Annual Report 2014 - 2015 Service Directory
Allied Health Services Endocrinology, including Diabetes Management • Dietetics Eureka Linen • Exercise therapy Falls and Balance • Occupational therapy Gastroenterology • Physiotherapy General Medicine • Podiatry General Surgery • Prosthetics and orthotics Geriatric Evaluation and Management • Psychology Gynaecology • Social work ICU Liaison Nurse Service • Speech therapy Infection Control Intensive Care Unit and Medical Emergency Response Team Acquired Brain Injury Lymphoedema Management Ballarat Regional Integrated Cancer Centre Maxillofacial Surgery • Chemotherapy Day Unit Medical Oncology • Oncology Clinics Neonatology • Radiation Oncology (BAROC) Nephrology and Renal Dialysis • Wellness Centre Neurology BreastScreen Maternity Services BHS Catering Operating Suite Cardiology Ophthalmology Central Sterile Supply Department (CSSD) Organ and Tissue Donation Service Centre Against Sexual Assault (CASA) Orthopaedic Surgery Cognitive Impairment and Dementia Management Otolaryngology Outpatient Services Community Programs Paediatric Medicine • Ambulatory Care Services Perioperative Day Procedure Unit • Carer Respite and Support Services Pain Management • Community Rehabilitation (home and centre based) Palliative Care • Continence Resource Centre Pharmacy • Direct2Care Plastic Surgery • Domiciliary Services • Gem in the Home Mental Health Community Care Teams • Grampians Aged Care Assessment Service • Infant and Child • Grampians Regional Continence Service • Adult • Grampians Regional Palliative Care Team • Aged • Hospital Admission Risk Program • Youth • Linkages (home care packages) Mental Health Inpatient Care Units • Planned Activity Groups • Adult Acute Unit • Post-Acute Care • Community Care Unit • Restorative Care • Secure and Extended Care Unit • Transition Care Program • Aged Acute • Victorian Paediatric Rehabilitation Service • Aged Residential Diabetes Education and Treatment Rehabilitation (in-patient and out-patient) Diagnostic and Radiology (X-ray) Services Residential Aged Care • BreastScreen Respite Care • CT Scan Safety Link • ECG Stroke Management • EEG Stomal Therapy • MRI Statewide Aids and Equipment Program (SWEP) • Nuclear medicine Thoracic Medicine • Ultrasound Thoracic Surgery Critical Care Unit Urology Dental Services Vascular Surgery Diabetes Education Wound Management Ear, Nose and Throat Surgery Emergency Medicine Contents
Ballarat Health Services is the principal referral Profile of BHS 2 hospital for the Grampians region, which extends from Bacchus Marsh to the South Australian border. The region, covering some 48,000 square kilometres, is Chair and CEO’s report 3 home to nearly 250,000 people. Organisational chart 12 Ballarat Health Services was established under the Health Services Act 1988. The incorporation came into effect on 1 January 1997 following the voluntary Board of Management 13 amalgamation of the Ballarat Base Hospital, the Queen Elizabeth Centre and Grampians Psychiatric Services. Our People 16 For the period 1 July 2014 to 3 December 2014 Ballarat Health Services was accountable, through its Statutory requirements 20 Board of Management, to The Honourable David Davis MLC, Minister for Health and Minister for Ageing and Financial statements & notes Inner back The Honourable Mary Wooldridge MLA, Minister for Mental Health. For the period 4 December 2014 to 30 June 2015 Ballarat Health Services was accountable, through its Board of Management, to The Honourable Jill Hennessy MLA, Minster for Health and Minister for Ambulance Services and The Honourable Martin Foley MLA, Minister for Mental Health. Copies of this Annual Report, the BHS Quality of Care Report and the BHS Strategic Plan 2014-2017 are available online at www.bhs.org.au
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 1 BHS Profile
Ballarat Health Services is Our Vision Victoria’s second largest Excellence in health care regional health service, Our Mission providing a comprehensive To deliver quality care to the communities we serve by range of general and providing safe, accessible and integrated health services specialist care across key resulting in positive experiences and outcomes. medical and healthcare Our Values disciplines including acute Our services and staff embrace the following: care, sub-acute care, residential aged care services, community care, Compassion - fair and caring to all those we come into mental health, dental and contact with, even during difficult times. We treat others rehabilitation services. as we would expect to be treated. Integrity - behaving in accordance with our professional, ethical and legislative requirements. Using our resources responsibly and transparently, we are honest and trustworthy. Excellence - striving to attain the highest standards of service delivery and clinical practice. We achieve this by acknowledging, recognising and promoting innovation, participating in continuous learning, development, training and research. We come to work to make a difference. Accountability - understanding our role in providing a safe environment for staff, patients, visitors and members of the community. We take personal responsibility to maintain the necessary skills and competencies to perform our workforce roles and encourage others to do the same. If we make mistakes, we support each other to be open about them in order to learn. Collaboration - Involving staff and services both internally and externally in decision making, sharing our knowledge and experiences to build a better health system. Together we work in partnership with our patients, their families, carers and colleagues.
2 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Chair and CEO’s Report
Capital Works
The ongoing redevelopment of the Base Hospital site continued with a Andrew Faull Andrew R Rowe number of significant major milestones, Chair, Board of Chief Executive Officer Management including the demolition of Yuille House and the completion of the multi-storey car park and helipad.
Helipad New Drummond Street building The Minister for Health and Ambulance Services, The Hon Jill Work on the redevelopment of the Base Hospital site has Hennessy MLA, officially opened the helipad on 17 June 2015. progressed, with the demolition of the Yuille House building and the commencement of construction on the new three- The helipad was built on top of the new three storey car storey building. park at the Base Hospital. The helipad enables critically ill patients to be transferred into BHS and also to major trauma The new building will include a general medical/surgical hospitals in Melbourne. With a saving of approximately one ward, additional space for future expansion of operating hour compared to transporting a patient by road, lifesaving theatres and a new main entrance including front of house care can be initiated earlier resulting in a better outcome for reception area. the patient. In addition, patients facing time critical medical In preparation for the construction, contractors also emergencies in the region can be transported directly to the demolished the old pharmacy building, installed more BHS Emergency Department via this fast and direct route. than 110,000 pieces of scaffold and completed all The helipad was built to international standards by local internal demolition. Ballarat construction company H.Troon, and features a 27 To facilitate the redevelopment, a number of internal access metre diameter concrete landing surface, as well as a further changes took place, including the relocation of the main 1.5 metre safety net. entrance to Sturt Street, the closure of the ground floor The opening was the culmination of many years of link way and the realignment of the first floor link. To assist community support. patients find their way around during the construction phase, additional directional signage and maps were installed. A dedicated team of volunteers have also assisted patients Mair Street car park and visitors by welcoming them at the Sturt Street entrance The first stage of the car park was opened in January 2015, and guiding them to their destination. with the remaining levels being opened in March 2015. The opening of the car park was a significant milestone for BHS, and has been welcomed by our patients, visitors and staff. We appreciate the community’s patience during construction, however the inconvenience experienced is well and truly worth it. BHS is very appreciative of the support provided by the City of Ballarat with planning issues, provision of staff car parking at the City Oval and a financial contribution for the construction of an additional level of the car park.
The first helicopter lands on the BHS helipad.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 3 Report of Operations
Accreditation
It has been a significant year for BHS, with Residential Accreditation accreditation for the health service, mental Throughout the year, BHS residential aged care facilities health and aged care divisions of BHS underwent accreditation by the Aged Care Quality Agency being undertaken. for eight of our ten facilities. The remaining two facilities are to be reviewed at another time.
Hospital and Mental Health Accreditation Assessed against 44 standards covering all aspects of care provided to residents, the accreditation process is BHS was awarded full accreditation status by the thorough and exacting. Australian Council on Healthcare Standards following The feedback from the surveyors at the summation a survey against the National Safety and Quality Health conferences was incredibly positive. The surveyors Service Standards and the National Mental Health highlighted the care and empathy shown to residents and Standards undertaken in February 2015. noted the strong evidence of ongoing improvements and BHS met all 256 core requirements of the ten standards a very positive culture amongst the care teams. for accreditation, with 16 of the requirements being All eight facilities achieved compliance with the 44 awarded ‘Met with Merit’ status. standards which is an outstanding effort. ‘Met with Merit’ status indicates that the surveyors saw The result of the accreditation provides the community examples of exceptional quality and a higher level of with assurance that the quality of care provided to achievement than was required to meet the requirements. residents of BHS facilities remains extremely high. All areas of the acute, sub-acute and mental health in-patient units were surveyed against the National Standards. The Mental Health Service was also surveyed Community Accreditation against the National Mental Health Standards, all of which were also satisfactorily met. The BHS programs that provide disability services were also surveyed and successfully accredited under the A significant amount of work was required over a two year Disability Services Standards. The remainder of our period to prepare for the accreditation against the newly community programs also underwent accreditation implemented National Standards. The success achieved against the Community Care Standards. The surveyors was due to the commitment and significant efforts of were very impressed with the standard of care provided all staff throughout the organisation and particularly by our community teams and this was supported by the the outstanding efforts of the Governance and Risk clients who were interviewed and involved in the reviews. Management Unit. The full accreditation status applies until 1 April 2018.
