Contents

Who we are 2

Quality of Care report 2

Board Chairs Report 3

CEO Report 3

Introduction/Strategic Plan 4

Key areas

Population health planning 4

Workforce capability 5

Acute Services – Sustainability 7

Care Co-ordination 8

Consumer, Carer and Community Participation 10

Koori Wellbeing 11

Cultural and Linguistic Diversity 12

Business Units 14

Building Infrastructure 15

Energy Efficiency 15

Our History 16

Governance 16

Board of management 16

Executive Staff 17

Workforce data 17

Overview of Services 18

Our Structure 20

Community Support Groups 21

Senior Personnel 24

Statutory Information 27

Service Level 29

Report of Operations 29

Statement of Priorities 31

Disclosure Index 33

Financial Statements

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 ' Who we are Quality of Care Report Central Gippsland Health Service (CGHS) is the major provider Central Gippsland Health Service is committed to quality and of health and residential aged care services in the Wellington excellence with the client/patient at the centre of care. Shire. In line with the Central Gippsland Health Service strategic plan It serves an immediate population of 42,000 in Central Gippsland, while acute specialist services reach a wider the health service reviews and improves on its existing quality community in East Gippsland and parts of South Gippsland. framework to ensure systems which embed a quality culture of continuous improvement across the organisation and At your service also processes of engagement from clinical and non clinical Central Gippsland Health Service has 80 acute beds; disciplines, consumers and other key stakeholder groups. approximately 180 high and low care residential aged care beds, The quality team is an integral part of Central Gippsland as well as 19 independent living units. Health Service and is central to the Quality and Risk Working Acute services include a 24 hour, seven day a week emergency Party which meets fortnightly to identify and monitor issues department, operating theatres, day procedure unit, oncology relating to patient/client safety and quality of service. and dialysis services. The Quality and Risk Working Party reports to the Quality and Risk Committee which meets bi-monthly, has Board The Health Service comprises: and consumer representation and reports directly to the Acute Services situated at Sale, Maffra and Heyfield; Community Board of Management. Three community and consumer Services provided throughout the Shire of Wellington specifically participation groups work with us to enable community and at Maffra, Sale, Heyfield, Rosedale and Loch Sport; and consumer perspectives to be at the centre of our continuous Residential Aged Care Services at Sale, Maffra and Heyfield. improvement efforts. Our services Comprehensive accountability reports relating to performance Population Served approximately 42,000 and legislative compliance are presented to the Board on a monthly basis. Emergency attendances 16,252 Inpatient services 12,230 Current Accreditation Status The Acute and Community Services of Central Gippsland Community Services hours of service 121,192 Health Service are currently accredited with the Australian Allied Health acute services attendances 4,493 Council on Healthcare Standards. People A full, organisation-wide survey was held in 2007, when Central Gippsland Health Service gained full accreditation 652 Full Time Equivalent employees valid for four years. Approximately 1,127 people employed, including casual, part A site visit, which is called a Periodic Review, was conducted time and full time active employees at 30 June 2011. in October, 2009. This determines ongoing accreditation Assets and Revenue status, reviewing mandatory standards as well as reviewing the progress of recommendations made at the organisation- $56m in Net Assets wide survey held in 2007. $54m in Buildings A self assessment report was sent to the Australian Council $5m in Plant & Equipment on Healthcare Standards in August, 2010 providing detail $70m in Revenue and Budgeted operations on continuous quality improvement under the three main functions of the framework. Central Gippsland Health Service is due for a further accreditation review in August 2011 against the ACHS Equip 5 standards. Our Aged Care Facilities – Laurina Lodge, Wilson Lodge, Stretton Park and McDonald Wing – all hold current Aged Care Accreditation.

( Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Report by Chair, Board of Management Our Partners Year in Review One of our key strengths lies in our ability to work with our various partners in the delivery of clinical services, other support It is with pleasure that we present the Central Gippsland Health services, research and education. Our ongoing relationship with Service 2010/11 Annual Report. our neighbours at Bairnsdale Regional Health Service, Latrobe Regional Hospital and Monash University continue to enable Our Strategic Plan us to achieve economies of scope and scale in our delivery This has been the second year of implementation of the of clinical services through various shared arrangements. In Strategic Plan and considerable progress has been made to particular, our ability to offer a range of quality specialist services assess our local population health needs to enable us to direct is enhanced through these partnerships and we will continue our health services appropriately in the future. Furthermore, a to pursue innovative opportunities to attract and work with the great deal of work has been done to streamline and coordinate specialist workforce we need. our services to optimise the quality of care our patients receive. In particular, people with chronic illness will benefit from these Thank you improvements through better linkages across the health service It has been another challenging and exciting year for Central and more seamless access to the range of specialist services Gippsland Health Service and we acknowledge and thank the they require. dedicated staff, our volunteer workforce, committee members, and the leadership and management team for their continued Central Gippsland Health Service’s workforce capability is integral commitment and excellent work. to the delivery of the Strategic Plan and it is pleasing to note that significant inroads have been made to identifying, building and We also acknowledge our Board members who have left or attracting staff with the right mix of skills and experience to meet retired this year. In particular, Mr John Lawrence who has served the future needs of the health service. The resulting capability on the Board since 2006 and whose term expired on 30 June framework provides a tremendous foundation for our continued 2011. John did not seek reappointment and we acknowledge his delivery of high quality, relevant health services and we significant contributions over the past five years, in particular his acknowledge the efforts and leadership of our Chief Executive thoughtful input into the strategic direction of the health service Officer, Dr Frank Evans, in this achievement. and passionate stance towards addressing disadvantage and community access issues. John’s business acumen and strong Maffra Hospital belief in social justice were much appreciated and have greatly The Board is delighted with the recently completed upgrade of assisted in the advancement of our health service. the McDonald Wing at the Maffra hospital which has resulted We also acknowledge and thank Ms Angela Todd who was in refurbishment of residents’ rooms; enhanced bathroom appointed in 2008 and resigned early in the 2011 calendar year. and toilet facilities and improved heating, cooling and other The Board sincerely thanks her for her valued contributions. amenities to ensure greater staff, patient and resident comfort. Other members of the Board during the year ended 30 June The project was delivered within budget and would not have 2011 were Mr John Sullivan (Chair until December 2010, been possible without the generous contribution from the Clyne now Deputy Chair), Mr Glen Stagg, Ms Helene Booth and Ms Estate fund. Elizabeth Thomson. Koori Traineeships My own appointment and that of Mr John Sullivan and Mr We were pleased to have funding approved for a significant Glenn Stagg also expired this year but each of us has been successfully reappointed for another term. We all look forward to Aboriginal traineeship program earlier this year and even more welcoming four new Board members who have been appointed thrilled to have successfully recruited six Allied Health Assistant to commence in 2011/12. trainees to our Community Services area in June. We look forward to supporting these young people in their exciting endeavour and shall watch their progress over the next 18 Catherine Greaves months with great interest. Board Chair

Chief Executive Officer’s Report of our volunteers, many of whom contribute year after year. This includes our hospital and health centre auxiliary members, who The past year has seen Central Gippsland Health Service make work hard to raise important funds for equipment to meet the considerable progress toward the implementation of its strategic needs of our patients, residents and clients. plan. This report has been formatted to enable you to follow our progress during what has been a very challenging year. Last year we established a consumer health advocate role. The role, in addition to supporting people to have their issues heard The report incorporates our Quality of Care report, which is or needs met has helped to keep community and consumer specifically written for you, our community member, patient, issues at the forefront of our considerations. Alan Murray is our client or carer to read about our progress in improving the Consumer Health Advocate in addition to being a volunteer quality of care we provide. community driver. Alan has had a busy year and many people We are grateful to our community and consumer groups for have taken advantage of Alan’s services. providing us with feedback on last year’s report and how to improve the content in this report. In particular we thank them Central Gippsland Health Service is fortunate to have a very for the contribution they make to the health service by providing capable and dedicated Board of Management. The health service us with advice and feedback on how we go about our work. benefits from a Board that has demonstrated an enormous commitment to ensuring our community gets the most from its This year our Community Liaison Group has designed a major health service. The Board has worked diligently to ensure the community consultation process that will form a significant health service is well governed, with quality and safety at the component of a comprehensive population health plan for forefront of their interest. Central Gippsland Health Service. I would like to take the opportunity to thank our community members who completed Finally I would like to acknowledge our staff. Central Gippsland the questionnaire and/or participated in a community meeting. Health Service is fortunate indeed to have such capable staff. What has impressed me so much is the genuine commitment I also would like to take the opportunity to thank our Chronic of our staff to make a difference for people and to place our Disease Network Group, for continuing to provide us with insight patients, clients and carers at the centre of our work. into what it is like to live with or care for someone with a chronic illness, injury or disability and for their advice on how to improve You can provide feedback on our annual and quality report our services. In particular this group has continued to assist us or any matter you might like to bring to our attention via the to implement the recommendations produced through our Care community feedback portal on our new website. Please visit Coordination Project. www.cghs.com.au and follow the prompts. We continue to be indebted to our many volunteers for their tireless work across so many areas of our service. I have been Frank Evans and remain absolutely amazed by the generosity and hard work Chief Executive Officer

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 ) Health care across the population: A group of Maffra Secondary School students, as part of their community studies, took residents of Stretton Park for a stroll to Victoria Park in Maffra. As well as a welcome diversion for the residents, it enabled the students to learn about aged care issues and how to assist those in wheelchairs.

Introduction Strategic plan In this annual report, the activities of the organisation are The strategic plan for the Central Gippsland Health Service will reported against the key areas of the Strategic Plan. guide the direction of the Health Service through to 2013. Central Gippsland Health Service is categorised as a subregional The full plan is available on the website www.cghs.com.au while health service within the Victorian public health care sector. As a summary of the plan is available in hard copy or via email to such the Health Service works within a positive government interested people. policy framework that seeks to strengthen and sustain rural health services to improve the health of rural Victorians. The plan was developed after extensive consultation with the community, including an extensive environmental scan, within a The framework describes sub-regional health services as major broader regional, state and national health planning framework. service providers in large rural areas. The strategy nominates 12 key result areas through to 2012. The subregional classification brings with it both role These include Population Health Planning, Workforce Capability, expectations and limitations. Sustainability of Acute Services, Sustainability of Specialist Central Gippsland Health Service is also part of a subregional Medical Services, Care Co-ordination, Koori Wellbeing, Cultural population health strategic planning alliance. The alliance and Linguistic Diversity (CALD), HACC Competitiveness, has produced a locally relevant and regionally integrated Business Units, Building Infrastructure, Junior Medical staff service delivery framework. CGHS has a very constructive and Accommodation and Energy Efficiency. supportive relationship with public health services in Gippsland. In particular we work very closely with Latrobe Regional Hospital The plan is more detailed than most strategic plans as it and Bairnsdale Regional Health Service, being our nearest represents a significant shift in focus for the organisation, with neighbours and partners on many projects and ventures. more detail required to support its implementation.

