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
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
(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.
(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;