must be addressed toensure that the identification of Kooripeople is accurate and that the servicesare culturally appropriate. Computersystems should be compatible with eachother and allow information to be easilytransferred and retrieved. The PMI recordshould have a third option besides ‘yes’and ‘no’ for answering the question ‘Areyou of Aboriginal or Torres Strait Islanderorigin?’ If admissions staff could select‘unknown’ when a patient is unable toanswer the question, the record could beupdated at a later stage. All hospitalsshould develop a central database ofKoori community services for guidance inmaking appropriate referrals.

Human resource management issues alsoneed to be addressed. Education andcross-cultural training programs wouldmake hospital staff more sensitive to theneeds of Indigenous people. Respect forcultural differences should be as much apriority as the nature and quality ofclinical services. It should also beemphasised that Indigenous issues are notjust the concern of the AHLOs. The currentdivision of responsibility represents abarrier to wider cultural understanding,and also prevents the skills andconnections of the AHLOs being usedmore extensively within the hospitalsystem.

The case studies suggest that the accurateidentification of Koori people may dependon the cultural credibility the hospital haswith the Koori community. The experienceof services as 'culturally safe’ appears tobe closely linked to the strength ofrelationships between the hospital andKoori services and organisations. Theeffectiveness of strong relationships inbuilding a culturally safe environmentwould be enhanced by managementapproval and the support of formalarrangements and agreements.

Drawing on the findings of the casestudies, some clear directions are indicatedfor developing an ‘accountabilityframework’ for hospitals receiving theWEIS supplement for services to


Aboriginal and Torres Strait Islanderpeople. Executive policy, technical systems,human resource management andrelationships with Koori organisations areall factors that should be considered.

Most importantly, the accountabilityframework should be based on thepremise that the accurate identification ofKoori people is linked to the culturalcredibility a hospital has with the Koori

community. The framework shouldtherefore take a developmental focus andpromote continuous quality improvement.It should recognise that buildingcredibility is not a technical exercise but asocial one. A focus on the numbers ofidentified Kooris as the most accuratemeasure of change in a hospital’s culturalsensitivity would be misguided. It wouldtake the focus away from the systemsdevelopment that is needed to create aKoori-friendly environment and maximisethe health benefits to Koori patients.

The hospital accreditation projectcommunity report looks at gapswithin the hospital structure andwhat is clear is that hospitals needto be accountable to the Aboriginalcommunity. This report needs to beimplemented to ensure theVictorian Admitted Episodes Data(VAED) information becomes moreaccurate. Aboriginal Hospital LiaisonOfficers program needs to bereourced at a appropriate level toensure quality of care in providingculturally relevant services to theircommunity thus giving theAboriginal people a communitydriven program, this is in line withcommunity control.

It is an important process that thehospitals have an Aboriginalcomponent to their existingaccreditation for hospitals to bemore accountable to the Aboriginalcommunity. The WathaurongAboriginal Community have builtand maintained an excellentworking relationship with BarwonHealth and other mainstreamservices within the Barwon Regionproviding culturally relevant servicesto the Aboriginal Community ofGeelong.

Lyn McInnes

Aboriginal Hospital Liaison Officer -Geelong Hospital.


The structure

Once the hospital case studies and literature reviews were complete, the next phase ofthe project began. The case studies had revealed some reasons why hospitals were failingto accurately identify Koori patients and provide appropriate services and referrals tothem. The literature review highlighted accountability models that had proven effectivein creating change within other organisations. The project team took the findings fromboth phases and designed a program to guide hospitals in addressing their problems withidentification and service provision. The result was the Quality Framework. 2

Structured as a series of questions, the Quality Framework asked hospitals to review theirpolicies, procedures and monitoring systems in six areas:

1. Staff values, skills and knowledge.

2. Relationships with Koori organisations.

3. Inter-agency and interdisciplinary planning and evaluation processes.

4. Resources for making appropriate referrals.

5. Information technology (IT) systems for recording Indigenous status.

6. Evaluation of identification and recording systems.

The style of the framework is developmental in that it does not imply minimum levels ofperformance. It does not set targets that must be reached in order to ‘pass the test’, anddoes not rank the issues in a hierarchy of importance. Instead, the framework guideshospitals in examining each area so that they can see where they are succeeding andwhere they need improving. The framework does not prescribe any methods forimplementing change. Rather, it encourages hospitals to incorporate the self-assessmentprocess into their existing continuous improvement strategy.

