Fenaughty Street PO Box 564 Kyabram VIC 3620 Phone: (03) 5857 0200 Email: [email protected] Web: www.kyhealth.org.au

35 Birdwood Avenue Stanhope VIC 3623

Phone: (03) 5857 2400 Email: [email protected] Web: www.kyhealth.org.au

37 Mangan Street VIC 3621

Phone: (03) 5857 0245 Email: [email protected] Web: www.kyhealth.org.au

ANNUAL REPORT 2013 − 2014

54TH ANNUAL REPORT OUR NEW BRANDING

The ultimate goal of our BRANDMARK TYPE new logo is to create positive The abstract shapes of our Using simple sans serif typography recognition of our brand in a brandmark represent people. The strengthens the concept that way that would make people varying sizes further reflects the we are a contemporary and If the Financial Statements are not attached and you would think of us as their best different people that make up our forward-thinking organisation. like a copy, please contact the office of the CEO: choice for healthcare. We also organisation – staff, patients and wanted to create something community. Phone: (03) 5857 0250 COLOUR Email: [email protected] that our community would be The close formation shows the proud to own. people all coming together, A vibrant colour palette allows us forming an abstract cross in the to portray ourselves as something In researching and reviewing negative space between them that is alive, fresh, dynamic and our brand, three key elements which is symbolic of healthcare distinctly identifiable. were identified.People, and the central role that we play Healthcare and Community. in the community. When redesigning our logo, The softly curved shapes help to it was important to create give the sense that we are warm a strong human element to and welcoming. reflect this.

ECHUCA

TONGALA KYABRAM

ROCHESTER

TATURA STANHOPE

RUSHWORTH

MURCHISON KYABRAM AND DISTRICT HEALTH SERVICES REPORT OF OPERATIONS The Kyabram and District Health Services Annual Report has been compiled to meet the requirements of the Annual Reporting (Contributed Income Sector) Regulations 1988 (as amended).

Our Purpose Healthy Community. Local Care

Our Values Empathy Wellbeing Community

Responsible Minister The responsible Minister during the reporting period was The Hon. David Davies MLC.

Life Governors Mr G. Stone (dec) Mr. J. H. Brown (dec) Mr. I. Purdey Mrs. D. Rowston Miss F. M. Wallis (dec) Mr. E. Scott-MacKenzie (Ladies Auxiliary) Mr. F. Wooller Mr. S. Muir-Smith Mr. T. W. McMaster-Smith (dec) Mr. T. J. Tehan (dec) Mrs. J. Stone Mr. F. Billings (dec) Mr. W. Brewster Mr. P. Hann Mr. A. J. Hutchinson (dec) Mrs. L. N. King (dec) Mr. R. Tuhan Mr. A. G. McCormick (dec) Mr. B. A. Ruler Mr. D. Crow

TABLE OF CONTENTS Page No.

Board members 4

Declarations and Attestations 2, 7, 21, 22

Disclosure Index 23-24

President & CEO Report / Highlights 2-4

Organisational Chart 17

Senior Officers 18

Services 16

Statement of Priorities, Part A 7-13

Statutory Requirements 19-22

Workforce Data 19

KDHS Report of Operations 2013/2014 Page 1 President and Chief Executive Report Responsible Bodies Declaration In accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for Kyabram and District Health Services for the year ending 30 June 2014.

Maureen Atkins formal assessment and has implemented a strong focus on continuing education to ensure effective PRESIDENT Maureen Atkins board governance processes. Peter Abraham President BOARD OF DIRECTORS Chief Executive The Board, this year established a Kyabram committee to review its branding, including the 30th June 2014 organisation’s logo. Following a consultancy review and key stakeholder workshops, our new brand was Kyabram and District Health Services (KDHS) has developed. Please see the inside front cover of this continued to meet the health care needs and service Report of Operations which explains the meaning of level demands through the provision of a wide range our new brand and brand-mark. of health services to achieve broad and effective health outcomes for our catchment community. The Board welcomed Mr. Adam Basile and look forward to Adam’s contribution to the Board’s KDHS has adopted an “experience” led approach to deliberations. the provision of care and services through the development of key core values that underpin the Projects patient’s expectations. Stage 1 of the Health & Wellbeing Centre project commenced this year. This project is funded by the The values of empathy, community and wellbeing Commonwealth Government of $3.45 Million under have been adopted across KDHS as being the Health & Hospital Fund and when completed, will fundamental to the care we provide. provide 14 consulting rooms, two treatment rooms, expanded allied health service areas, training areas Governance and integration between existing service areas, which The Board has worked through a comprehensive will result in improved community access and flow of service and strategic planning framework which patient services for ambulatory care. Ambulatory care included an extensive community consultation is those services that are considered walk in/walk process to develop a new KDHS Strategic Plan for out, such as physiotherapy, counselling, specialist 2013 – 2017. appointments or pathology.

This plan sets the future directions of the organisation Stage 2 of the Health & Wellbeing Centre will result for the coming four years under an agreed purpose to in the development of the radiology service to house promote a healthy community through the provision of a CT scanner as well of relocation of the existing local care. pathology collection centre from their existing location in the rear of the KDHS grounds to a more The Strategic Plan is actioned through the Annual prominent position close to the KDHS main Business Plan & Statement of Priorities and reception. incorporates local priorities with government imperatives. As a result of the Health & Wellbeing works, there have been many service and staff relocations to Board priorities for the 2014-2015 year have been enable builder access to the site. This has however established and include improved in-patient activity, resulted in no service disruption. We are extremely cancer care, men’s health, aged care, initiatives to grateful to the community and our wonderful staff, support ehealth development and staff development. doctors and volunteers for managing so well under these circumstances. The Board has worked collectively, to embed the revised governance processes implemented in the Services previous reporting period. These processes have There continues to be strong demand for KDHS ensured that the Board has remained focused on the services. KDHS has continued to see marked growth key governing areas of quality and safety, financial in demand for surgical services, such as day stay sustainability, risk management and community procedures, while the number of patients requiring a engagement. Board subcommittee functions are hospital bed for overnight stay has remained aligned with the strategic direction of KDHS. relatively stable, as has the number of patients attending our urgent care service. Throughout the year, the Board has been committed to a strong model of stewardship and undertakes The renal dialysis service continues to provide