Yuille House demolition Residential Aged Care
4 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Report of Operations
Ballarat Regional Integrated Cancer Centre (BRICC)
The BRICC has completed its second year of clinical established groups including Social Work, Dietetics, operations. The service consolidated internal processes Speech Pathology and Occupational Therapy. and operations to enhance oncology procedures and The Wellness Centre within BRICC has experienced integration within Ballarat Health Services and the significant growth with six new programs added including broader Grampians region. In terms of oncology services, Pilates, Why Weight? and financial management programs. BRICC treatment activity and consultations increased by approximately 30 percent, new treatment options became available, oncology clinical trials increased, additional New Treatment Technologies supportive care services were offered and a 40 percent increase in complementary therapy programs occurred The BRICC, in partnership with BAROC (The Ballarat through the BRICC Wellness Centre. Austin Radiation Oncology Centre) and Austin Health, became the first regional Victorian cancer centre to offer Chemotherapy outreach is now available in two western deep inspiration breath hold (DIBH) radiotherapy for left- Grampians locations with service partnerships established sided breast cancer patients. This high-end treatment with Stawell Regional Health and Wimmera Healthcare process, in which patients are coached to hold their Group. Radiation Oncology outreach also commenced as breath during radiation treatment in order to reduce the a consultative service in Stawell in September 2014. dose to cardiac structures, has seen patient numbers It is expected that in 2015/16, further outreach sites increase and reduced the need for patients to travel to will be added to the BRICC network, with further Melbourne for this specialised treatment technique. opportunities in nursing oncology education and leadership to be explored with regional service partners. Community Support and Grants The community continues to offer significant philanthropic Activity Growth support to the BRICC with another local gift provided The number of treatment procedures and consultations to establish a Stereotactic Radiation treatment program undertaken within the Medical Oncology unit has grown within BRICC in 2015/16. by 32 percent in the 2014/15 period and 63 percent from During 2014/15 BRICC again benefitted significantly the commencement of services within BRICC in 2013. through the financial support of community groups, local Outreach Medical Oncology services in Stawell have businesses, individuals and community initiatives such as more than doubled, with the newly commenced Horsham Dry July, Masters Football Clubs (Ballarat and Melton) and service also increasing by 50 percent. the Ballarat Girls Night Out. The BRICC Café continues Radiation Oncology services have increased, with an to provide funds to the Wellness Centre for program activity gain of approximately 20 percent. An outreach development and delivery. consultation service commenced with approximately 15 patients per month receiving post treatment review or follow-up in Stawell rather than in Ballarat. Cancer Accommodation Six new cancer accommodation units, ‘Pleasant The visiting Haematology service established in BRICC Apartments’ were opened for patients in Pleasant Street, in early 2013 continues to grow with the weekly Visiting Ballarat, in February 2015. The units are fully self- Medical Officer service now at capacity. During 2014/15, contained, with kitchen, laundry and bathroom facilities. activity gains approached 60 percent for this service. They are available for patients and carers from regional New Oncology clinical trials within BRICC commenced areas to use whilst undergoing treatment at BRICC. with eight pharmacology trials currently accruing patients and another four in the assessment phase. Radiation Oncology clinical trials are expected to be added to the trials team portfolio during 2015/16. Patients with a cancer diagnosis within BRICC can now access eight different allied health and supportive care professional groups including Psychology, Physiotherapy, Exercise Physiology and Allied Health Assistants. These groups were added in 2014/15 to the previously
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 5 Report of Operations
Dental
It was a very exciting year for the BHS Dental Clinic, with It was also an exciting year for the Dental Clinic as it was its relocation in April, 2015, to new premises at Phoenix a runner up in the Public Dental Clinic of the Year Award in College, Sebastopol. November 2014. The new state-of-the-art facility offers additional dental Further to this, the BHS Dental has been chosen as one suites, as well as laboratory facilities, a fully equipped of three sites to be a part of an aged care pilot project by CSSD department and a shell space for future expansion Dental Health Services Victoria (DHSV). This was due to of BHS radiology services. The clinic also incorporates ten the success of our program in which 289 BHS nursing training chairs for dental students and additional space for home residents were fully examined and those needing consultations with patients about their treatment options. treatment were referred back to the Dental Clinic. In most cases, residents were treated on site in their homes. The BHS enjoys an extremely strong relationship with Phoenix program has now been expanded to a number of non-BHS College and Principal Scott Dellar, who has been very supported residential facilities in Ballarat and Learmonth. supportive of the dental clinic project. BHS Dental also undertook a number of school visits, The teaching component of the new facility opened providing oral health information. The clinic continued its in June 2015, with the employment of additional staff Smiles for Miles program (with Ballarat Community Health) (including ten teachers, five assistants, one co-ordinator to provide oral health information and free examinations for and a receptionist). Fourteen dental students from Latrobe kindergarten children. University commenced at the clinic in June 2015 and are seeing patients under the guidance of experienced dentistry teachers. Dementia Care in Hospitals Program (DCHP)
The ground-breaking BHS Dementia Care in Hospitals The aim of the DCHP is to assist health services to better Program (DCHP), designed to improve the care of patients meet the needs of patients with cognitive impairment and with dementia, received national recognition, with Federal their carers. Minister for Health, Sussan Ley, announcing a $2.3 million BHS will partner Alzheimer’s Australia and Deakin University grant to BHS to rollout and evaluate the program nationally. to rollout and evaluate the Dementia Care in Hospitals This is the largest service development grant received Program nationally to The Queen Elizabeth Hospital in by BHS and will allow four hospitals across the nation to Adelaide, Canberra Hospital, Sir Charles Gairdner Hospital in become leaders in the program. Perth and The Royal Hobart Hospital. Emergency Department Initiatives
During 2014/15 BHS implemented a number of new the Emergency Department waiting room - improving initiatives to address the growing acuity of patients safety, communication, initiating care and providing presenting to the Emergency Department (ED). information about alternative care options for patients. The ED has also created internal guidelines for nurses for Over the past few years, higher numbers of patients common conditions in order to improve initiation of both presenting to the ED with more complex conditions has management and investigation. meant that waiting times for less urgent patients has increased. Another initiative to assist patients waiting for treatment at ED is the new ‘Find a GP’ Helpdesk. The Helpdesk was An external review of the Emergency Department developed in partnership with Grampians Medicare Local made multiple recommendations, many of which and offers patients a touch screen computer that provides were progressed through the year. This included the information on: appointment of additional consultant staff and several nursing staffing initiatives which have helped with the day • Medical Practices offering ‘walk-in’ appointments to day running of the department. • Medical Practices taking new patients In addition, BHS appointed a Clinical Initiative Nurse to • Medical Practices open on weekends and public holidays assist patients waiting for treatment. The Nurse oversees • After Hours GP helpline
6 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Report of Operations
Occupational Health and Safety
Ballarat Health Services is committed to providing a safe The approach also includes: and healthy environment for staff, patients, residents, • Risk assessment visitors and volunteers. This commitment includes • Risk reduction and elimination measures achieving best practice in occupational health and safety, • Reviewing incidents and initiating investigations with a strong emphasis on prevention and risk minimization • Evaluation and auditing of the program in identified key risk areas including occupational violence • Clinical practice and intervention and aggression and safe patient handling. • Rapid follow up and support for affected employees Management of workplace violence and aggression Key achievements in the area of violence and aggression has continued to be a key focus of safety improvement management that were realised included: initiatives implemented by BHS with the adoption of the Management Of Clinical Aggression (MOCA) program. • 1 MOCA trainer accredited at Master level • 4 MOCA trainers accredited at Train The Trainer level The MOCA program is being rolled out under the guidance • 800 BHS employees MOCA trained and direction of the BHS Prevention and Management • Policy and procedure development in clinically led of Aggression Committee - a multidisciplinary team, code grey and clinical aggression management committed to creating and maintaining a safe clinical • Additional patient experience signage and information environment for staff and patients. installed into the Emergency Department to better inform The MOCA approach is a framework designed to provide and involve patients in their care to reduce triggers of fear maximum safety and support to the staff of BHS in the and anger that can lead to incidents of aggression. area of clinical based aggression and violence. A full time In the future BHS will be taking a lead role in partnership MOCA program coordinator was appointed in August with Melbourne Health in assisting health services in the 2014 to deliver training within a quality framework defined Grampians region to implement the MOCA model. by Melbourne Health and has met and exceeded the initial goals of the project. BHS will continue to monitor its health and safety performance and implement initiatives to ensure a culture of continuous improvement in health and safety is maintained.
Specialist Clinics Reform
In accordance with the Department of Health and Human all Specialist Clinics to ensure timely access for patients Services’ Specialist Clinics in Victorian Public Hospitals requiring clinic appointments. Access Policy, BHS is currently undertaking a review of The introduction of the Victorian Integrated Non-Admitted all specialist clinics to ensure the expectations outlined in Health (VINAH) minimum data set has enabled BHS to the policy are being met. establish the infrastructure and reporting capabilities to The Specialist Clinics Redesign Steering Committee measure performance outcomes. began work in November 2014 and continues to review
Mental Health
The Mental Health directorate continues to expand its • Implementation of requirements under the new Mental clinical services across the Grampians region. Health Act 2014 • Increased service provision to the Indigenous Highlights from the Mental Health directorate include: community • Construction of the Mother and Family Unit has been • Cultural Sensitivity training led by the Aboriginal Mental completed and is expected to open late 2015 Health Liaison Officer is being provided to all clinicians. • Significant redevelopment of the Psychiatric Intensive Care Unit of the Adult Acute Unit is scheduled for commencement at the end of 2015
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 7 Report of Operations
Wound Care
BHS continues to be a leader in evidence based best The results of the 2015 Pressure Injury Points Prevalence practice wound management and the early identification Survey (PIPPS) conducted in June found that BHS acute and prevention of potential pressure related injury. services is at 7 percent, sub-acute at 9 percent and Working closely with Smith and Nephew, the BHS residential aged care at 8 percent, giving BHS an overall Wound Care Improvement Program ensures that as an PIPPS of 8 percent. organisation we continue to look for ways to improve. The August 2009 PIPPS indicated an 11 percent Benchmarking against other healthcare services nationally prevalence across BHS acute services. The improvement and internationally indicates that BHS is a forerunner in since the inception of the Wound Care Improvement the prevention of pressure related injury. Program has been due to substantial interventions in the prevention and management of pressure related injuries.
Spiritual Centre Opening
BHS officially opened its new Spiritual Centre in a multi- away from the busy schedule of treatments and time faith commissioning ceremony in October 2014. spent on the wards. The centre also offers a Muslim prayer room. The ceremony involved a number of faiths conducting ceremonial rituals in the centre and the adjacent Sister The Sister Paula Fleming Reflective Garden is named Paula Fleming Reflective Garden. in honour of Sister Paula, who spent 20 years providing spiritual guidance and support to patients of BHS. The Spiritual Centre and Sister Paula Fleming Reflective Garden are places where patients, their carers, family The Spiritual Centre is located on the ground floor of BHS, members and staff can seek a quiet moment to reflect, via the Sturt Street entrance. MRI
In its first full year of operation, the new MRI has scanned low-radiation dose technologies and complements more than 3,250 patients. other recent ‘class-leading’ technology in Ultrasound, CT, Nuclear medicine, mammography (including tomo- The service has provided significant benefits to BHS synthesis) and digital x-ray. patients. The 3T MRI was opened in June 2014 and is located within the Radiology Department, adjacent to the The new facility has been specifically designed for patient ED. It is housed in a purpose-built facility and provides comfort. The ‘state-of-the-art’ MRI system enables faster high-resolution images. exam times meaning patients spend a minimum amount of time undergoing their scan. The new MRI maintains the commitment of BHS to
Baby Friendly Accreditation
Ballarat Health Services’ commitment to supporting providing health care environments where breastfeeding is the breastfeeding mothers was acknowledged with a further norm and where health care practices which support, protect three year accreditation as a Baby Friendly Health Service. and promote breastfeeding are followed. BHS first gained Baby Friendly Health Initiative (BFHI) Being recognised as a Baby Friendly Health Service means accreditation in May 2001 and is re-assessed against ten that we are committed to supporting women giving birth criteria every three years. at BHS to make an informed choice about infant feeding. We are also committed to providing flexible arrangements BFHI was launched by the World Health Organization in 1991 and support for female staff returning to work at BHS after and is administered in Australia by the Australian College of maternity leave who are still breastfeeding. Midwives. It aims to give all babies the best start in life by
8 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Report of Operations
Aboriginal Health
For many Aboriginal people, hospitals are symbols of the • Support and advocacy for Aboriginal people very institutions that had a role in their marginalisation in experiencing mental health problems has been Australian society. Reluctance to access health services provided with the appointment of an Aboriginal Mental early means that for Aboriginal people their chronic Health Liaison Officer who works closely with the BHS disease state and cancers are often well advanced Mental Health team and BADAC Medical Clinic. before they are diagnosed leading to higher rates of • Timely access to dental care for local Aboriginal people hospitalisation, increased readmission rates, poorer health following a reduction from a three year waiting list for outcomes and a shorter life expectancy. dental services provided in Melbourne, to no waiting For more than a decade, BHS has been working in list with dental care provided locally at BHS. With many partnership with the Ballarat and District Aboriginal Co- Aboriginal people experiencing significant dental health operative (BADAC) to improve access, service delivery and issues, this initiative has improved health outcomes, health outcomes for the local Aboriginal community. The enabled better-quality dietary intake, education and partnership is recognised as one of the most effective to access to ongoing dental care. influence positive health outcomes for Aboriginal people • The appointment of an Aboriginal Care Coordinator within the State of Victoria and is an important component at the Ballarat Regional Integrated Cancer Centre to of the BHS Strategic Plan. ensure that access, pathways and support are in place Over the past 11 years, the partnership has resulted in a for Aboriginal people with a cancer diagnoses. number of significant achievements, including: • Prior to 2010 only 23 percent of Aboriginal and Torres • Enhanced access pathways and discharge planning Strait Islander women in the target age group of processes. 50-69 years were participating in breast screening. Through concerted efforts by both BHS and BADAC, • A significant increase in referrals and attendances at screening rates have since doubled with a 47 percent Specialist Clinics. participation rate. Where required, women have • Improved support and advocacy for Aboriginal people been referred for follow up medical care. Prior to this attending BHS services through the Aboriginal Hospital initiative, these medical conditions would have gone Liaison Officer. undetected until well advanced. • Provision of high quality, consistent and culturally sensitive • A more recent strategic approach by BHS ensures care for pregnant Aboriginal women with the appointment that staff have access to Cultural Awareness training of a Midwife for Indigenous Maternity Services. This and that local Aboriginal people have a connection to appointment has improved Aboriginal women’s attendance the Health Service through employment opportunities, at the Maternity Outpatient clinic resulting in lower mortality artwork displays, consumer representation and rates, higher birth weights, educational opportunities and celebration of key events for Aboriginal people. pre/postnatal support initiatives. In 2014/15 there were • BHS has embarked on an Aboriginal Employment 79 Aboriginal babies born at BHS. Many of these families Strategy with the aim of Aboriginal people representing utilised the BHS Indigenous Midwife program that links 1-3 percent of total employees. closely with the BADAC Maternal and Child Health Nurse and Medical Clinic to provide continuity of care. Ballarat Centre Against Sexual Assault (CASA)
Ballarat CASA provides counselling and advocacy The demand for services continues to grow which has to victims and survivors of sexual assault as well resulted in the Centre receiving increased funding in the as affected family members and friends. CASA also 2015 Victorian State Budget, with a particular focus on provides therapeutic treatment to young people up to supporting survivors of institutionalised child sexual abuse. 15 years with sexually abusive behaviours or children The Royal Commission into Institutional Responses under 10 with problem sexual behaviours. Group work, to Child Sexual Abuse held a hearing in Ballarat in community education and secondary consultation to May 2015. During and after the hearing Ballarat CASA other professionals is also a part of the programs offered supported clients who gave evidence. There was intense as well as specialist assessments for the Child Protection media coverage throughout this time which contributed to Unit where abuse is suspected. a large increase in demand across all CASA programs.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 9 Report of Operations
Run Ballarat
More than 5,500 people took part in Run Ballarat in Funds raised through Run Ballarat each year will enable October 2014 raising $232,870 for the redevelopment of facilities to be upgraded and improved, so we can offer the Children’s Ward. The event has now raised in excess patients and their families from across the Grampians of half a million dollars since its inaugural year in 2012. region access to a state-of-the-art paediatric and adolescent ward. We thank the community for their The Children’s Ward at BHS treats around 2,000 children ongoing support of this initiative. each year with an average length of stay of two days.