THE QUALITY FRAMEWORK

2 The complete Quality Framework is contained in Appendix I.


Applying the Quality Framework

The eight hospitals involved in the case studies were invited to a three-hour trainingsession on how to use the Quality Framework. Six hospitals attended:

• Austin and Repatriation Medical Centre, Heidelberg

• Mercy Hospital for Women, East Melbourne

• The Northern Hospital, Epping

• Royal Children’s Hospital, Parkville

• Mildura Base Hospital

• Southern Health, Dandenong.

Sixteen hospital staff members attended the workshop, representing the followingprofessional areas:

• nursing

• information management (IT)

• health information management (admissions, medical records, etc.)

• social work

• patient liaison

• Aboriginal liaison

• multicultural liaison.

The training session explained the background and goals of the Aboriginal and TorresStrait Islander Hospital Accreditation Project so that the participants could understand thecontext of the exercise. The different components of the Quality Framework werediscussed, and suggestions were made about how the hospitals could use it as a tool forself-assessment. There was no set timeframe for using the framework. The hospitals wereencouraged to view it as an evolving process and examine the issues at their own pace.

Feedback from the hospitals

The project team asked the hospitals for their feedback on the Quality Framework. Theywere asked to evaluate its usefulness as a tool for assessing Koori identificationprocedures and service provision. They were also asked to comment on the effectivenessof the training session.

Generally, the Quality Framework was found to be a user-friendly document. A number ofchanges were suggested, and the project team made some modifications to theterminology based on this feedback. The Quality Framework proved to be an effectiveself-assessment tool because it encouraged the hospitals to examine their policies andprocedures. It highlighted some examples of good practice that the hospitals could buildon, and it also revealed areas where improvements could be made to identificationprocedures and services.

All the hospitals agreed that the training program was essential in helping themunderstand the purpose of the Quality Framework and how to apply it. Two majorfeatures of the training were considered to be fundamental to its success:

• the inclusion of Aboriginal people (e.g. AHLOs) to validate the systems and practicesthat are implied in the Quality Framework

• the inclusion of several hospitals so that different ideas could be discussed andinnovative practices could be shared and adopted by other institutions.


RECOMMENDATIONS FORACCREDITATIONWhat is accreditation?

The purpose of accreditation is to providea guarantee that the quality of goods orservices provided is at an acceptable level.In the health sector, accreditationgenerally requires:

• a set of standards against whichperformance is compared

• an assessment of compliance withthose standards by independentpersonnel.

This is the most common system ofaccreditation in the Australian health careindustry. 3

Minimum standards

‘Minimum standards’ is a term used todescribe the minimum with which aservice must comply in order to gainaccreditation. Developing a set ofminimum standards for Kooriidentification and service provision is not astraightforward matter, especially if it is toapply to all public hospitals.

Accreditation systems commonly usequantitative minimum standards – theyare concerned with quantities or numbers.If reliable data is available, this approachcan be very effective. The project teamconsidered whether a quantitativestandard could be used here. Given thequestions about the current accuracy ofthe data collected in hospitals, it wasdecided that this type of standard wouldnot be appropriate.

The literature review in Phase II revealedanother type of minimum standard that isused extensively in the Australian healthcare industry. To achieve accreditation,services must have systems in place forregular performance surveillance. Self-assessment ensures that hospitals examine

their internal systems and consider howwell they are performing. This exercise isvaluable when it promotes an interest inquality and encourages ownership of thefindings. If hospitals accept responsibilityfor problems identified through self-assessment, this paves the way for change.

To meet this minimum standard of self-assessment, hospitals could use the QualityFramework. The framework could beintroduced progressively over severalyears, depending on the size of thehospital. For instance, an identificationaudit4 may be an appropriate minimumstandard for hospitals with a largethroughput of Koori patients. In smallerhospitals with a low throughput of Kooripatients, such an audit is unlikely to be a

14

3 Commonwealth Department of Health and Aged Care 2000, Standards and Quality Improvement Processes in Health and Community Services: A Review of the Literature, Quality Improvement Council Ltd, Bundoora.

