Operational Plan of Management

Abbotsford Private Hospital

PRIVATE & CONFIDENTIAL

Date: 21 August 2019

Site Name: Abbotsford Private Hospital

Contact person: Dale Nelligan

Address: 61-69 Cambridge Street, West Leederville, WA 6007

Telephone: (08) 9381 1833 Fax: (08) 9381 7581

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Operational Plan of Management

Approved by Dale Nelligan

Title Chief Executive Officer

Date August 2019

Review August 2020

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Contents Operational Plan of Management iii

1 Introduction 1

1.1 Purpose of Plan of Management 1

1.2 Site Context 2

2 Capacity of the Hospital 2

2.1 Operational Hours 8

3 Admission Procedures 9

3.1 Day Patients 9

3.2 In Patients & Waitlist Management 10

4 Discharge Procedures 11

4.1 Day Patients 11

4.2 In Patients 11

5 Ambulance Transfers 13

6 Parking and Transport Arrangements 13

7 Workforce Planning 13

8 Safety and Security 15

8.1 Surveillance 15

8.2 Lighting 15

8.3 Signage and Space Management 15

8.4 Access Control 15

8.5 Staff Training 15

8.6 Police Involvement 16

8.7 Weapons 16

8.8 Incident Register 16

8.9 First Aid 16

8.10 Medicine Storage 16

8.11 Sharps Management 17

9 Fire Safety and other Emergencies 17

10 Catering and Laundry 17

11 Site Maintenance 18

11.1 Cleaning 18

11.2 Waste Management 18

12 Complaint Management 18

13 Existing Policies and Procedures 18

14 Updating/Review of the Operational Plan of Management 19

15 Consultation 19

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1. Introduction

This Plan of Management (PoM) has been prepared to accompany a Development Approval for the proposed

alterations and additions to the existing health services facility at Abbotsford Private Hospital (Hospital), located

at 61- 69 Cambridge Street, West Leederville WA 6005.

Abbotsford Private Hospital recognises the need to ensure the safety and security of patients, visitors, staff,

residents and the greater West Leederville community. The following measures will be implemented to ensure

the utmost safety of all parties involved.

1.1 Purpose of Plan of Management

The purpose of this PoM is to ensure the proposal is consistent with the principles of Designing Out Crime

Planning Guidelines prepared by the Western Australian Planning Commission. The facility will comply with the

Private Hospital Building & Design Guidelines and Licensing & Accreditation Regulatory Unit, Department of

Health, Western Australia.

The policies and procedures outlined in this PoM will help to make the premises a safe, efficient and pleasant

environment in which to work, visit and stay. Additionally, the safety and security issues addressed in this PoM

have been devised to ensure the amenity of neighbouring properties is maintained at all times during the

operation of the premises.

As part of the induction process, all staff at Abbotsford Private Hospital (Hospital) will be required to be familiar

with this PoM.

The Hospital is a privately owned, for profit Psychiatric Facility which caters for voluntary mental health patients.

Services are inpatient, day therapy and the expansion will include a Trans Magnetic Stimulation (TMS) suite.

The service philosophy, scope and proposed level of service will be an extension of the existing Hospital model.

Healthe Care Australia (HCA) is a well-established mental health provider offering 600 mental health beds

across Australia in 15 sites.

The model strives to maintain favourable aspects of the existing unit and hopes to provide an even higher level

of service with expanded Hospital.

The service models will be continually improved as part of a well-established Quality Improvement process. The

Hospital is operated as a Private for-profit arrangement.

Source of funding include (a) Health fund direct funding related to inpatient stays and day programs

attendances (b) Self-funded patients or (c) Workers Compensation.

Contact has been made with relevant funders regarding the expansion.

Philosophy

We work together to create a thriving community that lives up to our local core values of Sanctuary,

Respect, Acceptance and Change.

Mission Statement

We aim to provide a high standard of patient care that is clinically competent and specific to the needs of the

individual patient, dynamic, integrated, considerate, safe and effective and an environment both physical and

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emotional where people can feel safe, secure and are respected and ask all associated with the organisation to

work with us in this mission.

Vision Statement

To create a Hospital environment conducive to developing stakeholders, consumers, carers and staff to their full

potential, with high morale, motivation for learning, and job satisfaction; incorporating the principle of ongoing

quality improvement of service delivery and outcomes in all areas of Hospital activities.

1.2 Site Context

The site is described as 61 – 69 Cambridge Street, West Leederville. It is situated within the local government

area of The Town of Cambridge. The site is legally described as Lot 181 D84657 and has an area of

approximately 2,721m2.

2. Capacity of the Hospital

The Hospital will accommodate 77 extended stay hospital clients and provide up to 36 day patient positions.

This facility does not include an acute emergency component. The below outlines the key aspects of the

hospital:

(i) Bed Numbers: The Hospital is licensed for 77 inpatient beds. Each room is a single

room with ensuite bathroom facility.

(ii) Day Patient Numbers: The Hospital will provide assistance to up to 36-day patients

attending full day or half day approved and contracted therapy programs, each program

will have a maximum of 12 patients.

(iii) Emergency Services: The Hospital does not offer any emergency services, treatment

or facilities. Signage around the hospital outlines this and directs people to Sir Charles

Gairdiner Hospital (Queen Elizabeth II Centre) as the closest Emergency Department.

2.2 Hospital Client Profile

The Hospital has established access and exclusion criteria for clients wishing to use the service.