Stepathlon
For the third consecutive year BHS conducted a team based corporate physical activity and lifestyle challenge during 2014. The event chosen was Stepathlon. The 2014 Stepathlon corporate challenge was designed to build upon the 2012 and 2013 Global Corporate Challenge events and further develop a culture of health within the workplace. The aim of the program was to encourage participants to be more active at home and at work. A total of 327 staff completed the 100 day event in which a pedometer was used to count the number of steps taken each day. The participants recorded a daily average of 14,415 steps. The winning team was Andy and The Supremes based in the Dialysis unit. The winning Stepathlon team, Andy and The Supremes. Staff Scholarships
Each year, BHS awards scholarships to assist staff • Julie Lodge, Clinical Nurse Educator – Midwifery - to to access an overseas or interstate professional attend a symposium in the UK on improving maternity development opportunity or complete further study. outcomes through multidisciplinary training in obstetric emergencies. Congratulations are extended to the following winners of the 2015 staff scholarships: Ken Burnett Travelling Scholarships
Doreen Bauer Travelling Scholarships • Michelle Cowie-Scott, Dementia Behaviour Consultant • Ricky Relouw, Residential Aged Care Advanced Care - to visit The Netherlands to visit two specific models Coordinator / Quality Support Officer – to attend the of dementia care, and also to attend the International 5th International Society of Advance Care Planning and convention of Psychological Science in Amsterdam. End of Life Care conference in Germany and undertake • Wendy Hocking, Mental Health Therapy Nurse - visits to aged care facilities to review the “End of Life Secure Extended Care Unit - to visit three facilities in care” strategies for aged care residents. the United States to study their very successful and • Dawn Veale, Senior Case Manager, ABI Service and diverse programs. Maureen MacPhail, Coordinator of BHS ABI Service - to attend the Brain Injury summit in Colorado which has a strong focus on innovations in treatment and current research. They will also visit the Concussion Clinic in New York and other centres of excellence to observe concussion assessment and treatment processes.
10 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Report of Operations
Patient Throughput
Continuing what has become a trend in recent years, it has been another extremely busy year across all areas of BHS. As demonstrated in the table below, activity across a number of areas increased again during the year, whilst there was a small reduction in the number of Emergency attendances and births.
2014/15 2013/13 Change Percent Change
WIES (funding units) 27,538 27,167 371 1.37% Inpatients treated 36,519 34,573 1,946 5.63% Bed days 84,032 84,250 -218 -0.26% Births 1,352 1,385 -33 -2.38% Theatre Cases (including endoscopies) 12,503 12,362 141 1.13% Emergency Attendances 51,433 52,250 -817 -1.56% Outpatient Attendances (VACS) 56,993 56,645 348 0.61%
Financial Performance Recognition
BHS has continued to implement a wide range of On behalf of the Board of Management and Executive initiatives aimed at ensuring financial sustainability and as Staff Council, we would like to recognise and thank all a result it is very pleasing to report a full year surplus of BHS staff for their continued dedication to the provision $134,000 before capital and specific items. This exceeds of quality healthcare to the community we serve. the target of a $100,000 surplus contained within the BHS enjoys a very positive and constructive relationship Statement of Priorities. with the Department of Health and Human Services and BHS has a strong history of recording Pre-Capital surplus the Minister for Health. We extend our appreciation to results, which has enabled BHS to invest surplus funds officers of the Department of Health and Human Services into equipment, information technology and refurbishments and the Minister for their substantial support throughout throughout the service, and staff should be congratulated 2014/15. for the vast array of cost saving and revenue generating initiatives that continue to be implemented.
Responsible Bodies Declaration
In accordance with the Financial Management Act 1994, we are pleased to present the Report of Operations for Ballarat Health Services for the year ending 30 June 2015.
Andrew Faull Andrew R Rowe Ballarat Chair, Board of Management Chief Executive Officer 28 August 2015
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 11 Organisation Chart
Chief Executive Officer
Andrew Rowe
Board and CEO Services
Foundation and Fundraising
Media & Communications
ED Medical ED ED Acute ED ED Sub ED Mental ED Finance ED ED Human Services Operational Nursing & Residential Acute & Health Information Corporate Resources ++ Performance Midwifery & Clinical Community Services & Business Services & ## Governance ** Development Improvement Services Philip Rowena Leanne Sue Wendy Tamara Andrew Russell Trevor Reasbeck Clift Shea Gervasoni Hubbard Irish Kinnersly Hardy Olsson
• Cancer • Perioperative • Emergency • Residential • Sub-Acute • Infant & Child • Finance • Asset & • Human Services- Services Department Administration Services Facility Resources • Youth • Health BRICC including: Management • Intensive Care • Nursing • Allied Health Information • Chaplains - Child & Youth • Internal - Operating Unit Education • Engineering • Allied Health Redesign • IT • Corporate Medicine Theatres • Women’s and • Nursing education Project • Supply Education & Service • Imaging and - Anaesthetics Children’s Research Development • Community • Adult Mental Breastscreen • Contracts • Medical - Day Procedure • Acute Wards • Ballarat East Programs Health and Tender • OH&S Administration Unit • Consulting Comple Services Management • Acute Nursing • Dental and • Industrial • Senior and - Endoscopy Eureka Villag Services - Community Diagnostic • Food Services Employee Junior Medical Geoffrey • State-wide -Cardiovascular Teams Ballarat Suite Relations Staff Service • Nursing Cutter Centre Equipment SE, SW, NE, NW, • Environmental administration Programs • Data • Equal • Medical - CSSD • QE Centre Ararat, Wimmera • Safety Link management Opportunity education • Nursing Talbot Place • CASA Southern Mallee • Elective and reporting • Eureka Linen Education Bill Crawford • Volunteers • Research Surgery - Acute Inpatient Lodge Services • Information • Switchboard and Ethics Management • Same Day • Emergency Technology Unit including • Queen - Secure Extended Planning and • Medico-Legal • Outpatient Alliance • Print Shop Transit Lounge Elizabeth Care Preparedness Services • Mortuary Village • Payroll • Car parking • Hospital in - Community Care • Library • Activity QE Village • Pharmacy the Home Unit - Salary Performance Hostel • Security Packaging • Pathology and Planning • Centralised PS Hobson - Perinatal Mental Allocations Nursing Health - FBT • Infection • Patient Flow Unit Hailey House compliance Control Co-ordinators • Aged Persons • Sebastopol Mental Health • Patient • Dialysis • Redesign/ Complex Services Services Facility Jack Lonsdale Operational - Community Lodge Team Planning James Thomas Court - Acute Inpatient Unit • Centralised Allocations - Aged High Unit Level Needs Nursing Home • Governance and Risk • Education Management Team Unit
Key Professional Reporting Lines Close and co-operative relationship Chief Nursing Officer ## in respect to the operation of Chief Medical Officer ++ Acute Services Chief Allied Health Officer** Shared Responsibility
12 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Board of Management as at 30 June 2015
Chair Vice-President Vice-President Chair of Finance Andrew Faull Mark Patterson Virginia Fenelon Committee BEc, LLB (Hons) MBA, Cert Public Relations, Dip M.Ed Management Jock Selkirk Lawyer Education and Training BBus CA GAICD Chief Executive Officer, Consultant Chief Financial Officer, Board member North Ballarat Football Selkirk Group of since 2011 Club Board member since 2009 Companies Term of appointment: Board member Board member 01.07.14 - 30.06.17 since 2008 Term of appointment: 01.07.12 to 30.06.15 since 2012 Board meetings Term of appointment: Term of appointment: attended: 11 01.07.13 to 30.06.15 Board meetings attended: 11 01.07.12 – 30.06.15 Board committees: Board meetings Board Executive and Human Board meetings attended: 10 Board committees: Resources, Credentials Audit, Board Executive and attended: 10 Board committees: Appeals Tribunal, Medical Human Resources, St John Board committees: Board Executive and Human Credentials and Appointments of God Joint Liaison, Project Audit, Board Executive and Resources, Finance, Committee, St John of God Control Group. Human Resources, Finance. Joint Liaison. Quality Care.
Craig Coltman Dr. Mark Harris Victoria Kennedy Rowena Coutts MAICD MBBS Dip.RACOG BPhysio LLB BJuris Board member Medical Practitioner Physiotherapist Retired Senior Deputy since 2011 Board member Board member Vice-Chancellor, Term of appointment: since 2012 since 2013 Federation University 01.07.14 – 30.06.17 Term of appointment: Term of appointment: Board member Board meetings 01.07.12 to 30.06.15 30.07.13 – 30.06.16 since 2013 attended: 11 Board meetings Board meetings Term of appointment: Board committees: attended: 11 attended: 10 03.12.13 - 30.06.16 Audit, Finance, Primary Care Board committees: Board committees: Board meetings and Population Health, Community Advisory, Human Community Advisory, attended: 11 Quality Care. Research Ethics, Primary Quality Care. Board committees: Care and Population Health, Finance, Human Research Quality Care. Ethics, Medical Credentials and Appointments Committee.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 13 Executive Team
Chief Executive Officer Andrew Rowe BHA, MHA, AFCHSE, CHE Appointed June 2003 The Chief Executive Officer is responsible to the Board of Management for the efficient and effective operational management of Ballarat Health Services. Major responsibilities include the development and implementation of service and strategic planning, the promotion of quality care, optimising financial performance and implementation of human resource strategies. The Chief Executive Officer chairs the Executive Staff Council which comprises the senior executive staff of Ballarat Health Services. He provides leadership through collaborative management with staff and consultation with the community.