KEY AREA

Population Health Planning about current health needs, what helps people to stay healthy, and what types of services residents feel are needed to help Goal: To adopt a population health approach them achieve their goals and aspirations. to health service planning and delivery. The survey was open to everyone in the Wellington Shire area, Central Gippsland Health Service has this year undertaken excluding the Yarram area which is served by the Yarram and comprehensive community and stakeholder consultation as it District health service. moves to a service delivery capability model, underpinned by a A Community Survey was accessible on line through a link on population health planning approach to healthcare delivery. the Health Service’s website and also distributed in hard copy This approach means the services provided and delivered form from all campuses and other sites associated with the have the greatest potential to match the needs of the local Health Service. community and therefore maintain and improve the health of The results were being collated early in the 2011/2012 financial the entire population. year and will inform the needs assessment process. The broader thinking behind this approach is to recognise that Put simply, this needs assessment, informed by both evidence ‘health’ is a capacity or resource rather than a state of not being and policy, determines the work that needs to be done with ill. It corresponds to the notion of health being about having regard to delivering services, which in turn determines the work capacities and opportunities to pursue one’s goals, to acquire that needs to be done to support the delivery of services. skills and education, and to grow as a person. Once this is understood, strategic planning becomes highly This concept demands an evidence and policy informed focused, as does the response of the organisation to develop the approach, which is one of the key outcomes of the Health necessary capability, across all areas, to achieve both strategic Service’s Strategic Plan developed last year. and service delivery objectives. All forms of capital – financial, As part of this process, the health service this year undertook human and facilities – become aligned to achieve these ends. a community consultation coordinated through the Central Draft evidence and policy informed case studies have been Gippsland Health Service’s Community Liaison Group. completed for the majority of the national health priorities and The survey, completed at the end of June, gathered information key issues facing the Wellington population. * Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 KEY AREA

Workforce Capability Australian Institute of Flexible Learning (AIFL) by flexible delivery; combining online, face to face and on the job learning and Goal: To develop and implement a assessments. comprehensive workforce capability The health service is continuing to build capability within its development framework. trainee/apprenticeship program, with a number of those who Central Gippsland Health Service continues to develop and have qualified able to gain ongoing employment into permanent implement a workforce capability framework as part of an vacant positions, in, for example, the Payroll Department and overall service delivery capability model. Service delivery (or Information Technology Department. organisational) capability can be defined as “the sum of all Another part of the workforce capability program is an things that enable an organisation to deliver services.” undertaking to up-skill the existing workforce to minimum The implementation of this framework supports high levels of Certificate 3 qualifications within the relevant skill area. As an personal performance and service excellence. The framework example, this has commenced within the Linen Service and has is based on an understanding that capability is the critical link enabled staff to gain recognised prior learning as part of gaining between strategy and performance and the importance of the this foundation qualification. relationship between what is needed to be done (the work) and The Health Service’s first allied health assistant traineeship the personal abilities and attributes needed to do it. program was completed in March 2011 and resulted in four The framework provides the link between functional capabilities Gippsland residents becoming fully qualified Allied Health and processes such as: Assistants. Four graduates are now employed in positions within the Allied Health Department. s strategic workforce planning, work and role design The health service was again successful in receiving a $75,000 s recruitment and selection training grant from the Department of Health “Closing the s career and succession planning Gap Management” strategy. This funding has enabled six local indigenous people to participate in the next allied health s performance management and learning management assistant traineeship. The framework includes a 360 degree questionnaire, which has The applicants were interviewed in May and June and those been built online and in-house, and completed for all senior successful commenced on 4 July 2011. The partnership with management and all but a few middle and front line mangers the Australian Institute of Flexible Learning continues to support and service coordinators. the Certificate IV in Allied Health Assistance to deliver combined The 360 degree questionnaire forms part of a comprehensive online, face-to-face and on the job learning. capability development plan that includes the individual’s The online learning management system, Moodle, continues relationship to the strategic plan (key responsibilities), to expand with an increasing number of staff able to access contingency and succession planning, knowledge management learning in a flexible and resource efficient way. An increased and capability development priorities and learning strategies number of programs are being developed on this platform, one As part of the implementation process 33 middle managers and of the more recent being an e-learning preceptorship training, service coordinators have completed a nationally recognised for which a $10,000 grant was received from the Department of Diploma of Management. The course was delivered through the Health.

From left are Mary Hoodless, General Manager of the Australian Institute of Flexible Learning, then Board of Management Chairman John Sullivan, Helen Ried, Christina Weatherall, Jennifer Dennett, Maureen Wilson, Jo Ollier, Jo Bennett, Louise Vuillermin, Sue Roberts, Lyn Lancey, Rod Cusack, Bernadette Lord, Hannah Cole, Jon Millar, Sue Ingrouille, Mary Hartwig, Daryl Cooper, Barb Cook, Sue King, David Askew, Raquel Cumming, Gary McMillan, and CGHS Chief Executive Officer Dr Frank Evans. Case study Australian Institute of Flexible Learning. Available to frontline managers and those aspiring to frontline positions, it was Health service staff receive Diploma of structured to meet the needs of the Health Service by Management including topics in the program that have direct relevance to Thanks to an innovative internal training program, 33 staff at its operation. Central Gippsland Health Service have gained a Diploma of Some of these included leadership, change management, Management. team development, financial management, workforce The participants received their Diplomas at a graduation planning and professional and personal development. ceremony late in 2010 after taking up the opportunity to As well as providing individuals with a professional undertake the nationally-recognised qualification early last development opportunity, it is anticipated that the benefits year. will flow through to the whole organisation by having a more The program was run internally by Health Service CEO, skilled workforce in areas such as leadership, financial and Dr Frank Evans, who is an accredited coordinator with the project management and strategic and operational planning.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 + Trainees first in new health program A group of young local people gained a start to a career in Allied Health this year through a program funded by the State Government’s Workforce Innovative Grant Program. The trainees, including Jacob Tilley, Dell Colcott, Emma Schroeter, Melanie Hawthorn and Marney Dee, gained a Certificate IV qualification in Allied Health Assistance through the Australian Institute of Flexible Learning while undertaking on the job training under the program. The aim of the program was to help the Health Service develop its own workforce, while providing opportunities to local people. Pictured with their graduation certificates are, from left, Danielle Colcott, Chief Executive Officer Dr Frank Evans, Marney Dee, Lyndal Cass, Jacob Tilley, Sue Morley and Emma Schroeter.

How is Central Gippsland Health Service elements of each can develop a better program. It is hoped that the work undertaken locally will benefit diabetes patients in the involved in research? future. Central Gippsland Health Service takes part in a range of research activities throughout the year, with direct participation ARISE trial continues by staff or in conjunction with external groups, such as Central Gippsland Health Service continues to take part in a universities. major research project to test the best treatment care options for During this year Diabetes Educator Sue Kewming received a people who develop severe sepsis, which is a complication of scholarship to undertake research to compare Australian and severe infection. international models of diabetes education and treatment. The trial is known as ARISE-RCT, which stands for Australasian The project will consider the relative benefits of the current Resuscitation In Sepsis Evaluation – Randomised Control Trial. program utilised at the Health Service and a Canadian model that is being rolled out in some parts of Australia. The trial is assessing whether there are better results from a treatment called Early Goal-Directed Therapy (EGDT®) versus Ms Kewming received the scholarship funding through Monash standard care. It is trialling the therapy in patients with severe University under the Australian Government’s Primary Health sepsis presenting to the Emergency Departments of hospitals in Care Research Evaluation and Development (PHCRED) Strategy Australia, New Zealand, Finland and Hong Kong. and is comparing a local program with one developed in Canada. During March 2011 the ARISE-RCT started recruitment at 37 Central Gippsland Health Service’s model is based on a five sites internationally, with the overall enrolment target 1,600 week program looking at all aspects of diabetes, using a range of patients. So far 10 patients have been randomised at Central interactive methods and resources, while the method developed Gippsland Health Service, where the principal investigator is Dr in Canada is called Conversation Maps and is based around Howard Connor with research coordinators Tim Coles, Anne van what is described as four conversation maps, which support a Berkel and Jennifer Dennett. four week course. The ARISE-RCT is being conducted in collaboration with the The research is to assess the differences and benefits of each Australasian College for Emergency Medicine (ACEM) Clinical program and whether either produces better results, or whether Trials Group.

, Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 One of the new full time medical specialists attracted to Central Gippsland Health Service was peadiatrician Dr Sylvia Welgemoed (left), pictured in the paediatrics area at Central Gippsland Health Service with Clinical Nurse Specialist Leanne Jackson, Hospital Medical Officer Dr Elena Nefedova and fellow paediatrician Dr Austen Erasmus.

KEY AREA

Acute Services – Sustainability During this year, two full-time medical specialists were appointed, general surgeon Mr Paul Strauss and peadiatrician Dr Goal: To provide acute care services efficiently Sylvia Welgemoed. and effectively and within designated funding Mr Strauss is a general surgeon with extensive experience in and associated revenue streams while South Africa and the United Kingdom, and started at CGHS in continuing to improve quality of care. August 2010. Dr Sylvia Welgemoed joined Central Gippsland Health Service in December 2010, moving here from South As with most health services, Central Gippsland Health Service Africa. has a pressing need to improve the efficiency of its acute care services. While this is very challenging, the health service is Both have settled well into the local community and the clear about the need to continuously improve the quality of organisation looks forward to long and fruitful relationships with them. services and ensure that achieving improved efficiency supports improved quality of care. Supporting the senior medical officers is a sizeable and diverse contingent of junior medical staff. Some have come to Gippsland During this year, a number of activities have occurred that as International Medical Graduates – on average for about will help with these aims. Most importantly we have made two years – while others are on secondment from Melbourne considerable progress towards achieving our care coordination hospitals. goals and objectives. This progress is described in the Care Coordination section below. We have also worked very hard In 2011, through a combination of improved annual leave to improve our bed management, reduce wasted theatre time management and reduced reliance on locum junior medical and staff the hospital efficiently. We have increased the number staff, the Health Service was able to appoint a new registrar of dialysis treatments we provide. Unfortunately, and due to a position in surgery and emergency medicine. number of short term reasons, we did not treat as many patients as the previous few years and this has resulted in us earning Junior medical staff accommodation approximately $800,000 less than planned. This situation is not To improve the quality of accommodation for junior medical staff expected to continue into the new financial year. – International Medical Graduates and seconded doctors from Melbourne hospitals alike – Central Gippsland Health Service is Sustainability of specialist medical undertaking a three year program to renovate those units that it owns. In 2010/11, two new kitchens were installed and one services unit had its electrical wiring and guttering replaced. There will be Central Gippsland Health Service has continued to recruit high a focus on re-painting, re-carpeting and replacing light fittings in quality medical specialists. 2011/12.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 - How does Central Gippsland Health Service Some examples of changes to practice as a result included: monitor issues? s 2EVIEWOFRESUSCITATIONANDend of life plans to ensure improved patient involvement in discussion about Limited Adverse Occurrence Screening resuscitation choices (LAOS) s -AJORREVISIONOFmUIDBALANCECHARTSANDmUIDBALANCE The Limited Adverse Occurrence Screening process has been in documentation practice place at Central Gippsland Health Service since April 2005. s )MPLEMENTATIONOFORGANISATIONALWIDEBESTPRACTICEPAIN The occurrences screened are: management tools s -EDICAL%MERGENCY4EAMCALLS s 2EVIEWOFPATIENTTRANSFERPROCEDUREANDDEVELOPMENTOF escalation processes for time critical transfers s #ARDIAC!RREST s )MPROVEDDIRECTADMISSIONPATHWAYSFORPALLIATIVEPATIENTS s 5NPLANNEDRETURNTO4HEATREWITHINSEVENDAYS clients who require admission to hospital s $EATHS s 3TRATEGIESTOREDUCETHENEEDTOTRANSFERAGEDCARERESIDENTS s 5NPLANNEDTRANSFERSTO#RITICAL#ARE5NIT to emergency departments for care through optimising clinical assessment and management of aged residents in s %MERGENCY#AESAREAN3ECTIONS their home environment s 5NPLANNEDREADMISSIONSWITHINDAYS Review of Limited Adverse Occurrence Screening events is undertaken by a multidisciplinary clinical screening process, with records determined to require further review forwarded to the Quality and Risk Working Group for further discussion and recommendations.

