Annual Report Incorporating Quality of Care Report 2009-2010

Bairnsdale Regional Health Service Annual Report incorporating Quality of Care Report 2009-2010

Bairnsdale Regional Health Service PO Box 474 Bairnsdale VIC 3875 Telephone (03) 5150 3333 Facsimile (03) 5152 6784 Email [email protected] www.brhs.com.au ...focusing on you Mission Contact Details

Leading, shaping and delivering quality health care services to East Gippsland Bairnsdale Regional Health Service PO Box 474, Bairnsdale VIC 3875 Ph: (03) 5150 3333 Fax: (03) 5152 6784 Vision Email: [email protected] Website: www.brhs.com.au To be a key provider of healthcare services in East Gippsland through: • Innovation in the delivery of health care services Hospital • Recognition by its clients as being committed to quality care 122 Day Street, Bairnsdale VIC 3875 • Working in partnership with other healthcare providers • Responsiveness to community needs Community Health Centres • Recognition by its staff as an employer who values their contributions; and Ross Street, Bairnsdale VIC 3875 Shop 19, The Esplanade, Paynesville VIC 3880 • Delivery of cost effective services Residential Aged Care Values Maddocks Gardens, McKean Street, Bairnsdale VIC 3875 Sutherland Lodge, McKean Street, Bairnsdale VIC 3875 • Customer Service • Respect Planned Activity Groups • Teamwork Ross Street, Bairnsdale VIC 3875 • Efficiency Ph: (03) 5152 0222

Our motto Acknowledgements ...focusing on you Design & Printing Egee Printers P: (03) 5152 5055 F: (03) 5152 1387 E: [email protected] W: www.egee.com.au

Photography Jets Photography P: 0419 169 859 E: [email protected]

External Auditors Auditor-General, Victoria

Internal Auditor Grant Thornton

Construction of new Oncology & Dialysis Unit - June 2010

The Bairnsdale Regional Health Service is established under the Health Services Act 1988. The responsible Minister during the reporting period is the Hon Daniel Andrews MP.

The Bairnsdale Regional Health Service Annual Report 2009/10 has been prepared in accordance with the Health Services Act 1988, Financial Management Act 1994, Standing Directions of the Minister for Finance (Section 4 Financial Management Reporting) and Financial Reporting Directions (Specifically FRD 22).

CONTENTS

Proﬁ le 2 Management Committees 18 Services 3 Specialists and Visiting Specialists 19 President and CEO Report 4 Financial Donations 20 Summary of Strategic Goals 6 Life Governors 22 Summary of Key Result Areas 7 Community Engagement 23 Financial Results 9 Quality of Care 24 Activity Data 10 Report of Operations 30 Workforce Data 12 Glossary of Terms 32 Corporate Governance 13 Donations / Bequests 34 Organisational Structure 16 Index 35 Organisational Chart 17 Disclosure Index 36

Bairnsdale Regional Health Service 2010 Annual Report 1 PROFILE

Bairnsdale Regional Health Service (BRHS) provides healthcare services to more than 40,000 people across the East Gippsland Shire covering an area of BRHS HISTORY

21,000 square kilometres. Towns to beneﬁ t from the 1887 Opening of the Bairnsdale District Hospital services of BRHS include Bairnsdale, Benambra,

Bruthen, Buchan, Ensay, Lakes Entrance, Mallacoota, 1930 Opening of the Orbost Hospital Metung, Omeo, Orbost, Paynesville, Swan Reach

and Swifts Creek. 1940 Relocation of the Bairnsdale District

Hospital to Day Street (current site) • Hospital services operate from the main campus

in Day Street, Bairnsdale and include acute and 1963 Training facilities for nursing built on site post acute services, specialist consulting rooms,

dialysis and oncology outpatient services, allied 1967 Extension of hospital to facilitate health outpatient services, radiology, pathology outpatient facilities and residential aged care facilities.

1975 Name changed to East Gippsland Hospital • Community health services are located in both

Bairnsdale and Paynesville providing outpatient 1981 Opening of children’s ward allied health services, Planned Activity Group,

and dental services in Bairnsdale. Outreach 1986 Completion of building works incorporating Planned Activity Groups are also located in Metung, radiology, pathology, pharmacy and Buchan, Bruthen, Lindenow and Paynesville. medical records

• Outreach healthcare and education services are 1992 Opening of new operating theatre also provided throughout the region including

allied health services at the Lake Tyers Aboriginal 1992 Bairnsdale Regional Health Service Trust and the Gippsland and East Gippsland established as an entity under the Health Aboriginal Co-operative (GEGAC); outreach Services Act 1988 following amalgamation midwifery and maternal health, district nursing and of the East Gippsland Geriatric Centre and in-home palliative care. East Gippsland Hospital

1993 Amalgamation of Community Health Services into the Bairnsdale Regional Health Service

1996 Establishment of Sutherland Lodge, dementia speciﬁ c aged care facility

2004 Establishment of Maddocks Gardens residential aged care facility

2007 Construction of the new Emergency Department and associated works

2008 Extension of the Monash Rural Clinical School

2009 Master Planning commenced for construction of Oncology & Dialysis unit, and extension to pharmacy

2010 Pharmacy extension completed, construction underway on Oncology & Dialysis unit.

2 Bairnsdale Regional Health Service 2010 Annual Report SERVICES

Services offered by Bairnsdale Community Health Adolescent Health Regional Health Service include: Breast Care Cardiac Rehabilitation Acute & Sub Acute Health Community Dental Health Program Dialysis Continence Advisory Service Emergency Services Diabetes Education Geriatric Evaluation and Management Home Based Nursing Service (District Nursing) Medical Hospital Admission Risk Program (HARP) Medical Imaging Hospital in the Home (HiTH) Obstetrics Needle Exchange Program Oncology Palliative Care Paediatrics Planned Activity Group (PAG) Palliative Care Post Acute Care (PAC) Pathology Pulmonary Rehabilitation Pharmacy QUIT program – smoking cessation Rehabilitation Women’s Health Stomal Therapy Surgical Care Theatre Visiting Specialists Audiology Cardiology Aged Care Cognitive Dementia and Memory Service Rehabilitation Gastroenterology Rehabilitation Physician General Physician Residential Dementia General Surgeon Residential High Care Gynaecology Residential Low Care Head, Throat, Neck & Nose Respite Care Counselling Services Low Fertility Clinic Low-Vision Clinic Allied Health Neuropsychology Dietetics Oncology Equipment Service - Aids and Equipment Program Ophthalmology Inpatient Rehabilitation Orthopaedic Koori Hospital Liaison Outreach Polio Clinic (bi-annual) Occupational Therapy Paediatric Surgeon Outpatient Service Paediatrician Physiotherapy Rehabilitation Cardiologist Podiatry Renal Physician Social Work Rheumatologist Speech Pathology Urology Vascular Surgeon

Ancillary Audiology Medical Library Mental Health Orthotics

Bairnsdale Regional Health Service 2010 Annual Report 3 PRESIDENT AND CEO REPORT

On behalf of the Board of Management, management and staff, we are pleased to present the Annual Report of Bairnsdale Regional Health Service (BRHS) for 2009-10.

During 2009-10 BRHS adopted a new strategic plan for the years 2009-2013. The plan builds on BRHS’s mission of; leading, shaping and delivering quality health care services to East Gippsland and a summary of the goals and strategies can be found following this report. The plan sets out the pathway for BRHS to build on its services as the opportunities arise over the next four years and to achieve these objectives whilst maintaining core clinical services and operating effectively within the resources we have.

The healthcare landscape we operate in is both dynamic and challenging and the Board and management of BRHS are pleased to report that we have successfully met and navigated through these challenges for the beneﬁ t of all sections of the community. With the ever increasing demands for service provision and costs of healthcare, it is our priority to ensure that BRHS is able to meet as many as possible of the needs of our community. Satisfying these competing demands is a constant and complex challenge for management.

Without question the issue of the consulting suites and whether visiting consultants should pay for the use of the rooms and BRHS staff to conduct private clinics was locally controversial. A successful outcome for the visiting consultants and BRHS, in line with accepted industry wide practice, was achieved through the goodwill and co-operation of all parties concerned. In late 2009 BRHS committed $196,000 towards renovating the consulting suites and staff accommodation. This project will be completed in August 2010 resulting in improved reception and waiting areas, air-conditioning, painting, carpeting, blinds and disabled access and toilets etc.

In November 2009 BRHS signed a contract with local builder Brooker Builders, for the construction of the much awaited Oncology and Dialysis Unit. Construction has commenced and it is anticipated that the building will be operational in early 2011. This will bring to fruition a project that will have a total budget of 3.5 million dollars which in the main is self funded by BRHS and community fundraising. We would like to acknowledge the wonderful work of the many individuals and companies who have contributed to this project either directly or through the Toonalook Waters Project. Special mention needs to be made of the tireless fundraising efforts and contributions of the Pelicans, the Practical Men of the Village, particularly Mick Campbell & Vin Martin, and Mina Armstrong who donated the land for the Toonalook Waters Project, whose contribution made this project such an outstanding success.

In delivering our mission of “quality health services” BRHS continues to seek independent affi rmation of our progress in this area and it is pleasing to report on some signifi cant outcomes. BRHS Radiology Department successfully undertook accreditation through the Royal Australian and New Zealand College of Radiologists/ National Association of Testing Authority. The BRHS Radiology Department at the time was the only Victorian radiology department to successfully achieve accreditation and is one of only three accredited services in Victoria. BRHS’s midwifery service was also reaccredited under the “Baby Friendly” accreditation scheme. “Baby Friendly” is an internationally recognised accreditation process and provides reassurance to our community that the services provided are both best practice and benchmarked. Maddocks Gardens, our Aged Care service, was likewise reaccredited by the Federal Government Aged Care Standards & Accreditation Agency. BRHS also commenced year one of a three year program to improve the focus on customer service throughout the organisation. In excess of 200 front line staff undertook customer service training during 2009 and we are confi dent of building on the gains made to date. The achievements outlined are representative of multiple activities that are undertaken by BRHS staff on a continuous basis. We commend our staff on their achievements to date and encourage their future pursuits in this area.