Page 2 KDHS Report of Operations 2013/2014 President and CEO Report services at six days per week to both local and health outcomes and life expectancy of the regional clients. Aboriginal and Torres Strait Islander people of and non-indigenous Australians. In addition to our successful transitional care In 2012 KDHS signed a ‘Statement of Intent’ on program, KDHS has also obtained funding to behalf of the Kyabram and district community with provide restorative care for patients who require the Minister for Health, Aboriginal & Torres Strait longer stay in hospital or care at home whilst Social Justice Commissioner and the CEO Victorian recovering from illness or disability. Aboriginal Community Controlled Health Organisation. Our innovative Community and Hospital Midwifery (CaHM) program, which offers a safe and quality Our People birthing and pregnancy care service through a nurse We would like to sincerely thank our valued led model, has seen a gradual decline in the number employees for their hard work and enthusiasm and of eligible women able to access the service. This for supporting KDHS in its endeavours to meet the service has also seen a gradual reduction in sometimes challenging and demanding health care availability of key midwifes. In response, KDHS needs of our community. commissioned an independent consultant review of the program and KDHS has developed a new We are saddened by the loss of Moira Campbell who collaborative model of care which includes had provided over 30 years of dedicated nursing midwives, medical staff and obstetricians. This new services to KDHS. model will be implemented in the 2014-2015 year. This year two of our long term employees retired: The Sheridan residential aged care facility remains Robyn Busch was well known in her role as fully occupied post its re-development in 2013. To Manager of the District Nursing Service and supplement our aged care services and provide worked for KDHS for 34 years. greater choice for the aged community, a new Marg Chalker was well known in her role in the community aged care brokering service is now Urgent Care Centre and worked for KDHS provided by KDHS to clients who are eligible for for 43 years. home aged care packages under the Southern Cross Aged Care program. We wish to recognise the management group for their dedication and commitment to the ongoing KDHS is particularly proud of the support it provides success of our services and consistently working the community to develop advanced care plans and towards KDHS’ objectives. directives. This year KDHS reached a milestone of providing its 100th Advance Care Plan in the local This year, the medical workforce has been bolstered community. This valuable program was also by the appointment of Dr Sameer Badgoti and Dr. awarded a Silver Award in the 2013 Premier’s Marla Gupta as well as the return of Dr Lawrence Healthcare Awards Tay following completion of his anaesthetic training.

Our primary and community care services have We wish to congratulate Dr. Michael McQueen continued to respond to changing community needs Thomson who was recognised for his distinguished in increasing demand across the three sites of service to the community when he received a Kyabram, Stanhope and Tongala. Significant Victorian Rural Health Award. increased demand was seen in the diabetes management, chronic disease management and We would like to acknowledge the support of our dietetic services with GP referrals to these services Visiting Medical Officer workforce, in particular that of increasing markedly. Kyabram Regional Clinic who provide continuous 24 hour on-call coverage to our urgent care and KDHS was successful in expanding the number of inpatient services. funded places allocated to the Campaspe Early Childhood Intervention Service. This has resulted in Mr Muhammad Abdullah has been appointed to an expansion of the catchment population seen by KDHS as a General Surgeon. this service.

We acknowledge the work of Mr Stephen Smith in We are pleased to have been able to work with The ear, nose & throat surgery over a ten year period at Gift this year on a future solution for cancer services KDHS. in our community. The Gift is an organisaiton that supports community members and their families who We remain highly appreciative of the many are living with cancer. volunteers, who contribute their valuable time to

support health service provision. Without this Cultural awareness support, KDHS would not be able to provide the level KDHS is committed to closing the gap between the of service provision it currently enjoys.

KDHS Report of Operations 2013/2014 Page 3 President and CEO Report We are appreciative of the hard work and dedication This year the Board ran a fundraising appeal to raise of our health advisory groups, including Stanhope funds to purchase the furniture, fittings and Community Health Group and the Tongala Health equipment for the new Health & Wellbeing Centre. Connect Group for their commitment to the provision The response to this appeal was much more than of community health services in their communities. we expected. At 30th June 2014 $120,000 has been donated. Thank you to everyone who has supported We also thank the Kyabram Hospital Ladies this appeal. Auxiliary who this year celebrated 80 years of fundraising for the hospital and health service with a On behalf of KDHS, we thank the Department of function attended by a crowd of over 100 people. Health for their support throughout the year. As well, we would like to acknowledge the support of our The Kyabram Heart Group also raises money, local government representatives, and local and mainly through the sale of tomatoes, which is regional political members. donated to KDHS to purchase furnishings and equipment. We are appreciative of their support. Kyabram and District Health Service is a vibrant, These groups donate significant funds that enable dynamic and responsive health service that is KDHS to purchase new and replacement furnishings meeting its purpose to promote a healthy community and vital medical equipment. through the provision of local care.

Pecuniary Interests Board of Directors is required in accordance with KDHS policy to declare all pecuniary interests, which may reasonably and foreseeably, be considered to create the potential for a conflict of interests with their position as a member of the Board. These interests have been recorded.

Board Membership Board of Directors as at 30th June 2014 Mrs. Maureen Atkins—President Mr. Adam Basile Mr. Geoffrey Cootes—Vice Chair Mrs. Jean Courtney Mrs. Nicole Ryan—Chair Clinical Governance Committee Mr. Dale Denham Mr. Mike Sweeney—Chair Community Governance Committee Ms Judy Greer Mr. (Graeme) Paul Jackson—Chair Corporate Governance Committee

Corporate Governance / Audit Committee all members are independent Mr. (Graeme) Paul Jackson (Chair) Mrs. Jean Courtney Mr. Michael Sweeney Mr. Geoffrey Cootes Mr. Robert Jackson (community representative) Mr. Kevin Livingston (community representative)

The purpose of the Corporate Governance / Audit Committee (CGC) is accountability and responsibility to the community and the funding bodies of KDHS for the performance of KDHS in relation to the key areas of the Finance and Audit Charter, legislative compliance, risk management, service delivery performance and internal and external report.

