Blank Sale Maffra Heyfield All Correspondence Acute Care Services 48 Kent Street 14 Licola Road Chief Executive Officer 155 Guthridge Parade PO Box 313, Heyfield VIC 3858 Central Gippsland Health Service Sale VIC 3850 Maffra, VIC 3860 Telephone 03 5139 7979 AnnuAl QuAlITY OF CARE REpORT 155 Guthridge Parade Telephone 03 5143 8600 Telephone 03 5147 0100 Facsimile 03 5139 7922 Sale Victoria 3850 Facsimile 03 5143 8633 Facsimile 03 5147 0152 Telephone 03 5143 8660 Community Services Facsimile 03 5143 8633 Email [email protected] Telephone 03 5143 8800 Facsimile 03 5143 8890 Wilson Lodge Nursing Home 2010 Telephone 03 5143 8540 Facsimile 03 5143 8542 www.cghs.com.au • seamless: coordinated, integrated and timely • work within an intersectoral and collaborative provision of person centred care; framework to maximise benefits for our • capable individuals and teams working within community; appreciate the positive impact on structures and processes that support quality organisational and community capacity that outcomes and continuous improvement; comes from diversity. • facilities and equipment that enable the People – Respect and support. provision of efficient, effective and sustainable In doing so we will: service delivery; and • strive to provide an environment that assists our • a workforce that places a very high value on staff to: excellent customer service and client/patient • achieve their personal goals and objectives; advocacy. • live ethically within their personal value Our Vision: system; and All correspondence to: Caring – Support, compassion and • enthusiastically support CGHS to achieve A safe and healthy community where everyone tolerance. To do this we will: our strategic and service delivery goals and Executive Office feels they are valued, supported and have the • be welcoming, caring, supportive, share objectives. Central Gippsland Health Service knowledge freely and support learning in every opportunity to participate. Social issues have been • develop a workplace where people are enabled 155 Guthridge Parade addressed through the joint efforts of community setting; to: Sale, Victoria 3850 and supporting agencies. • relate to our community with tolerance and • be efficient and effective; compassion; • put forward ideas and participate in decision Telephone: 03 5143 8660 Our Mission: • assist our community to understand their rights making; Fax: 03 5143 8633 and responsibilities and have access to genuine • be creative and innovative; and Email: [email protected] Our Mission is to provide health and community complaints resolution processes; • develop their learning and career in a manner services that will best meet the current and future consistent with their strengths and interests. Should the financial statements not be included needs of our community. • support our community to identify the need for and make decisions relating to the • foster very high levels of staff capability and with this copy of the annual report, a copy can In doing so we will focus on: development, delivery and evaluation of satisfaction. be obtained by contacting the Central Gippsland • supporting community identified need and services; Health Service, telephone 03 5143 8600 or by genuine community participation; email to [email protected] • placing our clients/patients and community at the centre of our work; • supporting individuals, groups and communities to maintain and improve their health and wellbeing and minimise the negative impact of chronic disease and injury; • Integrating and co-ordinating our services within an interdisciplinary service delivery model; • allocating and using our resources effectively and efficiently; Dargo • achieving through collaboration and partnerships; Licola • being creative, innovative and open to discovery. Our Values In achieving our goals and objectives we will develop an organisational culture that supports: BriagBriagolongolong Social Justice - equity of outcome. To do this we will: To Sydney • focus on achieving equality of outcome for Heyfield StratforStratford individuals and groups; Maffra • understand the impact of poverty and Loch Sport disadvantage on behavior and health status; • support affirmative action for the disadvantaged and marginalised amongst us; Rosedale Sale • ensure our fees policy takes into account ability To Melbourne LongforLongford Golden Beach to pay; Gormandale • support harm minimisation and targeted community support programs; and Seaspray • be compassionate, tolerant and embrace diversity. Honesty, transparency and integrity. To do this we will: • set and model standards of behaviour YaYarrramram consistent with the Victorian public sector code PoPorrtt Albert of conduct; To Melbourne • embrace open disclosure and provide meaningful and clear information to our stakeholders; and • support ethical leadership development at all levels of the organisation. Quality – Excellence with the client at the Melbourne centre. To do this we will: • embed a quality culture of continuous improvement across the organisation such that our clients’ experience with CGHS is characterised by the following: Contents

Who we are 2 Quality of Care report introduction 2 Board President’s Report 3 CEO Report 3 Introduction 4 Key Areas Population Health Planning 4 Workforce Capability 6 Acute Services – Sustainability 7 Care Co-ordination 9 Koori Wellbeing 14 Cultural and Linguistic Diversity 15 Business Units 16 Building Infrastructure 17 Energy Efficiency 18 Our History 19 Governance 19 Board of Management 19 Executive Staff 20 Workforce Data 20 Overview of Services 21 Our Structure 23 Community Support 24 Senior Personnel 26 Statutory Information 28 Report of Operations 30 Financial Statements