BRHS continues to pursue partnerships for the improved client outcomes and was pleased to have the BRHS and Gippsland Lakes Community Health joint draft work plan, as mentioned in last year’s report, adopted. This has resulted in a number of joint projects getting under way. BRHS is proud of its many working partnerships which include; the many auxiliaries that provide invaluable service to BRHS, partner organisations, our community advisory committee and the many volunteers throughout BRHS.

4 Bairnsdale Regional Health Service 2010 Annual Report Recruitment and retention of skilled staff in the rural setting is an on-going challenge. BRHS has been fortunate to receive funding to facilitate two GP Obstetric registrars, Drs Daniel Otounye and Andrew Linton and we are appreciative of the opportunity to provide this experience and hope that we will be able to provide such programs in the future. In the addition to the Obstetric registrars BRHS was able to secure $125,000 in funding from the Department of Health to review and develop alternative models of care for maternity services. A multi-disciplinary working party consisting of GP Obstetricians and Midwives has been exploring ways we can improve our maternity model of care and the recruitment and retention of both GP Obstetricians and Midwives. We also acknowledge the retirement of Dr. Geoff Brown, who during more than 34 years at BRHS, held roles of Medical Superintendant and Chief Radiologist and we acknowledge his dedication and commitment to the Health Service.

BRHS notes the retirement of Mr Ian Roberts and Ms Lidia Thorpe from the Board of BRHS and thanks them for their contribution. Thanks is also extended to the Board who contribute many hours in a volunteer capacity to ensure that the mission, vision and values of BRHS remain at the fore front of our endeavors.

BRHS commends the commitment of Board members, staff, medical ofﬁ cers and volunteers for their efforts and looks forward to a continuing contribution and partnership in the provision of health services to the East Gippsland community.

Philippa deVoil Wayne Sullivan President, Board of Management Chief Executive Ofﬁ cer

Bairnsdale Regional Health Service 2010 Annual Report 5 SUMMARY OF STRATEGIC GOALS

Innovation in Commitment Working in Responding Valuing and Cost effective the delivery to providing partnership to community developing our service delivery of healthcare quality care needs workforce services

Develop and Provide Promote open Enhance the Achieve a full Provide efﬁ cient promote excellence in communication community’s workforce services and integration and customer with staff, health engagement compliment make best use continuity of service service partners with BRHS skilled to meet of existing care and other services service delivery facilities stakeholders requirements

Develop Enhance Work with other Strengthen Promote an Develop innovative and quality health service capacity in core organisational facilities to sustainable practice organisations clinical services culture that meet service models throughout to develop reﬂ ects contemporary to meet BRHS cooperative organisational health care community strategic values in all requirements needs partnerships aspects of BRHS activities

Develop sub Build Support and Establish a high Ensure staff Develop acute services recognition and strengthen dependency feel informed, shared service consistent with support in the subregional unit (HDU) within listened to and solutions with DoH subacute community health care ﬁ ve years engaged other Gippsland policy directions partnership health providers forums

Effectively Enhance Develop strong Provide Develop ﬂ exible Prudently manage cultural partnerships residential aged and adaptable manage discharge competence with teaching care services professional roles ﬁ nancial, planning and training that best meet to best utilise the capital and staff organisations community workforce and resources within needs skills available to the annual BRHS health services agreement and funding availability

Provide services Progressively Improve Support staff to Develop an that are develop community gain and keep information appropriate and information health through current technology accessible to systems that health qualiﬁ cations strategy to Koori patients, link seamlessly promotion, illness and experience support clinical clients and with local and prevention and needed to sustain and business families regional health service BRHS service improvements services coordination requirements

Progressively Advocacy Partner with implement for improved regional health environmentally services for our services to friendly policies community support service and reduce delivery and the BRHS workforce environmental requirements footprint

6 Bairnsdale Regional Health Service 2010 Annual Report SUMMARY OF KEY RESULT AREAS

Key Result Area Comment Compliance

All category 1, 2 and 3 patients presenting Partial themselves to the Emergency Department (ED) are seen within the time performance expectations established by the Department of Health. Benchmark: Category 1 – 100% seen immediately Category 2 – 80% seen within 10 minutes Category 3 – 75% seen within 30 minutes

90% of patients admitted through the ED should not Substantial be waiting longer than 12 hours for a bed.

The waiting time for outpatient allied health services Whilst there is only a partial compliance, Partial should not exceed the DH target number of working there has been consistent improvement days. over the ﬁ nancial year, with the end result being an 82% compliance.

Conservative dental interventions should not exceed BRHS Dental Services has maintained a Substantial the Victorian State target identiﬁ ed by Dental Health consistently low waiting period with an Services Victoria. average of 11.7 months, compared to the State target of 22 months.

The number of acute care bed days occupied by BRHS achieved 100% compliance for this Substantial patients awaiting residential care placement should target. not exceed 90 days during the month.

The overall level of inpatient satisfaction should BRHS score for the individual questions Partial exceed the performance of BRHS’s peer group. in the patient satisfaction survey varied considerably with some areas being well above peer average, but others below. The overall care index was 77 for BRHS compared to 78 for peer health services.

The rate of medical readmissions within 28 days BRHS’ average rate of medical Substantial should not exceed 10%. readmissions was less than 1%.

The rate of pressure ulcers acquired at BRHS should BRHS’ performance in stage one Partial not exceed 30% of reported cases. pressure ulcers was BRHS 0.5, State-wide 0.48, peer group 0.7. In regards to stage two pressure ulcers, BRHS .25, State-wide .65 and peer group .78. Overall pressure ulcer rates per ‘000 bed days, BRHS .78, State-wide 1.1 and peer group 1.59.

No incident during the month should exceed a Partial severity rating more than 6.

There are no clinical death reviews outstanding Substantial greater than 30 days.

Staff agree their contribution to the organisation is BRHS as a value driven organisation is Substantial valued as assessed via staff survey. pleased that an average of 77% responded positively in regards to their contribution being valued.

Bairnsdale Regional Health Service 2010 Annual Report 7 100% of staff have completed a current Substantial performance development plan.

BRHS has less sick leave, as a percentage of Nineteen agencies participate in the Substantial productive hours, than 90% of other agencies sick leave benchmarking across Victoria. participating in the Regional HR Benchmarking BRHS has consistently remained in the exercise. top 10% of agencies within the survey.

The number of WorkCover claims remaining month BRHS has maintained its compliance Substantial end, with time off greater than 10 days and no return with ensuring all WorkCover claims have to work plan, is zero. a speciﬁ ed return to work program developed.

There has been an in-house development / Applications include: vaccination Substantial applications of IT solutions to improve the efﬁ ciency booking system; chemotherapy cancer of clinical staff time. streams statistics reporting; ambulance transport management system; aged care packages management system etc.

Overall elective surgical day of admission rates Substantial should exceed 95%. There should be no YTD variation for any of the top This key result area measures length of Partial 20 DRG’s in comparison to the State average. stay for speciﬁ ed medical conditions. In an effort to reduce length of stay based on State guidelines, without compromising patient health, BRHS is consolidating clinical pathways for conditions including chronic obstructive pulmonary disease, chronic heart failure, cellulitis and chest pain.

The YTD average length of stay for GEM patients Substantial should not exceed the State average.

The YTD average length of stay for rehabilitation Substantial patients should not exceed the State average.

Hospital in the home bed days YTD should constitute Signiﬁ cant gains have been made in Partial 10% of multi day stay bed days. Note: excludes regards to this Key Result Area, the nursery and patient discharged with a postcode target is being amended in line with outside Bairnsdale/Lakes Entrance catchment. State average.

The combined YTD public and private WIES actuals Whilst the target was not met due to Partial at least exceeds the DH target extended periods of absence by our resident general surgeon, the outcome was within the 2% variance as allowed by the Department of Health. GEM bed days at least exceed the DoH target. The GEM and rehabilitation bed day Partial funding is interchangeable. Although GEM bed days were under target, the shortfall was recovered in rehabilitation bed days.

Rehabilitation bed days at least exceeds the DoH Substantial target.

There is documented evidence that 90% of all Substantial multi day stay patients have been asked if they are receiving service from another community provider and that e-notiﬁ cation message has been sent. Eighty percent of all specialist discharges are Strategies are in place to address this Partial completed. Key Result Area.

Financial Outcome. Compared to budget, ﬁ nancial Substantial outcome was an improvement of 13%.

8 Bairnsdale Regional Health Service 2010 Annual Report FINANCIAL RESULTS

The organisation produced an operational surplus of $1,036,000 (2008/09 $2,156,000) before transfers to and from reserves, capital grants and depreciation being applied. During the year BRHS received capital grants of $1,323,000 (2008/09 $1,343,000) and applied a total depreciation amount of $3,856,000 (2008/09 $2,051,000). This resulted in an overall Deﬁ cit of $1,556,000 (2008/09 surplus $1,385,000).

2010 2009 2008 2007 2006 $000 $000 $000 $000 $000

Total Revenue 54,816 53,356 52,200 50,005 44,573 Total Expenses 56,372 51,971 49,555 46,218 43,160 Overall Surplus / (deﬁ cit) (1,556) 1,385 2,644 3,787 1,413 Retained Surplus / (Accumulated Deﬁ cit) 27,633 28,708 27,171 24,378 21,762 Total Assets 65,521 66,901 48,545 43,281 39,964 Total Liabilities 17,854 17,679 15,087 12,901 13,370 Net Assets 47,667 49,222 33,458 30,380 26,593 Total Equity 47,667 49,222 33,458 30,380 26,593

Changes in Prices, Fees, Charges, Rates and Levies

The Service charges fees for services it provides to: Aged Care Residents, Allied Health Clients accessing services through HACC and CACPs and district nursing, as well as private patients in our main hospital. In all of these occasions the organisation charges according to schedules of fees published by the appropriate federal authority, and fees are only increased when advise is received from the appropriate Commonwealth Department.