4 See policy issue 6 in the Quality Framework (Appendix I).


sensitive indicator of performance. Inthese cases, a more appropriate minimumstandard might be an examination ofreferral arrangements. 5

A good starting place for all hospitals,regardless of size, would be a focus on

staff values, skills and knowledge relatingto cultural sensitivity. 6 Another minimumstandard that should apply to all hospitalsis the development of relationships withAboriginal organisations.7




During the past 2 years since Mercy Hospital for Women (MHW) participated in theAboriginal and Torres Strait Islander Accreditation Project, there have been severalimportant developments in the Mercy’s care of our Aboriginal women and theirfamilies:

- After 20 years at MHW, our AHLO, Beryl Thomas, has been joined by AboriginalHealth worker, Michelle Hickey-Donovan. Michelle’s main responsibilities are: todeputise for Beryl when she is not available, to assist in the development ofprograms which aim to improve health outcomes for Aboriginal women & familiesand, with Beryl, to provide cross-cultural training for MHW staff. Together, Beryland Michelle form MHW’s Aboriginal Women and Family Support Unit. Wereceived a grant from DHS to produce a pamphlet.about the Unit – the pamphlethas been designed by Beryl & Michelle, and features "Mother, Child", a painting byLyn Briggs which she donated to the Mercy. The Unit was officially launched inNovember 2003 by Gavin Jennings, Victorian Minister for Aboriginal Affairs. TheLaunch featured a memorable speech by Beryl, Joy Murphy as Guest speaker, a didjplayer, and was MC’d by Michelle.

- Increasing numbers of Aboriginal women are attending our Transitions Clinic,which provides ante-natal care to 3 categories of women with complex needs.There are currently 19 Koori women attending the Clinic, almost all of them aredoing Shared Care with VAHS.

- Posters about our Aboriginal Women and Family Support Unit, and encouragingAboriginal and Torres Strait Islander women to identify themselves to MHW staff,have placed at all locations where patient registration takes place, eg Outpatientreception, Admissions, Emergency Dept, postnatal wards. Staff members in allthese areas of the hospital receive ongoing education re the importance ofaccurate identification of Aboriginal and Torres Strait Islander women and babies.We are also working with our IT staff to ensure that when a patient is identified,the information is not "lost" between the different IT systems used within thehospital

- Since June 2003, a small Aboriginal flag sticker is placed by Beryl or Michelle onthe inside cover of medical files of women who identify themselves or their babiesto MHW staff as being of Aboriginal origin & who give permission for theplacement of the sticker.

- Work on a written policy about MHW’s care of our Aboriginal patients iscontinuing, and has included some discussion of shared issues with the RCHAboriginal Family Support Unit.

- Work on production of a resources folder, for use by MHW staff caring for anAboriginal and Torres Strait Islander patient After Hours or when Beryl & Michelleare not available, is almost complete.

Beryl Thomas – Aboriginal Hospital Liaison OfficerMichelle Hickey-Donovan – Aboriginal Health WorkerMercy Hospital


The accreditation process

The project team investigated differentaccreditation models and found that thetwo most widely used systems inAustralian hospitals are the AustralianCouncil on Healthcare Standards programEQuIP8, and the Quality ImprovementCouncil program QIC. Both programscould be adapted to make them suitablefor Aboriginal and Torres Strait IslanderHospital Accreditation. This would be amore practical option than creating anentirely new accreditation program andaccreditation body to administer it.

In order to implement an accreditationprogram, two initiatives would berequired:

• As there is currently no accountabilitystructure attached to the 10% WIESsupplement, the Department of HumanServices should link the payment to anaccreditation program. For hospitals toreceive the WIES payment, they wouldhave to be accredited by a recognisedaccreditation body, such as theAustralian Council on HealthcareStandards or the Quality ImprovementCouncil.

• The Department of Human Serviceswould have to direct the accreditationbodies to modify their programsappropriately. Existing systems likeEQuIP and QIC would need to include afocus on Koori identification practicesand service provision. Adopting theQuality Framework would ensure thatthese issues were addressed and thatthe minimum standard of self-assessment was fulfilled.

Additional accountabilityrequirements

As well as undergoing accreditation by arecognised accreditation body, hospitalscould be asked to meet a range of otherrequirements. Together theserequirements would form an‘accreditation package’.

Hospitals could be asked to reportregularly to the Department of HumanServices on data trends identified in theinformation collected about Kooripatients. Without breaching State andCommonwealth privacy legislation,hospitals could submit data on:

• total numbers of Aboriginal peopleusing the hospital

• age range of Aboriginal people usingthe hospital

• referrals from Aboriginal services andorganisations

• the locality (post code) profile ofAboriginal people using the hospital

• the locality profile of Aboriginal peopleusing adjacent hospitals’ facilities (e.g.nearby hospitals with an AHLO onstaff).