(i) Inclusion criteria: include that all Hospital clients are over the age of 16 years, are

voluntary patients, have a treatable mental health condition, able to self-care, are

independently mobile (ambulant), under the care of an accredited psychiatrist, and (if

substance dependence is part of the diagnosis) agree to be substance-free for the

duration of the hospital stay.

(ii) Referral: All clients are referred to the Hospital by private psychiatrists from their private

practices.

(iii) Exclusion criteria: include anyone under the age of 16 years, clients with a non-

treatable mental health condition, people with a history of or current issues with

violence/ aggression, people unwilling to be substance-free for the duration of the

hospital stay, people unable to self- care, people in psychosis, people who are actively

suicidal, people not under the care of an accredited psychiatrist.

(iv) Types of Patients: all patients using Hospital services must hold private health

insurance or be able to self-fund (in advance) the admission (total length of stay).

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(v) Service Need: mental health issues are amongst the most common causes of disease

burden, mortality (suicide) and social cost in Australia. Prevalence studies indicate that:

(A) Up to 25% of the population will experience an episode at some point in their

lives.

(B) 20% of the Australian population will experience a mental health condition in

any 12-month period. 8.5% of that proportion will have 2 or more disorders.

(C) Australian youth (18-24) have the highest proportion of mental health conditions

than any other group.

(D) 21.2% of Australian youth (15-19) met the criteria for serious mental illness.

(Source: Mission Australia Youth Survey 2014)

(E) In 2015-16 there were 18 million GP encounters with mental health conditions.

(F) 9.9% of the Western Australian population report high to very high levels of

psychological distress.

(G) 17% of the Western Australian population aged 14 & over reported illicit

substance use; 2% higher than the national levels.

(H) 21.6% of the Western Australian population aged 14 & over reported alcohol

use at risky levels; 3.4% higher than the national levels.

(I) 2.8% of young Australians (4-17) experience a depressive disorder.

(J) 13.9% of young Australians (4-17) experience a mental health condition.

(K) 3 in 4 adults with mental health conditions have experienced onset by age 24.

(L) 2 in 4 adults with mental health conditions have experienced onset by age 14.

Recent analysis concludes that Western Australia has fewer acute mental health beds than other states and

territories in Australia (AIHW 2011).

Increasing demand has been noted from increasing:

(i) population numbers;

(ii) awareness of mental health disorders;

(iii) increased awareness of substance use risks;

(iv) social media/ digital media connection; and

(v) escalating needs of defence personnel and their families (ADF, 2011) in addition to

emergency services and first responders.

The current Hospital (30 beds) has operated a waitlist to accommodate patients needing admission. All people

on the waitlist are treated by the treating psychiatrist and reviewed on a weekly basis at multidisciplinary team

reviews.

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Treatment is provided for people experiencing Anxiety, Depression, Post Traumatic Stress Disorder, general

mental health disorders, Substance Dependence Addictions and Non-Substance Addictions (Internet addictions,

Social Media addictions, Computer & Gaming addictions, Behavioural Addictions).

These issues are frequently co-existent and co-occurring (Dual Diagnosis/ comorbidity). They impact on the

person’s ability to work/study, social functioning (isolating and withdrawing from the community and world,

negatively affects relationships with family and friends, and has financial impact for the individual.

Demographic information shows that patient types are equally distributed across gender fields (approximately

48-52 female:male ratio), predominantly living with a partner or family and a minority living alone. Functionally,

the group is diverse with professional representation inclusive of Registered Nurses, Doctors, Psychologists,

teachers, pharmacists, lawyers, emergency responders (police, ambulance) and serving/retired military,

students and home duties. There is also representation of Disability Pensioners and Newstart / Unemployed

sectors.

Whilst the Hospital currently only provides services for persons 18 years and above, it is proposed to include a

Youth floor within the Hospital. A variation in the current licence will be required to lower the age threshold to 16

years. Those between 16 – 18 years of age will require consulting room assessment by an Accredited

Psychiatrist prior to admission. There is a range of maturity in this group, with some 16-year olds working and

living independently. There will be no interaction between the Youth floor and other floors.

Patients older than 65 years of age also require further assessment regarding their physical and medical needs

prior to admission. If not appropriate, the patient will be directed back to the referrer for a more appropriate

service.

2.3 Type of Treatment

(a) Inpatient

Inpatients are admitted under the care of a credentialed psychiatrist and linked with a multidisciplinary

health team consisting of Clinical Psychologists, Psychologists, Counselling Psychologists,

Psychotherapists, Counsellors, Social Workers, Occupational Therapists and Registered Mental Health

Nurses, Registered Nurses and Enrolled Nurses. The team is supported by Administrative staff and

Facility staff.

The average length of stay is 14 days. Each inpatient attends a minimum of 4 hours group therapy/

psychotherapy per day followed by 1:1 therapy, nurse education and care and self-directed learning

modules.

Each inpatient is reviewed by the treating doctor and may be prescribed and administered medications

to treat physical health issues such as diabetes, high blood pressure as well as medications for mental

health conditions such as anti-depressants, anti-anxiety medications, mood stabilisers or medications to

assist in managing substance dependence e.g. diazepam.

Each inpatient has established goals of admission and is included in care planning and care review in

addition to discharge planning.

The Hospital does not offer or provide invasive treatments such as intravenous medications or surgical/

treatment options requiring anaesthetic such as electroconvulsive therapy (ECT).