Completed Toonalook Waters home

Bairnsdale Regional Health Service 2010 Annual Report 9 ACTIVITY DATA

Admitted Patient

Admitted Patient Acute Sub-Acute Mental Other Total Health

Separations

Same Day 7,886 0 0 0 7,886 Multi Day 4,465 379 0 14 4,858 Total Separations 12,351 379 0 14 12,744

Total WIES 5,904.26

Total Bed Days 26,535 6,148 200 32,883

Non Admitted Patient

Non Admitted Patients Acute Sub-Acute Mental Other Total Health

Emergency Department Presentations 16,339 16,339

Outpatient Services – occasions of 9,807 9,807 services (VACS and Non VACS clinics)

Other Services – occasions of services

Total occasions of service 16,339 9,807 26,146

Private Patient Initiative

The private patient initiative continued in 2009/10, providing net income of $955,305 an increase of 32.3% compared to the previous ﬁ nancial year. This initiative is very important for the hospital as it provides additional revenue to the service which is used to supplement government funding.

2010 2009 2008 2007 2006

% of Total Bed Days 13.69% 13.99% 14.13% 12.47% 9.15% Total Bed Days 32,795 32.970 34,640 32,380 30,220

10 Bairnsdale Regional Health Service 2010 Annual Report Private Patient Net Income

1,200,000

1,000,000

800,000

600,000

400,000

200,000

- 2010 2009 2008 2007 2006

WIES

The Weighted Inlier Equivalent Separations (WIES) is the Casemix instrument that is used by the Victorian Government to fund hospitals. All health services have WIES targets and funding depends on the number of WIES the organisation attains. BRHS’ WIES target for the year was 6,050 and achieved 5,904 or 146 less than target.

The result was heavily inﬂ uenced by the fact that we lost our resident surgeon through the year and had to source locum surgeons to continue to provide our services to the community. Although the result is under target it is within an acceptable range.

Target Actual Variance

Public 4,387.00 4,350.95 -36.05 Private 1,012.00 987.57 -24.43 Renal 217.00 213.27 -3.73 TAC 27.00 27.34 0.34 DVA 407.00 325.13 -81.87

TOTAL 6,050.00 5,904.26

Bairnsdale Regional Health Service 2010 Annual Report 11 WORKFORCE DATA

Labour Category June Current Month FTE June YTD FTE

Nursing 108.42 176.45 Administration and Clerical 79.61 76.33 Medical Support 21.93 27.05 Hotel and Allied Services 101.25 106.34 Medical Offi cers 3.82 2.67 Hospital Medical Offi cers 10.18 8.82 Sessional Clinicians 0 0 Ancillary Staff (Allied Health) 30.92 32.44 Dental Offi cers 3.00 2.11 Other Dental Clinicians / Specialists .49 .52

The industrial relations environment at BRHS remains stable. BRHS has not experienced any lost time through industrial accidents or disputes.

The Human Resources Department at BRHS has worked very closely with the Information Technology Department to redevelop our Workforce Development Software. The new system allows us to better document our staff competencies, allowing us to track mandatory qualiﬁ cations and competencies that staff must meet to provide excellent patient care.

Occupational Health and Safety (OH&S)

The Health Service complies with all its obligations under the Occupational Health and Safety Act 2004. BRHS has in place an OH&S Policy and a Return to Work Policy, it collects information about all OH&S incidents and its OH&S Committee analysed them at every meeting to try to identify trends and to put in place corrective actions to protect the health and safety of all staff, patients and clients visiting our facilities.

Over the last twelve months BRHS has performed very well in all OH&S areas of the service.

In order to improve Occupational Health & Safety the organisation invested in a software program that allows us to centralise all chemical’s Material Safety Data Sheets (MSDS) that the organisation uses. Together with this program the process for purchasing chemicals has been centralised to our supply department, who will be responsible to source not only the chemical but the MSDS required for its safe use.

Whistleblowers Protection Act 2001

Under the provisions of the Whistleblowers Protection Act 2001 (the Act), Bairnsdale Regional Health Service does not tolerate improper conduct by its employees, ofﬁ cers or members nor the taking of reprisals against those who come forward to disclose such conduct.

Bairnsdale Regional Health Service is committed to the principles and intent of the Act and to the protection of genuine whistleblowers against action taken in reprisal for the making of protected disclosures. In line with this, Bairnsdale Regional Health Service has in place a corporate policy and procedure, which complies with the Act. Disclosures made under this policy will be investigated swiftly, professionally and discretely.

A copy of the Act is available for inspection from the Health Service’s library. The policy is also available to all staff on the BRHS intranet.

12 Bairnsdale Regional Health Service 2010 Annual Report CORPORATE GOVERNANCE

There was only one change to the Board of Management throughout 2009/10, that being the resignation of Lidia Thorpe.

Board of Management

President Vice President Philippa deVoil Angela Hutson Appointed 2001 Appointed 2000 BA (Admin); Dip App Sc. (Nursing) BA (UM); Dip Ed; MBA; Masters in Former Executive Director of Organisational Leadership; Nursing, served on various Graduate Dip Business in government advisory committees. Entrepreneurship and Innovation; Extensive health service experience Grad Cert Enterprise Management; including aged care services in public and private Diploma of Frontline Management. sectors at management and board levels. Rotarian Extensive experience in executive management and and local volunteer. governance in the public sector. Currently CEO of East Gippsland TAFE.

Treasurer Peter Crick Ken White Appointed 1992 Appointed 2009 Held various bank management BBus; CA; GradCert FP positions in the Gippsland region and Tasmania over a 23 year Chartered Accountant, Director period from 1979 – 2002. Vice of Whites Accounting and President of the Pelicans Taxation Solutions. Extensive community fundraising committee. experience in public practice Signiﬁ cant association with accounting, taxation and business management. Freemasonry for over 40 years. Keen gardener and walker.

Dr David Formby Anoop Chauhan Appointed 2008 Appointed 2009 MB BS.DCH; FRACP; FRCP; B. Comm., Ll.B., C.A. (Ind), FRACMA; MHA. Member CPA Australia; ACHSE; Former Medical Director Princess Dip. in System & Program Margaret Hospital for Children, Development / Management, Perth, Wangaratta Regional Grad Cert - Human Resources & Hospital and Latrobe Regional Industrial Relation Hospital. Previous Treasurer Extensive experience in executive management and Chairman of the Federal Assembly of the AMA. and governance in public and private health sector Former surveyor with the Australian Council of Health incl. acute, aged, sub-acute, primary health care etc. Care Standards. Formerly Consultant Paediatrician at at senior executive and board level. Hands-on Princess Margaret Hospital, Latrobe Regional Hospital involvement in business, ﬁ nancial and corporate and Bairnsdale Regional Hospital. Past President of the strategic planning and policy development/ Bairnsdale Golf/Bowls Club. implementation for over twenty years.

Bairnsdale Regional Health Service 2010 Annual Report 13 CORPORATE GOVERNANCE

Ian Roberts Tony Ward Appointed 2000 Appointed 2000 Former Regional Manager VECCI, B. Laws; B. Jurisprudence Gippsland. Experience in training Principal, Wards Barristers & and workplace assessment, Solicitors Pty Ltd. Married to staff management. Trade Sharon, four children. Former qualiﬁ cations in carpentry, current Chairman, Nagle College School Bail Justice/Justice of the Peace, Council. past President East Gippsland Legacy, past member of Bairnsdale Rotary, and past President Bruthen RSL. Board of Management Attendance 2009/10 Lidia Thorpe P. de Voil 8 of 11 Appointed 2008 A. Hutson 10 of 11 (resigned May 2010) K. White 10 of 11 Manager, Lake Tyers Aboriginal A. Chauhan 7 of 11 Training Centre and own business P. Crick 9 of 11 in Aboriginal Events Management. D. Formby 8 of 11 Past member of Government I. Roberts 10 of 11 advisory committees, current L. Thorpe 5 of 11 fellow in Aboriginal leadership in Victoria. Victorian representative to the National T. Ward 9 of 11 Indigenous Body Workshop. The Board recessed for January 2010

Completed Pharmacy renovation

14 Bairnsdale Regional Health Service 2010 Annual Report CORPORATE GOVERNANCE

Finance, Audit and Business Medical Credentialing Development Committee Committee

The Audit and Compliance Committee was renamed The Medical Credentialing Committee is a the Finance, Audit and Business Development sub-committee of the Board of Management. The Committee. It is a sub-committee of the Board of Committee is responsible for assessing the professional Management. The Committee assists the Board in expertise, competence, reputation and authenticity fulfi lling its governance responsibilities relating to, of the qualifi cations of medical staff seeking and including, the accounting and fi nancial reporting appointment or re-appointment to the medical staff processes, external and internal audit functions, the of BRHS. The Committee meets as required. risk management system and legal and regulatory requirements. The Committee meets quarterly. Board Committee members during 2009/10 were:

Board Committee members during 2009/10 were: Peter Crick

Philippa deVoil Ken White Tony Ward Angela Hutson Tony Ward Community Advisory Committee Anoop Chauhan The Community Advisory Committee is a sub-committee of the Board of Management. The Quality Audit Committee Committee provides mechanism for local community involvement in the BRHS strategic planning process The Quality Audit Committee is a sub-committee of and local health service delivery. The Committee the Board of Management. The Committee oversees meets quarterly. progress of the strategic quality plan and monitors each dimension of quality, safety, effectiveness and Board Committee members during 2009/10 were: appropriateness to ensure an organisational wide quality program and culture exists. Peter Crick Board Committee members during 2009/10 were: David Formby Lidia Thorpe Philippa deVoil Ian Roberts Lidia Thorpe

Bairnsdale Regional Health Service 2010 Annual Report 15 ORGANISATIONAL STRUCTURE

Chief Executive Ofﬁ cer and Directors

Wayne Sullivan Remberto Rivera Chief Executive Ofﬁ cer Director Corporate Services & Master of Business; Grad Dip Business Development Health Science (Administration); BEcon; Grad.Dip Bus. (Accounting); Grad Dip Nursing (Community Grad.Dip. Aged Care Health); RN Div 1; Cert of Management; MBA; ASA; AHSFMA Gerontology; Diploma AICD The Corporate Services & Business Company Director’s Course; Development Directorate at FACHSM; CHE; GAICD. BRHS oversees the ﬁ nancial Broad experience within the health sector having management and compliance of BRHS; as well as commenced as a nurse and in the ensuing 27 years Human Resources, Facilities Management, Hotel held clinical and management roles in health. Prior to Services, and Health Information Management. In joining BRHS was CEO at Maryborough District Health short the directorate provides most of the ancillary Service. services BRHS needs to operate effectively.