The CGC monitors and reviews planning processes related to corporate improvement including but not limited to strategic plans, service plans, financial plans and the Board annual priorities.

The CGC provides oversight of the quality and effectiveness of physical resources of KDHS, including equipment and building fabric through effective planning processes.

Page 4 KDHS Report of Operations 2013/2014 President and CEO Report Donations Fundraising Appeal During the year a fundraising appeal was launched to raise funds to cover the cost of furniture, fittings and equipment for the new consulting rooms, public areas and offices in the new building that is under construction.

Thanks to the generosity of the our community, at 30th June 2014 almost $120,000 was raised.

Bequest We were extremely grateful to receive a bequests from the estate of Linda Joyce Jones which assists with the funding of upgrading buildings, furnishings and equipment that are not funded from any other source, to maintain the facility to the standard the community expects.

In Memoriam Donations were received from the family and friends of: Thelma Hoyling Ern Healey Bill Williams Patricia Lloyd Gwenneth Dickman Bob Woods Moira Campbell

Donations were received from the following businesses and groups: Bennets Sports Kyabram Italian and Bocce Club Betta Electrical Kyabram Refrigeration Fisher’s Stores Kyabram RSL Sub Branch Girls Night Out Kyabram Senior Citizens Knights Building Supplies Lions Club of Kyabram Knights Furniture Lions Club of Merrigum Kyabram Bakery Lions Club of Stanhope Kyabram Club MEOFF Charity Run Kyabram Cross Piston Saloon Club Merrigum Ladies Lions Auxiliary Kyabram Free Press Rotary Club of Kyabram Kyabram Heart Group Tongala CWA Kyabram Hospital Ladies Auxiliary Tongala & District Community Bank

Thanks to generous donations that were not part of the fundraising campaign, the following were able to be purchased / funded during the year: Emergency Trolley for the Acute Ward (MSW) Monitor for Acute Ward (MSW) Defibrillator for Stanhope Health Television for Stanhope Health waiting room Wheelchair Funding towards Renal Dialysis Equipment for Sheridan Funding towards Palliative Care Education for Breast Care Nurses Funding towards Breast Care Nurses Funding towards Emergency Care and Physio classes Funding towards the Tongala Community Kitchen Sponsorship for Tongala Men’s Health Night

No donations or bequests were used for administration costs.

KDHS Report of Operations 2013/2014 Page 5 Donations

The Kyabram Hospital Ladies Auxiliary’s donated a total of $5,000 to purchase an Emergency Trolley.

The Emergency Trolley has a defibrillator, drugs and equipment that can be wheeled anywhere around the organisation in the event that a patient or client suffers a cardiac arrest.

The Emergency Trolley that was replaced was getting difficult to wheel and had less storage space than the new trolley.

The Kyabram Heart Group donated $10,000 to purchase two monitors for use in theatre, day procedure unit and the acute ward.

These are additional mobile units that are moved from room to room and location to location. Having extra monitors in strategic locations provides a more streamlined working environment for the nursing staff.

Funding for the Emergency Trolley and the Monitors was not available from any other source. We are extremely grateful for these special donations, and all donations, which help us to purchase modern furnishings and equipment that we would otherwise not be able to.

STANHOPE LIONS CLUB donated $3,000 to Stanhope Health this year. A television was purchased for the waiting area with the first donation and is used to display health information. The second donation was used to purchase a defibrillator for Stanhope Health. With services expanding in Stanhope to include a Planned Activity Group, the defibrillator is a welcome item.

Pictured are members of the Stanhope Lions Club, members of Stanhope Community Health Inc, staff of Stanhope Health and KDHS. Pictured: (back) Christine Owen, Peter Abraham, Alan Londey, Owen Wallace, Rob Hill, Howard Pascoe, Pauline Keegan, Alan McGrath, Meaghan Browne, Ray Tuhan (front) Alice Bourke, Cynthia Downing, Ruth Green

Page 6 KDHS Report of Operations 2013/2014 2013-2014 Statement of Priorities Attestation on Data Integrity I, Peter Abraham, certify that Kyabram and District Health Services has put in place appropriate internal controls and processes to ensure that reported data reasonably reflects actual performance. Kyabram and District Health Services has critically reviewed these controls and processes during the year.

Peter Abraham CHIEF EXECUTIVE

Part A: Strategic Priorities Victorian Health Priorities Framework Action Deliverable Outcomes priority areas

Developing a system Implement formal advance care Advanced care planning Advanced care planning well that is responsive to planning structures and systems are evaluated to advanced. Utilised by the people’s needs processes that provide patients ensure patient / client / community, patients and with opportunities to develop clinician satisfaction. residents. review and have their expressed preferences for Completed future treatment and care enacted Configure and distribute In partnership with the Community consultation and services to address the health Tongala community, develop workshops have been held. needs of the local population a sustainable, community Tongala participants expressed a driven, primary health model desire to hold a Showcasing for Tongala Tongala Expo. An organising committee has been developed. La Trobe University is providing support for the event. An Interim Governance Committee has been established and the Governance framework has been endorsed by the KDHS Board. The membership of the Governance committee is:  3 members of the Tongala Community Health Inc committee  2 members of the KDHS Board  4 independent members of the Tongala community In attendance (no voting rights)  KDHS Chief Executive  KDHS Primary Care Manager  Tongala Project Worker

Completed

KDHS Report of Operations 2013/2014 Page 7 2013-2014 Statement of Priorities Part A: Strategic Priorities (cont.) Victorian Health Priorities Action Deliverable Outcomes Framework priority areas Developing a system Establish and develop the Board adopted new Governance that is responsive to Community Engagement & structure in September 2013 people’s needs (cont) Stakeholder Board including Terms of Reference Subcommittee for the Community Engagement & Stakeholder Board Subcommittee. The first meeting of the committee was held 10th November with quarterly meetings scheduled in 2014.