(b) Day Patients

Day Patients are admitted and discharged on the same day under the care of a treating psychiatrist.

They are referred and booked to attend specific therapy programs. The programs are reference as

being pre-intensive, intensive, and graduate.

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Day Patients' therapy programs are scheduled only on business days and will be either:

(i) the full day program, being 5.5 hours per day consisting of linked morning and afternoon

session; or

(ii) the half day program, being 3.5 hours per day consisting of a single morning, afternoon

or evening session. Day Patients who are admitted to the half day program are not

permitted to attend more than one session per day.

Intensive programs are scheduled for full day sessions for two weeks. The pre-intensive and graduate

programs are scheduled for standalone sessions as either full day or half day once a week.

Day Patients groups commence at 9.30am for full and half day patients. For Day Patients in the half day

program who are only attending afternoon or evening therapy sessions, these commence at 1pm and

6pm respectively. Full day patients do not attend evening sessions.

Irrespective of the program, the maximum number of patients per program at any one time is 12.

Programs are undertaken under the supervision of appropriately qualified Allied Health Professionals,

contracted to HCA to provide such services. To maintain consistency across treatment types, the

Hospital uses the same healthcare professionals to treat Day Patients as it does for Inpatients.

Day therapy programs are evidenced based, talk-based, skills-enhancing programs utilising Cognitive

Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), Mindfulness, Act Belong Commit

(ABC) Therapy, Acceptance Therapy, Schema (Behavioural- Life patterns), Emotional regulation

Therapy.

2.4 Organisation Structure

At a local level, the organisation headed by Chief Executive Officer (CEO). The Director of Nursing, Therapy

Team Leader, Corporate Administration, Finance and Accounts Manager report directly to the CEO.

There is a Medical Advisory Committee and Chairperson who advise the CEO on medical matters. The Medical

Director and Director of Day Programs, both senior psychiatrists, consult with and advise the CEO on

operational and clinical matters.

Nursing staff, Allied Health and Support services report to the Director of Nursing and Therapy Team members

report to the Therapy Team Leader. Reception & Administration staff report to the Corporate Administration

Manager.

The organisation reviews and reports at a local level via Risk, Quality and Management Committee, Department

Head Committee, Continuum of Care Committee and Medical Advisory Committee.

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RbbotsfordORGANISATIONAL STRUCTURE

Private HospitalNATIONAL MENTAL HEALTH MANAGERJoanne Levin

CHIEF EXECUTIVE OFFICER Dale Nelligan

/ BUSINESS DEVELOPMENT MANAGER WA

Andrea LoveDIRECTOR OF NURSING

Jane Dowling V

i—Him

LEGEND

i7»? May 2019

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2.5 Clinical support services linkages

Infrastructure and the equipment needed is available to support safe practice of the types of procedures/care

and/or the operation of the Hospital. All equipment and materials contained within the hospital is owned by (or

leased) by the proprietor.

This includes equipment required for performing the procedure and arrangements for oxygen (First Aid

Response) supplies.

The specific contractors for the Hospital are MedElect Biomedical Services who are registered suppliers of

equipment. Maintenance arrangements are in place for equipment.

The Hospital's Equipment and Infrastructure processes have been independently reviewed by ACHS and

indicate high levels of effectiveness; processes are consistent with standards, hazardous materials are

managed effectively, training is in place and there are clear lines of reporting responsibility. Inspections are

carried out in accordance with a fixed schedule. The external contractors who provide building maintenance are

the same group that completed the refurbishment and this knowledge contributes to effective and timely

rectification of maintenance issues.

Efficiency in energy use is apparent with energy saving lighting and signage in rooms promoting energy saving.

Disability access is achieved via a designated room for a person with a disability.

The organisation has affiliation with GP practices, private psychology practices, and private psychiatric

consulting rooms.

The Hospital is accredited within the Specialist Training Program (Royal Australian New Zealand College of

Psychiatrists) and provides ongoing clinical training programs for Psychiatric Registrars and has Clinical

Training Placement Agreements with Educational facilities, Universities and Registered Training Organisations.

Clinical placements are provided for:

(i) Medical students (University of Notre Dame);

(ii) Nursing students (University of Notre Dame, Curtin University, University of Western

Australia, Edith Cowan University);

(iii) Enrolled nursing students (West Coast TAFE, Think Education, Institute of Health

Nursing Australia);

(iv) Psychology students (Curtin University, Murdoch University); and

(v) Certificate IV Mental Health Workers, Aboriginal & Torres Strait scholarship (Marr

Mooditj).

The Hospital ensures clinical support relationships with key health providers to ensure holistic care is

maintained within the community. These include Clinipath, Stirling Pharmacy, Diabetes Australia, Silver Chain,

Primary Health Networks, Healthy Minds, Consumer Networks Australia, Western Australia Association Drug

and Alcohol Network (WANADA), Mental Health Commission and GROW.

2.6 Infection Control

The infection control program is compliant with the relevant standards and guidelines. The program is managed

by an on-site registered nurse, supported by an external infection control consultant (Hands on Infection). The

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unit is a mental health facility which does not provide surgical or general medical treatment, and therefore is

low acuity from a medical standpoint. Where possible only single-use items (e.g. medicine cups) are used.

Reviews are conducted annually of unit requirements and compliance with infection control processes. The

infection control program includes general provisions such as compulsory staff education with provisions of

hand washing facility, treatment areas, basic treatments, and sterile supply.