Vicki Farthing Megan Morse Director of Nursing Director Allied & Community RN; Stomal Therapist; BA Nursing; Health Services Grad Dip Health Informatics; B.Pod (Hons); M.Ed. (Ed & Tr); Masters, Health Management; MBA; Grad Cert H.Ec FRCNA; AACHSE The Allied & Community Health The Nursing Clinical Services Services Directorate at BRHS Directorate at BRHS incorporates provides inpatient and outpatient a wide range of nursing, allied health services at the Day community and residential aged care services. It is Street campus, in addition to providing outreach able to provide 24 hour emergency care, general services to two Community Health sites. The Ross Street surgical services, obstetric service, district nursing campus accommodates a Dental service, along service, provide patient assistance in the management with Community Health Nursing and the Bairnsdale of chronic disease, plan and assist patient discharge Planned Activity Group (PAG), one of six PAG’s that and follow-up, pharmacy services and aged care for BRHS manages for local communities. The Paynesville high and low level residential care needs. The nursing site hosts a similar range of services on a visiting basis, division includes a dialysis unit for patients with chronic and serves as the base for the East Gippsland Post renal disease and treats patients requiring Acute Care program. The Directorate also includes chemotherapy agents and manages infection the Aids & Equipment program, the Consulting Rooms prevention at BRHS. and Medical library.

Ka Chun Tse Lorraine Parsons Director of Medical Services (Former) Director Allied & MB; BS; Community Health Services Resigned January 2010 The Medical Services Directorate at BRHS supports the development BA (Social Sciences); BSW; Grad Cert Management; and planning of the medical MAASW workforce of Bairnsdale Lorraine joined BRHS in February 2008 after working in Regional Health Service, as well the public health sector for 16 years in Victoria and as the quality of care and clinical the Northern Territory. governance framework of the Health Service. Medical Services provides advice on the operational management of medical staff in the Health Service, and works collaboratively with East Gippsland Regional Clinical School to promote medical student placements in Bairnsdale.

16 Bairnsdale Regional Health Service 2010 Annual Report Allied Health Koori Liasion Diabetes Education Health Promotion Community Nursing Post Acute Care PAG Aids & Equipment Public Dental Medical Library Medical Consultants Suite & Community Health Services Director of Allied ORGANISATIONAL CHART Director of Acute Wards Theatre Accident & Emergency Rehabilitation Unit Aged Care Hospital in the Home Infection Control Discharge Planning / Clinical Initiatives Direct Nursing Community Programs Pharmacy Nursing Services cer ﬁ ICT Quality Radiology Education Board of Management Chief Executive Of Director of Medical Clinical Team Leadership / Emergency Intern Supervision (via Medical Clinical Team) Medical Services Supply Payroll Reception Security OH&S Committees • Committee Community Advisory Committee • Remuneration • Quality Audit Committee • Committee Medical Credentialing Committee • Finance, Audit & Business Development Fundraising & Community Engagement Finance Hotel Services Regional Supply Facilities Human Resources Medical Records Development Director Corporate Services & Business Endorsed by CEO May 2010

Bairnsdale Regional Health Service 2010 Annual Report 17 MANAGEMENT COMMITTEES

Bairnsdale Regional Health Service (BRHS) believes The Occupational Health & Safety Committee committees are an excellent means of continues to function within the scope of the communication and has an active committee Occupational Health & Safety Act. meeting structure which provides a valuable means of formal communication. All committee meetings are minuted and available to staff through the intranet. BRHS Management Committees support our role through the exchange of ideas, decision-making, investigation of events, assessment and review of patient care and services, consideration of reports, BRHS Board Quality Audit Committee ensuring legislative or funding requirements are met and overseeing the implementation of plans or policy.

All our committees have ‘Terms of Reference and Quality Management Committee Membership’, which set out the role and function of the Committee. Membership for each committee is Clinical Committees Corporate Committees appropriate for the role and function it performs.

The Board sub-committees as listed on page 15. Information • Finance, Audit and Business Development Theatre / Anaesthetics Management Committee & Surgery Committee Committee • Quality Audit Committee • Medical Credentialling Committee • Community advisory Committee Obstetrics & Neonatal Corporate Services Committee Report directly to the Board. Committee

All clinical and non clinical committees at BRHS report to the Board through our peak committee which is the Quality Management Committee. These committees Emergency Department Occupational Health are listed below. & Medicine Committee & Safety Committee

• BRHS Quality Management Committee • Theatre/Anaesthetics & Surgery Committee Pharmaceutical / Transfusion / Infection Human Resources • Obstetrics & Neonatal Committee Prevention Committee Committee • Emergency Department & Medicine Committee • Pharmaceutical/Transfusion/Infection Prevention Committee Maddocks Gardens Continuous Improvement • Maddocks Gardens Continuous Improvement Committee Committee • Ambulatory Care Committee

• Information Management Committee Ambulatory Care • Corporate Services Committee Committee • Occupational Health & Safety Committee • Human Resources Committee

During the year each committee has reviewed its Terms of Reference and Membership.

18 Bairnsdale Regional Health Service 2010 Annual Report SPECIALISTS AND VISITING SPECIALISTS AT BRHS

Audiologists Paediatricians Jeremy Grummett Sue Clutterbuck Dr Peter Goss Jeremy Ryan Neil Clutterbuck (ceased June) Dr Jo McCubbin Jo McCubbin Sue Luscombe John Scarlett Paediatric Surgeons John Urie Cardiologists Mr Chris Kimber Justin Mariani Dr David Bertovic Mr Neil McMullen Krishna Mandaleson Dr Justin Mariani Poh Ng Dr Meroula Richardson Physician Margaret Niemann Dr James Shaw Dr Krishna Mandaleson Mark Frydenberg Dr Andrew Taylor Meroula Richardson Rehabilitation Physician Michael Sedgley Head, Neck, Nose & Throat Dr David McConachy Myles Chapman Prof Andrew Sizeland Naveen Joshi Renal Physician Peter Goss Gastroenterologists Dr. David Hooke Peter Lindstedt Dr David Iser Peter Milne Dr Jeremy Ryan Rheumatologists Peter Rehfi sch Dr Anthony Boers (ceased May) Peter Worboys General Surgeons Assoc Prof Peter Ryan Phillip Sewell Mr Adrian Aitken Pradeep Madhok Mr Bob Irungu Urologists Robert McKimm Mr Anamitra Sarkar Prof Mark Frydenberg Ross de Steiger Mr Clem Smith Dr Jeremy Grummet Scott Deller Sema Yilmaz Gynaecologists Vascular Surgeon Sue George Dr Robert McKimm Mr Peter Milne Tomasz Grabinski Dr Michael Sedgley Wanda Wysocka-Grabinska Dr Mac Talbot Visiting Medical Offi cers Warwick Wright Dr Gareth Weston Adrian Aitken Y “Echo” Jiang (RMO) Andrew Rutherford Nephrologists Andrew Sizeland Gippsland Lakes Community Dr. David Hooke Andrew Taylor Health District Medical Offi cers Prof David Power Animitra Sarkar serving the Hospital in the Home Ash Arunachalam (RMO) Program Oncologists Bob Irungu Dr John Scarlett Clem Smith Cunninghame Arm Medical Daniel Otuonye (RMO) Centre District Medical Offi cers Opthalmologist Andrew Linton (RMO) serving the Hospital in the Home Dr Pradeep Madhok Daryl Smith Program David Bertovic Orthopaedic / Legal David Hooke Dr Stan O’Loughlin David Iser David McConachy Orthopaedic Surgeons David McConville Mr Andries DeVilliers Elizabeth Boyd (commenced April) Emma Wong (RMO) Mr Peter Rehfi sch Gareth Weston Mr Peter Smith Graham Bromwich Mr Warwick Wright James Shaw

Bairnsdale Regional Health Service 2010 Annual Report 19 FINANCIAL DONATIONS TO BRHS 2009/2010

Bequests and Estates Lindenow Lioness Club $700.00 Lions Club of Lakes Entrance $500.00 Erica Cromwell Trust $5,523.59 Paynesville Bowling Club $350.00 Estate of Letitia Maynard $319.93 Paynesville Hospital Auxiliary $1,000.00 Ian & Jeannie Cooper-Brown $93,341.13 Paynesville RSL $100.00 Paynesville Uniting Church Friendship Shed $2,000.00 BRHS Auxiliaries Riviera Quilters Inc $1,000.00 St Johns Anglican Op Shop $550.00 Bower Birds EGH Fund Raising Group $10,050.00 Urban Funk Dance $1,502.00 Paynesville Pelicans $2,142.00 Pelicans Interest $28,083.51 Toonalook Waters proceeds $313,990.70 Individuals

Rebecca Ah Chow $10.00 Business Sector KN & J Alexander $100.00 Allan Corrie Painting $100.00 R & S Alexander $100.00 Bairnsdale Golf Club $2,101.00 Anonymous $2,511.80 Bairnsdale RSL Sub Branch $1,150.00 Wilhelmina Armstrong $1,000.00 Bairnsdale Windscreens $200.00 E MacArthur $50.00 Brooker Builders Pty Ltd $250.00 Glenn Baberton $4.00 Bunnings Warehouse $5,000.00 GH Barnett $200.00 Collins Booksellers $250.00 Mrs MJ Bell $15.00 D A Johnson $250.00 Carol Beveridge $8,000.00 Dahlsens $100.00 R & F Bills $50.00 Dulux Group $405.00 Mr Brennan $20.00 GSI $2,000.00 John Brookes $100.00 House & Gift $736.90 Mr & Mrs Bryant $50.00 James Yeates & Sons Pty Ltd $893.30 Kylie Peter & Jayne Bud $165.00 King & Heath $50.00 Mr & Mrs Burrowes $50.00 Reg Biggs $200.00 Jean Butcher $20.00 Safetech $100.00 L & V Calvert $20.00 Slap Architects $250.00 MD Campbell $1,000.00 Tyco Healthcare $585.41 John & Maureen Campbell $200.00 Whiters Street Glass & Glazing $200.00 Kath Cassidy $20.00 Ron Claridge $45.00 Woolworths Bairnsdale Social Club $428.05 Joyce Clemm $1,000.00 Community Groups Alan & Christine Clyne $50.00 Stan M Collins $1,000.00 Bairnsdale Day Centre $700.00 Maureen Connolly $20.00 BRHS Flower Auxiliary $3,000.00 Gweneth Cooper $2,250.00 Community Nursing $6.50 Janine Cooper $30.00 CWA $500.00 Allan Cracknell $50.00 CWA High Country Branch $100.00 Deirdre Crick $110.00 Kilmany Remote Family Services $110.00 R & W Cunningham $50.00