KEY AREA

Care co-ordination The multidisciplinary team, in negotiation with patients and clients, develops a Service Delivery Plan which clearly states Goal: To enhance the health and wellbeing the suite of service supports of people with chronic illness and or complex required to ensure people “My adult son who has health care needs through access to a highly achieve their goals and a disability was recently aspirations. Service Delivery discharged from the coordinated health care and community Plans are “living” documents Medical Ward. I was support system. that are adjusted or amended very impressed to be The key objective of the Care Coordination Project is to bring as required. advised how my son’s into line the way in which care is coordinated for patients and Patients and carers are reporting ongoing care was going to be coordinated. It clients with complex care needs, so they can achieve their goals on their experience with Care was wonderful to also and aspirations. Coordination. know all subsequent “This week I was involved This year Central Gippsland Health Service Consumer and carer appointments had been with Central Gippsland commenced the process of incrementally participation is directly made.” Health Service staff re: introducing the Care Coordination model, beginning influencing the progression of March 2011. discharge of a client in the acute setting of medical and surgical wards. achieving the major strategic who has a Community One of the key values that underpin Care goal of Care Coordination. The health service is actively seeking Aged Care Package Coordination at Central Gippsland Health Service is input and informed feedback from the Central Gippsland Health with UnitingCare from respecting patient-determined goals, ensuring that Service Chronic Disease Network, a consumer and carer group the medical ward. Just the person is placed at the centre of their own care. specifically established to inform the Care Coordination project. wanted to let you know that from a To achieve this, the Health Service needs to work The project is being progressively implemented through the community services in a collaborative and respectful partnership with organisation and across the care continuum. The health service perspective, I really the person by taking the time and making the effort will also be introducing a centralised Intake system, which will appreciated the contact to genuinely understand the person’s goals and see all information gathered at this point relayed on to service and feedback from the aspirations, and the likely impact on their significant providers so that further documentation is not duplicated, but Care Coordinator on the other/s. will enhance the assessment and care coordination activity. Medical Ward. It was great to be invited to To achieve this, the health service ‘negotiates’ with the discharge planning its patients and clients a comprehensive service meeting and also to delivery response. Negotiation in this sense means receive a copy of the the health service respects the contribution the service delivery plan upon person can make to their own health, such as their discharge. Well done values, goals, past experience, and knowledge of CGHS!” their own health needs, and the person in turn Aged Care Provider 2011 respecting the contribution of a multidisciplinary team who contribute their professional expertise, skills and knowledge to the best of their ability. Members of a multidisciplinary team are not limited to internal service supports. Instrumental key members also include General Practitioners, Specialist Services, agencies such as Aged Care providers, government and not-for-profit agencies, where relevant. Care Coordinators Jeff Thomas and Chris Ronalds

. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 How does Central Gippsland Health Hand Hygiene Compliance Service implement infection control? The Australian Commission on Quality and Safety in Health Care (ACSQHC) has engaged Hand Hygiene Australia (HHA) The Infection Control Program is responsible for monitoring all to implement the National Hand Hygiene Initiative. Hand aspects of infection risk, ranging from ensuring correct systems Hygiene Australia reports directly to the ACSQHC. Hand Hygiene for food handling, environmental safety, water supplies and air Australia has worked closely with all States and Territories to conditioning systems, to correct operating theatre and sterilising establish a national system of outcome measures to assess the procedures. effectiveness of the National Hand Hygiene Initiative. Infection Control and Compliance Audits are performed annually The ‘Five Moments of Hand Hygiene’ define the essential hand in each clinical area as well as at an organisational level. Results washing opportunities on which the audit is based. Staff are are collated and forwarded to the Rural Infection Control Practice categorised according to job description and the total number of Group (RICPRAC) where they are benchmarked against other opportunities for hand hygiene that are observed are compared like-sized facilities across rural Victoria. to the number of those opportunities that staff miss. Through the Victorian Hospital Acquired Infection Surveillance The Infection Control Team at Central Gippsland Health Service System (VICNISS), surgical site infections, staphylococcus aureus monitors hand washing compliance rates on a minimum of two blood stream infections, occupational blood and body fluid acute ward areas one of which must be the Critical Care Unit. exposures, clostridium difficile cases, influenza staff vaccination This data is then reported to the Victorian Hospital Acquired rates, haemodialysis infection events, Vancomycin resistant Infection Surveillance System co-ordinating centre, where it enterococcus (VRE) and multi-resistant staphylococcus aureus is collated and benchmarked against the State average. The (MRSA) infections are monitored, reported on and bench program has been expanded this year to include other clinical marked against other Group 2 health care facilities. areas and these results have been reported to the Quality and The Infection Control Co-ordinators are nurses with specialised Risk Committee. Significant improvement has been observed in training who provide leadership throughout the organisation these areas since auditing has begun. for the prevention and management of infections. The Central Gippsland Health Service has improved its hand washing Infection Control Co-ordinators report directly to the Quality compliance since the program first began and have continued to and Risk Working Party and the Safe Practice and Environment maintain a level of compliance above the national average this Committee. year.

Case Study and practices. These have included, for example, the introduction of employee thank you notes, regular patient Quality program to encourage hourly rounding, introduction of communication tools and excellence whiteboards next to each bed. Hardwiring Excellence is a quality project which was Evaluation of the project has taken place through staff and introduced in the Medical Ward in July 2010. patient surveys, monitoring of patient fall rates, pressure areas and medication errors. Results to date have been The project affects all aspects of hospital function from positive showing improved patient outcomes, including a the leadership to staff interaction and the way patients are reduction in falls and medication errors and an increase in approached and cared for. staff and patient satisfaction. Plans to implement this project The aims are to support cultural changes within Central throughout Central Gippsland Health Service are in progress Gippsland Health Service which often involve new procedures during 2011.

Medication Management ACHS medication Indicator July - December 2010 Delivering medication safely depends on providing the right Events with significant adverse outcome medication to the right patient in the right dose at the right time. Central Gippsland Health Service has an active program of monitoring any incidents that occur in relation to drug All Hospitals administration. All Registered Nurses complete an annual medication administration education program as part of their ongoing professional development and credentialing program. CGHS At right is a graph of the incidence of significant medication incidents benchmarked through the Australian Council on 0 0.002 0.004 0.006 0.008 0.01 0.012 Healthcare Standard Indicators Prevention of Pressure Ulcers CGHS All Hospitals Series 1 0 0.01 Pressure Ulcers result from damage to the skin when patients are unable to move freely in bed. There are four levels of severity and recognising the subtle changes in the skin before it breaks down has a major influence ACHS Pressure Area Indicators on reducing the occurrence of pressure ulcers. July - December 2010 Central Gippsland Health Service submits Pressure Ulcer Clinical Indicators quarterly to the Australian Council on Health Care Standards. All Hospitals Results of this benchmarking show that Central Gippsland Health Service had an increase for the time period July – December CGHS 2010. A quality Improvement project led by the Clinical Nurse Consultant, Wound Care, reviewed the risk assessment and management of patients at risk of developing pressure areas to 0 0.02 0.04 0.06 0.08 0.10.12 0.14 address this increase. CGHS All Hospitals Series 1 0.12 0.08