The Director of Nursing is responsible for the infection control program, committee structure and overall

management the infection control program. HCA is a registered HHA compliance auditor and will be

implementing the national infection control program within the Centre.

All staff and visiting practitioners (doctors) are required to complete hand hygiene training on an annual basis.

The hospital provides free influenza vaccination programs on an annual basis as part of an Employee

Assistance Program.

2.7 Sterile Supply

Sterile supply will be reviewed and provided by external contractor (Medline International Two Australia Ltd)

and Surgical House. Single use items are not to be reused. Sterile supplies are contracted externally and are

appropriate for a mental health hospital setting.

2.8 Operational Hours and Staffing

The Hospital operates 24 hours per day. Accordingly, there are always staff present on the premises. The breakdown of staff number and shift allocation is detailed below.

(i) Nursing Staff - 8.5 hour shifts beginning (seven days):

(A) 7am - 3.30pm (13 nurses)

(B) 3pm - 11.30pm (13 nurses); and

(C) 11pm - 7.30am (9 nurses).

(ii) Administration Staff - 8 hour shifts beginning at 8.30am (business days);

(iii) Housekeeping Staff:

(A) Split shift beginning 6.30am - 8pm (Monday - Thursday (Friday - morning only)) (five staff); and

(B) 10am - 2pm (Saturday and Sunday) (one staff).

(iv) Doctors - 8 hours shifts beginning at 8.30am (business days) (two staff).

(v) Allied Health Professional - external contractors - as required depending on need and therapy scheduled to be conducted (maximum six staff).

(vi) Catering Staff - external contractor (maximum five staff).

2.9 Visitors

Inpatients are permitted to receive visitors during their stay at the Hospital. Inpatient visiting ours are strictly

adhered to and are as follows:

(i) 4pm - 8pm - business days; and

(ii) 10am - 8pm - Saturday, Sunday and Public Holidays.

Patient visitation is closely monitored by the Hospital. In the usual course of treatment an Inpatient will not be

permitted to receive visitors within the first seven days of their treatment beginning. Importantly, whether a

patient may receive visitors is also conditional on the opinion of the treating psychiatrist, who may deny visitor

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access if such access is deemed to adversely affect the patient, the patient's treatment, other patients, or the

Hospital.

If, in the treating psychiatrist's opinion, family only visitation restrictions are placed on an Inpatient, then any

family members attending the Hospital are required to provide photographic identification before seeing the

Inpatient.

3. Admission and Waitlist Management Procedures

To gain admission to the Hospital all patients are required to have a general practitioner referral to a treating psychiatrist with admitting rights to the Hospital. As part of the referral process the treating psychiatrist elects whether the patient is to be admitted to the Hospital as an Inpatient or a Day Patient.

Currently there exists a patient waiting list for admission to the Hospital. Once a patient has been placed on the

waiting list, regular contact is maintained with the patient to ensure the patient's safety until a bed becomes

available. Patients on the waiting list are also offered access to other services that may be of assistance until

admission.

Despite the above, if the patient's health needs are classed as high priority the Hospital actively liaises with

other health providers in order to streamline access to the required care.

During the referral pre-admission process, history taking and health surveys are electronically provided to the

patient to reduce stress and eliminate unnecessary duplication of paperwork and repetitive 'storytelling'.

The admissions process for Inpatients and Day Patients is detailed below.

3.1 Inpatient Admissions

All people referred to the inpatient program are placed on a waitlist by a treating psychiatrist from their private

practice, a current GP referral is needed. The referral is linked with comprehensive risk assessment which

incorporates suicidal risk, non-suicidal self-harm risk, and falls risk.

Individuals assessed and found to rate highly in these areas are not suitable for admission as Inpatients and

are referred back to the treating psychiatrist for placement elsewhere. Individuals who are psychotic are also

not considered suitable for admission to the Hospital.

Prior to attending the Hospital, all Inpatients are required to sign a contract and consent for treatment

document, which includes a commitment to not use substances during treatment and a Behavioural Code of

Conduct.

On the day of admission, Inpatients present to reception and complete their admission forms. Nursing staff

conduct a breathalyser test on all admissions and a property check is completed. If both assessments are

satisfactory, the patient is escorted into the Inpatient Unit and provided with an orientation to the ward.

Physical assessments of the Inpatients include measurements of blood pressure, pulse, respiration, urinalysis

and an Electrocardiogram (ECG).

In addition, each Inpatient:

(i) is weighed and assessed for dietary involvement (metabolic screening);

(ii) is assessed and provided with comprehensive care plans and action steps for achieving

admission goals. Each are documented and signed;

(iii) has a Therapy Attendance Plan developed by the therapy team;

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(iv) must disclose and provide any medications brought into hospital, which are counted and

reconciled to the doctor’s prescriptions; and

(v) will undergo an assessment in relation to the appropriateness of use of digital devices. The

assessment is diagnosis dependent and device use may be restricted for the first seven days

or ongoing depending on the outcome of the assessment.

During their stay Inpatients are permitted to leave the Hospital, for example to go for a walk. However, prior to

leaving the Hospital the Inpatient is required to be assessed by a nurse, complete a leave log which specifies a

contact mobile number, details of where they are going and time of return. They are also required to sign a

declaration that they willingly comply with behavioural expectations, which includes answering calls from the

Hospital and being respectful of neighbours. On return, the Inpatient is breathalysed and, if property is being

brought into the hospital, bags are searched.