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 1 Board President’s Throughout the last year our Chief Ex- McDonald Wing utilising a sum of Who we are Quality of Care Report ecutive Officer, Dr Frank Evans has been $233,000 from the Department of Health Central Gippsland Health Service (CGHS) Central Gippsland Health Service is involved in undertaking a comprehensive and an equal contribution from the Clyne Report needs assessment with a Community Estate funds, which was established by a is the major provider of health and committed to quality and excellence Board Personnel Advisory Group to develop a compre- bequest from the Clyne family more than with the client/patient at the centre of residential aged care services in the hensive plan to form a firm basis for the 30 years ago. Members of the Board during the year Wellington Shire. care. In line with the CGHS strategic implementation of the strategic plan. This ended 30th June, 2010 were Catherine We have also been invited by the plan we reviewed and improved on our work will continue through the next year. It serves an immediate population of existing quality framework to ensure Greaves, John Lawrence, Glenn Stagg, Department to work up a plan for a new Helene Booth, Kevin Young and Angela Executive Staff development at Maffra which we hope will 42,000 in Central Gippsland, while systems which embed a quality culture Todd. come to fruition during the life of the next acute specialist services reach a wider of continuous improvement across As mentioned our Chief Executive Officer, State Government. community in East Gippsland and parts of the organisation and also processes All members made significant contribution Frank Evans has continued to grow into South Gippsland. of engagement from clinical and non to the governance of our health service the position as he has become more Government Support clinical disciplines, consumers and other during the year. familiar with our community and the needs and demands of our population Your Health Service continues to key stakeholder groups. The quality th At your service Kevin Young’s term expired on the 30 and the ever changing role of the Health enjoy substantial support from the team is an integral part of Central June, 2010 and he did not seek reap- Service in the delivery of services in our Victorian Department of Health and the Central Gippsland Health Service has 80 Gippsland Health Services and is central pointment. Kevin served on the Board region. Commonwealth Department of Health and acute beds, approximately 180 high and to the Quality and Risk working party from 1st July, 2006, since the Board was Ageing. The positive relationships that we Our Director of Nursing, Bronwyn Beadle low care residential aged care beds, as well which meets fortnightly to identify and reconstituted after the appointment of an have with these bodies are fundamental also continued to settle into her position to being able to maintain and extend the as 19 independent living units. monitor issues relating to patient/client Administrator. I wish to acknowledge his and make her mark on the Health Service. services that we provide to the community. safety and quality of service. valued contribution to the Board over that Acute services include a 24 hour, seven period not only in the area of his expertise Michael Clamp continued in his position Conclusion day a week emergency department, The Quality and Risk working party in finance but across the whole spectrum as Manager of Corporate Services as did operating theatres, day procedure unit, reports to the Quality and Risk of the management of the health service. Mandy Pusmucans in her role as Director Finally, I cannot conclude without expressing our gratitude to the more oncology and dialysis services. Committee which meets bi-monthly, His contributions will be missed. of Community Services. than 900 people who work in our Health has Board and consumer representation The terms of Helene Booth and Angela This group was joined by Dr Ka Chun Tse Service and are responsible for providing and reports directly to the Board of th The Health Service Todd also expired on the 30 June, 2010. as our new Director of Medical Services. and maintaining the high level of service Management. Both members have been reappointed to This position is shared with the Bairnsdale that the community has come to expect. continue their service. Health Service and we look forward to his comprises: Accountability reports relating to growing contribution in the future. Thank you also to our various auxiliaries, Acute Services situated at Sale, Maffra and performance and legislative compliance Implementation of Strategic Plan support groups and volunteers who give Maffra Hospital Heyfield; are presented to the Board on a At the Annual Reporting Meeting last year so freely of their time to enhance the monthly basis. we launched our strategic plan for the A project group has been developed Health Service. Community Services provided throughout Health Service to take us through to 2012. to oversee the refurbishment of the John Sullivan, Board President the Shire of Wellington specifically at Current Accreditation Maffra, Sale, Heyfield, Rosedale and Loch Status Sport; and Residential Aged Care Services The Acute and Community Services of tion health, evidence and policy informed community driver. We are very grateful at Sale, Maffra and Heyfield. Chief Executive needs assessment. When the time comes to Alan for all his hard work and commit- Central Gippsland Health Service are we will be grateful if you could let us know ment to his community and our health currently accredited with the Australian Officer’s Report