20 Bairnsdale Regional Health Service 2010 Annual Report Marie Curtis $100.00 RA Murphy $100.00 Tanya & Simon Dalley $30.00 Karen Nattrass $50.00 Ellen Davies $75.00 B & R Nicholes $50.00 Deller Donations $5,879.35 Betty Noris $50.00 Philippa de Voil $100.00 A Norman & Family $40.00 Ruth Engel $50.00 Carl Poeschel $100.00 Nicola Fanning $50.00 Millicent Reggardo $20.00 Jim Ferguson $65.00 WA & GM Roberts $100.00 Jan & Mike Finn $30.00 Dr Jeremy Ryan $500.00 Ken Firth $50.00 M E Sanders $50.00 KS Ford $400.00 Noel Scott $50.00 Dr David Formby $100.00 Ken Simpson $100.00 Robert Franck $1,000.00 Sizeland Donations $5,558.55 T & M Goode $100.00 Joyce Smiley $50.00 MF Greenwood $10.00 Gus & Jennifer Sperti $500.00 Mr & Mrs Grifﬁ ths $50.00 Lois Stewart & Friends $420.00 JB Guerin $40.00 Denis & Rosalie Stringer $50.00 Mrs A M Guy $20.00 Ian & Gwen Strobridge $50.00 Elise Hall $20.00 Wayne Sullivan $100.00 Ken Hall $7.00 Gail Swankie $20.00 K & M Hanley $135.00 Leigh & Marc Tricard $220.00 AC & LE Harrington $40.00 Spiros Tsetsos $1,000.00 Maureen Hartigan $10.00 John & Mendy Urie $1,000.00 Dael & Leo Heirman $200.00 Anthony Veale $100.00 Mark Hocking $100.00 Mary Waites $100.00 WD Holden $548.27 Tess Walker $50.00 Mrs I Hutton $20.00 Norma Ward $100.00 Lorraine Jennings $20.00 Mary Wassink $50.00 Shirley Keamy $20.00 Sara Wayman $500.00 TP Keyte $100.00 Matthew White $300.00 Bertha Khote $100.00 Laurel Wilesmith $10.00 Ros Kleinitz $50.00 Jennelle Wilkes/Paul Start $100.00 Elizabeth Lade $50.00 Elaine Winterbottom & Family $50.00 Elizabeth Leadoux & Family $100.00 The Young Family $500.00 SM & PM Logan $30.00 Friends of Joyce Young $950.00 June Mackie $20.00 Arthur Thomas Martin $4,000.00 Philanthropic Ron & Roma Martin $100.00 Collier Charitable Foundation $50,000.00 Marijke Mascas $100.00 Michelle McNairn $20.00 Merle McRae $1,500.00 Barry Mills $50.00 Wayne Morgan $20.00

Bairnsdale Regional Health Service 2010 Annual Report 21 LIFE GOVERNORS

Bairnsdale District Hospital opened 1921 AT Bieri 1940 VV Vincent in 1887. In 1940, the hospital moved 1922 Alex McPherson 1940 Mrs VV Vincent to its current site in Day Street. 1922 EJ Williams 1941 Mrs T Varney 1923 Mrs H Bankin 1941 N Dunn In 1975, the hospital changed its 1923 WP Craig 1941 JG Clapperton name to East Gippsland Hospital and then again in 1992 to its 1923 EJ Roder 1941 H Clues current name Bairnsdale Regional 1923 C Healey 1941 B Chadwick Health Service. The East Gippsland 1925 Miss Irene Leonard 1941 Mrs G Baker Geriatric Centre and East Gippsland 1926 Mrs H Wood 1941 WD Gibbs Hospital were amalgamated from 1927 Mrs L Dawe 1941 Mrs AJ Gilsenan this date. 1927 Mrs A Goodman 1941 Miss BJ Hollingsworth 1928 Robert Gilder 1941 PC Murray 1890 William Bird 1928 Harry Hopkins 1941 Miss Julia O’Shea 1890 John Kennedy Smith 1928 Mrs C Neal 1941 Mrs EM McCann Pre1917 HT Arthur 1928 THC Johnson 1941 Mrs M McNeill Pre1917 Richard G Brownlow 1928 Mrs Mary Liddell 1941 Mrs PE McPherson Pre1917 Mrs Richard Brownlow 1928 Ernest Lindeman 1943 Mrs J Dean Pre1917 GH Cole 1930 Mrs J Bull 1943 Miss Grace Buse Pre1917 John Connelly 1930 AJ Gilsenan 1943 Mrs J Appleton Pre1917 F Eastwood 1930 EP Burke 1943 Mrs Patten Pre1917 HB Gibbs 1930 F Healey 1943 Mrs T Willhelme Pre1917 WB Giles 1930 Mrs T Mathieson 1943 C Moon Pre1917 Sharp Halmshaw 1930 Mrs RJ Loveridge 1943 Mrs N Norris Pre1917 Mrs WL Harris 1930 JW Marriott 1943 Mrs TW Murphy Pre1917 Mrs Hawkes 1930 A McPherson 1943 Mrs R Calder Pre1917 John Holford 1931 JG Stanway 1943 Mrs ME Martin Pre1917 Frank V Holloway 1931 MT Walsh 1943 Mrs C Meddings Pre1917 HF Holloway 1932 Mrs L Jemmeson 1943 Mrs TK Lloyd Pre1917 J Hutchison 1932 Mrs E Ross 1943 TK Lloyd Pre1917 John King 1933 LR Skipworth 1944 Mrs AE Bieri Pre1917 JH Lawler 1933 W Garlick 1944 CW Pittman Pre1917 J Laurent 1934 Roy Rieper 1944 Mrs WJ McCormack Pre1917 Mrs Mudie 1934 F Rogerson 1944 P McFarlane Pre1917 A Murray 1934 Mrs W Vickers 1944 HR Growcott Pre1917 Mrs John Mills 1934 Mrs A Leask 1944 Mrs E Kidd Pre1917 AJ McKenzie 1935 Mrs Grace Douglas 1944 Joseph Lay Pre1917 PJ O’Connor 1935 Miss Elizabeth Bull 1945 J Doyle Pre1917 J O’Keefe 1936 AW Collins 1945 Kay Donoghue Pre1917 GB Osborne 1936 Mrs S Stein 1945 HC Reynolds Pre1917 Hon William Pearson 1937 Mrs AE Bell 1945 LJ Taylor Pre1917 GW Peart 1937 Lord Nufﬁ eld 1945 Miss E Stokes Pre1917 Mrs George Ross 1938 Dr Charles J Alsop 1945 Mrs AC Yandle Pre1917 E Saunders 1938 Mrs R Alsop 1946 Mrs BE Thewlis Pre1917 Angus Shaw 1938 Arthur Dyer 1946 J O’C Davies Pre1917 Mrs James Stewart 1938 Mrs V Glen 1946 Rev A McMillan Pre1917 Mrs E Twentyman 1939 W Buchanan 1946 Miss Margaret Johnston Pre1917 Mrs W Winkelmann 1939 Mrs W Buchanan 1946 Mr AT Gunn 1919 W Garlick 1939 Mrs Clancy 1946 Dr A Robertson 1919 TW Murphy 1939 Mrs HJ Arthur 1946 CE Goodman 1921 John Reid 1940 Mrs R Meek 1946 W O’Doherty

22 Bairnsdale Regional Health Service 2010 Annual Report 1946 A O’Leary 1993 Peter Engel 1947 FH Redman 1993 Robert Mansell Community Engagement 1947 Mrs V King 1993 Milton Murphy 1947 Mrs Jean Lafsky 1993 GJ Foard In 2009/10 Bairnsdale Regional Health Service delivered two 1947 Mrs E McLaren 1993 Ewan Logan newsletters to the general 1948 Glynn D Timmins 1993 Helen M Schutt (Trust) community, providing an 1950 FL Johnston 1993 Mrs GF Barter overview of news and events 1950 W Thatcher 1993 LG Tipper at our organisation and they 1951 Mrs Judy Beatty 1993 J Siggins presented an excellent 1951 John Spirason 1993 Miss JH Scott opportunity to disseminate 1953 Mrs Betsy Cathcart 1993 FH Ray information relating to acute, 1953 Mrs Jean Loud 1993 J Parker sub-acute and community health services at BRHS. 1954 S Telfer 1993 Rev DM Muller 1954 Ian Thatcher 1993 Mrs DM Mitchell 1954 Leonard Rule 1993 W Meade 1955 CR Holman 1993 J Leatham 1955 Ben Ogden 1993 Mrs E Ingle 1955 Mrs Anne F Ikin 1993 EGR Horsﬁ eld 1955 Arthur Winter 1993 Miss JH Holford 1955 Mrs Flora Brumby 1993 JW Hawksley 1957 Mrs B Watson 1993 Mrs Patricia Evans MBE 1959 Mrs Margaret Latimer 1993 WH Elridge 1959 Mrs Phyllis Rodgers-Wilson 1993 Mrs J Court 1961 Rev Canon GFD Smith 1993 HN Cox The 2009-2013 Strategic Plan 1963 Mrs Isabel (Doris) Savige 1993 KL Cook was also ﬁ nalised during the 1965 Thomas Hansen 1993 M Campbell year, with copies available to 1965 PJ Thompson 1993 Mrs MA Cameron the public from the hospital or 1968 Victor Cole 1993 AE Boucher on the BRHS website. 1968 Dr Thomas O’Beatty 1993 W Bills 1968 Mrs Mary Nicholls 1994 Derek Dahlsen 1969 Mrs M (Peg) Bailey 1994 Ray Holloway 1969 Joe Alvin 1994 Mrs P Lane 1970 Rex Foard 1994 T Grass 1970 Kenneth Beynon 1994 Mrs A Grass 1972 Miss Eileen O‘Leary 1995 Ms T Gillies 1972 William Rodgers-Wilson 1995 Dr F Malatt 1973 Gordon Arthur Henry Smith 1996 Mrs K Heath 1974 Clement John Sharp Pre2006 Mr E Dahlsen The Health Service also 1975 Miss Margaret McIntyre Pre2006 Mr T Eager updated the community 1976 Mrs Margaret Sheehan Pre2006 Mr WH Eldridge through media releases in the 1979 William McCallum Pre2006 Mr R Gregory local papers on issues such as 1979 Robert Bosworth Pre2006 Miss JH Holford the progress of the Toonalook 1987 DM Yeates Pre2006 Mr P Lay Waters project, the building of 1992 Alan Glass Pre2006 Mrs R Marsh the new Oncology & Dialysis 1992 Mrs Thelma Glass Pre2006 Mrs M McRae Unit, the pharmacy extension, donations to the Health 1992 Ron Nation Pre2006 Mrs M Winnette Service, accreditation 1992 Albert Rodd 2008 Dr James Evans achievements, fundraising 1992 Mrs May Winnett 2008 Mr Michael Padula events, community health 1993 Ian Campbell services and more. 1993 Brian Hopkins