Every Inpatient is monitored for clinical assessments. These include:

(i) sleep chart for the duration of the first week of admission after which it may be continued or

ceased;

(ii) Acute Deterioration & Detection Scales (ADDS) on every shift;

(iii) vital observations – blood pressure, pulse, respiration, oxygen saturation levels;

(iv) ECG - as a baseline reading;

(v) skin integrity - for any wounds or skin tears that may require treatment;

(vi) urinalysis - baseline clinical reading;

(vii) urine drug screen - baseline reading at point of admission and minimum of three times per

week. These may also be conducted randomly and without notice;

(viii) asthma screening - preventative baseline reading;

(ix) alerts & allergies - preventative baseline; and

(x) Substance Withdrawal Scales (if applicable) - as per care plan and recommended standards of

care.

In addition, every Inpatient is also monitored psychologically and behaviourally. These include:

(i) HONOS (Health of Nation Outcome Measures) - measuring key areas of Behaviour,

Impairment, Symptomatic & Social;

(ii) MHQ14 (Mental Health Questionnaire 14)- measuring four keys areas of Mental Health, Vitality,

Social Functioning and Role Functioning;

(iii) DASS21 (Depression Anxiety Stress Scales);

(iv) Kessler 10 – measuring levels of psychological distress;

(v) ASSIST- (Alcohol Smoking Substance Involvement Screening Test)- measuring lifetime use of

substances, use of substances within the past three and six months periods, frequency of use,

type of use, impact of use on self, impact of use on others, impact on social relationships and

role functioning; and

(vi) Life Skills Profile- measuring knowledge and current skills in life functioning and performance.

3.2 Day Patient Admissions

Day Patients are referred to the program by a GP referral to a treating psychiatrist in their private practice. A

written referral is then completed which includes a medical, psychological, psychiatric and social history. The

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referral is linked with comprehensive risk assessment which incorporates suicidal risk, non-suicidal self-harm

risk, and falls risk.

Individuals assessed and found to score highly in these areas are considered not suitable for admission to the

Hospital and are referred back to the treating psychiatrist for placement at a more suitable facility.

Prior to attending the Hospital, all Day Patients are required to sign a contract and a consent to treatment,

which includes a commitment to not use substances during treatment and to comply with a Behavioural Code

of Conduct.

At admission, a brief risk and behavioural assessment is conducted. If the person presents as being verbally

aggressive, agitated, distressed, upset or possibly affected by substances a senior therapist and/or the director

of nursing are required to carry out a thorough assessment to determine whether the individual is fit to be

admitted.

If following further assessment, it is deemed that the individual is not suitable for admission, the treating

psychiatrist is contacted and an appointment in private practice is arranged. If required, the person’s nominated

support person next of kin is contacted to collect the individual from the Hospital.

If the individual is suitable for treatment, they are admitted to the Hospital.

4. Discharge Procedures

4.1 Inpatients

Each Inpatient has an estimated or scheduled discharge date which is logged into the electronic patient

administration system (WebPas). Discharge planning commences at admission and is linked with goal setting,

action plans, physical and psychological health needs, and social needs.

Inpatients attend discharge planning therapy sessions and develop Wellness Recovery Action Plans to assist in

leaving hospital and sustaining recovery.

Prior to the day of discharge, Inpatients are also pre-booked into Day Therapy Programs in either the Pre-

Intensive, Intensive or Graduate treatment programs.

Family members are encouraged to participate in discharge planning and to identify their own knowledge and

skill needs to assist in the return of the patient to the home environment.

Prior to discharge a medication review is completed to ensure that the patient is discharging with the minimum

amount of medications required. Prescriptions are sent to pharmacy and/or arrangements made to collect

medications from pharmacy.

4.2 Day Patients

At the conclusion of their therapy session Day Patients collect their property from the lockers and present to

reception and sign the discharge section of the claim form and attendance sheet.

Day Patients are required to leave the Hospital within 30 minutes following their final session.

4.3 Independent Review Process (ACHS/CDMS)

The service is fully accredited with the Australian Council of Healthcare Services (ACHS) and provides data for

the Australia wide Centralized Data Management Service (CDMS).

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The ACHS Organisational wide survey (2017) resulted in 1 recommendation, being evidence of Hand Hygiene

Training by visiting medical officers. This was successfully addressed. Quality Improvement processes will

ensure that standards are maintained or improved with expansion.

4.4 Clinical Indicators

The below table outlines the clinical indicators for the Hospital.

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5. Emergency and Incident Management

5.1 Ambulance Transfers

As an accredited and licensed hospital, it is a requirement that certain policies and procedures relating to

recognising, responding and reporting clinical deterioration (physical, behavioural and mental) are mandatory.

These include protocols for use of ambulance services for transfers to higher levels of care.

The Hospital is committed to using the least restrictive transport option at all times. This includes contacting

family members to transport the patient (if safe to do so) or using Patient Transport Services.

If these options are not viable nursing staff will contact the St John’s Ambulance service directly and provide a

summary of the reason for transfer.

Once an ambulance is requested, a staff member is assigned ambulance bay duty to ensure Hospital access is

not delayed. On arrival, ambulance staff are escorted by nursing staff to the patient and a written handover

summary provided.