your views. service and for supporting our continuous Our services Council on Healthcare Standards. The past year has been a period of improvement efforts. I would like to take the opportunity to Population served approximately A full, organisation-wide survey was renewal for the health service as we have commenced the implementation of our thank our Chronic Disease Network Group, Central Gippsland Health Service is very 40,000 held in 2007, when Central Gippsland new strategic plan. for providing us with insight into what it is fortunate to have a very capable and Health Service gained full accreditation like to live with or care for someone with Emergency attendances dedicated Board of Management. The valid for four years. This report has been formatted to present a chronic illness, injury or disability and health service benefits from a Board that 16,059 the key issues addressed through the plan for their advice on how to improve our has demonstrated an enormous commit- A site visit, which is called a and describe our progress in implementing Inpatient services services. In particular this group is helping ment to ensuring our community gets the Periodic Review, was conducted the agreed strategies. us to improve the way we co-ordinate care most from its health service and from a 12,225 in October, 2009. This determines I encourage you to use the report to follow and support people with complex needs. Board that has worked diligently to ensure ongoing accreditation status, Community Services hours of service our progress during what has been an We are indebted to our many volunteers the health service is well governed, with reviewing mandatory standards 129,906 exciting and challenging year. for their tireless work across so many quality and safety at the forefront of their as well as reviewing the progress concerns. The report incorporates our quality of care areas of our service. I have been and Allied Health acute services attendances of recommendations made at the report which is specifically written for you, remain absolutely amazed by the generos- Finally I would like to acknowledge our 3,878 organisation-wide survey held in 2007. our community member, patient, client or ity and hard work of our volunteers, many staff. Central Gippsland Health Service is of whom contribute year after year. This A self assessment report was sent carer to read about our progress in improv- fortunate indeed to have such capable People includes our hospital and health centre to Australian Council on Healthcare ing the quality of care we provide. staff. What has impressed me so much auxiliary members, who work hard to raise 614 Full Time Equivalent employees is the genuine commitment of our staff Standards in August, 2010 providing We are grateful to our Consumer and important funds for equipment to meet to make a difference for people and to Approximately 900 people employed detail on continuous quality Carer Consultative Committee for provid- the needs of our patients, residents and place our patients, clients and carers at the improvement under the three main ing us with feedback on last year’s report clients. Assets and Revenue functions of the framework. and how to improve the content in this centre of our work. report. In particular we thank them for This year we have established the new vol- You can provide feedback on our annual $60m in Net Assets The Aged Care Facilities – Laurina the contribution they make to the health unteer role of consumer health advocate. and quality report or any matter you Lodge (Heyfield Nursing Home), Wilson service by providing us with advice and The role, in addition to supporting people $60m in Buildings might like to bring to our attention via the feedback on how we go about our work. to have their issues heard or needs met, Lodge (Sale Nursing Home), Stretton community feedback portal on our new $5m in Plant & Equipment In the coming year the Committee will helps to keep community and consumer Park (Maffra Hostel) and McDonald website. Please visit www.cghs.com.au and Wing (Maffra Nursing Home) all hold design a major community consulta- issues at the forefront of our considera- $70m in Revenue and Budgeted tion process that will form a significant tions. Alan Murray is our Consumer Health follow the prompts. current Accreditation Status. operations component of a comprehensive popula- Advocate in addition to being a volunteer Frank Evans, Chief Executive 2 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 3 Introduction Central Gippsland Health Service is also while a summary of the plan is available part of a subregional population health in hard copy or via email to interested The Central Gippsland Health Service strategic planning project. This project, people. developed and adopted a new strategic which commenced in 2007, has produced The plan was developed after extensive plan during this financial year. a locally relevant and regionally integrated consultation with the community, including service delivery framework, capable of In this annual report, the activities of the an extensive environmental scan, within a adding value and more detail to the “Rural organisation are reported against the key broader regional, state and national health Directions” policy framework. areas of the Strategic Plan. planning framework. Central Gippsland Health Service is Strategic plan released The strategy nominates 12 KEY AREAs categorised as a subregional health Extensive community consultation was through to 2012. These include service within the Victorian public health undertaken to assist in the development Population Health Planning, Workforce care sector. As such the health service of a new strategic