Completed In partnership with other local Review the Community and CaHM evaluation reported to providers, apply existing service Hospital Midwifery (CaHM) Board in October 2013. capability frameworks to model and develop initiatives Discussions have occurred with maximize the use of available that increase local service Department of Health (Regional resources across the catchment uptake. and Central) with workforce and nursing and midwifery policy branch, regarding models and workforce strategies. Project manager has been engaged to look at an alternative collaborative medical obstetric model. An update on the project has been completed. The new model concept has been approved by the Board and an operational model for the delivery of services is to be presented to the July 2014 Board meeting.

Completed

Review the auspice Current review: arrangement for Renal Dialysis  Contract services.  Budget  WIES  Demand  Workforce  Clinical Risks Review undertaken: actions identified include planning to increase occupancy to 12. Workforce strategies developed to ensure this can occur.

Completed

Page 8 KDHS Report of Operations 2013/2014 2013-2014 Statement of Priorities

Part A: Strategic Priorities (cont.)

Victorian Health Priorities Action Deliverable Outcomes Framework priority areas 1. Developing a system In partnership with other local In conjunction with the local Regional and Isolated Practice that is responsive to providers, apply existing service GPs and the local community, Endorsed Registered Nurse people’s needs (cont.) capability frameworks to ensure the safe and effective (RIPERN) program commenced in maximize the use of available introduction of the urgent care the Urgent Care Centre in July 2013 resources across the catchment nurse medication dispensing with support of local GP’s. 6 (cont.) model. patients have been seen under the RIPERN model.

Completed In partnership with Goulburn Blood, blood product infusions and Valley Health (GVH) develop venesections referred from GVH program of local support for commenced in September 2013, cancer services in the however there has to this date been Kyabram catchment. small uptake of this referral service from GVH. Further discussions to occur with GVH to increase referrals of appropriate treatments to KDHS

Working with Loddon Mallee Integrated Service (LMICS). Partnering with The GIFT, LMICS and La Trobe University in developing a Cancer Support House in Kyabram.

In partnership with Goulburn Formal agreement for the Valley Imaging (GV Imaging) establishment of a CT imaging seek opportunity for the service with GV Imaging reached. establishment of a CT imaging New facility design completed. device. Awaiting RCF round 4 funding submission outcome.

Completed 2. Improving every Improve the thirty-day Provide quarterly reports to Review of sample number of Victorian’s health unplanned readmission rates. clinical services, visiting unplanned readmissions status and medical officers and the Board commenced and reported to Clinical experiences. on unplanned readmission Risk Management Committee. Now rates. incorporated into performance measures.

Completed. Clinical services review of all Regular auditing occurs of all unplanned readmissions. deaths—findings are reported at the Clinical Risk Management Committee.

Completed

KDHS Report of Operations 2013/2014 Page 9 2013-2014 Statement of Priorities Part A: Strategic Priorities (cont.) Victorian Health Priorities Framework Action Deliverable Outcomes priority areas

2. Improving every Identify service users who are Develop formal partnerships Planning for the development of a Victorian’s health marginalized or vulnerable to with local Aboriginal groups Board led Aboriginal Health working status and poor health, and develop and the neighbouring group to support the engagement of experiences. interventions that improve their Aboriginal Cooperatives. local aboriginal people. outcomes relative to other groups, for example, Aboriginal Transferred to the 2014-2015 people, people affected by Business Plan mental illness, people at risk of elder abuse, refugees and Review the KDHS Aboriginal Aboriginal Health Plan review asylum seekers. Health Plan to ensure greater completed and submitted to the focus on attraction of Department of Health. Aboriginal Aboriginal patients / clients to Health Plan is available to all staff the service. on PROMPT for review.

Completed

Partner with Loddon Mallee A strategic priority of the Primary Medicare Local on the Care Partnership is access to all Partners in Recovery initiative services. to support people with severe and persistent mental illness with complex needs and their carers and families. Develop health promotion Working with Primary Care programs targeted at Partnership stakeholders on addressing drug and alcohol strategies. abuse in the community.

3. Expanding service, Optimise workforce productivity Indicators for workforce Reported to Board February 2014 workforce and system through identification and planning, including succession capacity. implementation of workforce planning, established. Completed. models that enhance individual and team capacity and support flexibility.

Explore regional partnership Continue to work with opportunities to develop a Regional Health on developing a medical intern model with the model through the Central Loddon local GP providers. Mallee Medical Workforce Group.

Transferred to 2014-205 Business Plan.

Develop a locally attractive Targeted advertisement for health traineeship program across trainees clinical and support programs. Transferred to 2014-205 Business Plan.

Page 10 KDHS Report of Operations 2013/2014 2013-2014 Statement of Priorities Part A: Strategic Priorities (cont.)

Victorian Health Priorities Action Deliverable Outcomes Framework priority areas

3. Expanding service, Optimise workforce productivity Support the clinical nursing KDHS is supporting 4 nurses to workforce and system through identification and workforce in the development undertake the RIPERN training. capacity (cont.) implementation of workforce of new skill set consistent with models that enhance individual the introduction of new 2 nurses have completed Prostrate and team capacity and support programs such as urgent care Care training flexibility (cont.) nurse dispensing and cancer services. Work collaboratively with the Planning and development of Planning completed meeting all department on service and the Health and Wellbeing objectives within budget. Minuted capital planning to develop (H&WB) Centre achieves through H&WB Project Control service and system capacity. intended project outcomes Group. within budget and on time. Builder appointed and work commenced. Seeking funding for North Wing.

Transferred to 2014-2015 Business Plan

Develop capital submission for Transferred to 2015-2016 Business the redevelopment of the Plan Urgent Care and Day Procedure facilities.