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 / Falls Monitoring medicines, communication between medical and other staff, and amount of time given to plan going home. Central Gippsland Health Service continues to identify those patients who are at increased risk of falls in the hospital setting According to the report from the firm which undertakes the as well as in their home environment. survey process on behalf of the Department of Health, high performance scores were obtained for the courtesy of nurses, Falls risk assessment tools and falls minimisation plans are responsiveness of nurses and for treating patients with respect. developed and continuous improvements implemented in acute, community services and aged care. Completion of assessments “Responsiveness of nurses’ scores was highly correlated and implementation of plans continue to be audited. with overall satisfaction, making them (nurses) key drivers of satisfaction. Consistent with the key drivers of satisfaction, The Falls Group meets regularly and the Falls Prevention Group qualitative analysis revealed that 42 percent of the sample made continues to monitor data related to falls, in particular incidents positive comments about staff in response to the question reported. ‘What were the best things about your stay in hospital?’ Taken Nursing staff complete mandatory education relating to Falls Risk with those items with high performance scores, this illustrates Assessments as part of their ongoing professional development the importance of maintaining a courteous, respectful and program. Falls minimisation education strategies have included responsive staff,” the report said. poster displays and education quizzes The results for key areas included Overall Care scored 80, The result of benchmarking through submission of Falls Clinical compared with the Category B hospitals average of 79; Indicators to the Australian Council on Health Care Standards is Access and Administration 78 (average 77); General Patient presented below. Information 85 (average 83); Treatment and Related Information 81 (average 79); Complaints Management 82 (average 81); Physical Environment 77 (average 76); Discharge and Follow Up ACHS Falls Indicator July - December 2010 77 (equal with average); and Consumer Participation 81 (equal with average). Consumer, Carer and Community All Hospitals Participation Governance CGHS Central Gippsland Health Service has detailed the importance of consumer and carer participation in the organisation’s Strategic 0 0.05 0.1 0.15 0.2 0.250.3 0.35 0.4 Plan 2009, which requires that services are person centred. In the 2008 EQUIP Accreditation; Central Gippsland Health CGHS All Hospitals Service achieved “Moderate Achievement” against Standard Series 1 0.21 0.37 2.4, which required that “the governing body is committed to consumer participation.” Since development of the new Strategic Plan, the health service is moving to improve that rating with the Incident Reporting creation of new systems and consumer groups. Central Gippsland Health Service promotes a robust incident Consumers and carers are now further represented on key reporting system. governance groups including: Regular monitoring and management of incidents takes place s The Central Gippsland Health Service Community Liaison within the Quality Department. Significant reported incidents are Group – current membership of 12 community members tabled at the fortnightly meeting of the Quality and Risk Working which meets monthly. This Committee has led the Party, with specified reporting to the Quality and Risk Committee. organisation’s Community Consultation process which will be a major component of the comprehensive needs assessment From July 2010 Central Gippsland Health Service became part of to inform future service delivery plans. the Department of Health Incident Monitoring system Victorian Hospitals Incident Management System (VHIMS) s The Central Gippsland Health Service Chronic Disease Network – current membership of eight people who have De-identified monthly reports on clinical incidents and incidents met on a monthly basis since its inception in October 2009. involving aggression directed at nursing staff are submitted to This group has agreed to provide the major consumer and the department of health as part of this system carer input into the organisation’s Care Co-ordination project. This enables the organisation to conduct trend analysis on s The continuing role of the inaugural Consumer Advocate, a incidents reported under certain categories. position established in late 2009. Patients find satisfaction at health s The continuation of a consumer representative member on the organisation’s Quality and Risk Committee, which is a service subcommittee to the Board of Management. This came into Central Gippsland Health Service rated well in the Victorian effect in April 2010. Patient Satisfaction Monitor survey undertaken in the last six The establishment of an Aboriginal and Torres Strait Islander months of the 2010 calendar year, improving its performance in Advisory Committee occurred in May 2010, following open all areas and leading the way for similar sized hospitals across consultation with the relevant local community. A member from the state. this group also participates in the Central Gippsland Health The Patient Satisfaction Monitor, based on surveys auspiced Service Consumer Liaison Group. by the Department of Health, showed that patients were very Smaller community and service specific advisory groups satisfied with most aspects of their stay at Central Gippsland and working parties, such as the Loch Sport and Rosedale Health Service, at both Sale and Maffra Campuses. Community Health Centre Advisory Committees; the Meals on The health service improved in all areas compared to the Wheels Consumer Reference Groups; and others also provide previous Patient Satisfaction Monitor survey. input. Central Gippsland Health Service is in the Category B band of Accountability hospitals, which includes other medium sized regional hospitals across the state. During the year, there was consultation with the Community Liaison Group seeking their input into this Quality of Care Report. The health service achieved results better than the category average for Overall Care, General Patient Information, Treatment A revised Accountability Framework has been developed with and Related Information, Complaints Management and Physical the support of the Board of Management and as part of the Environment indices as well as the Consumer Participation current Strategic Plan. Indicator. The lower scoring items – all in line with the Category This framework enables accountability and transparency on B average benchmark – were strongly related to overall a number of fronts, including to various funding bodies, local satisfaction included recovery room, explanation of purposes of government and more importantly to the community. The '& Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 framework responsibilities have been assigned to the various right person(s), at the right time, in the right setting, to achieve Committees within the organisation’s Quality Structure, ultimately the best outcome. reporting through to the Board of Management. It is led by a Project Steering Committee which includes Health Care and Treatment members from across the organisation’s continuum of care as well as a representative from the Central Gippsland Health As indicated above, Central Gippsland Health Service Service Consumer Liaison Group. emphasises the importance of providing services that are person centred. Central Gippsland Health Service has also facilitated a two year, Improving Care for Older People project. The resulting Functional This is most evident in the major Care Co-ordination project Design Toolkit and related strategies has and will influence care that commenced across the organisation in August 2009 and co-ordination practices into the future. is ongoing. This project seeks to ensure the right service by the

KEY AREA

Koori Wellbeing has held its second Flag Raising Ceremony for NAIDOC Week which was attended by local Elders, Board members, Goal: To receive direction from our Koori community members and staff. Central Gippsland Health communities about what is required of CGHS Service now has a formal policy and procedure that requires to enhance Koori health and wellbeing. acknowledgement of the traditional owners of this land. In the 2006 census, 432 people in the Wellington Shire s Workforce: Central Gippsland Health Service was successful reported to be an Aboriginal or Torres Strait Islander, which in securing funds to support six local young Aboriginal people equated to 1.07% of the total Shire population and compares to take up traineeships as Allied Health Assistants. This has to 0.6% for all of Victoria. This population is a significant group occurred with the support of the ATSI Advisory Committee within the Health Service catchment because of the enduring and Ramahyuck District Aboriginal Corporation. These people health inequities that exist in comparison to the non-Aboriginal have now commenced. population. s Regional and local engagement: Central Gippsland Health Central Gippsland Health Service continues to walk alongside the Service continues to participate in the Gippsland Closing the Health Gap Advisory Committee, as well as the local local Aboriginal and Torres Strait Islander community members sub-committees of that initiative. The health service is also and appreciates their support in achieving some important consolidating its relationships with service staff at Ramahyuck milestones over the year. District Aboriginal Corporation, and now has a commitment to s Walking alongside our local community: Thank you to the formally meet at least three times per year, as well as engage members of the now established Aboriginal and Torres Strait with service specific areas. Islander Advisory Committee. This group has been extremely s Cultural awareness for staff: Central Gippsland Health Service important in helping to progress the health service’s has commenced a review of its orientation program and objectives. within this, will embed Aboriginal cultural awareness as both s Demonstrating symbolically recognition for the traditional a requirement of new staff and an ongoing competency for owners: Over the past year Central Gippsland Health Service all staff.

Clinical Educator Sue King, left, introduces Allied Health Trainees Rhiannon Munro, Karly Walker, Kayla Kennedy-Hill and Kimberley Pepper to some of the training aids they will work with during their course. Case study trainee program specifically designed to create career opportunities and pathways for Aboriginal health workers and NAIDOC Week starts new career for also improve Aboriginal health outcomes. local people The six trainees will combine practical work with a flexible For a group of six young Aboriginal people, the beginning of online course through the Australian Institute of Flexible NAIDOC Week 2011 had a special significance. Learning that on completion will earn a Certificate IV in Allied The group took part in a flag raising ceremony at Central Health Assistance. Gippsland Health Service which coincided with their first day The new program has been made possible by a $75,000 on the job as Allied Health Assistance Trainees. grant through the Department of Health’s ‘Closing the Health Lynette Davis, Kayla Kennedy Hill, Rhiannon Munro, Kimberley Gap in Victoria’ program with matching support from the Pepper, Jai Walker and Karly Walker all started an 18 month Health Service.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 '' Pictured after receiving the award are from left, Dr Liz Wearne, award winners Sandra Neilson, who is the Central Gippsland Health Service Koori Liaison Officer, Marlene Drysdale and Bonnie O’Shannassy, and Dr Patrick Kinsella. Koori training team takes national award awareness sessions to doctors undertaking the Southern GP Training. Southern GP Training is one of an Australia-wide Central Gippsland Health Service Koori Liaison Officer Sandra network of regional training providers and coordinates the Neilson was part of a team that has earned a national award training program in Gippsland for doctors who want to specialise during the year. in general practice. Part of the curriculum includes issues relating The team, also including Head of Indigenous Health with to Aboriginal health. Monash University’s Department of Rural and Indigenous Health, The national award was testament to the hard work and Associate Professor Marlene Drysdale and Bairnsdale-based dedication of Sandra, Marlene and Bonnie to support the training Koori Liaison officer Bonnie O’Shannassy, earned the Australian of medical professionals to work with the Gippsland Aboriginal General Practice Training (GPET) Aboriginal and Torres Strait community. Islander Health Training Award for 2010. The award was presented at the annual General Practice The trio coordinates and delivers Aboriginal health and cultural Education and Training (GPET) convention held in Alice Springs.

KEY AREA

Culturally and Linguistically Diverse people from the CALD community. This is in line with the ‘Doing It With Us, Not For Us’ Strategic Direction 2010-2013. backgrounds s Use of Interpreter Services: Central Gippsland Health Service Goal: Ensure people from culturally and continues to access this service. linguistically diverse backgrounds experience s Networking: Central Gippsland Health Service participates equitable access to services to maximise their in regional and local networks, particularly with Gippsland health and wellbeing. Multicultural Services. A significant number of people from Culturally and Linguistically s Listening to our local community: Some consultation has Diverse backgrounds live in the Wellington Shire and it is very occurred with this local community, however this continues important that the health service continues to support the ageing to be an aim for Central Gippsland Health Service. It is population to access services and maximise their health and important for the health service to listen to local Cultural and wellbeing. Activities towards achieving this important goal this Linguistically Diverse community members. year have been: s Cultural awareness for staff: Central Gippsland Health Service s Provision of appropriate information: Central Gippsland has commenced a review of its orientation program and Health Service is now developing a procedure that requires all within this, will embed CALD cultural awareness as both a client/patient information to meet the needs of the particular requirement of new staff and an ongoing competency for all client group, and to do this, it will require consultation with staff. '( Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Case study ‘Count Us In’ project progresses The ‘Count Us In’ project which had a range of activities including some in the CALD area, has made great progress this year. A major part of the project has been the development of the garden area at Wilson Lodge Nursing Home in Sale, including construction of a vegetable garden with a Culturally and Linguistically Diverse (CALD) component that will involve people from different cultural backgrounds. As well as developing the general garden areas in the grounds of Wilson Lodge, a sensory garden has been developed, with the ability for people in wheelchairs to access raised garden beds, a large planting of native plants has taken place and a sensory herb garden developed. A centrepiece has been the construction of a giant outdoor ‘comfy couch’ made from brick rendered straw bales, which forms a conversation area for residents and visitors. The project has involved numerous groups, including students from Sale College as part of its Helping Hands Project, various local businesses and Fulham Correctional Centre, which provided a work crew to assist with installation of crushed granite pathways designed for easy accessibility. Other components of the project include creation of a ‘Tree of Life’ mosaic by artist Meg Viney in conjunction with residents and the local Aboriginal community producing a weatherproof work of art depicting the history of indigenous people in the region.