This data would assist the DHS with policy-making, planning and service provision. Itwould also give the hospitals usefulfeedback about the impact of strategiesdesigned to improve the accuracy of Kooriidentification and service provision.

Hospitals could be required to participatein regular forums, perhaps on an annualbasis. Each hospital would describe thestrategies they have used to improveidentification procedures and services toKoori patients. International research andexperience10 suggest that this type ofbenchmarking is an effective stimulant toservice development because itencourages hospitals to monitor andimprove their systems. The forums wouldgive recognition to hospitals that haveimplemented effective strategies, andallow these examples of good practice tobe shared. The impact of the forumswould be enhanced by visits betweenhospitals so that effective systems can beexamined directly.

In addition, hospitals could be asked toreport regularly to local Aboriginalorganisations or co-ops on the nature andprogress of strategies designed to improveKoori identification processes and services.

8 See the Australian Council on Healthcare Standards website <http://www.achs.org.au>.

9 See the Quality Improvement Council website <http://www.latrobe.edu.au/qic/>

10 See the Institute for Healthcare Improvement website <http://www.ihi.org>.


A flexible approach to accreditation

An accreditation package is recommendedbecause it would give the Department ofHuman Services the flexibility to introduceaccreditation requirements over a periodof time.11 A progressive increase ofrequirements would make it easier forhospitals to comply, and would alsoimprove their acceptance of theaccountability process.

Another advantage of an accreditationpackage is that requirements can beapplied selectively to suit each hospital,depending on its size, location and thescale of services provided to Aboriginalpatients. For example, the data reports tothe Department of Human Services couldbe modified for different hospitals.Changing trends in the postcode data forKoori patients may not be a sensitiveindicator in rural and remote areasbecause of low throughput levels. It mighttherefore be appropriate to remove thisreporting requirement.

For small, rural services, the numbers ofKoori patients, and therefore WIESpayments, may be so low as to make theaccreditation compliance costsuneconomical. In these cases, acollaborative approach between severalregional hospitals may be appropriate.This might involve strategies for creatingbetter links with health care providers,including Aboriginal health services, toimprove information exchange aboutKoori patients and build more effectivereferral arrangements.

Involving Aboriginal people in theaccreditation process

There are several ways that Aboriginalpeople could be represented in theaccreditation process. Aboriginal peoplecould be directly involved as part of theaudit team. However, there would bemajor logistical hurdles to this level ofinvolvement, relating to training andskills, payment and availability. 12

11 See Appendix II, Roll-out Schedule.

12 Consumer Focus Collaboration 2001, Consumer Participation in Accreditation: Project Report, Commonwealth ofAustralia.Canberra.

Hospitals and Aboriginalcommunities need to sit around atable and talk more about what thelocal health issues are and how theyare going to be fixed. When we allwork together a lot can be achievedbut it is important that hospitalsunderstand how the communityworks. Community control isessential in working togethersuccessfully and Aboriginal peopleknow better than anyone how itshould work to benefit our people.Being guided by the localAboriginal community/organisationsis important if hospitals want tocontribute to our health andwellbeing.

Liaison officers play a major role inthe hospitals in many differentareas such as supporting Aboriginalpatients and their families, crosscultural training for staff andcontributing to policy andprocedures. Liaison officers alsobreak down the barriers betweenhospital staff and Aboriginalpatients and families. Sometimes ifinformation is presented with toomuch medical jargon Aboriginalpeople may not always feelcomfortable asking questions andthis could lead to further medicalproblems down the track. Whenliaison officers are properly involvedthese problems are usually avoided.

Liaison officers are often notrecognized for their skills anddedication to their role within thehospital, supporting patients andtheir involvement in the Aboriginalcommunity. Many liaison officers gobeyond their paid work and take onvoluntary work outside of workhours and give in many differentways to their community.

Jemmes HandyAboriginal Hospital Liaison Officer –Mildura Hospital


A second option is for Aboriginal peopleto participate in interviews with the auditteam. AHLOs or Aboriginal communityorganisations could help recruitAboriginal people to take part in theseinterviews. In some cases, establishedAboriginal advisory bodies, such as localAboriginal co-ops or the VictorianAboriginal Community Controlled HealthOrganisation (VACCHO), might participateas a key stakeholder group in theinterview process.

A third approach is to invite Aboriginalcommunity groups to make a writtensubmission or participate in a writtensurvey process that can be considered bythe audit team.