Executive Director - Medical Services Philip Reasbeck MA MBBChir MD MRCP FRCS FRACS FRACMA MBA Grad Dip Law Appointed November 2010 The Executive Director of Medical Services has overall responsibility for medical services including direct service provision in the Division of Internal Medicine, management of all senior and junior medical staff, ongoing medical education in all specialities and other professional issues. He chairs the BRICC Governance Committee which coordinates and supervises activities in the Ballarat Regional Integrated Cancer Centre, and leads cancer services throughout the organisation. He is also responsible for research and ethics, medicolegal issues, pathology and infection control. Philip ensures all medical staff have appropriate credentials and actively encourages the placement of medical students at Ballarat Health Services. In conjunction with all the clinical executives, he has an active role developing clinical governance frameworks, embracing clinical risk management and continuous quality improvement.
Executive Director – Acute Nursing and Midwifery Leanne Shea RN, AdvDipBusMgt, DipProjMan Appointed April 2011 The Executive Director provides organisational and professional leadership to contribute to developing and achieving strategic goals, policies, healthcare reforms, budget and quality management of acute nursing and midwifery services at Ballarat Health Services. Major management responsibilities include business, resource management, service planning and provision, and quality improvement and compliance.
Executive Director – Residential and Clinical Governance Services Sue Gervasoni RN, RPN, BN, CertCritCare, MBA Appointed December 2010 The Executive Director has direct operational responsibility for Residential Aged Care Services. This role supports the organisation to achieve its strategic goals through the provision of leadership and support for safe and high quality residential aged care services. Key accountabilities include the monitoring of the clinical care and outcomes for residents, management of resources, business performance and compliance with legislation and Aged Care Standards. Sue also has the portfolio and organisational responsibility for clinical governance and risk management. She chairs the Patient Safety and Quality Committee, has executive responsibility for the Consumer Advisory Committee and supports the Governance and Risk Management Unit in all aspects of their service.
Executive Director - Sub-Acute and Community Wendy Hubbard BAppSC(PT), MAppSc(HM), MBA Appointed March 2000 The Executive Director has responsibility for nine allied health disciplines, carries executive responsibility for the sub-acute inpatient and ambulatory services including rehabilitation, aged care evaluation and palliative care, and has responsibility for community-based programs. Wendy also has responsibility for the State-Wide Equipment Program (SWEP), the Centre Against Sexual Assault, pharmacy and dental services.
14 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Executive Director - Mental Health Services Tamara Irish RN, RM, RPN Appointed June 2010 The Executive Director is responsible for the full range of Mental Health Services provided by Ballarat Health Services within the Grampians Region. These services include Infant and Child, Perinatal, Youth, Adult, and Aged persons Mental Health Services both within the community and as inpatient services. Tamara has professional responsibility for all Mental Health Services staff. She has a particular interest in the routine delivery of evidence-based “best practice’’ treatments to clients and their carers, in the context of a family inclusive, recovery orientated, model of integrated mental health care.
Executive Director - Finance, Information and Business Development Andrew Kinnersly BBus, MBA, ACHSE, AHSFMA, CPA Appointed September 2010 The Executive Director has responsibility for the financial management of Ballarat Health Services including accurate and timely budget reports for the Board of Management and staff. Andrew also has operational responsibility for finance, information technology, radiology services, payroll, insurance and taxation systems.
Executive Director - Human Resources Trevor Olsson BBus, AIMM, CAHRI, AFACHSM Appointed October 1999 The Executive Director Human Resources responsibilities include all aspects of strategic human resource management including recruitment, organisational change, industrial/employee relations, equal employment opportunity, security services, occupational health and safety, the library, chaplaincy services, corporate training and development, volunteer co-ordination and emergency management.
Executive Director - Corporate Services Russell Hardy GradCertMgt, CertIV (Food Tech), PTC, MIHHC Appointed November 2012 The Executive Director Corporate Services has responsibility for supply, engineering and environmental services as well as the business units including BHS Catering, Eureka Linen, and Safety Link. Russell also has responsibility for service planning, capital building projects and equipment, accommodation and facilities management and development.
Executive Director – Operational Performance and Improvement Rowena Clift RN, DipAppSci(Nsg), BANsg(Mid), GradCertHlthAdmin, AFCHSE Appointed May 2009 The Executive Director is responsible for leading the organisation on patient access, performance, improvement and service redesign. The role works across the divisions and portfolios in acute and sub- acute services to develop and implement an organisation-wide improvement program to ensure BHS responds to current and future needs of the community. The role oversees Specialist Clinics, Perioperative Services (including operating theatres, anaesthetics, endoscopy, day procedures and preadmission and cardiovascular suite), Access Team, Redesign and Improvement.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 15 Our People
JUNE JUNE Labour Category Current Month FTE YTD FTE 2014 2015 2014 2015 Nursing 1192.9 1181.4 1175.17 1204.2 Administration and Clerical 480.63 505.8 470.15 497.0 Medical Support 237.77 259.7 238.15 248.1 Hotel and Allied Services 343.09 371.9 344.36 347.8 Medical Officers 42.87 46.4 37.79 41.9 Hospital Medical Officers 126.6 138.1 124.55 122.1 Sessional Clinicians 36.19 40.6 35.31 39.3 Ancillary Staff (Allied Health) 249.9 249.3 237.32 245.1 Total 2709.95 2793.3 2662.8 2745.5 Number of employees occupying full, part time and casual positions at 30/6/2015 is 4029.
Medical Education Officer Endocrinologist (Paediatric) Dialysis Michelle Bodey BCom, BEd Christine Rodda MBBS FRACP EXECUTIVE SERVICES Nurse Unit Manager Internal Medicine Service Neurologist (Paediatric) Catherine Thomas RNBN CertHlthSrvMgt Chief Executive Officer Michael Hayman MBBS FRACP Andrew Rowe BHA MHA Acting Clinical Director AFCHSE CHE Internal Medicine Acting Head of James Hurley MBBS BMedSci PhD Medical Oncology CORPORATE SERVICES Director Board and FRACP Stephen Brown MBBS FRACP CEO Services Executive Director Katrina Hishon AdvDipBusMgt RN/ Physicians Medical Oncologists Corporate Services DIV1 AdvCertPaed CertNurseImm Stephen Brown MBBS FRACP CertBusAdmin Russell Hardy GradCertMgt Acting Head of Lee Na Teo MBBS FRACP CertIV(FoodTech) PTC MIHHC Director Foundation General Medicine Pinky Baghi MBBS FRACP and Fundraising James Cameron Bsc(Hons) MBChB Geoff Chong MBBS FRACP Facilities Manager FACEM FRACP Geoff MillarBA BEd GradDipEdAdmin Bhuamik Shah MBBS FRACP Bob Pickard BEng(Mech)Hons DipTeach GradCertMgt EMFIA Saw Yee Yap MBBS FRACP General (Sub-Specialty) Prashanth Prithviraj MBBS FRACP BHS Catering Manager James Cameron Bsc(Hons) MBChB Media and Communications AdDipBusMgt Cert IV FACEM FRACP Craig Carden MBBS FRACP Robert Fraser Manager WTA RAB QSA AMS Cert IV Hosp James Hurley MBBS BMedSci PhD Kate Hamilton MBBS FRACP Daniel Anderson BSocSci FRACP (Extended leave) GradDipJourn AMICDA Anthony Kemp MBBS FRACP Safety Link General Radiation Oncologists Brett Knight MBBS FRACP Manager (BAROC) Mark Czulij BCom(Mgt/Mkt) Raquel Cowan MBBS FRACP Louise Gorman MBBS FRANZCR MEDICAL SERVCES David Song MBChB FRCPA FRACP Simone Reeves MBBS FRANZCR Eureka Linen Manager Executive Director Head of Cardiology Jonathan Tomaszewski MBBS Monica McMahon Philip Reasbeck MA MBBChir MBA FRANZCR MD MD MRCP FRCS FRACS FRACMA Romulo Ernesto Oqueli Flores FRACP Kim Ung MBBS FRANZCR GradDipLaw Environmental Services Chemotherapy Manager Deputy Director Cardiologists Don Colbert GradCertMgt Romulo Ernesto Oqueli Flores MD Linda Danvers MBBS FRACGP Day Unit FRACP DipRACOG MPH AFRACMA AdDipMgt Supply Services Manager Christopher Hengel MBBS FRACP Nurse Unit Manager Ron Hiller MAHSPO MCIPSA Ballarat Regional Integrated John van den Broek MBBS FRACP Robyn Wilson RN Cancer Centre Director Robert MacFadyen BSc MBChB MD PhD FRCP Radiation Oncology Capital Building Projects Steve Medwell MBA BAppSc Manager GradDipEd John Zhu PhD FRACP (BAROC) Anand Sharma MRCP (UK) FRACP Gerard Kennedy Junior Medical Workforce Nurse Unit Manager Unit Manager Gastroenterologists Rachel Hodges RN Victoria Fara MPA, BA (Humanities) Maree Pekin MBBS FRACP Mohammed Al-Ansari MBChB FRACP GP Liaison Unit MENTAL HEALTH Manager Infection Timothy Elliott MBBS PhD FRACP SERVICES Prevention and Control Unit GP Liaison Manager Sue Flockhart RN BN MNsg Neurology Jannine Rigby RN RPN BN Executive Director GradDipMgt&InfectCntrl DipPrjctMgt Thomas Kraemer MBBS FRACP GradDipHealthAdmin MastersBusMgt Tamara Irish RN RM RPN CertIVAAT Mandy Lau MBBS FRACP GP Liaison Consultant Director of Clinical Services Manager Senior Medical Nephrology Malcolm Anderson MBBS DA FACRRM Abdul Khalid (A/Prof) MBBS, Governance, Workforce John Richmond MBBS FRACP FRANZCP, MD(Psych), CCST and Research Office Susheel Sharma MBBS FRACP Susan Shea BAppSc(Pod) PhD FAAQHC GAICD