Greg Simmons shows off his handiwork with the completion of the outdoor giant couch, while student Adam ‘Buckets’ Schade helps Lisa Ross plant out the garden.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 ') KEY AREA

Business Units Service Medical Imaging. The two business units generate a significant net financial benefit for the health service. Goals: To develop and protect profit centres to Identification of key outcomes supports the drivers that enable enable the generation of discretionary funds the business units to operate at optimum capacity and maintain that can be targeted to address priority needs. competitive advantage, while not compromising need and their reputations as high quality service providers. Background Central Gippsland Health Service includes two major business units, the Sale Linen Service and Central Gippsland Health

Outcomes Medical Imaging Linen Service Medical Imaging had a productive year, with the replacement of the radiography processing equipment contributing to In an effort to improve in areas such as infrastructure improved efficiency and effectiveness of medical imaging replacement, energy and water efficiencies and other long services while maintaining currency with rapidly changing term business decisions, a comprehensive strategic plan is medical imaging technology. being developed to drive the linen service for the next five years and beyond. There were improvements to the department’s main patient waiting area and one of the ultrasound rooms. As a part External stakeholder analysis has been completed with an of a patient service and centralised intake redevelopment, internal stakeholder planning day scheduled for September planning has taken place so the Medical Imaging Department 2011. will receive a much needed upgrade to the administration, The implementation of structured meetings and consultation reception and patient waiting areas. with the Engineering Services Department has enabled A review of the fee structure has been completed with a view the linen service to implement a comprehensive regular to remaining competitive and financially beneficial to the maintenance program to reduce equipment break downs and health service, while living up to the value of social justice and any major impacts on business production. supporting access for people. Workforce capability development has commenced, with six A review of the medical imaging referral form has been staff members in the process of completing staff traineeships completed and distributed to the wider medical community which recognises their ongoing service to the organisation as to assist with maintaining and supporting the overall well as providing them with an education pathway. sustainability of the service.

Pictured is part of the garden area at Wilson Lodge which was redesigned as part of the ‘Count Us In’ project '* Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 KEY AREA

Building Infrastructure The Engineering Services Department has also developed and delivered new Essential and Planned Preventative Maintenance Goal: To meet our short to medium term schedules to maximize long term effectiveness of the built infrastructure requirements and to position environment. These schedules are based on the maintenance ourselves to receive the major capital funding standards for critical areas in Victorian health facilities, released in 2010. required to meet our long term needs. A minor restructure within the department has led to additional Building Infrastructure capability in the mechanical field allowing for additional works The Engineering Services Department has worked hard to to be conducted internally. This reallocation of resources has support physical infrastructure and enable the effective and resulted in the ability to overhaul more than 90% of the Heating, efficient delivery of services across the Central Gippsland Health Ventilation and Air Conditioning (HVAC) system plant during Service. This last year has seen several key projects delivered, this year. Returning these systems to near new condition not on time and on or under budget, that have both increased only improves patient and staff comfort, but also improves the capability, and ensured viability of existing services into the operating efficiency of the equipment. future. Some of these projects include: Minor new works completed in the Medical Imaging Department s Installation of an Uninterruptible Power Supply have created much needed space for an additional patient (UPS). This piece of vital infrastructure will ensure the waiting area. This has worked well to minimize congestion at the health service has seamless electrical supply to critical areas main reception while providing a more comfortable environment of the hospital, regardless of external supply issues. Areas for patients. Money raised by the Medical Imaging Department protected by the UPS include the Operating Theatres, Central was used to install a television to improve the patient Sterilisation and Supply Department, Critical Care Unit, Renal experience. Further works are planned to further improve the Dialysis, Emergency Department and Medical Imaging Unit. patient journey, by redeveloping the reception area to be more accessible and user friendly. s Modernisation of the Community Services Elevator. The elevator servicing the Community Services Building has Upgrade works at the Maffra Campus and McDonald Wing been upgraded and standardized against the rest of the were completed during the year. The works included a general elevator fleet across the Sale Campus. refurbishment of residents’ rooms, providing en-suites where possible, improved access to bathroom and toilet access, and s Wilson Lodge Emergency Generator. Following on converting a four-bed room to a three bed room with en-suite. from the installation of automatic electrical supply switching A range of energy efficiency improvements were incorporated equipment in 2009/10, an emergency generator set has from the onset of the project and are evident in all aspects of been successfully integrated and will enable Wilson Lodge to the finished product. operate autonomously in the event of a power supply failure. The project was supported by a significant contribution from the s Radio Frequency Paging System Upgrade. A new Clyne Estate Fund as well as funding from the Department of computer based radio frequency paging system has been Health. installed providing enhanced capability and improved system integrity. This communications infrastructure supports both day to day operations, and also forms the backbone of the emergency communications system.

KEY AREA

Energy Efficiency performance benchmarks and provide leadership for the entire organisation on improving all aspects of environmental Goals: Our goal is to significantly improve our performance. This is vital if the health service is to meet strict energy related performance and to engage Department of Health and Victorian State Government targets. in activities that will support substantial and Particular areas of interest for the Group include, but are not limited to: long-lasting reductions in energy use and s reducing energy and water usage through open generation of waste. communication and targeted education programs, Following on from an extensive Level 2 Energy Efficiency audit conducted in 2010, Level 3 audits were commissioned s thinking creatively in order to reuse excess/obsolete furniture to quantify actual savings based on recommendations from negating disposal, etc. the initial audit. The outcome has been welcomed and the s expanding the existing recycling schemes to transfer more Engineering Services Department is now ready to undertake two waste away from landfill, and projects aimed at reducing electricity and natural gas usage. It is s reducing waste generation by selecting products which use hoped that new capability established within the organizational less packaging. structure will be able to take advantage of opportunities that exist for state and federal funding and will see these and other Several small pilot programs are currently in planning to test such projects come to fruition. cost effective and real opportunities to improve environmental performance at all levels. It is hoped that by leading the way, the In late 2010, an Environmental Management Group was health service will set an example local residents will be proud formed. The purpose of this Group is to establish operational to follow.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 '+ Our History to two not-for-profit private facilities, Stretton Park Hostel Inc and Heyfield Hospital Inc. These facilities have acute and aged care The Gippsland Base Hospital, forerunner to the current Central services as well as 19 independent living units. Gippsland Health Service, was established more than 140 years ago. More than 1,100 staff members occupying more than 650 full time equivalent positions are employed by Central Gippsland In the intervening years, various other service entities were Health Service, which is also supported by some 600 volunteers established in the surrounding districts of what is now the Wellington Shire. and has total revenues of $70 million. These included home and community services, community The organisation serves the immediate population in Central health centres and maternal and child health centres established Gippsland, while acute specialist services reach a wider by municipalities based in and around Maffra, Sale and Rosedale community in East Gippsland and parts of South Gippsland. in the 1970s. Governance Through a series of amalgamations, the Gippsland Base Central Gippsland Health Service is a Body Corporate listed in Hospital, Maffra and District Hospital, the JHF McDonald Nursing the Victorian Health Services Act 1988 and operates under the Home and Evelyn Wilson Nursing Home became the Central provisions of this Act. Gippsland Health Service in 1999. As well, the Heyfield Hospital, Stretton Park and Laurina Lodge Hostel became associated by Two Ministers were responsible for the administration of the management agreement with the Central Gippsland Health Victorian Health Services Act during the reporting period. The Service. Hon. Daniel Andrews, M.P. was the Minister for Health until December 2010. Central Gippsland Health Service is responsible for the majority of acute and residential aged care as well as a wide range of From December 2010, the Minister for Health was The Hon. community services throughout Wellington Shire, excluding David Davis. Yarram and district. The registered office of Central Gippsland Health Service is 155 The health service provides management and corporate services Guthridge Parade, Sale, 3850. Telephone (03) 5143 8660.

Board of Management The Board members at 30 June 2011 were:

Catherine Greaves: (Chair) John Sullivan: (Vice Chair) A Glenn Stagg: A local accountant, John Lawrence: John is Executive A manager at Wellington Shire local lawyer, John is also a past Glenn is a former Board Chair. Director of Kilmany Uniting Care, Council, Catherine has also been a President of the Board of the with a background in business Board Member of Kilmany Uniting Gippsland Base Hospital and of management and health policy. Care. Central Gippsland Health Service.

Helene Booth: Helene brings Dr Angela Todd: Angela is Libby Thompson: Libby is a a strong finance background as a Chiropractor with the Todd former nurse who worked with a partner in Booth Cartledge Chiropractic Wellness Group. She Central Gippsland Health Service Accountants in Sale. resigned from the Board early in in Maffra as well as in private the 2011 calendar year. practice. She is also involved in the agricultural sector through involvement in the family farm. ', Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 New Board Chair After a three year role as Board Chair of Central Gippsland Health Service, John Sullivan stepped down, with Catherine Greaves taking on the job. Mr Sullivan, a local lawyer, has been Chair for the past three years and will remain on the Board as the Vice Chair. It is Ms Greaves’ first term as Board Chair. A manager with Wellington Shire, she has been on the Board since 2006 and was the Vice Chair for the past two years. Executive Staff As at 30 June 2011 Chief Executive Officer Dr Frank Evans Director Medical Services Dr Ka Chun Tse Director of Nursing Ms Bronwyn Beadle A group of nurses graduated during 2010. They are pictured celebrating their Director Community Services graduation. Ms Mandy Pusmucans Solicitors Milstein and Associates Bill Kee and Associates Lucy Hunter Banker National Australia Bank Limited

Workforce data Labour Category Female % Male % TOTAL FTE Administration & Clerical 91 9.20% 15 1.52% 106 77.62 Ancilliary Support Services 38 3.84% 7 0.71% 45 30.30 Hospital Medical Officers 13 1.31% 15 1.52% 28 13.29 Hotel & Allied Services 176 17.80% 57 5.76% 233 148.58 Medical Officers 5 0.51% 23 2.33% 28 16.55 Medical Support Services 54 5.46% 12 1.21% 66 44.85 Nursing Services 454 45.90% 29 2.93% 483 256.46 Total 831 84.02% 158 15.98% 989 587.65 Labour Category Female % Male % TOTAL FTE Central Gippsland Health Service 831 73.74% 158 14.02% 989 587.65 Heyfield 90 7.99% 5 0.44% 95 42.20 Stretton Park 41 3.64% 2 0.18% 43 22.09

Total number of staff employed 962 85.36% 165 14.64% 1127 651.94 by the Whole Network This report includes casual, part-time and full-time active employees as at 30th June 2011

Central Gippsland Health Service accepts its legislated requirements to develop both a safe environment and an organisation and culture that embraces and operationalises the principles of merit, equity and diversity.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 '- Overview of Services Acute Care

Clinical Visiting Specialist Services Support Services Outpatient Services Cardiology Genetics Nursing Administration Continence Advisor Critical Care Ophthalmology Bed Allocation Podiatry Day Procedure Paediatric Surgery Infection Control Cystic Fibrosis Dialysis Ear, Nose and Throat Stomal Therapy Wound Audiology Emergency Dermatology Management Antenatal Specialist Medicine Lithotripsy Professional Development Specialist Surgery Gastroenterology Food Services General Practice Urology Pharmacy Hospital in the Home Orthopaedic Surgery Environmental Obstetrics and Renal Medicine Breast Care Gynaecology Fertility Care Coordination Paediatrics Oncology Operating Theatres Pre Admission