If regular reporting to Aboriginalcommunity organisations is adopted aspart of the accreditation package, nofurther involvement by Aboriginal peoplemay be necessary.


CONCLUSIONEach stage of the Aboriginal and TorresStrait Islander Hospital AccreditationProject was an important step indeveloping ‘a strategy for theaccreditation of public hospitals in regardto the reporting of Indigenous status andthe provision of hospital services,including discharge planning, forAboriginal and Torres Strait Islanderpatients’.

The Phase I case studies examined eighthospitals to evaluate their systems foridentifying Koori patients and providingappropriate services and referrals. Somecommon trends were revealed:

• There was a need for explicit policiesregarding Koori identification andservice provision to give hospitals clearguidelines and help them bettercoordinate their procedures.

• Some hospitals had effectiveprocedures in place, but often themaintenance of these practicesdepended on the initiative ofindividuals, such as the AHLOs.

• Hospital computer systems need to beimproved to allow information aboutKoori patients to be accuratelyrecorded and transmitted betweendepartments.

• Cross-cultural training is needed forhospital staff to help them providemore appropriate services to Kooripatients.

• Stronger relationships with local Kooriorganisations are needed to helptransform hospitals into more Koori-friendly environments and increasetheir ‘cultural credibility’ with the Kooricommunity.

The Phase II literature review revealedthat self-assessment is an effective andwidely used accreditation technique. Onthis basis, the project team created thePhase III Quality Framework, a series ofquestions about policies, procedures andmonitoring systems relating to Kooriidentification and service provision. It wasdesigned to encourage hospitals toexamine their current systems, identifyeffective strategies and locate areas forimprovement. The framework was givento the hospitals and they were asked toevaluate its effectiveness as a self-

assessment tool. Some modifications weremade, based on the hospitals’ feedback,but it was generally found to be a usefulprogram.

In Phase IV, the project team formulatedan ‘accreditation package’ for hospitals:

• Accreditation should be conducted by arecognised accreditation body, whichcould modify existing programs toinclude a self-assessment componentsuch as the Quality Framework.

• A minimum standard for accreditationshould include a requirement thathospitals develop relationships withKoori organisations.

• In addition, hospitals could be requiredto report regularly to the Departmentof Human Services on data trendsregarding Koori patients.

• Hospitals could report to Kooriorganisations about their strategies forimproving identification proceduresand services to Koori patients.

• Hospitals could attend regular forumsto discuss Koori cultural issues andshare effective strategies with otherhospitals.

• The accreditation package could beintroduced in stages, and therequirements could be modified to suitthe size and location of differenthospitals.

• The 10% WIES payment should bedependent on compliance with theaccreditation program.

In November 2002, a final report of theproject findings and accreditationrecommendations was submitted to theDepartment of Human Services. Theproject team is pleased to report thatseveral of the hospitals involved in theproject are continuing to use the QualityFramework and are making changes totheir identification procedures andservices to Koori patients. It is hoped thatin the future the Quality Framework willbe used as part of an accreditation processin all Victorian public hospitals, and thatthis will lead to better treatment for Kooripatients and a much needed improvementin the health status of the Kooricommunity.


GLOSSARYAHLO Aboriginal Hospital Liaison Officer

ATSI Aboriginal and Torres Strait Islander

Clinical staff Doctors, nurses, physiotherapists, psychologists, etc.

DHS Department of Human Services

EQuIP Australian Council on Healthcare Standardsaccreditation program

IT Information Technology

PMI Patient Master Index (computer record of patient information)

QIC Quality Improvement Council accreditation program

Support staff Administration, medical records, ward clerks, etc.

VACCHO Victorian Aboriginal Community Controlled Health Organisation

VAED Victorian Admitted Episodes Data

WIES Weighted Inlier Equivalent Separations

Summary of Findings from Hospital Case Studies & Recommendations for Accreditation 21

APP

END

IX I:

QUA

LITY

FRA

MEW

ORK

Polic

y Is

sue

Rel

evan

t Pr

oce

du

res

Res

po

nsi

bili

ty f

or

H

ow

is im

ple

men

tati

on

H

ow

can

im

ple

men

tati

on

mo

nit

ore

d?

acco

un

tab

ility

fo

r th

is p

olic

y is

sue

be

imp

rove

d?

Staf

f va

lues

, ski

lls

and

kn

ow

led

ge

rela

ted

to

cu

ltu

ral s

ensi

tivi

ty

in t

he

pro

visi

on

o

f se

rvic

es t

o

Ab

ori

gin

al p

eop

le.