Bairnsdale Regional Health Service 2010 Annual Report 23 QUALITY OF CARE

Infection prevention • Moment 1 – Before touching a patient • Moment 2 – Before a procedure • Moment 3 – After a procedure or body fl uid Infection prevention is very important to hospital staff exposure and the community. BRHS has an Infection Prevention • Moment 4 – After touching a patient Coordinator with expert knowledge to assist staff, • Moment 5 – After touching a patient’s surrounding patients and visitors to minimise infection risks. (bed, medical equipment). The Infection Prevention Coordinator helps by: Bloodstream infections continue to be monitored with a priority focus on Staphylococcus aureas • Developing policies and procedures to help staff bacteraemias. Rates remain extremely low and well know what to do about infection prevention within the accepted rate for health services of • Minimising the risks to patients, staff and visitors equivalent size. from infection transmission • Reducing the risk that a patient’s existing Surgical site infections continue to be monitored with infections may spread the main focus being on caesarean sections. There • Observing and examining high risk procedures to have been two infections reported for the year. reduce risks • Ensuring that infection prevention standards are Results from all infection prevention activities are met reviewed by doctors, nurses, and other relevant staff • Education of staff, patients and visitors about to work out the best way to reduce the risks identifi ed. infections and prevention strategies All staff work with the infection prevention coordinator • Managing outbreaks of infections such as and reduce the risk of infection by making appropriate gastroenteritis and infl uenza when they occur so changes to practice. they do not spread to others. Education for the staff has continued to be a focus Along with other hospitals in Victoria, BRHS continues especially in the health of our staff and minimising to review/audit areas of infection risk with the exposures. Victorian Nosocomial Infection Surveillance System (VICNISS). VICNISS monitors infections patients get Hand washing is the single most important activity that while in hospitals. Included in this auditing are areas minimises risk of infection for staff, patients and visitors such as: in hospitals and in the community. • Hand Hygiene (washing your hands) You can and should ask staff members caring for you • Infections you may get in your blood stream “Have you washed your hands?” • Infections you may get in your wound after surgery

• Infections that are resistant to treatment (multi-resistant organisms) • Staff injuries from exposure to blood or body ﬂ uids • Staff compliance with vaccination requirements.

Hand washing compliance has had a strong focus within BRHS throughout this year. This national initiative through the Australian Commission on Safety and Quality in Healthcare has a target of 65% compliance across Victoria for the 2010-2011 year.

During the audit period every person who steps into the patient area is monitored. BRHS has performed well in the audits conducted for the 2009-2010 year with results equal to and above the Victorian expected compliance rate for the period.

The ‘5 Moments’ of hand washing are observed in the audit to make sure they occur and at the required standard. The 5 moments are:

24 Bairnsdale Regional Health Service 2010 Annual Report How Clean is Your Hospital? Patient Satisfaction at BRHS

Cleaning standard audits are undertaken regularly - Results of 2009-2010 Survey and completed in accordance with the Department of Health Cleaning Standards for Victorian Health BRHS takes part in an annual patient satisfaction Facilities 2009. survey. The survey is undertaken to inform us, from the patients’ view, what we do well and how we can The audit results indicate that cleaning processes in improve. A company contracted by the Department place are suitable, as the cleaning outcomes (Scores) of Health called UltraFeedback collects the are well above the Acceptable Quality Levels (AQL) information through questionnaires it sends to required for each risk category. patients that have been discharged from BRHS. If you do receive a questionnaire from UltraFeedback, Risk Location and Acceptable we encourage you to complete it and return it to Categories Frequency of Audit Quality Level them in the envelope provided. Your opinion is (AQL) important to us.

Very High Monthly – Operating 90 BRHS Category B Hospital All Hospitals Risk Areas Theatres, Central Key: All Hospitals = All Public Sterilising Supply Unit Hospitals in Victoria Group B Hospitals = Rural High Monthly - Emergency 85 Hospitals similar in size and patient mix to BRHS Risk Areas Department, acute wards, pharmacy, oncology, dialysis 77 78 78 Average of Overall Care

Moderate Quarterly – Dental 85 78 76 77 Access and Admission Risk Areas Services, Rehabilitation areas, residential 81 82 82 General Patient accommodation, day Treatment and Related activity centres, 77 78 79 medical imaging Information (X-Ray), waiting rooms, public areas including 78 80 80 Complaints Management toilets. 74 75 76 Physical Environment

All areas/issues that are identiﬁ ed are noted during 76 76 77 Discharge and Follow-up the audit are actioned by cleaning staff immediately or within 24hours. 78 79 80 Consumer Participation

The last patient satisfaction survey let us know that our cleaning standards meet patient’s approval. Thirty nine percent (39%) of BRHS patients who were sent the survey completed and returned it to We welcome any feedback from you about the UltraFeedback. Group B hospitals, of which BRHS cleanliness of the hospital and if you visit, please let a is one, had 37% of patients return surveys. staff member know about your concerns. Patients were very satisﬁ ed with most aspects of their stay at BRHS. We are performing in line with the Category B hospital average. The majority of patients reported that they were helped a great deal by their stay at BRHS and felt that the length of time spent in hospital was about right.

Bairnsdale Regional Health Service 2010 Annual Report 25 High performing scores were obtained for the Falls Prevention following items: ► The courtesy of the nurses Slips, trips and falls can happen to anyone but ► The courtesy of the doctors they are more common and more signifi cant as we ► The cleanliness of the room where patients spent get older. most of their time ► Being treated with respect It is easy to dismiss falls as part of “getting older” or “just not concentrating,” but they are often warning Areas where we could most improve include: facilities signs that something is “just not right.” It is important for storing belongings - availability, security and ease to discuss all falls with your doctor. Falls are a common of use; privacy in the room where patients spent most problem and are often the reason why people come of their time; and waiting room comfort. to hospital. These fi ndings are supported by comments made The Good News by patients, with 8.4% mentioning facilities for the • Many falls are preventable question “what could the hospital do to improve the • Injury from falls can be minimised care and service it provides to better meet the needs • Aging does not have to mean loss of of the patients?” independence We are working out ways to improve in each of the The reasons or causes of falls are known as areas and will monitor how we have met your needs RISK FACTORS. Some people are more likely to fall when the next survey is done in 2011. than others because they have more risk factors. Risk factors for falls include: Continuous Improvement and • Poor eyesight Accreditation • Reduced balance, weak muscles, stiff joints • Less feeling in your legs BRHS is committed to continuous improvement and • Slower reaction times in the last year has undergone external reviews by • Some health problems such as stroke, Parkinsons a number of external agencies. These reviews have disease, arthritis, postural hypertension (low blood confi rmed that improvement is ongoing, and we have pressure when you stand up), dizziness, diabetes, successfully met all requirements against the following dementia, problems with your “waterworks” or standards: bowels (incontinence), poor nutrition (not eating enough, not eating a balanced diet or In June 2009 we were reviewed against the Evaluation drinking enough water) and Quality Improvement Program where we • Even short term sicknesses (the “fl u” and other underwent self assessment of our clinical care in the infections) or surgery can increase your risk of acute services of BRHS. Feedback from the Australian falling Council on Healthcare Standards was very positive • Medicines – some types of medicines can and comments have been used to make increase your risk of falling, including those you improvements in the 2010 Organisation Wide review. may take for sleeping, anxiety or depression

November 2009 saw us assessed against the Post Falls prevention is a priority at BRHS. Graduate Medical Council standards. These standards review us as a teaching hospital for junior doctors. The results were positive and suggestions for improvement Total BRHS Falls 2009-2010 have been actioned. 60 The Aged Care services were reviewed by the Aged 55 Care Standards and Accreditation Agency. Aspects 50 of care reviewed included, management systems 45 stafﬁ ng and organisational development, health and 40 personal care, resident lifestyle and physical 35 environment and safe systems. The feedback has been 30 positive and full three years accreditation granted. Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

26 Bairnsdale Regional Health Service 2010 Annual Report In the last year there has been an eighteen percent (18%) reduction in falls. Serious injury from falls remains stable.