4. Increasing the Reduce variation in health Seek opportunities to KDHS, Echuca Regional Health system’s financial service administration costs. collaborate with neighbouring (ERH) and Rochester Elmore sustainability and health services on shared District Health Service (REDHS) productivity administration process. shared costing agreement for purchased services reached. KDHS and ERH shared positions for Support Services Manager and Payroll support. KDHS & REDHS shared positions for Payroll support. Project commenced for acute, urgent care, maternity and visiting medical officer retention. Identify opportunities for Review the financial services All-staff meeting to discuss efficiency and better value department as part of the changes to Administration held in service delivery Health & Wellbeing October 2013 and a working group administration relocation was appointed to assist in the process development of the strategy. Working group meetings have been held during November and December, and a draft Change Impact Statement completed. New manager appointed and process of transition to new arrangements in progress. Transferred to 2014-2014 Business Plan

KDHS Report of Operations 2013/2014 Page 11 2013-2014 Statement of Priorities

Part A: Strategic Priorities (cont.)

Victorian Health Priorities Action Deliverable Outcomes Framework priority areas 4. Increasing the Identify opportunities for Actively participate in Health Facility Manager is currently system’s financial efficiency and better value Purchasing projects participating as a reference group sustainability and service delivery (cont.) that achieve improved member in Electricity Supply productivity (cont.) efficiency through utility Agreement and services. Telecommunications Supply Agreement. He has also been nominated on the Natural Gas Supply Agreement reference group and is currently participating as an executive group member in Wast Management Services. CEO is member of the Hume/ Loddon Mallee Sustainability Project

Completed 5. Implementing Develop and implement Undertake clinical service Clinical service system review has continuous improvement strategies that system reviews in line with the occurred. Gaps have been improvements and optimise access, patient flow, requirements of the National identified and action plans have innovation. system coordination and the Standards program been placed in RiskmanQ. quality and safety of hospital services. Completed

Evaluate and improve the Completed effectiveness of the Infection Control program in line with guides for antimicrobial stewardship.

Redesign of the elective Transferred to the 2014-2015 patient admissions process Business Plan cognizant of the patient journey and experience.

Implement the patient safety Commenced a number of initiatives plan developed from the Ko including regular safety share walk Awatea / Institute for Health rounds by senior managers, Improvement Patient Safety bedside handover. project. Completed

6. Increasing Prepare for the National Safety Provide the Board with Monthly reports on progress accountability & and Quality Health Service progress updates and gap provided to the Board. transparency Standards as applicable identification on the National Self assessment of progress Safety and Quality Health completed. Service Standards Completed

Page 12 KDHS Report of Operations 2013/2014 2013-2014 Statement of Priorities

Part A: Strategic Priorities (cont.)

Victorian Health Priorities Action Deliverable Outcomes Framework priority areas 6. Increasing Prepare for the National Safety Board is provided with Reporting to the Board accountability & and Quality Health Service education on their obligations A report on one standard is transparency (cont.) Standards as applicable (cont.) for Clinical Governance under provided to the Board at each the National Governance meeting, educating them on that Standard standard. More detailed education is provided to the Clinical Governance committee, which meets bi-monthly.

Completed Implement systems that support Review Board clinical Framework for report developed. streamlined approaches to governance indicators Allocation of data collection clinical governance at all levels responsibility. of the organisation Completed Increase transparency and Recruit consumer to the Consumer recruited and attended accountability in reporting of Clinical Risk Management December meeting. accurate and relevant committee Consumer resigned in January for information about the personal reasons organisation’s performance. Transferred to 2014-2015 Business Plan Publish clinical indicator data Friday FacX and Quality quarterly on the health service newsletters are available on the website and social media KDHS website. When a newsletter is published a link to the website page is put on Facebook. Transferred to 2014-2015 Business Plan Broaden distribution of the Achieved quarterly quality & safety newsletter to patients, carers and consumers 7. Improve utilization of Maximise the use of health ICT Conduct a feasibility study into KDHS Strategic e-health plan e-health and infrastructure the uptake of a regional e- developed in line with KDHS communications health record that links to local Strategic Direction plan. technology private providers (GPs) and FF&E allocation for tele-health regional referral centres equipment made to the Health & Wellbeing development Trial, implement and evaluate Contribute to the roll out of the CEO is a Board member of the strategies that use e-health as Loddon Mallee Rural Health LMRHA an enabler of better patient care. Alliance (LMRHA) regional e- health strategy. Completed

KDHS Report of Operations 2013/2014 Page 13 Advance Care Planning

Statement of Priority Action

Priority Action Deliverable

Developing a system that is Implement formal Advance Advance Care Planning systems are responsive to people’s needs Care Planning structures and evaluated to ensure patient / client / processes that provide clinician satisfaction. patients with opportunities to develop, review and have their expressed preferences for future treatment and care enacted.

KDHS staff member, Loretta Lilford took on the role of clients of KDHS District Nursing Service and Chronic developing Advance Care Planning (ACP) structures Disease Management services are provided with and has been a champion of the program from it’s ACP information. inception. Loretta then identified a need in the community and, In Loretta’s own words, it is one of her biggest with the support of KDHS management, began passions. addressing Kyabram and district community groups.

After Loretta prepared the ACP policy & procedure, In her presentation Loretta says “Talking about dying forms and literature she trained the relevant staff, and is hard. That’s why the majority of us have never any staff who were interested, in how to implement expressed our wishes for a time when we are unable the program with patients and clients. to speak for ourselves.” Loretta calls them courageous conversations. At KDHS the Discharge Coordinator discusses ACP with patients prior to their discharge. All patients over In the first six months of 2014 Loretta has prepared the age of 18 years have access to information, all 65 Advance Care Plans with a total of 100 prepared residents of Sheridan (residential aged care) and in the financial year.

Compliment received I wish to compliment the Advance Care Planning idea and opportunity it gives to people of all age groups. I think its an excellent way for people to have their wishes for care upheld should they ever not be able to speak for themselves. I think this way of dealing with such cases would be helpful to both the client and the medical staff.

I also wish to compliment the facilitator of this service in Kyabram, Loretta Lilford, who made the whole arrangement of my Advance Care Plan very understandable and she handled it in a very caring and sensitive way.