In the circumstances of a Mental Health Deterioration event requiring transfer under the Mental Health Act

2014, a Transport Risk Assessment is completed. The results of the assessment determine whether a police

escort is also required. If this is the case, nursing staff liaise with both services to coincide arrival times.

5.2 Police Attendance

In the event that either a patient or a member of the public becomes violent, aggressive or unmanageable,

police may be called to the facility to assist. In these circumstances this will be fully documented in the

Hospital's incident register.

As mentioned above Police attendance may be required to assist in transport of patients placed under the

Mental Health Act 2014.

Police may also attend site to take statements from patients, deliver subpoenas for health information or for

assistance with community information (access to CCTV which may cover areas external to the Hospital

perimeter).

5.3 Fire Safety

The Hospital complies with the Western Australia's fire safety requirements. These include the following:

(i) An emergency back-up diesel/solar powered generator is required as part of the

hospital operations. This has been included within the plant room configuration of the

basement layout

(ii) Ensuring the routine maintenance, repair and testing of all fire safety equipment;

(iii) Annual Fire Safety Statements are completed;

(iv) Fire Safety education requirements for Fire Safety Officers and Fire Safety Managers

are met;

(v) Annual Fire Safety Education is provided for all employees, this includes evacuation

exercises, use of fire- fighting equipment and maintaining a safe working environment;

and

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(vi) There is a documented Emergency Management Plan in place that covers fire safety

and other emergencies and all employees are familiar with the contents.

The hospital has written Emergency Processes and training for emergency events such as water leak, gas

leak, medical emergencies, mental health emergencies, security breaches.

All staff have access to quick reference guides and participate in training at orientation and on an annual basis.

5.4 Weapons

Weapons of any type are not permitted on Hospital premises.

5.5 Incident Register

The Hospital maintains a detailed incident register. The incident register records any complaints, risks,

accidents and incidents (including anti-social behaviour) that occur within the Hospital or involve Hospital staff

or patients.

The incident register also records the response taken by the Hospital in relation to a particular incident and any

follow up action to be undertaken.

6. Parking and Transport Arrangements

Consistent with policies used within general health hospitals, the Hospital has policies of no driving for

Inpatients or Day Patients. Patients are advised of the no parking policy as part of the pre-admission

information provided by the Hospital.

There will be a maximum of 38 staff at the Hospital at any one time. However, on-site parking is provided for

medical and administrative staff only, meaning that of the 38 staff only 26 will be permitted to use the staff

parking spaces. Staff that do not fall within this category are not permitted to park on site. Further, staff that are

contracted by the Hospital, such as Allied Health Professionals and catering staff, are contractually obliged not

to park on site.

For those staff not permitted to park on site the hospital provides bicycle parking facilities and end of trip

facilities, which are secure and accessible 24 hours per day, seven days per week. In addition the Hospital is

well serviced by public transport, information regarding which is provided to staff and visitors and also available

on the Hospital webpage.

The Hospital has prepared and will implement a Travel Plan which outlines the local sustainable travel options

available for travel to and from the Hospital. The Travel Plan outlines how the Hospital will seek to promote the

available options for sustainable travel to and from the Hospital. To ensure the effectiveness of the Travel Plan

the Hospital will undertake a review of the effectiveness of the options set out in the Travel Plan after the first

six months of operation.

The Hospital carpark has a designated area for use by emergency service vehicles. This area is located by the

ambulance entrance allowing emergency service personnel efficient access to the Hospital.

Limited visitor parking and pick-up/drop-off spaces are also available on site.

The Hospital also provides motorcycle parking.

7. Workforce Planning

7.1 Medical Staff

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A Medical Advisory Committee (MAC) is in place for reviewing and monitoring clinical standards, processes

and performance. Credentialing is required prior to commencement of practice at the Hospital. The CEO may

authorize Temporary Accreditation, subject to the full requirements pending formal endorsement. The

Credentialing Committee will review applications quarterly.

Medical practitioners involved in training (e.g. Psychiatry registrars) are required to provide documentation in

conjunction with confirmation of status from the registered training body (the Royal Australian and New Zealand

College of Psychiatrists). If successful, Medical Practitioners are accredited for a period of 3 years with

mandatory annual updates of APRHA registration and professional indemnity cover. Any complaints to any

Regulatory body (e.g. APRHA), any proceedings (e.g. legal) or complaints must be reported to the Medical

Director and accreditation can be reviewed. Hard copies of all applications as well as electronic copies are

maintained for all practitioners with a living register to maintain review of Accredited Medical Practitioners.

Nursing services are provided by Registered and Enrolled Mental Health Nurses. All Registered Nurses require

current registration with the Australian Health Practitioner Regulation Agency (APHRA) as a Division 1 nurse or

Division 1 mental health nurse, or comprehensive nurse.

All Enrolled Nurses require current registration with Australian Health Practitioner Regulation Agency (APHRA)

as a Division 2 Enrolled Mental Health Nurse, or comprehensive nurse. All nurses require a current Working

with Children Check and Police Clearance, which is valid for 3 years.

Nurse Practitioners who apply for visiting rights to assess and consult with patients in the course of episodes of

care are required to submit an application for accreditation and provide the same documentation as required for

Medical Practitioners.

The review process by the Credentialing Committee is assisted with consultation of the Director of Nursing

attending the Credentialing meeting and reviewing the Nurse Practitioner’s application for accreditation to

practice at the Centre. The unit is utilised by training facilities with provisions made for students and graduate

nurses.