Do

es t

he

hea

lth

se

rvic

e h

ave

exp

licit

po

licie

s to

su

pp

ort

th

is is

sue?

Yes/

No

If y

es n

ame

the

sou

rce


Polic

y Is

sue

Rel

evan

t Pr

oce

du

res

Res

po

nsi

bili

ty f

or

H

ow

is im

ple

men

tati

on

H

ow

can

im

ple

men

tati

on

mo

nit

ore

d?

acco

un

tab

ility

fo

r th

is p

olic

y is

sue

be

imp

rove

d?

Rel

atio

nsh

ips

wit

h

Ab

ori

gin

al o

rgan

izat

ion

san

d s

ervi

ces.

Do

es t

he

hea

lth

ser

vice

h

ave

exp

licit

po

licie

s to

su

pp

ort

th

is is

sue?

Yes/

No

If y

es n

ame

the

sou

rce

Inte

r ag

ency

an

d

inte

rdis

cip

linar

y p

lan

nin

g a

nd

eva

luat

ion

p

roce

sses

wh

ich

fo

cus

on

th

e p

arti

cula

r cu

ltu

ral

and

so

cial

nee

ds

of

Ab

ori

gin

al p

eop

le

Do

es t

he

hea

lth

ser

vice

h

ave

exp

licit

po

licie

s to

su

pp

ort

th

is is

sue?

Yes/

No

If y

es n

ame

the

sou

rce


Polic

y Is

sue

Rel

evan

t Pr

oce

du

res

Res

po

nsi

bili

ty f

or

H

ow

is im

ple

men

tati

on

H

ow

can

im

ple

men

tati

on

mo

nit

ore

d?

acco

un

tab

ility

fo

r th

is p

olic

y is

sue

be

imp

rove

d?

Syst

ems

and

res

ou

rces

to

su

pp

ort

sta

ff t

o m

ake

tim

ely

rele

van

t re

ferr

als

and

see

k ap

pro

pri

ate

invo

lvem

ent

of

Ab

ori

gin

al w

ork

ers

and

ag

enci

es

Do

es t

he

hea

lth

ser

vice

h

ave

exp

licit

po

licie

s to

su

pp

ort

th

is is

sue?

Yes/

No

If y

es n

ame

the

sou

rce

IT s

yste

ms

wh

ich

su

pp

ort

th

e re

cord

ing

of

Ab

ori

gin

al a

nd

To

rres

St

rait

Isla

nd

er s

tatu

s an

d

com

mu

nic

atio

n b

etw

een

st

aff

and

dep

artm

ents

Do

es t

he

hea

lth

ser

vice

ex

plic

it p

olic

ies

to

sup

po

rt t

his

issu

e?

Yes/

No

If y

es n

ame

the

sou

rce


Polic

y Is

sue

Rel

evan

t Pr

oce

du

res

Res

po

nsi

bili

ty f

or

H

ow

is im

ple

men

tati

on

H

ow

can

im

ple

men

tati

on

mo

nit

ore

d?

acco

un

tab

ility

fo

r th

is p

olic

y is

sue

be

imp

rove

d?

Eval

uat

ion

of

the

effe

ctiv

enes

s o

f th

e id

enti

fica

tio

n a

nd

re

cord

ing

sys

tem

Do

es t

he

hea

lth

ser

vice

h

ave

exp

licit

po

licie

s to

su

pp

ort

th

is is

sue?

Yes/

No

If y

es n

ame

the

sou

rce


Minimum standards for accreditation

Year Large hospitals (over 50 Small hospitals (under Additional VAED Aboriginal and 50 VAED Aboriginal requirementsTorres Strait Islander admissions Torres Strait Islander per year) admissions per year)

One Staff values, skills and Staff values, skills and Data reports to knowledge related to knowledge related to DHScultural sensitivity13 cultural sensitivity

Two Same as Year One plus: Same as Year One plus: Same as Year • Relationships with • Relationships with One plus:

Aboriginal organisations14 Aboriginal organisations • Participation in quality forums

• Identification audits 15 • Referral arrangements

Three Same as Year Two plus: Same as Year Two plus: Same as Year Two• Communication systems16 • Communication systems plus:

• Referral arrangements17 • Reports to Aboriginal

organisations

Four • issues in the Quality • issues in the Quality Same as Year and Framework Framework Threebeyond

APPENDIX II: ROLL-OUT SCHEDULE






vichealth koori health research and community development...

Documents