Tracey Stokes, a Tongala mother of three who is in remission from leukaemia, was inspired to complete an Advance Care Plan while watching a television program where a wife made a life changing decision for her husband.

Tracey considered the situation she had witnessed and realised the importance of having her own wishes documented should there be a time when she could not speak for herself.

Not only does it let everyone know what her wishes are, it means her loved ones don’t have to make an agonising decision in a situation that is emotional.

Tracey says “I’m not saying this is how I want to die, I’m saying this is how I want to live.”

Information for this article was taken from Kyabram Free Press, January 22 2014

Page 14 KDHS Report of Operations 2013/2014 Health & Wellbeing Project

Priority Action Deliverable

Expanding service, workforce and Work collaboratively with the Planning and development of the system capacity. department on service and Health and Wellbeing project capital planning to develop achieves intended project outcomes service and system capacity within budget and on time.

Increasing the system’s financial Identify opportunities for Review the financial services sustainability and productivity. efficiency and better value department as part of the Health and service delivery. Wellbeing project administration relocation process.

Artists impression of the common areas of the project

Project Update  Streamlined intake, data collection and Stage 1 of the Health & Wellbeing Centre project referral processes; commenced this year on the Kyabram Health site.  Intake and service coordination is simple to This project is funded by the Commonwealth navigate, transparent and consistently applied Government of $3.45 Million under the Health & across the organisation; Hospital Fund and when completed, will provide 14  Improved identification of clients needs and consulting rooms, two treatment rooms, expanded prioritisation of access to the most allied health service areas, training areas and appropriate service at the earliest point of integration between existing service areas, which will contact; result in improved community access and flow of  Reduced response times to enquiries; patient services for ambulatory care. Ambulatory  Improved equity of access to clients; care is those services that are considered walk in/  A centralised, integrated appointment system; walk out, such as physiotherapy, counselling,  Enhanced communication and service specialist appointments or pathology. coordination for clients of multiple services;  A standardised approach to data collection, The architect firm appointed to the project is storage and analysis; Antarctica and the builders are Crow Constructions.  Minimised multiplicity of forms, tools, intake processes. A number of unavoidable delays have occurred which has extended the completion date to Other benefits include: November 2014. This is well within the funding  A coordinated approach to healthcare delivery guidelines. with the focus on health and wellbeing of the client / patient. Client Service Department Review  Protocols and guidelines for intake, referral, Staff from the finance administration department, service and care coordination are consistently front reception and community health reception have applied for all clients and patients; been consulted and a Customer Service model is  Staff are provided with ongoing professional being developed to combine these services. development;  Better access to the most appropriate service This means that when a client comes to Kyabram for walk-in clients and for clients from a Health there will be one general telephone number culturally and linguistically diverse one entry and one reception point. The benefits of background. this change to clients include:

KDHS Report of Operations 2013/2014 Page 15 About Kyabram and District Health Services The Kyabram Bush Nursing Hospital was opened on 29 July 1933. In 1960 the hospital moved to it’s current location and was opened on 27 March 1960 as the Kyabram & District Memorial Community Hospital. The organisation was renamed Kyabram and District Health Service (KDHS) in 2002 and operates in accordance with the Health Services Act 1988.

KDHS serves a catchment area of 10,000 people and employs more than 300 staff members.

The objectives, functions, powers and duties of KDHS are described in the Operational Practices and Governance policies of the organisation.

KDHS provides a broad range of hospital, allied and community services through the Department of Health Loddon Mallee Region. Locations include:

 At 86-96 Fenaughty Street Kyabram there are 38 beds providing acute medical, surgical, midwifery and transitional care. An Urgent Care Centre and a Renal Dialysis Unit are also on this site, as are Primary Health services, District Nursing Services and a 42 bed high care Residential Care facility.

 Primary Health and Planned Activity Group services are provided from 35 Birdwood Avenue, Stanhope.

 Primary Health services are provided from 12 Purdey Street, Tongala.

Our Services Following is a list of the range of services provided by KDHS:

Acute Hospital Primary and Allied Health 38 Acute Beds Asthma Education Medical Cardiac Rehabilitation Program Surgical Chronic & Complex Disease Management  Dental Community Health Nursing  Endoscopy Community Transitional Care—2 places  General Counselling Services  Gynaecology Diabetes Education  Opthalmology Dietetics  Orthopaedics Early Childhood Intervention Service  Urology Health Promotion Midwife led birthing service Occupational Therapy Palliative Care Physiotherapy Renal Dialysis Speech Pathology Transition Care beds—2 Well Women’s Clinic Urgent Care Centre

Aged Care Other Services Planned Activity Group/HACC District Nursing Service Meals on Wheels Residential 28 high care beds 12 dementia specific beds 2 respite care beds

Page 16 KDHS Report of Operations 2013/2014 Organisation Chart

KDHS Report of Operations 2013/2014 Page 17 Senior Officers Chief Executive Officer Director of Clinical Services Mr. Peter Abraham Mrs. Julie Russell The Chief Executive Officer (CEO) is The Director of Clinical Services has responsible to the Board of Directors for the professional and executive responsibility for all efficient and effective management of KDHS. Prime responsibilities include the development clinical services: Patient Care, Aged / Home and implementation of operational and strategic Care and Community / Primary Health. Major planning, maximising service efficiency and areas of responsibility include clinical quality improvement, and minimizing and governance, clinical leadership and standards of managing risk. Peter represents KDHS in a practice, service and strategic planning, clinical range of broader forums at a regional and state risk management and quality improvement and level. resource management. Julie represents KDHS in a range of broader forums at a regional and state level. Facility Manager Mr. Brendin Trudgett The Facility Manager has professional and Chief Financial Officer executive responsibility for the following: Mr. David Edwards Building Project Management, Capital The Chief Financial Officer has responsibility for Management, Asset Management, Maintenance the financial management and reporting Services and Fleet Management. Major areas requirements to the Board of Directors, of responsibility include corporate governance, managers and external bodies including the liaising between the architect and the builder, Department of Health. As well as financial and leadership and standards of practice, service performance reporting, this position has and strategic planning, corporate risk operational responsibility for Health Information, management. Information Technology, the Administration team, Payroll and Contracts. Human Resources Manager Ms Susan Briggs Quality & Safety Manager The Human Resources Manager is responsible Mrs. Bev McLaine for developing effective Human Resources The Quality & Safety Manager is responsible for strategies to ensure we attract, retain and Quality Improvement systems and OH&S motivate our people to uphold our values and systems. In consultation with committees, provide quality care and services. Included in managers and individuals, this position is the Human Resources function is Employee responsible for formulating and implementing a Relations, Industrial Relations, Workcover, strategic and systems driven approach to the Legislative Compliance, Strategic Planning and management of Quality, Safety and Risk at Leadership. KDHS.