There are a number of approaches we have to help recognise if you have a high risk of falls. These approaches will reduce the risk, and they are:

• Risk assessments (asking you questions about the risk factors above) • Accommodating those at risk in adjustable height beds • Use of alert devices that let staff know when you are getting up, so they can come and help you • The Pharmacist will review the tablets you are taking • If appropriate, refer you to the “No Falls” preventative exercise program • Talk with you/your family/carer about ways that you can reduce your risk of falls, particularly when You will be able to manage your health and you return home medications a little easier if you know the following • Review the suitability of your walking aids – on about the medications you are taking: occasions your needs may change • If you have had a fall at home that requires you • Is this a new medication that I haven’t taken to come to hospital we will arrange a visit to before? check the safety of your home and work with you • What is my medication for? to improve your safety if required • How much medication do I take? • When and how do I take my medication? Co-ordination of the Ambulance Victoria / Department • How long do I take my medication for? of Health / BRHS Falls referral program has enabled • Can you take it with food or other medications? clients across East Gippsland who fall, but are not • How should I store my medication? transported to hospital, to receive follow up in the • What do I do if I miss a dose? community eg initial phone contact by Integrated • What are the common side effects and what Care Coordinator and offered referral to should I do if I think I have side effects? physiotherapists. Liaison with GPs and Community Care Case Managers who may not be aware their Nursing and medical staff are required to explain what client has had a fall is also considered. your medication is for and answer any questions you may have about your medications.

Reducing Medication Errors Medication safety is very important to the staff at BRHS and there are many strategies in place to reduce the Prescribing (what the doctor does), dispensing (what risk of medication incidents occurring, including: the pharmacist does) and administering of medication to the patient (what the nurse does) is the most • All nurses have an annual test for medication common activity undertaken in hospitals. Managing safety. medications is a very complex task and requires • All staff are required to ask you “what is your hospital staff, patients and carers to work closely to name”, and check your armband, name and make it safe. check that the tablet prescribed matches the name and tablet recorded on the prescription as What Can You do to make Taking Medications Safer? well as the tablet bottle. It is very important that you know and tell staff about • BRHS uses the same prescription document as any previous side effects or bad reactions to any the rest of Australia. This standardisation means medications or if you have any allergies. It is also a that doctors, nurses and pharmacists Australia good idea to tell them about any “over the counter” wide use the same form, which reduces the risk of medications or tablets you are taking or considering errors occurring. taking as they may react with tablets the doctor • An expectation about medication safety is given prescribes. to all new staff when they begin employment.

Bairnsdale Regional Health Service 2010 Annual Report 27 • Medication incidents are discussed with staff Preventing Pressure Ulcers involved and corrective actions are taken. • Education about medication safety is ongoing A pressure ulcer (also known as a pressure sore or bed and includes a newsletter from pharmacy with sore) is an area of skin that has been damaged due to topics from the Department of Health or learning’s unrelieved pressure. A pressure ulcer may look minor, from incidents that have occurred. such as redness on the skin, but they can hide more • Interruptions to medication rounds are kept to a damage under the skin. minimum. Distractions / loss of concentration while giving medications is known to be the biggest Where are they found on the body? contributing factor to medication incidents. Pressure ulcers usually occur over bony areas, Nurses are currently trialling an apron with especially heels, buttocks and toes. “Medication Round - Do not Disturb” on it in order to reduce interruptions. These diagrams show you where pressure ulcers occur in various positions or postures. The number of incidents relating to medication prescribing, dispensing and administration has When sitting: remained stable when compared to the previous year. ○ tail bone (coccyx) There have been no serious patient complications ○ buttocks (ischium) arising from medication incidents. ○ backs of heels ○ elbows BRHS Medication Incidents 2009 -2010 ○ shoulder blades

30 25 When lying on your back: 20 ○ the back of your head 15 ○ shoulder blades 10 ○ tail bone (coccyx) 5 ○ elbows 0 ○ heels Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun ○ toes

If you would like written information about your When lying on your side: medication, the pharmacist will be happy to give it to you, and the nurses and doctors will be happy to ○ ear answerer any questions. Please ask them. ○ side of your shoulder ○ pelvis ○ hip ○ knee ○ ankle bones (malleolus)

Who gets pressure ulcers? Anyone conﬁ ned to a bed or chair, who is unable to move, has loss of sensation, loss of bladder or bowel control, poor nutrition or is unwell is at risk of getting a pressure ulcer.

The signs to look for (especially on skin over bony areas) are: Red / purple / blue skin, blisters, swelling, dryness or dry patches, shiny areas, cracks, calluses, or wrinkles

28 Bairnsdale Regional Health Service 2010 Annual Report The signs to feel for are: that ensures the food is safe for human consumption. Hard areas, warm areas, or swollen skin over bony This process of kitchen safety includes proper storage points of food items prior to use, maintaining a clean environment when preparing the food, and making What can we do? sure that all equipment is thoroughly clean and The best thing you can do is relieve the pressure by free of bacteria that could lead to some form of keeping active, and changing your position frequently, contamination. whether you are lying in bed or sitting in a chair. If you are unable to move yourself, the staff will help to Preventing cross contamination is also an important change your position regularly. aspect of food hygiene. Cross contamination can occur when cooking and preparation utensils are Special equipment such as air mattresses, cushions used with more than one type of food at a time. For and booties are available and may be used to example, if the knife used to debone a raw chicken reduce the pressure in particular places. breast is also used to chop lettuce for a salad, there is a risk that contamination will occur and possibly lead Looking after your skin to food poisoning. Keep your skin and bedding dry. Let staff know if your clothes or bedding are damp. Let staff know if you Staff that work in the kitchen play a vital role in have any tenderness or soreness over a bony area providing patients, staff and visitors with nutritious or if you notice any reddened, blistered or broken meals that are safe to consume. BRHS serves skin. Avoid massaging your skin over bony parts of the approximately 21,000 meals to patients each year body. Use a mild soap and moisturise dry skin. and also have a staff and visitor cafeteria which is well patronised. Pressure ulcer prevention and monitoring is an ongoing process at BRHS, and is an important part of As a health Service we undergo Food Safety Audits by care for all our staff. the East Gippsland Shire. The Food Safety Audit is an in-depth analysis of the following processes: Receiving food/ingredients, storage, preparation, cooking, hold- BRHS Total Pressure Ulcers - July 2009 - June 2010 ing, transportation to area for 30 consumption, staff training, food recall and record keeping. 25 20 There is a focus on how food is handled, hygiene of 15 those handling food, cleaning and sanitising of equipment used in food preparation, and the 10 temperature control of food, contributes to the safety 5 of our food. 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun The design and construction of the premises, fl oors, walls ceiling fi xtures, fi ttings and equipment are also assessed to make sure we meet required standards for The number of pressure ulcers has reduced by 17% in food safety. the past year. The East Gippsland Shire Audit indicated that We contribute information to the Department of compliance was reached in all areas. Health about our pressure areas and our rate of patients who get pressure areas when in hospital is half In addition to the Shire Audit, kitchen staff monitor that of similar sized hospitals. food safety standards on a meal by meal and monthly basis and this assures us that our food is safe and at Meeting the Standards for Safe the required standard. Food Handling/Hygiene Our patient satisfaction survey conducted this year told us that patients were very satisfi ed with the Food hygiene is a broad term used to describe the temperature of hot meals, the quality of the food and preservation and preparation of foods in a manner the amount of food provided.

Bairnsdale Regional Health Service 2010 Annual Report 29 REPORT OF OPERATIONS

Responsible bodies declaration Events subsequent to balance

In accordance with the Financial Management Act date 1994, I am pleased to present the Report of Operations for Bairnsdale Regional Health Service for At the date of this report, Management is not aware the year ending 30 June 2010. of any events that have occurred subsequent to balance date that may have a material impact on the results of the next reporting period.

Philippa deVoil Attestation on Compliance with President, Board of Management Australian/New Zealand Risk Bairnsdale Management Standard 16th August 2010

I, Wayne Sullivan, certify that the Bairnsdale Regional Summary of factors affecting Health Service has risk management processes in place consistent with the Australian/New Zealand Risk operations Management Standard and an internal control system is in place that enables the executives to understand, The reporting period was affected by the fact that the manage and satisfactorily control risk exposures. The service lost its general surgeon for around 30% of the Finance, Audit & Business Development committee year, this meant that the organisation had to rely on veriﬁ es this assurance and that the risk proﬁ le of the locum surgeons at a much higher cost. This issue also Bairnsdale Regional Health Service has been critically affected our ability to completely meeting our WIES reviewed within the last 12 months. targets consequently reducing the income level of the service.

Revenue Indicators

Average Collection Days Wayne Sullivan 09-10 08-09 Accountable Ofﬁ cer

Private 49 44 Bairnsdale TAC 83 86 16th August 2010 VWA 78 41 Other Compensable 7 32 Residential Aged Care 47 48

Debtors outstanding as at 30 June 2010

Under 30 31 - 60 61 - 90 Over 90 Total Total days days days days 30/6/2010 30/6/2009

Private 467,834 134,870 44,807 140,173 787,684 307,896 TAC 2,677 0 270 1,220 4,168 20,476 VWA 0 1,483 0 2,205 3,687 13,506 Other Compensable 0 247 0 421 668 3,797 Residential Aged Care 134,824 14,301 3,373 16,528 169,027 154,040

965,234 499,715

30 Bairnsdale Regional Health Service 2010 Annual Report Building Act 1993 Freedom of Information Act 1982

Bairnsdale Regional Health Service complies with the The Freedom of Information Act 1982 (the FOI Act) building and maintenance provisions of the Building gives people the right of access to information held by Act 1993. Bairnsdale Regional Health Service and applications for access to information and records are processed in accordance with the FOI Act by the Health Consultancies Information Manager under delegation from the Director of Medical Services. There were 21 consultancies in this fi nancial year (18 in 08/09), these consultancies included: Strategic Health Services charge a fee for Freedom of Planning, Board training, Executive training on Information (FOI) requests in accordance with the emergency procedures and development of training guidelines set by the Department of Justice. Fees modules for dealing with clients exhibiting challenging for Medico-Legal requests are also received. The behaviours. These consultancies cost $184,025 and revenue for this fi nancial year is $2,117.40. The no one consultancy cost more than $100,000 Freedom of Information Application Fee is waived for those applicants holding a health care card. Consultancy Details Type of request Number Processed Number of Consultancies 18 Freedom of Information 113 Total $ of Consultancies $ 161,813 Medico-Legal 43 Number of Consultancies > $100,000 0 Total 156 National Competition Policy Attestation on Data Integrity In accordance with the national competition principals agreed by the Federal and State Governments in I, Wayne Sullivan, certify that Bairnsdale Regional April 1995, Bairnsdale Regional Health Service has Health Service has put in place appropriate internal implemented policies and programs to ensure controls and processes to ensure that reported compliance with the National Competition Policy. data reasonably refl ects actual performance. The Bairnsdale Regional Health Service has critically These programs and policies include: reviewed these controls and processes during the • The benchmarking of signifi cant business activities year. against other agencies of a similar size and nature; • Examination of each business activity to establish the benefi ts or otherwise of applying market contestability; and • Tendering for the provision of services where appropriate. Wayne Sullivan Victorian Industry Participation Accountable Offi cer

Policy Act 2003 Bairnsdale 16th August 2010 BRHS did not commence or complete any contracts to which the VIPP Act 2003 would apply.