Residential and Aged Care Services

Nursing Home Care Respite Care Hostel Care Independent Living Units Maffra – McDonald Wing Heyfield - Laurina Lodge Maffra – Stretton Park Maffra – Stretton Park Sale – Wilson Lodge Maffra - Stretton Park Heyfield – Laurina Lodge Nursing Home Hostel Heyfield – Laurina Lodge

Community Services

Allied Health to both the Community Health and Home Support and Home Nursing Acute and Community Partnerships Service Co-ordination District Nursing Settings Community Health Home Care Palliative Care Physiotherapy Nursing Personal Care Hospital in the Home Occupational Therapy Respiratory Educator Respite Care Continence Nurse Podiatry and Foot Care Diabetes Educator Delivered Meals Consultancy Dietetics Maternal and Child Health Property Maintenance Speech Therapy Volunteer Program (CAVA) Planned Activity Groups Social Health Community Dental Community Transport Program Koori Liaison Care Coordination Children’s Services Health Promotion Post Acute Care

'. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Community Services (continued)

Partner/Member Community Support Co-located Visiting Groups Services Wellington Primary Care Partnership Childbirth Education Community Mental Classes Health Wellington Working Together for Families Parkinson’s Support Family Court Counselling Group Let’s Get Connected Family Mediation Transport Project Carers’ Support Groups Primary Mental Health Committee New Mothers’ Group SCOPE Gippsland Region Palliative Care Consortium Various other collaborative projects

Support Services

Finance Human Resources Support Services Information Services Financial and Management Recruitment Engineering Medical Records Reporting EEO Equipment Maintenance Freedom of Information / Accounts Payable Induction and Orientation Telecommunications Privacy Accounts Receivable Industrial Relations Asset Management Health Records Reception Occupational Health & Building Maintenance & Admissions Safety Development Information Technology Risk Management New Capital Works Information Technology Payroll Staff records Applications Payroll WorkSafe/Return to Work Environmental Services Information Technology Salary Packaging Porters Infrastructure Security Supply Services Medical Library Supply Fleet Management Accommodation Management

Food Services and Catering

Administration

Strategic Planning Business Units Major Projects Public Relations Medical Imaging Fundraising Linen Service Government Relations Prison Services Organisational Policy Consulting Suites Development Quality Management

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 '/ Organisational Structure Manager Food Services Food Manager Maintenance Engineering and Service Medical Imaging Manager Medical Imaging rooms CGHS Consulting Projects ICT Supply Service Risk and Special Sale Linen Support Services General Manager Switch Reception & Payroll Finance Finance General Manager Chief Executive Management Library Management Services Services Learning and Safety & Fleet Human Resource Occupational Health Learning Workforce Capability and General Manager Care Public Dental Allied Nursing Palliative Health Services Community Director of Coordination Community Intake and Care Support Services Support Services Health & Home and Community Community Partnerships HITH Lodge Wilson Stretton Hospital Heyfield Units Pharmacy Park Hostel Park Services Hospital (Inc CSSD) Emergency Department Theatre Suite Theatre Maffra District Director of Nursing Environmental Acute Inpatient Management Health Information Hospital Clinical Nursing Services Quality Operations & Specialist Patient & Client Services Patient Services (Inc. Pre-admission & General Intake Director of Medical Medical Specialists Visiting Medical Officers Visiting Hospital Medical Officers

(& Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Support Groups Friends of Central Gippsland Health Maffra Hospital Ladies Auxiliary Service Sale Campus (formerly Gippsland It is my pleasure to present this report for the year 2010 – 2011. Base Hospital Auxiliary) A faithful band of members continue to work to support the It is with pleasure that I again report what has been a very Maffra campus of our local hospital. This year we were very busy year for the Friends of Central Gippsland Health Service, pleased to welcome three new members to the Auxiliary, especially with gift wrapping done at Christmas, Mother’s Day bringing our membership to 18. and Father’s Day. We raise funds to provide items for the hospital, both to Thank you to the Gippsland Centre, Sale for all their wonderful enhance the comfort of residents and to assist the nursing staff. support and the general public for the gifts we raffle. The Annual Oaks Day Luncheon continues to be the highlight Once again we had a very successful Bingo night at the Sale of our fund raising and is well supported by members of the Greyhounds Club and extend our thanks to the staff for their support. We have purchased much needed equipment for community. We also had a morning coffee and “High Tea”. We several wards with more to be selected from the Equipment served Devonshire teas at the Open Day held at Maffra Hospital Wish List we have been provided. in October. Christmas gifts were once again given to patients in hospital at Our Easter and Christmas raffles were very well supported. Christmas time. We are grateful to members of the community who support us Congratulations to Vic Forrest, awarded a life membership of the through the I.G.A. Community Benefits Scheme which raised group this year despite some health issues. $1,636.00. In closing we would like to thank all the Health Service staff and No large items have been purchased this year as major works general public for their support, with special thanks to all our and refurbishment have been taking place at the Maffra Campus members and volunteers. for the past eight months. Residents are now returning to their rooms and so we are waiting for Sonya (our Health Services Manager) to come to our next meeting with her “wish list”. Elva Doolan-Jones We continue to cover the cost of bus hire for outings of President McDonald Wing residents. Thanks are due to all members who so willingly support our fundraising functions and take their turn delivering Meals on Wheels. Many thanks to our Secretary, Pat Cameron and to Treasurer, Pat McKenzie for so capably keeping track of our finances.

Lennie Stammers President

Case study with the life membership by Central Gippsland Health Service Chief Executive Officer Dr Frank Evans. Life membership for health service Mr Forrest broke new ground when he joined what was then supporter the Gippsland Base Hospital Ladies Auxiliary in 1995. He was the first man to join the group, which changed its name A decade and a half of dedicated effort has earned Sale to Gippsland Base Hospital Auxiliary to reflect the broader identity Vic Forrest a life membership of the Friends of Central gender involvement. The group has since adopted the name Gippsland Health Service, formerly the Gippsland Base Friends of the Central Gippsland Health Service. Hospital Auxiliary. Vic Forrest (left) receives his Life Membership certificate from Mr Forrest, who has served in most roles with the group and Central Gippsland Health Service Chief Executive Dr Frank undertook another term as secretary this year, was presented Evans.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 (' Partnership benefits health service Service for their support in recent years – although, as one member noted, most of the thanks probably should go the The co-operative partnership between Ritchies and the other way! Under the Ritchies Community Benefit Card Program Friends of the Central Gippsland Health Service Sale has been a percentage of the money spent by Ritchies customers is celebrated by the grocery chain. donated to charity. Ritchies Store manager at Maffra, Colleen Phillips, presented a Locally, the Friends of Central Gippsland Health Service, formerly plaque to commemorate its relationship with the Friends, which known as the GBH Auxiliary, has been one of the long term has seen donations in excess of $63,000 to the Health Service beneficiaries of the program and pass on that support by in the past few years. purchasing relevant equipment and other items for the Health The plaque was created to thank the Friends of the Health Service.

Pictured in the Emergency Department surrounded by items purchased with the support of Ritchies and the Friends of the Central Gippsland Health Service are, from left at back, nurse Rosalie Walker and group members Amanda Duck, Verna Pilgrim, Emergency Department Nurse Unit Manager Louise Vuillermin, and Iris Mitchell, while in front are Carmel McManus, Ritchies Store manager at Maffra Colleen Phillips, and Elva Doolan-Jones.

DONATIONS Central Gippsland Health Service gratefully acknowledges the support of individuals, families and organisations who gave donations of cash or equipment during the past year. Because of issues which may arise due to the Privacy Act, we have chosen not to list personal names in this report. Total contributions received 2010/2011 General Donations $25,172 Ward Specific and Restricted Purpose Donations $103,543.72 Clyne Estate (Bequest) $118,585.86 Donation helps heart patients The big job of keeping track of the records of people recovering from cardiac illness has been made a little easier, following another donation to Central Gippsland Health Service by Heartbeat Wellington. The group, established to assist others who had suffered from cardiac illness, has raised funds to purchase a laptop computer for use by Cardiac Rehabilitation Nurse Peta Griffiths. As well as working in the Critical Care Unit, Ms Griffiths, who is a cardiac care nurse, runs an eight week rehabilitation program for those recovering from heart illness. With between 50 and 70 people a year taking part in the programs, the dedicated computer will make record keeping more efficient. This donation by Wellington Heartbeat, who have provided Heartbeat Wellington members, from left, Lyn Answer and marvellous support over the years, is another example of the Margaret Gibbons, are shown how the new computer works group’s dedication. by Cardiac Rehabilitation Nurse Peta Griffiths.

(( Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Fund raising went so well. One of the key organisers, Ann Payne, a Stomal Therapy/Wound Consultant at the Health Service, said the aim Spring Ball raises $15,000 was to raise $15,000.00 to help purchase a specialised piece of A major fundraiser for the year was a Spring Ball, organised and wound management equipment. coordinated by a group of staff. After a few expenses, the desired result was made possible by The Spring Ball was a huge success, with more than 370 people the generosity of the more than 50 businesses who donated attending and $15,000.00 raised. items as prizes for the evening. The outcome exceeded the expectations of the organisers, who Local bands, the Soultana’s and The Uncles, as well as the Sale were delighted so many people attended and that the event College Big Band also donated their time and expertise to help.

The dance floor was packed all evening.

Sale-Lakes ride keeps benefiting health Sale to Lake Tyers then undertaking the reverse trip on Sunday. service According to one of the veterans of the event, Shirley Mowat, this year was a wonderful ride. A group of 81 hardy cyclists enjoyed close to ideal conditions for “Everyone was so friendly, I think the event has great the 18th annual Sale to Lakes Bike ride held as a fund raiser for organisation, great food and provides an excellent atmosphere the Central Gippsland Health Service. to have fun and socialise. The ride was superb, especially on the The group, under the guidance of first time organiser Renee ride home on Sunday with tail winds,” she said. Heath, traversed the scenic East Gippsland countryside in The ride raised several thousand dollars to add to the more than November, riding some 185 kilometres on the first day from $100,000 raised since the ride was first held in 1993.