Support Services Manager Director of Medical Services Ms Kim Bennetts Dr Craig Winter The Support Services Manager Manager is The Director of Medical Services has the responsible for the following services: Food responsibility of ensuring visiting medical Services, Laundry Services, Porters and Patient officers are credentialed and have the Service Assistants, Environmental Services and appropriate experience for the privileges they Stores. Major areas of responsibility include have applied for at KDHS. This position tendering for food requirements, ensuring provides support, advice and guidance for compliance with HPV, leadership and standards clinical risk and medication management. of practice.

Page 18 KDHS Report of Operations 2013/2014 Workforce Workforce Statistics Labour Category Current Month FTE - June YTD FTE - June

2013 2014 2013 2014

Nursing 88.4 83.1 83.0 85.9 Administration and Clerical 24.2 25.1 24.6 24.2

Medical Support 8.7 7.2 7.8 7.1

Hotel and Allied Services 40.2 37.0 38.9 39.1

Medical Officers 0.1 1.0 0.1 0.3

Hospital Medical Officers 0 0 0 0 Sessional Clinicians 9.1 9.4 9.8 8.9 Ancillary Staff (Allied Health)

170.7 162.8 164.2 165.5

FTE = Full Time Equivalent

Staff 2013-2014 2012-2013 2011-2012 2010-2011 2009—2010

Equivalent Full-time Staff—June 162.8 170.7 174.7 165.5 166.6

Total Staff 353 352 326 290 291

Industrial Relations and Workers Compensation There was no time lost due to industrial disputes in 2013/2014. Days lost due to industrial accidents are shown in the graph below.

Workers Compensation Days Lost

1000 900 800 700

600 500 400 300

200 Numberof days 100 0 2010-2011 2011-2012 2012-2013 2013-2014

Financial Year

KDHS Report of Operations 2013/2014 Page 19 Statutory Reporting

Merit & Equity Principles KDHS is committed to upholding the principles of merit and equity in all aspects of the employment relationship to ensure fair and transparent processes for recruitment, selection, transfer and promotion of staff.

Policies and procedures are in place to ensure employment related decisions are based on merit, and relevant legislation is complied with. Any complaints, allegations or incidents involving discrimination, vilification, bullying or harassment are taken seriously and addressed.

All staff are provided with training and education on their rights and responsibilities, and are provided with the necessary resources to ensure equal opportunity principles are upheld.

Freedom of Information Act Requests for access to document and records held by KDHS may be made under the Freedom of Information Act 1982. All applications are in writing are forwarded to KDHS. In the majority of cases a Freedom on Information request is to gain access to a patient’s own medical record. During the 2013/2014 financial year KDHS received 17 valid requests.

Consultancies The definition of consultancy was updated effective from 1 July 2013. Consequently, disclosures on the 2013-2014 consultancy expenditure cannot be compared with previous year disclosures.

Consultant Purpose of Consultancy Start date End date Total Expenditure Future approved 2013-2014 Expenditure project fee (ex GST) (ex GST) (ex GST) Kathleen Evaluation of 1/05/2013 10/09/2013 $37,785 $29,895 Nil Menzies Community and Consulting Pty. Hospital Midwifery Ltd. Program Flying Pig Branding and design 1/03/2014 30/06/2014 $17,840 $14,069 $3,771 Design services

In 2013-2014 KDHS engaged 5 consultancies where the total fees payable to the consultants were less than $10,000, with a total expenditure of $22,309 (ex GST).

Page 20 KDHS Report of Operations 2013/2014 Statutory Reporting Attestation on Compliance with Australian/New Zealand Risk Management Standard I, Peter Abraham, certify that Kyabram and District Health Services has risk management processes in place consistent with the Australian/New Zealand Management Standard and an internal control system is in place that enables the executive to understand, manage and satisfactorily control risk exposures. The Board of Directors verifies this assurance and that the risk profile of Kyabram and District Health Services has been critically reviewed within the last 12 months.

Peter Abraham Chief Executive Kyabram 30 June 2014

Occupational Health & Safety The Occupational Health and Safety Management System (OHSMS) addresses all OH&S levels and functions within the organisation. Within the objectives of the OHSMS, improvements are ongoing, monitored and evaluated to ensure the provision of a safe and healthy work environment.

The Health & Safety Committee continues to be actively involved in ensuring Kyabram and District Health Services (KDHS) provides a healthy and safe environment for staff, patients, visitors and contractors. 100% of designated work groups are represented on the Committee by OH&S trained staff with two management representatives to assist and support the consultation processes. Meetings have all been held as scheduled with a 90% attendance rate.

The OH&S Benchmarking Group meets bi-annually and incorporates five (5) health services from the Loddon Mallee Region. These network meetings have resulted in the sharing of strategies and programs to meet health and safety evidence-based practice and the availability of data and systems for comparison which provides valuable opportunities to improve services.

All objectives of the annual OH&S action plan have been achieved during 2013-2014 including scheduled audits and inspections and while incident and hazard reporting has increased, the current rate of staff incidents against EFT is 1.4%, substantially below the agreed indicator of 5% per annum.

Investigation and actioning is 100% within the requirements of OH&S policies and outcomes are reported to staff, management and the Board.