16 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Consultant Psychiatrists Manager Child and Security Manager Gandarra Palliative Care Unit Rajul Tandon MBBS, MD(Psych), Youth Mental Health Robert Dekleva Maree Kewish RNDiv1 BAppSc(Nsg) FRANZCP Services Redesign GradDipSocSci(SecMgt) CertIII(Sec) MPrimHlthCare(PallCare) Ram Singh MBBS, MD(Psych), MSc Demonstration Project (IPAS), CCST Library Manager Inpatient Rehabilitation Michelle Harper B.Sc (Psychology & Ramesh Chandra MBBS, MD(Psych) Psychophysiology) Gemma Siemensma BA(LIS) Mary Cranage DipAppSc(Nsg) David Barton (Prof) MBBS(UNSW), CertIVTAA MAppSc(LIM) MBA AALIA BAppScNsg GrdCertMgt GrdCertGeron FRANZCP, MRACMA Manager Quality and Richard Kefford MBBS, CertAccTrng, Safety (Acting) Sub-Acute Medicine C&APsych, FRANZCP FINANCE Michelle Harper B.Sc (Psychology & Clinical Director of Priya Allencherry MBBS, MD(Psych), Psychophysiology) INFORMATION FRANZCP Sub-Acute Medicine Priyanga Kodithuwakku MBBS, MD AND BUSINESS Joseph Ibrahim MBBS PhD FAFPHM (Psych), FRANZCP DEVELOPMENT FRACP Santhusha Wijekoon MBBS, MD HUMAN RESOURCES (Psych), FRANZCP Executive Director Geriatric Medicine Executive Director Ravindra Mutha MBBS, MRCPsych, Andrew Kinnersly BBus MBA ACHSE Mark Yates MBBS FRACP CCT Trevor Olsson BBus AIMM CAHRI AHSFMA CPA Judith Adams MBBS FRACP AFACHSM Anoop Lalitha MBBS, DPM, Philip Street MBBS FRACP MD(Psych) Deputy Director Deputy Executive Director Rosemarie Shea MBBS FRACP Grad Mick Smith BCom AHSFMA FCPA / Employee Relations Dip Clinical Education Service Managers Tamsin Santos BSC(Biomed), MBBS, Manager Director Radiography and FRACP Clinical Manager North Kevin Stewart BAppSc(PT) Diagnostic Services Michael J Brignell MBBS FRACP GradDipErg Ballarat Adult Mental Richard van Dreven MISRRT MIR FRCP GradDipBus DipAppSc(MedRadtn) GradDipAdmin Health Services Workforce and Recruitment Alfredo Obieta MD FRACP Carly Johnson BSoc Services Manager Tom Hale MBBS FAFRM(RACP) Director Information Binara Jayasinghe MBBS MRCP MD Clinical Manager South Angela Turley MLaw Kate Nolan MBA BHlthInfoMgt FRACP (EmploymentLabourrEL) BBus(HR/ Ballarat Adult Mental Marktng) CertIVTAA DipProjMgt MAHRI Yasmin Sheikh MBBS FRACP Health Services Billing Services Manager Michael Struth, RPN, GradDip Occupational Health Jenny Palmer DipBusMgt Rehabilitation Medicine (HealthSci/HSM), MHsm Richard Bignell MBBS FAFRM and Safety Manager Financial Accounting Alisha Bedggood PostGradDipOHM Thomas Kraemer MBBS FRACP Clinical Manager Wimmera CertIVHlth(Nsg) Manager Susan Hodson MBBS Dip and Southern Mallee Christena Renouf BAcc AHSFMA CPA RANZCO&G FRACGP Mental Health Services Learning and Michael McDonough MBBS Michael Fryar RPN Development Manager Management Accounting DipClinTox MAddSc FAChAM BAppSc(NsgAdmin) GradDip(PsychNsg) Megan Ali GradDipPsychology Manager Ngoc Le MBBS FAFRM (RACP) BMgt(HR/Marktng) CertIVTAA MAHRI Jenny Paulson GradDipBus MBA, Clinical Manager Ararat/ AFAIM, AHSFMA Palliative Care Medicine Stawell Mental Health Senior Human Resources Greg Mewett MBBS DRCOG FRACGP Services Consultant Remuneration Services PostgradDipPallMed FAChPM Michael Fryar RPN Maree Baker GradCertHRM Director Penelope Cotton MBBS(Hons) BAppSc(NsgAdmin) GradDip(PsychNsg) AdDipM(HRM) DipBusHR CertIVOHS Paul Keane AdvDipMgt, AHSFMA BMedSci MClinEd, FRACGP FAChPM CAHRI Clinical Manager Youth Pathology Paediatric Rehabilitation Mental Health Services Senior Human Resources Specialist Julie Rowse BOT(Hons) PhD Consultant Laboratory Manager Adam Scheinberg MMed FRACP Megan Ralston BMgt(HR) Michael Phyland BAppSc FAFRM MBBS Clinical Manager Infant and Child Mental Health Services Senior Human Resources Pathologists Centre Against Sexual Lisa Sambrooks RN RM Consultant Dr Swapna Sengupta MD FRCPA Assault Manager Joanne Innes AdDipBus(Mgt&HR) Dr David Clift MBBS FRCPA Shireen Gunn Dip T, BSW, AAMC, Clinical Manager Aged CertIVTAA MAHRI AccMAASW Persons Mental Health Radiology Services - Community Senior Human Resources Dental Services Consultant Kevin Harris RN RPN Nurse Unit Manager Leah Shillito BA GradDipBusHRM Bronwyn Bentley RN Critical Care/ Dental Services Manager Clinical Manager Secure Emergency Certificate Jacqui Nolan Extended Care Unit Senior Human Resources Toni Clark BAppSci (Nursing) Officer Dentists Colleen Fryar RN RPN Charisse Nuske BBus(Mgt) Dr Iven Affleck BDS Clinical Manager Aged SUB ACUTE AND Dr Pallavi Mishra BDS ADC MDSC Emergency Management Dr Nidhi Tandon BDS ADC Persons Inpatient Mental COMMUNITY Health Services Manager Dr Rachel Sim BDSHons Don Garlick MEmMgt AdvDipPubSaf Dr Kelsey Barker B.H.Sc(Dent) M.Dent Jane Lockhart RPN BN RN Executive Director (Emergency Management) GradDipNurs Dr Tiffany Chuo B.H.Sc(Dent) M.Dent GradCertGeron (Critical Care) Cert IV TrngAssmnt Cert Wendy Hubbard BAppSc(PT) IV Frontline Leadership Cert IV Proj Mgt MAppSc(HM) MBA Dr Preeti Grover BDS Clinical Manager Cert IV Fire Tech Dr Sandra Duong BDSHons Community Care Unit Director of Nursing Dr Mitchell Barker B.H.Sc(Dent) Brendan Thomas RPN GradDipCBT Pastoral Care Coordinator Sub-acute Services M.Dent Johanna Niedra TPTC Meredith Theobald RN RPN BN Clinical Manager Adult GradCertGrie&Loss GradCertNsg(MentHlth) CertRehabNsg Allied Health Acute Inpatient Unit Marice O’Brien RN RPN Volunteer Services Manager Nurse Unit Managers Dietetics Clinical Manager Sue Jakob DipTeach(Prim) Meredith Atkinson BAppSc(Nutn) Manager Education GradDipEd(Lit) CertIVTAA Inpatient Complex Care GradDipDiet MPH MDAA and Research (Jim Gay Unit-GEM) Dr Julia Hailes MEd PhD Karen Moran RNDiv1 GradCertGeron CertIVTAA
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 17 Our People
Exercise Therapy Grampians Regional Facility Managers Deputy Director of Clinical Manager Continence Service Intensive Care Geoffrey Cutter Centre Kerry Walsh BEd(PE) Manager Rob Gazzard MBBS FANZCA Nursing Home Shirley Whitaker RN, BNPostReg, FFICANZCA Occupational Therapy CertContProm ,GradCertHlth: Advanced Lynda Fraser RN BHlthSci Clinical Manager Continence Nurse Specialist Anaesthetists/Intensivists Eureka Village Hostel Michele Pearson BAppSc(OT) Bruce Christie MBBS FANZCA GradDip(HSM) Grampians Regional Sherin Jose RN Doug Paxton MBB FANZCA Palliative Care Team Greg Henderson MBBS FANZCA Physiotherapy Manager Ballarat North Robert Ray MBBS FANZCA Clinical Manager Jade Odgers RN GradDip(PallCare) and Wendouree Craig Mitchell MBBS FANZCA GradDip(Psych) GradDipMgt Georgie Kemp BAppSc(Physio) Angus Richardson MBBS FANZCA MPhysio GradCert(HSM) CertIVWrkPlAAT DipPrjMgt GradDipFrontMan MNsg Director of Nursing Ken Pfukwa RN, Bsc Mental Health Podiatry Operational Emergency Medicine Post-Acute Care and Nursing, DipBus, GradCert Public Health Manager MHM AFCHSM Central Intake Manager Clinical Director of Dimitri Diacogiorgis BPod GradCertDiabEd Helen Jarvis RN RM BN GradCertMgt Facility Managers Emergency Medicine GradCertHealthServMgmt MRCNA Andrew Crellin MBBS FACEM GradDipWoundCare MApplSc PS Hobson Nursing Home Sub-Acute Ambulatory Heather George RN BN BBGNC Acting Deputy Director of Prosthetics/Orthotics Care and Domiciliary GradDipMid CertIVAss&Tng Emergency Medicine Clinical Manager Services Manager Tanya Barun BN MCom (Professional Pauline Chapman MBBS FACEM Michelle Oliver BAppSc(P&O) Margaret Dawson BAppSc(Pod) Accounting) CertIVAss&Tng DipBusMgt GradDip(Pod) MBA DPH Emergency Physicians WB Messer Hostel Heather Crook MBBS FACEM Psychology Pharmacy Elizabeth Sayers RN RGNC Ali Al Joboory MBBS FACEM AdvDipMgt Clinical Manager Cherry Lau MBBS FACEM Kylie McKenzie BA(Hons) Director of Pharmacy Janie Worth MBBS FACEM MPsych(Clinical) Hailey House Hostel Aaron Fitzpatrick BPharm Jaycen Cruickshank MBBS FACEM GradCertMgt MSHP Linda Newby RN GradDipMidwifery Social Work GradDipRehabNsg CertIVOH&S Jocelyn Howell MBBS FACEM Clinical Manager Deputy Director of CertIVAss&Tng Treena Quarin MBBS FACEM Catherine Ludbrook BA BSW Pharmacy (Quality Use Nigel Beck MBBS FACEM of Medicines and Ballarat Central Mark Hartnell MBBS FACEM Speech Pathology Dispensary Services) and Sebastopol Amanda Lishman MBBS FACEM Clinical Manager Jaclyn Baker BPharm MPublicHealth Spiro Tsipouras MBBS FACEM Acushla Thompson BAppSc(SP) GradCertMgt MSHP MPS Director of Nursing Amanda Wilkin MBBS FACEM GradCert(Mgt) MSPAA CPSP Mick Kirby RN, BAppScNsg Alastair Meyer MBBS FACEM FCEM Deputy Director of GradDipBusMgt CCRN DipProjMan FRCP FRACGP Allied Health Quality and Pharmacy (Clinical Kirsty Dunn MBBS FACEM Safety Coordinator Pharmacy Services) Facility Managers Linda Chow MBBS FACEM Cathy Caruso BAppSci(OT) Steve Costa MBBS GradDipHlthSci(HEd) Renee Dimond BPharm (Hons), MClinPharm, MSHP Talbot Place Nursing Home Eileen Booth RN RPNPsych FamTh Senior Medical Officers Community CertDevPsych (Emergency Medicine) Director Community Bill Crawford Lodge Ahmed Alwan MBBS Programs RESIDENTIAL Nursing Home Waad Elias MBBS Jahir Ahmed MBBS Michelle Veal RN BA(Nsg) AND CLINICAL Tijamol Jacob RN BN GradCert(BusAdmin) DipPrjMgt GOVERNANCE GradCert(HlthSysMgt) Jack Lonsdale Lodge Women and Children’s SERVICES Nursing Home Health Services Aged Care Assessment Jenny Relouw RN PostGradGer Services Acting Manager Executive Director