plan for the Central Capability, Sustainability of Acute Services, works within a positive government policy Gippsland Health Service during the year. Sustainability of Specialist Medical Services, framework that seeks to strengthen and Care Co-ordination, Koori Wellbeing, sustain rural health services to improve the Community groups, staff, the Department Cultural and Linguistic Diversity (CALD), health of rural Victorians. of Health, local government and other HACC Competitiveness, Business Units, stakeholders were all provided with the Building Infrastructure, Junior Medical staff The framework: “Rural directions – for a opportunity to contribute their thoughts on Accommodation and Energy Efficiency. stronger health Victoria”, describes sub- what is required of the health service to The plan is more detailed than most regional health services as major service best meet local needs. providers in large rural areas. strategic plans as it represents a significant The full plan, which will guide the direction shift in focus for the organisation, with The subregional classification brings with it of the health service through to 2012, is more detail required to support its both role expectations and limitations. available on the website www.cghs.com.au implementation.

KEY AREA Population Health Put simply, the needs assessment, the need to reduce disadvantage, both informed by the evidence and policy, health and social. Planning determines the work that needs to be Goal: To adopt a population done with regard to delivering services, For Central Gippsland Health Service, health approach to health service which in turn determines the work an essential requirement for improving health is to enhance local democracy planning and delivery. that needs to be done to support the delivery of services. and strengthen community action. Central Gippsland Health Service has this year undertaken comprehensive Once this is understood, strategic Where people are able to influence community and stakeholder planning becomes highly focused, as governments and organisations to consultation as it moves to a does the response of the organisation build healthy public policy, they are population health planning approach to develop the necessary capability, more able to develop environments to healthcare delivery. across all areas, to achieve both that support healthy living. strategic and service delivery objectives. The same principles apply at the This approach means the services All forms of capital – financial, human provided and delivered have the service provision level. If people are and facilities – become aligned to involved and able to influence how greatest potential to match the needs achieve these ends. of the local community and therefore they receive support, care, or treatment, maintain and improve the health of the Health & demographic they are more likely to receive entire population. appropriate services and interventions profile that produce positive outcomes. The broader thinking behind this new The first step in a needs assessment approach is to recognise that ‘health’ The Central Gippsland Health Service methodology is to gain an is a capacity or resource rather than model requires the community understanding of the major health and a state of not being ill. It corresponds engagement / consultation strategy wellbeing challenges within a changing to the notion of health being about to be led by community members of having capacities and opportunities demographic, in addition to national the Consumer and Carer Consultative to pursue one’s goals, to acquire skills health priorities and major illness or Committee (CCCC) and supported by and education, and to grow as a disease burdens. The methodology a skilled and philosophically aligned person. also explains the local relevance of social researcher. the broader challenges and illness This concept demands an evidence- burdens, along with other local issues The outcomes of the community based approach, which is one of the and priorities identified through the consultation / engagement strategy are key outcomes of the health service’s development of local health and linked to relevant socio-demographic, new Strategic Plan developed during wellbeing and socio-demographic health and wellbeing or service this financial year. profiles. delivery frameworks. By doing this the community’s preferences and priorities Establishing the evidence for what Effective population health planning help define the needs and then is required necessitates a needs must be grounded in effective and determine the structures and process assessment, a crucial first step in meaningful community engagement, by which the health service will become population health planning. within a framework that understands accountable to the community. 4 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Case study How the CCCC functions in this context Short and Evidence longer range and policy Figure 1 Population health planning cycle (right) financial informed needs Figure 2 Case Study Format (below) planning assessment

Evidence & Policy Informed Needs Assessment Case Study format recommendations

National Health Business / priorities Support Plans + Health & Demographic Reflecting organisational Detailed Oral Health Profile capability dimensions: people, Birthing business processes, facilities service delivery Ageing and equipment, ITC, Knowledge, accountability and governance planning Disability Evidence & Policy Youth Informed Case Community Koori Consultation CALD Studies Socio-economic disadvantage Strategic Other Recommendations translated into services / Planning interventions / operating guidlines / how to etc.