One of the groups of riders included, from left, Shirley Mowat, Lorraine Duck, Mary Jackson, Julie Cowling, Jan Roberts, Pam Griffiths and Cathie Wake. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 () Executive Staff as at 30 June 2011 Dr DA Monash Chief Executive Officer Dr Frank Evans Dr D Mudunna Director Medical Services Dr Ka Chun Tse Dr IC Nicolson Director of Nursing Ms Bronwyn Beadle Dr C O’Kane Director Community Services Ms Mandy Pusmucans Dr R Nandha Senior Staff Dr AC Richards Dr U Sharma SENIOR MEDICAL & DENTAL STAFF 10/11 Dr H Stanley Anaesthetist Consultant Dr P Stevens Dr G Rooke Dr F Sundermann Anaesthetist GPs Dr LA Waters Dr N Atherstone Dr AJ Watt Dr N Fuessel Dr AJ Wright Dr J Lancaster General Practitioners Consultant Dr R Nandha Dr A Hughes Dr C O’Kane Dr A Wong IVF/Gynaecology Dr G Weston Dermatologists Dr C Baker Nephrologist Prof D Power Dr D Gin Prof R Langham Dr J Horton Dr A Mar Nuclear Medicine Physician Dr R L Nixon Dr Y Jenkin Dr D Orchard Obstetricians & Gynaecologists Director Medical Services Dr R Guirguis Dr K C Tse Dr RJ McKimm Echo Cardiologist Dr A Sarkar Dr J Gutman Obstetrician GPs Emergency Medicine Senior Medical Dr C O’Kane Officers Dr AJ Wright Dr B Cole Ophthalmologist Dr A Richards Mr A Amini Dr S Williams Oral Maxillofacial Surgery Forensic Medical Officer (Affiliated) Dr S R Hookey Dr R Hides Orthopaedic Surgeons General Practitioners Mr A De Villiers Dr Y Ahmad Mr P Rehfisch Dr S Anderson Otorhinolaryngologists (ENT) Dr M T Baker Mr PJ Guiney Dr F Begum Mr B Cook Dr JM Bergin Paediatricians Dr A Burk Dr A Erasmus Dr J Bvirakare Dr. Ophir Sylvia Welgemoed Dr P Dandy Dr LJ Derrick Paediatric Cardiologist Dr L Fong Dr RJ Hides Dr G Ivanoff Paediatric Rehabilitation Physician Dr CJ Jarman A/Prof H Rawicki Dr B Johnston Paediatric Surgeons Dr CA Martin Mr C Kimber Dr RH Melville Mr N McMullin

(* Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Pathologists Surgeon Upper GI Dr. Steuart Rorke Mr S Banting Dr. Modisha Peiris Surgeon Vascular Physicians Mr N Roberts Dr H Connor Surgeon Colorectal Dr V Das Assoc/Prof John Mackay Dr K Mandaleson Dr RW Ziffer Urologist Assoc Prof M Frydenberg Physician (Locum) Mr P McCahy Dr S Hii Dentists Radiologists Dr R Cox Dr R Bain Dr JJ Gibson Dr R Brownlee Dr T Kulatunge Dr R Malouf Dr G Savarkudele Dr B Pedrotti Dr K Stribley Dr T Ranten Dr A Zammit Dr I J Ronchi Surgeons General Dr O Husodo Mr A Aitken Dr J Roberts Mr A Sarkar Palliative Care Practitioners Mr P Strauss Dr Alexandra Burke Surgeon Honorary Dr Jane Fischer Mr I McN Miller Dr Scott King Surgeon (Locum) Dr Elizabeth Whyte Mr I Farmer Dr Brian McDonald

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 (+ ACUTE SERVICES RESIDENTIAL AGED CARE Director Critical Care and Emergency Services Dr Howard WILSON LODGE NURSING HOME Connor Nursing Unit Manager Sandra Knowles Deputy Director of Emergency Services Dr Brian Cole STRETTON PARK HOSTEL AND Head of Anaesthetics Dr Noel Atherstone INDEPENDENT LIVING UNITS Director of Aged Care Dr Krishna Mandaleson Care Manager Robyn Cotterill Director Pharmacy Annabel McNally Deputy Director of Nursing and Quality Improvement COMMUNITY SERVICES Manager Dianne Matcott Home Support and Service Coordinator Mary Hartwig Hospital Co-ordinators: Wendy Harwood; Neville Nicholas; Allied Health Managers Aletha Leendetz; John Heath; Therese Smyth; Judy Niziolek; Janny Steed; Michael Hams; Sue Kathy Cook; Jennifer Ensor. Shadbolt; Dianne Matcott; Caroline Rossetti; Jo Bennett; Jennifer Community Health and Partnerships Manager Dennett; Gary McMillan; Sue Roberts; Tim Coles; Heather Ruth Churchill Hayman; Jill Crosier; Therese Burke; Tracey Bland; Michelle Shanahan. SUPPORT SERVICES SURGICAL SERVICES General Manager Finance Daryl Cooper Nursing Unit Manager, Surgical Gary McMillan General Manager Support Services Jon Millar Nursing Unit Manager, Perioperative Services Sally Relph Engineering Services Manager Rod Cusack OBSTETRIC/PAEDIATRIC UNIT Environmental Services Manager Geoff Brown Food Services Manager David Askew Nursing Unit Manager, Obstetrics and Paediatrics Moira Tulloch Health Information Manager Heather Rowell MEDICAL SERVICES HMO Manager Hannah Cole Nursing Unit Manager, Critical Care, Dialysis, Payroll Manager Raquel Kenney Cardiology, Oncology Jenny Dennett Supply Manager Jon Millar Nursing Unit Manager, Medical Sue Roberts WORKFORCE CAPABILITY AND LEARNING Nursing Unit Manager, Emergency Kate Roberts General Manager Denise McInnes CLINICAL SUPPORT SERVICES Librarian Helen Ried Infection Control Officers Cathy Mowat and Andrea Page Human Resources Manager Hannah Cole Wound/Stomal Therapy Ann Payne BUSINESS UNITS MAFFRA CAMPUS Business Units General Manager Jon Millar Health Service Manager Sonya Hanratty Medical Imaging Practice Manager Nicole Sharp Nursing Unit Manager Karen Llewellen; Kylie Barnes Sale Central Linen Service Supervisor Sue Jenner HEYFIELD (including Laurina Lodge) Health Service Manager Anne Woollard Clinical Care Manager Belinda Cornwall

(, Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Statutory Information Statutory Compliance Central Gippsland Health Service is a public hospital listed in Schedule 1 to the Health Services Act 1988 (the Act). Central Gippsland Health Service is an incorporated body and is regulated by the Act. The Victorian Ministers for Health during 2010/2011 were The Hon. Daniel Andrews until December 2010 and The Hon. David Davis from December 2011. Reporting Requirements The information requirements listed in the Financial Management Act 1994 (the Act) the Standing directions of the Minister for Finance under the Act (Section 4 Financial Management Reporting) and Financial Reporting Directions have been prepared and are available to the relevant Minister, Members of Parliament and the public on request. Objectives, functions, powers and duties of Central Gippsland Health Service The principal objective of Central Gippsland Health Service is to provide public hospital services in accordance with the Australian Health Care Agreement (Medicare) principles. In addition to these, Central Gippsland Health Service has set other objectives which encompass the shared vision, core values and strategic directions of the organisation. Whistleblowers, FOI (REPORTED IN FOLLOWING SECTION) Consultancies engaged during 2010/2011 A number of consultants were contracted to work for Central Gippsland Health Service in 2010/2011. As required by the Victorian Industry Participation Policy Act 2003, a summary of the extent of contractual costs for consultants is outlined.

2010/2011 2009/2010 Number of consultants used to a value greater than $100,000 00 Total cost of consultants used to a value greater than $100,000 0 0 Number of consultants used to a value less than $100,000 4 4 Total cost of consultants used to a value less than $100,000 $26,295 $38,299 During 2010/2011 there have been nil contracts commenced or completed under the Victorian Industry Participation Policy Act 2003. Competitive Neutrality Central Gippsland Health Service supports the Victorian Government’s policy statements as outlined in Competitive Neutrality; a statement of Victorian Government policy. Competitive Neutrality is seen as a complementary mechanism to the ongoing quest to increase operating efficiencies by way of benchmarking and embracing better work practices. Building Act 1993 Compliance Central Gippsland Health Service complies with the Standards for Publicly Owned Buildings (the guideline). Central Gippsland Health Service controls nine (9) properties, six (6) residential care and three (3) non-residential care. All new work and redevelopment of existing properties is carried out to conform to current building regulations (1994) and the provisions of the Building Act 1993. The local authority or a building surveyor issues either a Certificate of Final Inspection or an Occupancy Permit for all new works or upgrades to existing facilities. As at June 30, 2011, fire risk audits had been completed for all Central Gippsland Health Service occupied residential care facilities. Central Gippsland Health Service installs and maintains fire safety equipment in accordance with building regulations and regularly conducts audits. The upgrading of fire prevention equipment in buildings is also undertaken as part of any general upgrade of properties where necessary and is identified in maintenance inspections. Central Gippsland Health Service requires building practitioners engaged on building works to be registered and to maintain registration throughout the course of the building works.

Non residential Residential Loch Sport CHC 1 Community Care 1 Community Rehabilitation Centre 1 Heyfield Hospital 1 Laurina Lodge 1 Maffra Hospital 1 Stretton Park 1 Sale Acute 1 Wilson Lodge 1

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 (- Freedom of Information making of disclosures, where these are supported by reasonable grounds, related to alleged improper or corrupt conduct in the A total of 101 requests under the Freedom of Information Act management or conduct of the organisation. were processed during the 2010/2011 financial year. Any staff person or member of the public who has reasonable Requests for documents in the possession of Central Gippsland grounds to believe that improper or corrupt conduct has Health Service are directed to the Freedom of Information occurred, is occurring or is about to occur in the management Manager, and all requests are processed in accordance with the or conduct of the organisation is encouraged to disclose this Freedom of Information Act 1982. to senior staff. The number and nature of disclosures shall be A fee is levied for this service based on the time involved in reported in this and subsequent annual reports. retrieving and copying the requested documents. No disclosures were made to Central Gippsland Health Service Central Gippsland Health Service nominated officers under the during the year Freedom of Information Act are: No disclosures were referred by Central Gippsland Health Service Services to the Ombudsman for determination or Principal Officer investigation. Dr Frank Evans, Chief Executive Officer No disclosure was referred to Central Gippsland Health Freedom of Information Manager Service Services by the Ombudsman, or taken over by the Ombudsman. Ms Heather Rowell, Health Information Administrator No requests were made under Section 74 to the Ombudsman Privacy to investigate. Central Gippsland Health Service has embraced the privacy No matters were declined for investigation. legislation and is committed to ensuring that consumer and staff No recommendations were made by the Ombudsman under rights to privacy are upheld at all times. The organisation has the Act that relate to Central Gippsland Health Service proper processes and policies in place to ensure compliance services. with privacy legislation and to provide information to staff and consumers regarding privacy rights and responsibilities. The Whistleblower Co-ordinator is Frank Evans, Chief Executive Officer. All Central Gippsland Health Service consumers have the right to have personal information stored in a secure location and to Availability of other information be assured that only that information that is necessary to ensure Other information, not contained in the Report of Operations high quality health care is to be collected. Central Gippsland including; Health Service has implemented a privacy complaints procedure that can be accessed by both staff and consumers that both s publications produced by the organisation about its monitors and enforces privacy issues. activities; Whistleblowers s details of any other research and development activities; The Whistleblowers Protection Act (Vic) came into effect on 1 s details of major promotional, public relations and marketing activities undertaken; January 2002. Central Gippsland Health Service has developed both a Policy and Procedure to encourage and facilitate the will be made available if requested in writing.

(. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Report of Operations Service level The population of the total area is approximately 40,000

ACTIVITY DATA ACUTE SUB ACUTE TOTAL Admitted Patients Separations Same Day 6,959 Multi Day 5,290 TOTAL SEPARATIONS 12,249 298 12,547 Emergency Surgery 400 Elective Surgery 3,807 TOTAL SURGICAL OCCASIONS 4,207 Babies Delivered 509 Total WIES 7,041 Total Bed Days 31,781 Non Admitted Patients Emergency Department Attendances 16,252 COMMUNITY SERVICES Hours delivered by Home Care and Community Services 75,486 Meals Delivered 21,832 Hours of Service to externally funded Community, Aged Care package clients 12,676 Palliative care contacts 3,472 Primary Health hours of service 7,726 Allied Health acute services attendances 4,493

KEY PERFORMANCE INDICATORS Responsible Bodies Declaration as at 30 June 2011 In accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for Central Gippsland Health Service for the year ending 30 June 2011.

Catherine Greaves Sale Victoria Board Chair 30 August 2011

SUMMARY OF FINANCIAL RESULTS 2010-11 2009/10 2008/09 2007/08 2006/07 2005/06 Total Expenses 75,882 74,239 65,605 60,482 56,818 54,320 Total Revenue 70,992 70,028 65,161 59,286 57,732 55,752 Operating Surplus/(Deficit) (4,890) (4,211) (444) (1,196) 914 1,432 Accumulated Surplus (Deficit) (14,796) (9,956) (5,745) (5,301) (4,105) (5,019) Total Assets 70,305 73,416 77,797 63,660 64,487 62,998 Total Liabilities 14,394 13,082 13,252 12,579 12,682 12,107 Net Assets 55,911 60,334 64,545 51,081 51,805 50,891 Total Equity 55,911 60,334 64,545 51,081 51,805 50,891

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 29 Summary of Operational and Budgetary Objectives The service recorded a net profit from continuing operations before capital & specific items of $0.04 million (2009/10 $0.7 million loss). After taking into account capital & specific items the net result was a loss of $4.9 million (2009/10 $4.2 million loss) The Health Service budgeted for a net surplus before capital & specific items of $0.0 million and a Net Result loss for the year of $4.9 million Summary of factors that have affected the Operations for the Year The results of the service during the reporting period have been affected by the following factors : - 4.97% below WIES targets which resulted in reduction of income of $0.8 million. - Cost reduction strategy that allowed budget to be achieved even though there was a substantial reduction in income - Significant sick leave Events Subsequent to Balance Date At the date of this report, management is not aware of any events that have occurred subsequent to balance date that may have a material impact on the results of the next reporting period.

Revenue Indicators Average Collection Days 2010/11 2009/10 Private Inpatients 37 27 Victorian Workcover Inpatients 79 42 Other Compensable Inpatients - 44 Nursing Home 4 7 Community Services 26 25

Patient Debtors Outstanding as at 30 June 2010 Under 30 Days 30-60 Days 61-90 Days Over 90 Days Total 30/06/11 Total 30/06/10 $’000 $’000 $’000 $’000 $’000 $’000 Private Inpatients 61 8 - 7 76 77 Victorian Workcover Inpatients 52 - - - 52 - Nursing Home 10 - - 1 11 18 Community Services 110 28 12 - 150 64 Total 233 36 12 8 289 159

Attestations Attestation on Data Integrity I, Frank Evans certify that the Central Gippsland Health Service has put in place appropriate internal controls and processes to ensure that reported data reasonably reflects actual performance. The Central Gippsland Health Service has critically reviewed these controls and processes during the year.

Dr Frank Evans

Accountable Officer

Sale Victoria 30 August 2011 Attestation on Compliance with Australian/New Zealand Risk Management Standard I, Frank Evans certify that the Central Gippsland Health Service 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 executives to understand, manage and satisfactorily control risk exposures. The audit committee verifies this assurance and that the risk profile of the Central Gippsland Health Service has been critically reviewed within the last 12 months.

Dr Frank Evans Accountable Officer Sale Victoria 30 August 2011

30 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Strategic priorities Deliverables Outcome

Population Completed comprehensive evidence and policy informed 50% complete Health needs assessment. 1 Comprehensive suite of service delivery plans 50% Not commenced complete. Workforce CGHS Workforce Capability Framework, based on a service Achieved Capability delivery capability model, implemented with detailed individual capability development plans in place for all senior 2 and middle managers. VET workforce in Allied Health >12.5% of total Allied Health Achieved workforce. Acute Services – All major processes and structural changes associated with Project is well advanced and all process changes have been Sustainability whole of agency Care Coordination Project implemented, identified and documented. Structural changes commenced including patient services, intake, and care coordination with centralized intake and community care coordination processes across whole of CGHS catchment. roles awaiting capital redevelopment project.

Care pathways project, utilizing hospital redesigning care Care pathway project delayed now 2011/12 priority methodology and funding completed. Care pathways 3 developed for top 10 - 15 high volume, high interest, diagnosis.

Community based rehabilitation expanded resulting in Achieved improved bed management and reduced emergency department length of stay.

Theatre productivity improved by >10% Achieved Sustainability HMO and junior medical workforce structure determined Achieved of Specialist with all specialist medical craft groups. Medical Modeling undertaken to estimate junior medical workforce Achieved 4 Workforce requirements to 2015. All specialist medical craft group structures finalized. Achieved

All specialist medical vacancies filled or candidates selected. Achieved Building Completed minor infrastructure upgrade project for Maffra Achieved Infrastructure Hospital. Monash University building upgrade completed including Achieved 5 CGHS learning services areas. Service planning for Maffra campus completed to inform Achieved Master planning for major redevelopment of Maffra site. Energy Efficiency Completed energy efficiency review and established short, Achieved 6 medium and long term goals for improvements. Potential projects and funding sources identified. Projects prioritized and currently seeking funding sources Koori Wellbeing Increased Koori workforce to exceed Closing the Gap targets. Recruitment for 6 ATSI allied health assistant trainees in progress as of 30 June 2011

Complete development of aboriginal reconciliation plan in In progress to be completed by Dec 2011 conjunction with CGHS Koori Liaison Group. 7 Increase Koori cultural awareness by including training in our Not achieved, training in development staff orientation program. In conjunction with the Koori Liaison Officer and other Koori advisors, we have developed and provide cultural awareness training to our existing staff with the aim to ensure >90% of staff attends training over the following 3 years.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 )' Statement of Priorities

Financial Performance

Operating Result 2010-11 actuals

Annual Operating Result ($m) 0.03

Cash Management/liquidity 2010-11 actuals

Creditors (days) 9

Debtors (days) 12

Service Performance

Quality and Safety 2010-11 actuals

Health Service Accreditation Full

Residential Aged Care Accreditation Full

Cleaning Standards >85%

Submission of Data to VICNISS (%) 100%

VICNISS Infection Clinical Indicators

Methicillin Resistant Staphylococcus aureus Infections 1

Vancomycin Resistant Enterococci Infections 0

Clostridium Difficile Infections 1

Occupational Exposures 12

Hand Hygiene Program Compliance (%) Full

SAB Rate (OBDs) 2

Victorian Patient Satisfaction Monitor (VPSM) 80

WIES activity performance 2010-11 actuals

WIES (public and private) Performance to Target (%) 95%

Maternity 2010-11 actuals

Postnatal Home Care 85%

Access Performance 2010-11 actuals

Percentage of Operating Time on Hospital Bypass N/A

Percentage of Emergency Patients Admitted to an Inpatient Bed within 8 hours 83%

Percentage of Emergency Patients with Length of Stay less than 4 hours 84%

Number of Patients with a Length of Stay in the Emergency Department greater than 24 hours 15

Percentage of Triage Category 1 Emergency Patients seen immediately 100%

Percentage of Triage Category 2 Emergency Patients seen within 10 minutes 69%

Percentage of Triage Category 3 Emergency Patients seen within 30 minutes 77%

)( Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Disclosure Index The annual report of the Central Gippsland Health Service is prepared in accordance with all relevant Victorian legislation. This index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements. Legislation Requirement Ministerial Directions Report of Operations Charter and purpose FRD 22B Manner of establishment and the relevant Ministers 16 FRD 22B Objectives, functions, powers and duties 27 FRD 22B Nature and range of services provided 2 Management and structure FRD 22B Organisational structure 20 Financial and other information FRD 10 Disclosure index FRD 11 Disclosure of ex-gratia payments 30 FRD 15B Executive Officer disclosures Financial Section 43 FRD 21A Responsible person and Executive Officer disclosures Financial Section 43 FRD 22B Application and operation of Freedom of Information Act 1982 28 FRD 22B Application and operation of Whistleblowers Protection Act 2001 28 FRD 22B Compliance with building and maintenance provisions of Building Act 1993 27 FRD 22B Details of consultancies over $100,000 27 FRD 22B Details of consultancies under $100,000 27 FRD 22B Major changes or factors affecting performance 30 FRD 22B Occupational health and safety 17 FRD 22B Operational and budgetary objectives and performance against objectives 30 FRD 22B Significant changes in financial position during the year 30 FRD 22B Statement of availability of other information 28 FRD 22B Statement on National Competition Policy 27 FRD 22B Subsequent events 30 FRD 22B Summary of the financial results for the year 29 FRD 22B Workforce Data Disclosures including a statement on the application of employment and conduct principles 17 FRD 25 Victorian Industry Participation Policy disclosures 27 SD 4.2(j) Sign-off requirements 29 Legislation Requirement Page Reference SD 3.4.13 Attestation on Data Integrity 30 SD 4.5.5 Attestation on Compliance with Australian/New Zealand Risk Management Standard 30 Financial Statements Financial statements required under Part 7 of the FMA SD 4.2(a) Statement of changes in equity Financial Section 7 SD 4.2(b) Operating statement Financial Section 5 SD 4.2(b) Balance sheet Financial Section 6 SD 4.2(b) Cash flow statement Financial Section 8 Other requirements under Standing Directions 4.2 SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements Financial Section 10 SD 4.2(c) Accountable officer’s declaration Financial Section 2 SD 4.2(c) Compliance with Ministerial Directions Financial Section 10 SD 4.2(d) Rounding of amounts Financial Section 20 Legislation Freedom of Information Act 1982 28 Whistleblowers Protection Act 2001 28 Victorian Industry Participation Policy Act 2003 27 Building Act 1993 27 Financial Management Act 1994 27

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 ))