Molly Martin RN Clinical Director and Head of Rachel Fishlock RN AdvDipMgt Sue Gervasoni RN RPN BN Obstetrics and Gynaecology CertCritCare MBA James Thomas Court Hostel Paul Davey MBBS FRANZCOG Carer’s Programs Manager Annette Vaarzon Morel RN BA Cheryl Hines DipWelf AdvDipBusMgt Clinical Governance (SocSci) BSW GradCertAcuteCare, Staff Obstetricians and Services GradCert ClinMgt GradDipMid Gynaecologists Hospital Admission Risk Transfusion Practice Clinical Zainab Sabri MBchBFRANZCOG Program Manager Director, Governance and Iruka Kumarage MBBS MRCOG Melinda Farnsworth BNPostReg Risk Management Unit Nurse Consultant GradDip (Advanced clinical practice Keren Day RN,BN,GradDip Wendy McLeod RN GradCert Gynaecological Oncologist infection control) Transfusion Practice AdvNsgWmnHlth MNursg DipProjMan Tom Jobling MBBS FRCOG Linkages Manager FRANZCOG CGO MD Risk Manager Nick Grakini BHlthSci(OT) DipMgt DipHrm Trudy Shortal RN BNGrad Cert ACUTE NURSING Urogynaecologist CCN, MMgt AND MIDWIFERY Jeanette Lim MBBS FRANZCOG Planned Activity Residential Services Groups Manager Executive Director Obstetricians and Gynaecologists Jan Stewart BAppSci(PE) Ballarat East Leanne Shea RN AdvDipBusMgt GradDip(HlthSci) AdvDip(Mgt) DipProjMan Russell Dalton MBBS FRANZCOG Deepika Monga MBBS FRANZCOG Director of Nursing Transition Care Program and Critical Care Services MD (O&G)DNBE GEM in the Home Manager Jacqui King RN, BN, AdvDipBusMgt Patrick Moloney MBBS FRANZCOG Roslyn McIntyre RN BNPostReg Clinical Director of Michael Bardsley MBBS FRANZCOG DipPrjMgt Intensive Care Katrina Guerin MBBS (Hons) FRANZCOG Tony Sutherland MBBS FANZCA FFICANZCA Natasha Frawley MBBS Michael Carter MBBS FRANZCOG
18 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Clinical Director and Special Care Nursery Redesign and Scott Mason MBBS FRACS (Orth) Head of Paediatrics Nicole Stevens RN RM Improvement Services Matthias Russ als Arzt FRACS David Tickell MBBS FRACP BN PostGradDipNsg(Geron) Development Officer Luke Spencer MBBS FRACS (Orth) CertWndMan PostGradDipNsg(Midwi) Lee-Anne Sargeant BA.DipAud Paediatricians CertNeontlIntCare Ear Nose & Throat Surgeons Louise du Plessis MBChB FRACP Paediatric and Nurse Unit Manager Paul Donoghue MBBS FRCS Mark Nethercote MBBS FRACP Adolescent Unit Specialist Clinics Mark Guirguis MBBS FRACS MBBS FRACS Fiona Noble MBBS FRACP Clinton Griffiths BN PostBasPaedNsg Wendy Giddings RN RM BHlthSc, Niall McConchie Philippa Bolton MBChB (Otago) FRACP DipBusFrontMan ProfCertHlthSymMgt GradDipAdvClinNurs(Critical Care), Karin Annertz MBBS FSSOR (Sweden) GradCertNursSci (Clinical Teaching) Shabna Rajapaksa MA MB BChir MRCPCH MSc Clinical Nurse Consultants Ophthalmologists Nursing Director Austen Erasmus MBBCh DCH FCP FRACP Wound Management/ Michael Toohey MBBS FRANZCO Stomal Therapy/ Surgical Access Trent Roydhouse MBBS(Hons) Nursing Director – Business Breast Cancer Support Joy Taylor RN CertPeriopNsg MRCOphth (FRANZCO GradDipMgt MRCNA and Service Development Marianne Crowe RN BN (PostReg) David Francis MBBS FRANZCO P.K. Peter – BBus (Eco), DipAppSciNsg CertStomThrpy Nurse Unit Manager, GradCertHEcom, MHthSc, MEdn, Maxillofacial Preadmission and Dip F & P, RN, RM., CCRN, PICNC, Wound Care Team Graeme Fowler MDSc FDSRCPS CertHthMge, Cet IV in A &T, Cert IV in E Matt Squire RN Day Procedure Unit & W, GradCertAdvNsg Lorraine Hoiles RN BN(PostReg) Donna Nair RN Anaesthetics Lisa O’Neil RN Nursing Director – Clinical Nurse Unit Manager Director of Anaesthetics Education and Practice Pain Management Endoscopy Fred Rosewarne MBBS (Melb) FANZCA Development Louise Humble RN GradDipAcute Sandra Holt RN Denielle Beardmore RN AAM MEd CareNsg ICU/CCUCert MRCNA GradDiPEd&T GradDipAdClinNsgOnc/ GradDipSciMed(PainMgt) Cognition Nurse Unit Manager CSSD Deputy Director of PallCare BN BHlthSci DipPrjtMgt CertIVTAA Michelle Morvell RN RPN BN Denise Jackson RN BN(PostReg) Anaesthetics CertIVAAT GradCertInfctnCntrl MRCNA Mick Shaw MBBS FANZCA Acute Inpatient Services Donation Nurse Specialist Nurse Unit Manager, Anaesthetists: Nursing Director Joanna Forteath RN BN PostGradDip Operating Suite Mike Bassett MBBS (Monash) FANZCA AdvClnclNsg-EmrgStrm Angie Spencer RN GradDipBus(e- Bernie Luka RN GradDipPeriop Deas Brouwer FANZCA Bus&Mkg) Diabetes Education GradDipHealthAdmin GradCertEducation Anne Chew MBBS FANZCA ProfCertHealthSystemsMan Bruce Christie MBBS FANZCA Nurse Unit Managers Barbara White RM CDE CertMid Graeme Clarke MBBS (Monash) CertCritCare BchHlthSci(Nsg) Director Perioperative 2 North GradDipAdultEd&Trng CertIVWAT FANZCA Danelle Klein RN BN GradCertOrthoNsg GradCertDiabEd Services Richard Connell FANZCA Judy Hatcher RN, CDE, Grad Cert Matthew Hadfield BSc MBCHB Suzy Cook FANZCA 3 North (Hons) FRCS(Eng)(Gen Surg) Diabetes Edu, Cert IV WAT FANZCA Annette McFarlane RN GradDipBusMgt ProfCertHealthSystemsMan (Melb) Rachel Cowell Joanne Eggleston RN Grad Cert GradDipHM Jonathan Evans MBBS (Melb) Diabetes Ed General Surgeons FANZCA (Hons) Sandra Anstis RN DE 3 South Ruth Bollard MBChB FRCS (Gen) FRACS MD Sam Frost MBBS FANZCA Nicole Snibson RN GCertDiabEd Patricia Baker RN, DNE David Deutscher BSc MBBS FRACS Rob Gazzard MBBS (Monash) AdvDipMgt McGrath Breast Care Nurses Stuart Eaton MBBS FRACS FANZCA FJFICM 4 South/Day Oncology Fiona Reeves RN Tom Fisher MBBS FRACS Greg Henderson MBBS (Monash) Stephen Hearn RN BN DipBisMgt Sue Bartlett RN Andrew Lowe MBBS FRACS FANZCA GradCertCanc&PallCare Bruce Stewart MBBS FRACS Malcolm Hogg BMBS (Flinders) 4 North CertIVWrkplceTAS CertICU/HDU Daniel Wong MBBS FRACS FANZCA, FFPMANZCA Vicki Thomas RN BN CertHlthSrvMgt Prostate Cancer Michael Ng MBBS FRACS Greg Hughes MBBS (Monash) FANZCA Emergency Department Specialist Nurse Ahmed Naqeeb MBchB FRACS Tony Keeble MBBS (Melb) FANZCA MRCS (Glasgow) Jeyanthi Kunadhasan MDM Phil Catterson RN BN CCRN MBA Gay Corbett RN BNsg GradDipEdn CertIVTAA DipPrjtMgt CertIVTAA Douraid Abbas MB ChB FRACS Anaesthesiol (Malaysia) FANZCA Kontoku Shimokawa MB ChB, FRACS Craig Mitchell MBBS FANZCA Critical Care Unit Dan McIntyre MBBS (Monash) FANZCA Andrew Thomas RN BN CertCritCare General and John Oswald MBBS (Adel) FANZCA CertIVAAT OPERATIONAL Vascular Surgeons Shaktivel Palanivel MD FANZCA PERFORMANCE AND Michael Condous MBBS FRACS (Vasc) Doug Paxton MBBS FANZCA Medical Day Unit Matthew Hadfield BSc MBCHB IMPROVEMENT MBBS (Melb) FANZCA Sylvia Mitting RNRM DipFrontlineMgt (Hons) FRCS(Eng)(Gen Surg) Ross Phillips Rob Ray MBBS (Melb) FANZCA Executive Director ProfCertHealthSystemsMan (Melb) Hospital in the Home Angus Richardson MBBS (Monash) Rowena Clift RN DipAppSci(Nsg) Lisa Brooks RN RM BN GradDipAdvNsg BANsg(Mid)GradCertHlthAdmin Urologists FANZCA MNS AdvDipHR AdvDipMgt Lachlan Dodds MBBS FRACS Rachna Shankar MBBS FANZCA Redesign and David Cook MBBS FRACS Sanjay Sharma MBBS (New Delhi) Women’s and Innovation Manager Lydia Johns-Putra MBBS FRACS FANZCA Children’s Services Laura Martin RN BA (Nsg) GradDip Richard McMullin MBBS FRACS Peter Shea MBBS FANZCA (Critical Care) GradCert (Mgt) Robert Forsyth MBBS FRACS Tony Sutherland MBBS (Melb) Nursing Director MBBS, Capital Works Service Adee-Jonathan Davidson FANZCA FJFICM Carolyn Robertson RN RM DipApp. FRACS Hock Tan MBBS FANZCA Sc(Nsg) BANsg PostGrad.DipMid, Master Development Officer Jyotsna Jayarajan BMedSci, MBBS Kiran Tippur MBBS FCARSCI, Clinical Midwifery Sally Kruger DipAppSci(Nsg) BaNsg (Hons), FRACS (Urology) GradCertCritlCare Cert IV Project FFPMANZCA Nurse Unit Managers Management Orthopaedic Surgeons Catherine Van der Herten MBBS Maternity Clinical Services FANZCA Nursing Director David Mitchell MBBS FRACS (Orth) Maree Dell RN, RM, Dip Management FAOA MAICD Radha Vivekananthan MBBS FANZCA Perioperative Services Shaun English MBBS FRACS (Orth) Mike Whitehead MBBS (Monash) Maternity Outpatient and Patient Flow John Nelson MBBS FRACS (Orth) FAOA FANZCA Services Margaret O’Neill RN BN (Post Reg) Critical Care Cert Grad Dip Health John Dillon MB MD (Thesis) FRCS (Orth) Marlene Martin RN, RM Dip ParaMed FRACS (Orth) AdvDipMgtt/HR Management
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 19 Organisation Performance
Statement of Priorities Strategic Priorities for 2014-15
Priority Action Deliverable Outcome
Developing a system that is Develop an organisational Implement the two final The End-of-Life Framework responsive to people’s needs. policy for the provision of elements of the End-of- has essentially been safe, high quality end of life Life framework beginning completed and a twelve care in acute and subacute in late 2014. This will month post implementation settings, with clear guidance include: a medical staff evaluation commenced. about the role of, and access communications skills A business case has been to, specialist palliative care. training program and a pilot submitted to appoint an of an organisation-wide Advanced Care Planning Advance Care Planning Coordinator whose role will (ACP) program. This is in be to set up and manage addition to the continued the process. embedding of the other elements of the framework. Care of the Dying Management Plan has been implemented across the organisation but is not fully embedded. Approval has been given to continue this project in order to embed the elements. Monthly auditing via mortality data is occurring. Registrar training has been approved and commenced. A Workshop has been developed by the BHS Palliative Care team. One workshop has been conducted to date. A paper is being prepared for publication around the research components of the project.
