Archived August 2005

Case Study 1 - Mornington Peninsula Hospital

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Background

The West Gippsland Hospital provides acute medical, acute surgical, midwifery, haemodialysis, chemotherapy and day procedures services. The hospital has 85 beds. There has been a position for a Koori Hospital Liaison Officer at West Gippsland Hospital since 1986.

Kirstie Mountain is the Chief MRA at West Gippsland Hospital and Alexandra Toth is the deputy MRA.

Kirstie was advised of the changes to the VIMD for the recording of Aboriginality in May-June 1993, at the same time that changes in regard to case mix funding were introduced at hospitals.

Organisational/Reporting Structure

At the time that the changes in recording Aboriginality were introduced, staff from the Admissions area were responsible for admitting patients from 7.00 a.m.-5.00 p.m. Staff rostered to cover the hospital switchboard were responsible for any admissions from 5.00 p.m.-7.00 a.m. This meant that a total of ten staff were responsible for admitting patients.

The switchboard staff were under the management of the then Director of Corporate Services, and the Admissions staff were responsible to the Chief MRA.

Initial Staff Training

Kirstie talked about the changes in recording Aboriginality with both groups of staff responsible for admitting patients. The talk was followed-up with a memo. She said that it had been hard to get all the switchboard staff together because the staff were rostered to cover after hours, so that follow-up in writing had been particularly important.

The Admissions staff did not appear to have any initial problems with the recording of Aboriginality. However, the then Director of Corporate Services, who was responsible for the switch board staff, contacted Kirstie and said that the switchboard staff felt uncomfortable with asking the Aboriginality question. He asked for Kirstie's advice as to how to handle this situation.

Kirstie had responded by saying that the Aboriginality question should be handled in the same way as all of the other questions asked in sequence at the time of an admission. She said that asking the Aboriginality question should be no different to asking patients their date of birth, religion and so forth.

Kirstie did not receive any feedback from individual staff to say that there had been continuing difficulties in asking the Aboriginality question. However, the Deputy Medical Record Administrator, Alexandra Toth, was aware that some staff in the Admissions area had initially been more hesitant in regard to asking this question.

One staff member who acted as a reliever in the Admissions area had reported that some patients were surprised to be asked the Aboriginality question and some patients would respond with a laugh.

Initial Computer Changes

There were enormous changes needed to the computer system at the time that case mix funding was introduced, and Kirstie was aware that the software would not be in place for 1 July 1993. The required changes were not fully in place until November 1993. Aboriginality was initially recorded manually and adjusted later. The field for recording Aboriginality was labelled 'Aboriginality' and was set up as a mandatory field which could not be bypassed unless a response to the question had been entered.

Initial Survey

Kirstie was informed that West Gippsland Hospital had been selected for the initial hospital survey and that she would be contacted by staff from the Koori Health Unit.

At the time that the changes to recording Aboriginality were introduced, Kirstie said that there was so much happening with the introduction of case mix that MRAs and Admissions staff needed to have more information on the reason that the Aboriginality question was being asked, in the hope that this would lead to a greater degree of compliance in asking the question.

Initial Survey Report

When the report of the initial survey was distributed in August 1994, the Deputy Medical Record Administrator, Alexandra Toth, was responsible for the implementation of the recommendations in regard to staff training. Alexandra also contacted the hospital's Information Systems Manager in regard to recommendations relating to the hospital's computer system.

Action Taken on Initial Survey Report

1. Hospital Forms

   At this hospital, the Aboriginality question has appeared on the pre-admission form and patient registration form for many years. Software changes were needed before the response to the Aboriginality question was actually printed out on the patient registration form. The necessary changes are now in place.

2. Staff Training

   From August 1994, the switchboard staff at this hospital were no longer responsible for undertaking admissions from 11.00 p.m.-7.00 a.m. The responsibility for after hours admissions was taken over by rostered nursing coordinators who were trained by the regular Admissions staff.