The nursing staff to patient ratio must be no less than 3.5 hours of mental health nursing care per inpatient day

of which 2 hours shall be by a registered mental health nurse. Registered nurses are provided 24 hours per day

for inpatient care.

Therapy staff accreditation requirements are based on requirements for Allied Health professionals,

Occupational Therapists and Psychologists. These include APHRA annual certification (includes a degree in

OT or psychology; CPD (Continuous Professional Development) points and Statutory Declaration of no

infringements having occurred within the last year. Less commonly, Counsellors are required to provide

evidence of PACAWA (Psychotherapists and Counsellors Association of WA) registration which requires a

degree in a relevant field and to meet the PACAWA Professional Training Standards of 2012, including CPD

points and Statutory Declaration as above. All therapy staff, separate to their registration body, are required to

provide a Working with Children Check (WWC) and a Police Clearance.

Allied health staff who apply as a private practitioner are required to submit an application for accreditation and

provide the same documentation as required for Medical Practitioners. The review process by the Credentialing

Committee is assisted with consultation of the Therapy Manager attending the Credentialing meeting and

reviewing the Allied Health Practitioner’s application for accreditation to practice at the Centre.

Staffing is in accordance with the provision of therapy, which include assessments for therapy group

participation, the conduct of group therapy, individual reviews and other activities.

Planning has allowed for further inpatient therapy groups (conducted mornings and afternoons) and concurrent

day therapy programs.

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All administration staff undertake orientation upon commencement of employment and annual training updates,

as well as mandatory training as set out in policies: Mandatory Education, Training and Competency – 1.4.2,

Training and Professional Development – 4.3.5, Training Annual Updates – 4.3.1, Orientation of New Staff –

4.3.4. Hospital administration staff will perform tasks including reception, patient accounts, admissions and

discharges and general administrative tasks.

All staff must attain competency in Life Support (CPR) on an annual basis. This training is inclusive of

recognising emergencies, asthma, anaphylaxis, choking, and bleeding.

7.2 Housekeeping

On commencement they will participate in orientation and mandatory annual training programs: Mandatory

Education, Training and Competency – 1.4.2, Training and Professional Development – 4.3.5, Training Annual

Updates – 4.3.1, Orientation of New Staff – 4.3.4. In addition, housekeeping staff will be trained in hazardous

waste handling and sterile cleaning to ensure the minimizing of cross contamination. Cleaning schedules are

strictly adhered to maintain a clean, safe environment for patients, visitors and staff.

8. Safety and Security

The security and safety of employees and the general public is an utmost priority for management and staff of

the Hospital. The following management strategies will be implemented to ensure the safety of patrons, staff

and public.

8.1 Surveillance

CCTV surveillance cameras are in place in and around the premises in strategic locations. All cameras operate

24 hours a day. If damage to CCTV cameras occurs repairs will be undertaken as soon as practicable. CCTV

footage of any security incident on the site will be copied and made available to WA Police Force as required.

Management also ensure that the coverage is operated with due regard to the privacy and civil liberties of all

persons within the operation.

8.2 Lighting

All lighting on the site shall be designed so as not to cause a nuisance to other residences in the area or to

motorists on nearby roads to ensure no adverse impact on the amenity of the surrounding area by light

overspill. Lighting shall comply with the AS 4282:1997 - Control of the Obtrusive Effect of Outdoor Lighting.

External lighting will be provided around the building, building entries and car park to enable clear vision and

will be designed in such a manner so as to prevent concealment and shadowing. The standard of lighting will

also serve to provide clear identification of activity using the high technology CCTV cameras proposed.

Broken light fixtures and bulbs within the premises and car park will be replaced within 24 hours where

practical.

8.3 Signage and Space Management

Clearly identifiable signage will be installed in and around the building to indicate which areas are open to day

patients, inpatients, visitors, staff and members of the public and which areas are restricted to staff.

Toilets for staff and patient use will be clearly sign posted.

The style and positioning of signs is completed as per Building Guidelines, Private Hospitals.

8.4 Access Control

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Access to the facility is controlled throughout the 24-hour period. Staff require individually numbered and

programmed swipe cards to access the Hospital. Each swipe card can be programmed for global or restricted

access and can be deactivated via remote computer override.

Booked Day Patients enter via the Reception area, are assessed and admitted before gaining access to the

therapy rooms. Drop in patients will not be permitted outside these hours. Visitor access is directly monitored

and controlled by electronic access operated by nursing staff. All visitors are required to sign in and out and to

report directly to the nurse base.

8.5 Staff Training

All staff are trained in relevant security measures. Staff training is held on a regular basis to reinforce safety

and security procedures for the business. Training ensures that in the event of violent or anti-social behaviour,

staff act in a manner to best protect themselves, other patients and local residents.

Employees are encouraged to report any anti-social activity or persons in and around the area to Management.

(recognition and responding to emotional escalation, de-escalation techniques and effective communication

strategies. When required police services are notified.

8.6 First Aid

At all times staff members and nurses proficient and appropriately certified in first aid qualifications are on duty

to respond to a medical incident on the premises. Appropriate emergency equipment inclusive of oxygen,

defibrillator and first aid response bag is maintained on site and checked every 24 hours.

8.7 Medicine Storage

Medicine is securely stored within the facility to the requirements and approval of the Poisons Act 2014 and

Poisons Regulations 2016, WA Department of Health. Stock is held to the minimal possible level.