During 2013-2014, further improvements have also been made to risk assessment and management ensuring all risks are identified, monitored and investigated for safe and appropriate management.

Carers Act 2012 KDHS has taken deliberate measures to ensure that our employees have an awareness and understanding of the Care Relationship Principles. The information is made widely available to staff and it makes up part of specific educational opportunities developed for general staff.

In addition, the persons within the care relationships in receipt of services are also aware of our organisation’s commitment to our obligations toward them in this area. The care relationship principles are made available and are included in material offered at the point of service commencement and at various other times throughout our involvement.

KDHS operates within these principles in our provision of care, in the development of Policy and in the evaluation, support and assistance during the term of the care relationship. The Continuous Quality Improvement program actively measures the outcomes of service provision which is then published for the staff and community information.

KDHS Report of Operations 2013/2014 Page 21 Statutory Reporting Attestation for compliance with the Ministerial Standing Direction 4.5.5.1—Insurance I, Peter Abraham, certify that the Kyabram and District Health Services has complied with Ministerial Direction 4.5.5.1—Insurance.

Peter Abraham Chief Executive

Kyabram 30 June 2014

National Competition Policy KDHS complied with all government policies regarding competitive neutrality with regard to tender applications.

Victorian Industry Participation Policy Act 2003 KDHS abides by the principles of the Victorian Industry Participation Policy. During the year there were no procurement or project activities above the threshold.

Building Act 1993 KDHS complies with the provisions of the Building Act 1993, in accordance with the Department of Health Capital Development Guidelines.

Additional information In compliance with the requirements of FRD 22D Standing Disclosures in the Report of Operations, details in respect of the items listed below have been retained by KDHS and are available to the relevant Ministers, Members of Parliament and the public on request (subject to the freedom of information requirements, if applicable):

 A statement of pecuniary interest has been completed;  Details of shares held by senior officers as nominee or held beneficially;  Details of publications produced by the Department about the activities of the entity and where they can be obtained;  Details of changes in prices, fees, charges, rates and levies charged by the Health Service;  Details of any major external reviews carried out on the Health Service;  Details of major research and development activities undertaken by the Health Service that are not otherwise covered either in the Report of Operations or in a document that contains the financial statements and Report of Operations;  Details of overseas visits undertaken including a summary of the objectives and outcomes of each visit;  Details of major promotional, public relations and marketing activities undertaken by the Health Service to develop community awareness of the Health Service and its services;  Details of assessments and measures undertaken to improve the occupational health and safety of employees;  A general statement on industrial relations within the Health Service and details of time lost through industrial accidents and disputes, which is not otherwise detailed in the Report of Operations;  A list of major committees sponsored by the Health Service, the purposes of each committee and the extent to which the purposes have been achieved;  Details of all consultancies and contractors including:  consultants/contractors engaged;  services provided; and  expenditure committed for each engagement.

Page 22 KDHS Report of Operations 2013/2014 DISCLOSURE INDEX

The Annual Report of Kyabram and District Health Services is prepared in accordance with all relevant legis- lation. This index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.

Note: The Disclosure Index consists of 2 pages.

Legislation Requirement Page Ref. MINISTERIAL DIRECTIONS

REPORT OF OPERATIONS

Charter and purpose FRD 22D Manner of establishment and relevant Ministers 1, 16 FRD 22D Objectives, functions, powers and duties 16 FRD 22D Nature and range of services provided 16

Management and structure FRD 22D Organisational structure 17

Financial and other information FRD 10 Disclosure index 23-24 FRD 11A Disclosure of ex-gratia payments Fin rep FRD 12A Disclosure of major contracts NA FRD 21B Responsible person and executive officer disclosures Fin rep FRD 22D Application and operation of Freedom of Information Act 1982 20 FRD 22D Application and operation of Carers Recognition Act 2012 21 FRD 22D Compliance with building and maintenance provisions of Building Act 1993 22 FRD 22D Details of consultancies over $10,000 20 FRD 22D Details of consultancies under $10,000 20 FRD 22D Employment and conduct principles 20 FRD 22D Major changes or factors affecting performance Fin rep FRD 22D Occupational health and safety 21 FRD 22D Operational and budgetary objectives and performance against objectives Fin rep FRD 22D Significant changes in financial position during the year Fin rep FRD 22D Statement of availability of additional information 22 FRD 22D Statement on National Competition Policy 22 FRD 22D Subsequent events Fin rep FRD 22D Summary of the financial results for the year Fin rep FRD 22D Workforce Data Disclosures including a statement on the application of employment and conduct principles 19, 20 FRD 25B Victorian Industry Participation Policy disclosures 22 FRD 29 Workforce Data disclosures 19 SD 4.2(g) Specific information requirements Fin Rep SD 4.2(j) Sign-off requirements 2

KDHS Report of Operations 2013/2014 Page 23 DISCLOSURE INDEX Legislation Requirement Page Ref.

SD 3.4.13 Attestation on data integrity 7

SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 22

SD 4.5.5 Risk Management compliance attestation 21

FINANCIAL STATEMENTS Financial statements required under Part 7 of the FMA SD 4.2(a) Statement of changes in equity Fin rep

SD 4.2(b) Comprehensive operating statement Fin rep

SD 4.2(b) Balance sheet Fin rep

SD 4.2(b) Cash flow statement Fin rep

Other requirements under Standing Directions 4.2 SD 4.2(a) Compliance with Australian accounting standards and other authoritative Fin rep pronouncements SD 4.2(c) Accountable officer’s declaration Fin rep

SD 4.2(c) Compliance with Ministerial Directions Fin rep

SD 4.2(d) Rounding of amounts Fin rep

Legislation Freedom of Information Act 1982 20

Carers Recognition Act 2012 21

Victorian Industry Participation Policy Act 2003 22

Building Act 1993 22

Financial Management Act 1994 Fin rep

KEY Fin rep = refer to the Financial Report NA = not applicable

Page 24 KDHS Report of Operations 2013/2014