Bairnsdale Regional Health Service 2010 Annual Report 31 GLOSSARY OF TERMS

Accreditation HARP To audit and give credentials to. Hospital Admission Risk Program that enhances and develops preventive models of care focused on Acute Care people with chronic and complex conditions to Care that is generally provided for a short period of prevent inappropriate emergency presentations or time to treat a certain illness or condition. admissions.

Cardiac HiTH Relating to, situated near, or acting on the heart. Hospital in the Home. The provision of hospital care in the comfort of the persons own home. Chemotherapy A type of pharmacotherapy used in the treatment or Intern control of disease, particularly cancer. A physician gaining supervised practical experience in a hospital after graduating from medical school. Dementia A usually progressive condition marked by the Midwifery development of multiple cognitive deﬁ cits. The act of assisting at childbirth.

Dialysis Nosocomial (as in VICNISS) The process of removing blood from an artery (as of Acquired or occurring in a hospital a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein – also called Obstetric hemodialysis. Relating to, or associated with, pregnancy and childbirth. Dietetics The science of diet and nutrition. Occupational Therapy Treatment aimed at assisting people overcome DVA limitations caused by injury or illness, enabling people Department of Veterans’ Affairs. to participate in the activities that have meaning to them. Gastroenterology A branch of medicine concerned with the structure, Oncology functions, diseases, and pathology of the stomach A branch of medicine concerned with the investigation, and intestines. diagnosis and management of people with cancer.

Geriatric Ophthalmology A branch of medicine that deals with the problems A branch of medical science dealing with the and diseases of old age and aging people. structure, functions, and diseases of the eye.

Governance Orthopaedic The way in which decisions important for the future of A branch of medicine concerned with the treatment organisations are taken, communicated, monitored of the musculoskeletal system. and assessed. It includes the processes an organisation has for holding managers accountable Paediatrics and measuring performance. A branch of medicine dealing with the development, care, and diseases of children. HACC Home and Community Care PAG Planned Activity Group

32 Bairnsdale Regional Health Service 2010 Annual Report Palliative Stoma A concept of care which provides coordinated An artiﬁ cial permanent opening especially in the medical, nursing and allied services for people who abdominal wall made in surgical procedures. are terminally ill, delivered where possible in the environment of the person’s choice, and which Sub-acute care provides physical, psychological, emotional and Goal-oriented interventions aimed at assessing and spiritual support for patients and for patients’ families managing often complex conditions to maximise and friends. independence and quality of life for people with disabling conditions. Pathway Clinical pathways are standardised, evidence-based TAC multidisciplinary management plans, which identify Transport Accident Commission an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for Toonalook Waters an homogenous group of patients. House constructed, and auctioned, to raise funds for the new Oncology & Dialysis unit. Physiotherapy The treatment of disease by physical and mechanical VICNISS means such as massage, regulated exercise, water, Victorian Nosocomial Infection Surveillance System light, heat and electricity. VWA Podiatry Victorian Workcover Authority (now known as The medical care and treatment of the human foot. WorkSafe Victoria)

Pressure Ulcer/Area WIES An area of skin that has been damaged due to Weighted Inlier Equivalent Separations – Unit of unrelieved pressure. payment for acute admitted care.

Radiology WorkSafe Victoria A branch of medicine concerned with the use of Formally Victorian Workcover Authority radiant energy (as X-rays or ultrasound) in the diagnosis and treatment of disease.

Registrar An admitting ofﬁ cer at a hospital Source: Merriam Webster Medical Dictionary (online); Pocket Macquarie Dictionary; Stedman’s Medical Renal Dictionary. Of or relating to the kidneys or the surrounding area

Social Work Social work is committed to the pursuit of social Justice and addresses situations of personal distress and crisis. Social work is informed by an understanding of human development and behaviour and of complex social structures and processes.

Speech Pathology The study and treatment of human communication disorders including disorders of speech, language and swallowing.

Bairnsdale Regional Health Service 2010 Annual Report 33 DONATIONS / BEQUESTS

The generosity of the community by their ﬁ nancial donations and volunteer support, to Bairnsdale Regional Health Service enables us to provide equipment, amenities and care that would normally be beyond our budgetary scope.

It is through these donations that we have purchased many pieces of equipment this year, such as thermometers, trolley’s, treatment chairs, oxygen equipment and more.

Thanks to everyone who contributed during 2009/2010.

To make a donation, call the BRHS Cashier on 5150 3413 and make a donation by credit card over the phone or join the BRHS Donor Program by completing the form below and sending it to BRHS Donor Program, PO Box 474, Bairnsdale VIC 3875.

First name Surname

Company name

Address Suburb P/code

Hm phone Other phone

All donations over $2 are tax deductible.

I would like my donation to support the: Please accept my contribution of (circle):

Purchase of equipment $1000 $500 $250 Other  Speciﬁ c equipment as arranged with BRHS

34 Bairnsdale Regional Health Service 2010 Annual Report INDEX

A K Accreditation 4, 23 ,26 Key Result Areas 7 Acute Care 3, 7 Auxiliaries 4, 20, 34 L B Life Governors 22 Brooker Builders 4, 20 M C Maddocks Gardens 2, 4, 18 Medication Errors 27 Cleaning 25, 29 Midwifery 2, 4 Community Advisory Committee 4, 15 Consulting Suites 4 Continuous Improvement 18, 26 O Obstetric Registrars 5 D Occupational Health & Safety 12, 18 Oncology 2, 4, 23, 25 Dental 2, 7, 12, 25 Department of Health 5, 25, 27, 28, 29 Dialysis 2, 4, 23, 25 P District Nursing 2, 3, 9 Donations 20, 23, 34 Palliative Care Pathology Patient Satisfaction 7, 25, 29 E Pressure Ulcer 7, 28, 29 Private Patient Initiative 10 Emergency Department 2, 7, 10, 18, 25 Q F Quality of Care 24 Falls Prevention 26 Financial Results 9 Food Hygiene 29 R Radiology 2, 4 G Rehabilitation 8, 19, 25 GEGAC 2 Gippsland Lakes Community Health 4, 19 S Goals, Summary of 6 Governance 13, 14, 15 Strategic Plan 4, 23

H T Hand Hygiene 24 Toonalook Waters 4, 9, 23

I W Infection Prevention 18, 24 WIES 8, 10, 11, 30 Workforce 6, 12 Workcover 8

Bairnsdale Regional Health Service 2010 Annual Report 35 DISCLOSURE INDEX

The Annual Report of the Bairnsdale Regional Health Service is prepared in accordance with all relevant Victorian legislation. This index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.

Legislation Requirement Page Reference

MINISTERIAL DIRECTIONS

REPORT OF OPERATIONS

Charter and purpose FRD 22B Manner of establishment and the relevant Ministers Front cover FRD 22B Objectives, functions, powers and duties 2 FRD 22B Nature and range of services provided 3

Management and structure FRD 22B Organisational Structure 16

Financial and other information FRD 10 Disclosure index 36 FRD 11 Disclosure of ex-gratia payments n/a FRD 21A Responsible person and executive officer disclosures 30 FRD 22B Application and operation of Freedom of Information Act 1982 31 FRD 22B Application and operation of Whistleblowers Protection Act 2001 12 FRD 22B Compliance with building and maintenance provisions of Building 31 Act 1993 FRD 22B Details of consultancies over $100,000 n/a FRD 22B Details of consultancies under $100,000 31 FRD 22B Major changes or factors affecting performance 30 FRD 22B Occupational health and safety 12 FRD 22B Operational and budgetary objectives and performance against 9 objectives FRD 22B Significant changes in financial position during the year 9, 30 FRD 22B Statement of availability of other information Back cover FRD 22B Statement of merit and equity Front cover FRD 22B Statement on National Competition Policy 31 FRD 22B Subsequent events 30 FRD 22B Summary of financial results for the year 9 FRD 22B Workforce Data Disclosures 12 FRD 25 Victorian Industry Participation Policy Disclosures n/a SD 3.4.13 Attestation on Data Integrity 31 SD 4.2(j) Report of Operations, Responsible Body Declaration 30 SD 4.5.5 Attestation on Compliance with Australian / New Zealand Risk 30 Management Standard

Legislation Requirement Page Reference

FINANCIAL STATEMENTS

Financial statements required under Part 7 of the FMA SD 4.2(a) Compliance with Australian accounting standards and other Finance 8 authoritative pronouncements SD 4.2(b) Comprehensive Operating Statement Finance 4 SD 4.2(b) Balance sheet Finance 5 SD 4.2(b) Statement of Changes in Equity Finance 6 SD 4.2(b) Cash Flow Statement Finance 7 SD 4.2(c) Accountable officer’s declaration Finance 1 SD 4.2(c) Compliance with Ministerial Directions Front cover SD 4.2(d) Rounding of amounts Finance 9

Legislation Freedom of Information Act 1982 31 Whistleblowers Protection Act 2001 12 Victorian Industry Participation Policy Act 2003 31 Building Act 1993 31 Financial Management Act 1994 Finance 1

Mission Contact Details