Implement an organisation- Review organisation-wide An organisation-wide security wide policy for responding security. The review will review was completed by to clinical and nonclinical inform the development of external consultants in violence and aggression by a revised Aggression/Code December 2014. patients, staff and visitors Grey Policy with inclusion An Action Plan has been (including code grey) that of clinically led protocols, developed from the aligns with department by May 2015. recommendations provided guidance (2014). from the Review. A revised Code Grey Policy and Protocol has been completed. Additional work includes: • the introduction of ‘Management of Clinical Aggression’ training with over 320 staff completing training to date;
20 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Priority Action Deliverable Outcome
• a DHHS funded ‘Violence and Aggression Project’ in the Emergency Department leading to improved signage and patient focused educational initiatives to inform patients about waiting times, the function of the department and various patient care processes.
Improving every Victorian’s health Use consumer feedback Continue to provide Monthly PET reports are status and experiences to improve person and customer feedback, including provided to the participating family centred care, health complaints, compliments and areas. The number of service practice and patient Patient Experience Trackers patients surveyed per month experience. (PET) to the managers and has increased significantly clinical teams to reflect and across the health service. drive improvements. Monthly patient feedback reports are provided to the relevant governance groups and an annual report on improvements resulting from feedback is provided to the highest level of clinical governance. Each item of patient feedback is provided to relevant managers and directors for a response to the consumer and consideration of any improvements required. BHS has commenced using the Victorian Healthcare Experience Survey (VHES) to gather feedback from patients. BHS has consistently achieved over 80% in total response targets. The VHES report is used to identify areas that need improvement with issues raised and addressed through the various governance committees.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 21 Priority Action Deliverable Outcome
Support local implementation Implement strategies from Collaboration was undertaken of the Victorian Health and the Healthy Together Victoria through the Population Wellbeing Plan 2011–2015 Project to improve health in Health Advisory Committee through collaboration with the workplace. to oversee a Health key partners such as Local Promotion Plan. Government, Medicare A Smoking Cessation Locals, community health Plan has been developed services and other agencies which includes training for (for example Women’s Health pharmacists and midwives Victoria and VACCHO). in motivational interviewing, offering nicotine substitution options and signposting of entrances as no smoking zones. The Healthy Eating Project has been completed and will involve further implementation into BHS cafeterias.
Expanding service, workforce Develop and implement a By April 2015 develop a BHS has a Workforce and system capacity workforce immunisation Workforce Immunisation Immunisation Plan in place plan that includes pre- Plan which will align with that aligns with the staff employment screening and the development of the new immunisation policy and immunisation assessment Staff Immunisation Policy provides guidance in relation for existing staff that work introduced in mid-2014. to immunisation requirements. in high risk areas in order to There is a system of align with Australian infection validation to ensure that all control and immunisation new staff are cleared to start guidelines. only if their immunisation requirements have been met. A staff health nurse has been employed to administer the staff health program.
Build workforce capability Continue to deliver the Group 4 of the Enrolled Nurse and sustainability by Enrolled Nurse traineeship traineeship conducted in supporting formal and program on site at BHS partnership with Federation informal clinical education in partnership with the University will be completed and training for staff and Vocational Education and in December 2015. A fifth health students, in particular Training sector. program will commence in inter-professional learning. 2016. By June 2015 review gaps identified through A new Diploma of Nursing the Best Practice curriculum has been partially Learning Environment developed for ANMC self-assessment. These accreditation and will be results will inform the finalised in 2015/16. development of a priority A total of 408 interdisciplinary work plan to embed best Grampians region staff have practice for clinical learning attended the clinical support environments. and supervision program
22 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Priority Action Deliverable Outcome
conducted by the BHS Centre for Education and Training. The Learning and Development team have completed a desk top audit of the gaps in the Best Practice Learning Environment self- assessment.
Increasing the system’s financial Reduce health service Implement a “rostering and A ‘Rostering and Time sustainability and productivity administrative costs. time capture” system with Capture’ system is currently a focus on reducing wage being implemented. related cost via improved ‘Progression of Care’ leave management, reduced meetings have commenced overtime, reduced casual to provide a whole of hospital penalties, and more efficient approach to patient access, payroll processes. work flow, care management Identify and implement a and discharge planning. range of initiatives to reduce Discharge processes are average length of stay currently under review and for acute and sub-acute include redesign work in Inpatients. the Pharmacy Department Continue to benchmark to ensure that patient’s with peer health services discharge medications are as a way of identifying being processed in a timely cost saving and revenue and cost effective manner. generating opportunities. The Pharmacy Department Review also includes changes to where stock is being procured, with a view to ensuring it is the most cost effective and efficient supplier.
Implementing continuous Drive improved health Implement the newly A consumer register has improvements and innovation outcomes through a strong developed Partnering with been developed with key focus on patient-centred Consumer policy which was information pertaining to care in the planning, adopted in 2014, to support training and interests of delivery and evaluation consumers in their role to the consumer group. The of services, and the plan, deliver and evaluate register supports suitable development of new models services as well as their consumers to be contacted for putting patients first. involvement in governance to participate in reviews to achieve continuous and provide feedback on a improvement and innovation. range of activities. All applicable governance committees have been provided with an appropriately selected, trained and supported consumer as a member of the group.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 23 Priority Action Deliverable Outcome
Increasing accountability & Undertake an annual board Complete the annual board The annual board transparency assessment to identify and assessment and utilise assessment was undertaken develop board capability to findings to continue to and results utilised to ensure all board members develop new and existing determine the content of an are well equipped to board member skills education program for the effectively discharge their supporting governance and Board of Management. responsibilities. accountability. BHS has supported the Continue to support the Advisory Committee through Grampians Regional Building the involvement of board Board Capability Advisory members in development of Committee. the education program.
Demonstrate a strategic Implement the Living The Living Longer Living focus and commitment to Longer Living Better Better reforms were aged care by responding to reforms, continue to implemented from 1 July, community need as well as monitor its impact and 2014. the Commonwealth Living where appropriate respond Changes implemented by Longer Living Better reforms. strategically. BHS include: • removal of the ‘high care’ ‘low care’ designation; • setting of differentiated room pricing; • utilisation of My Aged Care Portal; • changes to admission processes including resident contracts; • review of capital infrastructure to support opportunities for significant refurbishment; • upgrade of Class 3 buildings to Class 9C. The reforms have been implemented with minimal disruption to services.
Improving utilisation of e-health Ensure local ICT Strategic Following adoption by the The BHS ICT Strategic Plan and communications technology Plans are in place. Board of Management in 2014-2017 was adopted by July 2014, implement the the Board Of Management first stages of the ICT Plan on 29 July, 2014. for 2014–2017. Actions to date include: • The tender process to implement organisation wide wireless network infrastructure was finalised in June 2015.
24 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Priority Action Deliverable Outcome
• Capital Budget funding has been allocated to invest in storage area network (SAN) technology that will support the growth of BHS systems. • A business case is currently in development pertaining to developing an electronic patient journey board with the plan to progress this further in 2015/16. • Implementation of the iCare Medications module. • Implementation of the BOSSnet Clinical Handover. • Clinical Alerts Management business case, in relation to discharge medications, was endorsed by the BHS Executive. • ICT Work plan and Strategy have been developed to align with the BHS ICT Strategic Plan 2014-17.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 25 PART B: Performance Priorities
Safety & Quality Performance
Key Performance Indicator Target 2014–15 Actual
Patient experience and outcomes
Victorian Healthcare Experience Survey Full compliance Full compliance Healthcare associated infection surveillance No outliers No outliers ICU central line associated blood stream infections (ICU No outliers No outliers CLABSI) SAB rate per occupied bed days < 2/10,000 < 2/10,000 Maternity - Percentage of women with prearranged 100 100 postnatal home care Newborn - Percentage of eligible newborns screened for > 97 > 97 hearing deficit Mental health - 28 day readmission rate 14 7.37 Mental health - Post-discharge follow up rate 75 85.15
Mental health - Seclusion rate per occupied bed days < 15/1,000 6.03
Governance, leadership and culture
People matters 2014 Patient safety culture 80 Average 88
Safety and Quality
Health Service accreditation Full compliance Full compliance Residential aged care accreditation Full compliance Full compliance Cleaning standards Full compliance Full compliance Cleaning standards (AQL-A) 90 96.2 Cleaning standards (AQL-B) 85 93.57 Cleaning standards (AQL-C) 85 93.36 Hand hygiene (rate) – quarter 2 75 83.7 Hand hygiene (rate) – quarter 3 77 80.9 Hand hygiene (rate) – quarter 4 80 80.7 Health care worker immunisation – influenza 75 70.2
26 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Financial Sustainability Performance
Key Performance Indicator Target 2014–15 Actual
Finance
Annual Operating result ($m) 0.10 0.13 Creditors <60 days 33.13
Debtors <60 days 29.13
Percentage of WIES (public & private) performance to target 100 99.65%
Asset Management
Basic asset management plan Full compliance Full compliance
Access Performance
Key Performance Indicator Target 2014–15 Actual
Emergency Care
Percentage of operating time on hospital bypass 0 0 Percentage of ambulance transfers within 40 minutes 90 98.1 Percentage of Triage Category 1 emergency patients seen 100 100 immediately Percentage of Triage Category 1 to 5 emergency patients 80 65.6 seen within clinically recommended times NEAT - Percentage of emergency presentations to physically leave the emergency department for admission 81 67.1 to hospital, be referred to another hospital for treatment, or be discharged within four hours
Number of patients with a length of stay in the emergency 0 0 department greater than 24 hours
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 27 Key Performance Indicator Target 2014–15 Actual
Elective Surgery
NEST - Percentage of Urgency Category 1 elective patients 100 100 treated within 30 days NEST - Percentage of Urgency Category 2 elective surgery patients treated within 90 days 88 73.1 NEST - Percentage of Urgency Category 3 elective surgery 97 97.3 patients treated within 365 days
Number of patients on the elective surgery waiting list (1) 699 849 Number of Hospital Initiated Postponements (HiPs) per 100 scheduled admissions 8 5.4 Number of patients admitted from the elective surgery 1207 1212 waiting list – quarter 1 Number of patients admitted from the elective surgery 1330 1301 waiting list – quarter 2 Number of patients admitted from the elective surgery 1325 1228 waiting list – quarter 3 Number of patients admitted from the elective surgery 1398 1330 waiting list – quarter 4 Number of patients admitted from the elective surgery 5260 5074 waiting list – annual total
Critical Care
Adult ICU minimum operating capacity 7 7
Paediatric ICU minimum operating capacity N/A N/A
Level 2 Special Care Nursery Neonatal ICU standard operating capacity and flex capacity 10 OC – 10 Flex - 12
28 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 PART C: Activity and Funding
Financial Sustainability Performance
Funding type 2014–15 Activity Achievement
Acute Admitted
WIES Public 21,727.13 WIES Private 5,288.15 WIES (Public and Private) 27,015.28
WIES DVA 224.01 WIES TAC 138.62 WIES TOTAL 27,581.03
Subacute & Non-acute Admitted (Weighted Bed Days)
Rehab Public 10,346.14 Rehab Private 2,761.84 Rehab DVA 202.57 GEM Public 11,612.42 GEM Private 3,210.20 GEM DVA 411.96 Palliative Care Public 2,771.83 Palliative Care Private 1,343.59 Palliative Care DVA 111.71 Transition Care – Beddays 11,039 Transition Care - Homeday 6,479
Subacute Non-Admitted
Health Independence Program 39,629
Aged Care
Aged Care Assessment Service 2,617 Residential Aged Care 158,673 Linkages (hours) - 36,192 HACC PAGS & Allied Health (hours) – 64,122
Mental Health and Drug Services
Mental Health Inpatient - Beddays 11,207 Mental Health Inpatient - WOt not available Mental Health Ambulatory 47,212 Mental Health Residential 6,656 Mental Health Sub Acute 3,237
Primary Health
Community Health / Primary Care Programs 9,165
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 29 Reporting requirements and general information
Application of merit and equity
We are an equal opportunity employer and ensure open competition in recruitment, selection, transfer and promotion. Employment decisions are based on merit and without consideration of gender, marital status, age, pregnancy, disability, race, religious or political beliefs or activities, or on the grounds of being a parent, childless or in a de facto relationship. Our people are treated fairly and reasonably and provided with redress against any unfair or unreasonable treatment.