   Alexandra was responsible for the training of Admissions staff, whom she spoke to individually about the importance of recording Aboriginality accurately. She handed out a copy of the information sheet supplied by the Koori Health Unit for staff undertaking admissions.

   The individual contact with staff was followed up in writing with a memorandum. The posters and pamphlets provided by the Koori Health Unit were distributed around the Admissions area at this time.

   Alexandra said that she had spoken to each staff member on a one-to-one basis because she decided that this would be a more effective approach. The information provided by the Koori Health Unit had been 'interesting and informative'.

   Alexandra said that many people were aware of the differences in the health status of Aboriginal and non-Aboriginal Australians, but most people assumed that these differences occurred in Northern Australia, rather than in states such as Victoria where there was a full range of health services available. Alexandra said that the information provided by the Koori Health Unit had also helped to clarify the situation where staff may have assumed that they would be able to determine whether a person was Aboriginal without actually asking. The misconception was that all Aboriginal people have dark skin.

3. Computer System Changes

   The hospitals who have the computer software system used at West Gippsland Hospital have a national user group. The hospital's Information Systems Manager attends the meetings of this group. West Gippsland Hospital is the only public hospital in Victoria using this particular computer system.

   The recommendations of the initial survey in regard to changes to the PMI were raised with the software suppliers by the hospital's Information Systems Manager. The software supplier had said that the question was an attribute of the person which should be stored on the PMI. However, the MRAs initially believed that the PMI change had been made as requested, until the system was actually tested.

   Subsequently, Kirstie was advised by the Information Systems Manager that the software suppliers had not been able to comply with the request to change the PMI because of the costs involved.

4. Quality Assurance Audit

   Regular print outs of admissions to patients identified by the hospital as being of Aboriginal or Torres Strait Islander descent are now being provided to the Koori Hospital Liaison Officer, Dot Proctor.

   Dot is able to compare the hospital's recording of Aboriginal patients with her own knowledge of Koori community admissions. If Dot is aware that there has been an admission of a Koori patient who has not been recorded by the hospital, she can alert staff in the Admissions area so that a cross check can be undertaken to ensure that the question was actually asked at the time of admission. It is acknowledged that some Koori patients may chose not to be identified as being Koori at the time of a hospital admission.

   Copies of the Koori Hospital Liaison Officer's monthly reports are also sent to relevant areas of the hospital and this now includes the Medical Record Department. However, as the Koori Hospital Liaison Officer's reports do not contain any patient identifying information such as name or UR number, the Admissions staff depend on direct contact with Dot in regard to possible inaccurate recording of Aboriginality.

   Kirstie said that she strongly supported the need for quality assurance checks on the Aboriginality data item. Staff who are responsible for recording Aboriginality at the time of admission are working without close supervision. It was not possible to be certain that the question is in fact being asked every time. Quality assurance checks are also regarded as being imperative because of the wide number and variety of staff who are undertaking admissions.

Outcomes and Achievements

As a result of working with staff in an appropriate manner and using the information booklets, leaflets and posters provided by the Koori Health Unit, staff now understand the reasoning behind the Aboriginality question. They feel more confident in asking the question.

Other Issues

Kirstie said that experience had shown that actually asking this question still depends on the individual person.

'It is easier to ask something difficult if you know the reason you are doing it, but I believe that there are still staff who would "look and not ask". It is not possible to be there to determine exactly what happens'.

In regard to the recommended computer changes for the PMI, Kirstie acknowledged the need for asking the Aboriginality question at each admission. She believes that if the answer to the Aboriginality question has already been recorded on the PMI, it is most unlikely that staff will ask the question again.

While individual staff were responsible for recording correct information, Kirstie said that the actual computer system set-up could help when there were difficulties for staff in asking a question which was perceived to be 'sensitive'. The barrier to implementation of the necessary computer changes had been the costs involved to the hospital but there was strong support for the changes if additional resources were provided by Human Services.