All medicines are stored in locked cupboards in a digital coded locked room within an area accessible only by

electronic swipe cards. Medicines are checked by two nurses a minimum of once per shift.

Reportable Schedule 4 and Schedule 8 medicines are administered and checked by 2 nurses at all times.

Medicine log books are maintained and audited for all Reportable Schedule 4 and Schedule 8 medicines.

Expired medications or surplus patient medications at time of discharge are disposed of via a one-way

pharmacy disposal box which is bracketed and locked to the wall.

8.8 Sharps Management

As part of Licensing requirements no invasive or intravenous procedures are permitted onsite.

On rare occasions a doctor may prescribe an intramuscular injection which is administered by the nurse in the

patient’s room with the used needle immediately disposed of in a sealed/ small aperture sharps container.

Environmental Hotel Services Staff and Occupational Health Safety staff do regular checks of the external

grounds for discarded sharps. If found, they are reported via the Risk reporting systems.

Staff are not permitted to handle the sharps with bare hands. The hospital has shark skin gloves (highest grade

puncture proof) and tongs to retrieve the item for disposal within sealed sharps containers.

9. Catering and Laundry

Laundry is restricted to the servicing of bed linen and towels with deliveries occurring three times per week.

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Catering services are provided on site with all foods cooked fresh daily. Food deliveries are scheduled to

ensure freshness of supplies.

10. Site Maintenance

10.1 Cleaning

Staff will ensure as far as practical that the premises is kept in a clean and tidy condition both internally and

externally to the extent of the building. Cleaning of both internal and external areas of the premises will be

undertaken by cleaning staff.

Landscaping and gardening services has been outsourced to a contractor who will service the areas every

fortnight.

10.2 Waste Management

The management of waste at the Hospital will be carried out in accordance with the Operational Waste

Management Plan dated 7 August 2019 and prepared by Elephants Foo Recycling Solutions (OWMP).

Sorting of waste will be conducted at the point of disposal. The waste will then be transported by cleaning staff

to the bin store area and deposited into the appropriate receptacle.

Waste (including recycling and green waste) will be collected by private contractor. The main bin store is

proposed to be located at the western end of the Hospital car park which provides the waste contractor with

convenient access to the bin store. The waste contractor will be given access to the bin store and will collect

and return the bins to the store. The bin store has been designed to hold:

(i) general waste - four 1100L mobile garbage bins; and

(ii) recycling - two 1100L mobile garbage bins;

In addition, two 240L green waste mobile garbage bins will be located in the vicinity of the bin store.

The bin collection will be undertaken through the use of a vehicle no larger than a Small Rigid Vehicle to

ensure that the car park is entered and exited in a forward direction.

With respect to other types of waste these will be disposed of in line with the OWMP and where required the

relevant statutory obligations, for example, the disposal for pharmaceutical and biohazardous material.

11. Complaint Management

The Hospital maintains a confidential complaint management system.

Complaint forms are available at numerous points around the hospital and on its website. Each feedback form

is assigned a number and is logged into the Feedback Reporting System before being issue to the appropriate

line manager for review and, if necessary investigation. Complaints are required to be resolved within 15 days,

if possible.

In addition, members of the public may make complaints directly to Hospital staff or to the relevant manager,

either in person, by phone or via email. All such contact information is available on the Hospital's website.

The hospital participates in annual reporting to HADSCO (Health and Disability Services Complaints Office) as

well as reporting locally, at state and national levels.

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12. Existing Policies and Procedures

Abbotsford Private have comprehensive policies and procedures covering all aspects of managing a mental

health hospital. These include:

(i) Risk & Incident Management & Reporting

(ii) Access to Service Criteria

(iii) Admission & Discharge Procedure

(iv) Management of Medications

(v) Physical & Visual Observation of Patients

(vi) Emergency Protocols (Water leaks, gas leaks, earth quake, natural disaster, medical

emergencies)

(vii) Management and administration;

(viii) Health and personal care;

(ix) Lifestyle and safety of the environment (infection control, work health and safety, living

(x) environment, fire and other emergencies safety);

(xi) Catering;

(xii) Laundry; and

(xiii) Cleaning.

The systems are reviewed on an ongoing basis by the Executive Management Team of The Hospital.

13. Updating/Review of the Operational Plan of Management

The Operational Plan of Management will be reviewed by the Abbotsford Private Executive Management Team

on an annual basis (next review is Scheduled for August 2020). All stakeholders will have input into the plan by

way of meetings, surveys, suggestion box, audit reports or directly to the manager. Stakeholders include

employees, hospital clients and their families and visitors, allied health professionals, external contractors and

audits by regulatory personnel.

Copies of the operational management plan will be made available to those who wish to have a copy as well as

being displayed at the sign on desk on each level.

14. Consultation

Abbotsford Private Hospital is committed to ongoing consultation with adjoining property owners, WA Police

Force and The Town of Cambridge to foster a better understanding of relevant operational issues that may

arise at the site and would be available to be contacted to discuss potential issues as they may arise.

In addition, the Hospital will establish a Community Consultative Committee (CCC) to proactively engage with

the community and other relevant stakeholders. The aim of the CCC will be to discuss issues, and resolve

issues raised by the community in a timely manner. The CCC also provides for the Hospital to positively

engage with the community.

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Ongoing review of this document may be undertaken to ensure that the PoM remains relevant to the operation

of Abbotsford Private Hospital and that issues that arise can be managed into the future.