Ex-gratia payments
We did not make any ex-gratia payments during 2014/15.
30 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Freedom of information requests
Ballarat Health Services complies with the Victorian Freedom of Information Act 1982 (FOI). Since 2011 we have received the following number of requests: 2011: 408 2012: 464 2013: 497 2014: 475 2015: 511
Building Act 1993
Ballarat Health Services complies with building standards and regulations. All buildings constructed after July 1994, have been designed to conform to the Building Act 1993 and its regulations, as well as meet other statutory regulations that relate to health and safety matters. All buildings have been issued with occupancy permits and all building practitioners engaged by Ballarat Health Services are required to produce evidence of current registration on commencing a project, as well as evidence that their registered status will be maintained throughout the year.
Consultancies
In 2014-2015, there were two consultancies where the total fees payable to the consultants were $10,000 or greater. The total expenditure incurred during 2014-2015 in relation to these consultancies is $212,631 (excl GST). Details of individual consultancies can be viewed at www.bhs.org.au/node/19. In 2014-2015, there were six consultancies where the total fees payable to the consultants were less than $10,000. The Total expenditure incurred during 2014-2015 in relation to these consultancies is $30,586 (excl GST).
National Competition Policy
Ballarat Health Services complied with all government policies regarding competitive neutrality with respect to all tender applications. Protected Disclosure Act
Ballarat Health Services had no disclosures notified to the IBAC under section 21(2) of the Protected Disclosure Act 2012 in the past financial year.
Contracts
We abide by the Victorian Industry Participation Policy Act 2003. In 2014-2015 there were two contracts continued by Ballarat Health Services under this Act. The contracts were: • Community Programs – Personal and Domestic Care, to the value of $2 million. This service proposes the use of more than 85 per cent local content and has created more than 100 new jobs. • Statewide Equipment Program – Non-Customised Equipment, to the value of $4 million distributed via 10 suppliers awarded. On average the suppliers propose to provide goods and services and utilise around 60 per cent local content and in total creates the possibility of 40 additional EFT and the possibility of nine new apprenticeships.
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 31 Carers Recognition Act
The Carers Recognition Act 2012 promotes and values the role of people in care relationships and formally recognises the contribution that carers and people in care relationships make to the social and economic fabric of the Victorian community. Ballarat Health Services has taken all practicable measures to comply with its obligations under the Act. Ballarat Health Services has promoted the principles of the Act to people in care relationships who receive our services and to the wider community by: • distributing printed material about the Act at community events or service points. Ballarat Health Services has taken all practicable measures to consider the carer relationships principles set out in the Act when setting policies and providing services by: • reviewing our employment policies such as flexible working arrangements and leave provisions to ensure that these comply with the statement of principles in the Act.
Environmental Performance
Ballarat Health Services has an active Environmental Sustainability Committee which meets regularly throughout the year. Membership of the committee is made up of staff from all directorates of BHS and includes representatives from the community and Federation University. Over the past 12 months, the committee has undertaken a number of sustainability initiatives including the recommendation to replace standard downlights within the ward block to LED energy saving bulbs. This followed a period of testing and assessment within a ward setting, in which LED lighting was found to perform well. BHS continues its long standing association with a local worm farm, in which food scraps generated at the BHS kitchen and Base Hospital Cafeteria, are collected for composting. This compost has been reused on the vegetable patch at Geoffrey Cutter Centre to complete the cycle. Environmental Sustainability information is now embedded into the staff induction process and ensures all new staff are aware of BHS’ environmental sustainability processes and policies. Ongoing sustainability education of staff continues through the staff newsletter and intranet as opportunities are identified. All new building works undertaken at BHS are constructed to the Department of Health and Human Services Environmental Sustainable Design Measures and The Building Code of Australia Section J sustainability requirements. This includes the new Drummond Street building, car park/helipad, Dental Clinic and Mother and Family Unit Projects. All projects include both passive and active environmental sustainable control measures to ensure the best holistic outcome for each project is achieved.
32 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Financial performance
Ballarat Health Services recorded an operating surplus of $134,000 for the year ended 30 June 2015.This compares favourably to the expected target of a $100,000 surplus contained in the Statement of Priorities.
2015 2014 2013 2012 2011 $000 $000 $000 $000 $000 Total Revenue 388,957 372,541 346,418 329,341 287,312 Total Expenses 388,823 372,230 345,710 329,127 287,147
Net Result for the Year (before 134 311 708 214 165 capital and specific items) Net Result (11,523) (10,027) 446 16,511 (8,155) Retained surplus/ (32,905) (21,372) (11,370) (11,860) (28,459) (accumulated deficit) Total assets 420,177 418,584 335,444 331,990 285,326 Total liabilities 125,208 117,954 101,019 98,011 87,544 Net assets 294,969 300,630 234,425 233,979 197,782 Total equity 294,969 300,630 234,425 233,979 197,782
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 33 Statutory Requirements
Attestation on Data Integrity
I, Andrew Rowe, certify that the Ballarat Health Services has put in place appropriate internal controls and processes to ensure that reported data reasonably reflects actual performance. Ballarat Health Services has critically reviewed these controls and processes during the year.
Andrew R Rowe Chief Executive Officer Ballarat 31 August 2015
Attestation for compliance with the Ministerial Standing Direction 4.5.5.1 – Insurance
I, Andrew Rowe, certify that the Ballarat Health Services has complied with Ministerial Direction 4.5.5.1 - Insurance.
Andrew R Rowe Chief Executive Officer Ballarat 31 August 2015
Attestation for compliance with the Australian/New Zealand Risk Management Standard
I, Andrew Faull, certify that the Ballarat Health Services has risk management processes in place consistent with the Australian/New Zealand Risk Management Standard and an internal control system is in place that enables the executive to understand, manage and satisfactorily control risk exposures. The Board verifies this assurance and that the risk profile of Ballarat Health Services has been critically reviewed within the last 12 months.
Andrew Faull Chair Board of Management Ballarat 28 July 2015
34 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 Disclosure Index
The annual report of Ballarat Health Services 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 22F Manner of establishment and the relevant Ministers 1 FRD 22F Purpose, functions, powers and duties 2 FRD 22F Initiatives and key achievements 4-11 FRD 22F Nature and range of services provided Inside front cover Management and structure FRD 22F Organisational structure 12 Financial and other information FRD 10 Disclosure index 35 FRD 11A Disclosure of ex‑gratia expenses 30 FRD 12A Disclosure of major contracts 31 FRD 21B Responsible person and executive officer disclosures In finance report FRD 22F Application and operation of Protected Disclosure 2012 31 FRD 22F Application and operation of Carers Recognition Act 2012 32 FRD 22F Application and operation of Freedom of Information Act 1982 31 FRD 22F Compliance with building and maintenance provisions of Building Act 1993 31 FRD 22F Details of consultancies over $10,000 31 FRD 22F Details of consultancies under $10,000 31 FRD 22F Employment and conduct principles 30 FRD 22F Major changes or factors affecting performance 33 FRD 22F Occupational health and safety 7 FRD 22F Operational and budgetary objectives and performance against objectives 33 FRD 22F Significant changes in financial position during the year 33 FRD 22F Statement on National Competition Policy 31 FRD 22F Subsequent events In finance report FRD 22F Summary of the financial results for the year 33 FRD 22F Workforce Data Disclosures including a statement on the application 16, 30 of employment and conduct principles FRD 25B Victorian Industry Participation Policy disclosures 31 FRD 29A Workforce Data disclosures 16 SD 4.2(g) Specific information requirements In finance report SD 4.2(j) Sign-off requirements In finance report SD 3.4.13 Attestation on data integrity 34 SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 34 SD 4.5.5 Risk management compliance attestation 34 Financial Statements Financial statements required under Part 7 of the FMA SD 4.2(a) Statement of changes in equity In finance report SD 4.2(b) Comprehensive operating statement In finance report SD 4.2(b) Balance sheet In finance report SD 4.2(b) Cash flow statement Other requirements under Standing Directions 4.2 SD 4.2(a) Compliance with Australian accounting standards and other In finance report authoritative pronouncements SD 4.2(c) Accountable officer’s declaration In finance report SD 4.2(c) Compliance with Ministerial Directions In finance report SD 4.2(d) Rounding of amounts In finance report Legislation Freedom of Information Act 1982 31 Protected Disclosure Act 2001 31 Carers Recognition Act 2012 32 Victorian Industry Participation Policy Act 2003 31 Building Act 1993 31 Financial Management Act 1994 In finance report
BALLARAT HEALTH SERVICES Annual Report 2014 - 2015 35 Additional information available on request
Consistent with FRD 22F (Section 6.18) the Report of a) a statement that declarations of pecuniary interests Operations should confirm that details in respect of the have been duly completed by all relevant officers; items listed below have been retained by Ballarat Health b) details of shares held by a senior officer as nominee or Services and are available to the relevant Ministers, held beneficially in a statutory authority or subsidiary; Members of Parliament and the public on request (subject c) details of publications produced by the entity about to the freedom of information requirements, if applicable): itself, and how these can be obtained; d) details of changes in prices, fees, charges, rates and levies charged by the entity; e) details of any major external reviews carried out on the entity; f) details of major research and development activities undertaken by the entity; g) details of overseas visits undertaken including a summary of the objectives and outcomes of each visit; h) details of major promotional, public relations and marketing activities undertaken by the entity to develop community awareness of the entity and its services; i) details of assessments and measures undertaken to improve the occupational health and safety of employees; j) a general statement on industrial relations within the entity and details of time lost through industrial accidents and disputes; k) a list of major committees sponsored by the entity, the purposes of each committee and the extent to which the purposes have been achieved; l) details of all consultancies and contractors including: i. consultants/contractors engaged; ii. services provided; and iii. expenditure committed to for each engagement. m) Details about feedback and complaints procedures.
36 BALLARAT HEALTH SERVICES Annual Report 2014 - 2015
Ballarat Health Services PO Box 577 Ballarat Vic 3353 Phone: 5320 4000 www.bhs.org.au www.facebook.com/BallaratHealthServices www.twitter.com/BallaratHealth
Ballarat Base Hospital Drummond Street North Ballarat Vic 3350 Phone: 5320 4000
Queen Elizabeth Centre 102 Ascot Street South Ballarat Vic 3350 Phone: 5320 3700
Mental Health Services Sturt Street Ballarat Vic 3350 Phone: 5320 4100
Dental Clinic Corner Hertford Street & Tuppen Drive Sebastopol Vic 3356 Phone: 5320 4225
Ballarat Regional Integrated Cancer Centre Corner Sturt and Drummond Streets Ballarat Vic 3350 Phone: Radiation Oncology – 5320 8600 Oncology Consulting Clinics – 5320 8500 http://bricc.bhs.org.au www.facebook.com/BRICCWellnessCentre www.bhs.org.au
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