with chronic disease, taking part in the network after the first six Case study months and all found it very useful. Network tackles chronic disease issues As a group, the members have contributed greatly to the Central Gippsland Health Service’s new Strategic Plan, and are An innovative project that assists people with chronic disease now focusing more on Client Care Co-ordination. was established by Central Gippsland Health Service with funding assistance of $106,700 from the Federal Government’s Wellington Shire has quite a high burden of disease. For Department of Health and Ageing. example, diabetes in Wellington is ranked at 10.0 for males compared with 8.0 in Gippsland and 6.5 in Victoria. For The Chronic Disease Network was developed initially to females, the rate is 6.0 in Wellington, compared to 7.0 in provide advice to Central Gippsland Health Service as it Gippsland but 5.7 in Victoria. reviews and improves client care co-ordination practices across the organisation. It also aimed to benefit those with chronic Cardiovascular disease in Wellington is rated at 29.1 for males disease and their carers by educating and empowering people compared to 25.5 for males in Victoria. For females, the ranking with chronic disease and those who support them about the is 24.9 in Wellington, compared to 22.4 in Victoria. role they can play in self management, then passing on this As well as helping those with an existing chronic disease, it knowledge to the wider community. is hoped the Network will help develop greater community There were 12 community members, either carers or those awareness and understanding of chronic disease issues.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 5 KEY AREA Workforce capability contingency and succession planning, The introduction of Moodle (an open knowledge management and capability source online learning management Goal: To develop and implement development priorities and learning platform) has enabled many staff to a comprehensive workforce strategies. access learning in a more flexible and capability development resource efficient manner. A number As part of the implementation framework. of programs have been delivered via process, 33 middle managers and Moodle, for example components of One of the key goals for Central service co-ordinators have undertaken the Diploma of Management and Gippsland Health Service has the nationally recognised Diploma the Graduate Nurse Program. Central been to develop and implement a of Management. The course was Gippsland Health Service is constantly workforce capability framework as delivered through Australian Institute part of an overall service delivery expanding the use of its online learning of Flexible Learning (AIFL) by flexible capability model. Service delivery delivery; combining online, face to platform. (or organisational) capability can be face and on the job learning and defined as “the sum of all things assessments. that enable an organisation to HOW IS CENTRAL deliver services.” Also as a strategy to build capability, eight traineeships/apprenticeships were GIPPSLAND HEALTH The framework is based on an offered this year across a range of understanding that capability is the SERVICE INVOLVED non-clinical support services, including critical link between strategy and information technology, library, performance and the importance of the IN RESEARCH? relationship between what we need to business administration, engineering and food services. Central Gippsland Health Service has do (the work) and the personal abilities a clinical trials group that is regularly and attributes needed to do it. With support from a $140,000 involved in research projects and has this The framework provides the link Workforce Innovation Grant from year participated in two large multi-centre between functional capability and the Department of Health, Central randomised controlled trials. processes such as: Gippsland Health Service established an allied health assistant traineeship The first examined benefits of increasing • strategic workforce planning, work program. This has enabled five young HDL cholesterol in patients following acute and role design, Gippsland residents to undertake a coronary syndromes, while the second • recruitment and selection, Certificate IV in Allied Health Assistant evaluated early goal directed therapy in patients presenting to the Emergency • career and succession planning, within their own community. The program helped workforce redesign Department with sepsis. Other quality • performance management and within allied health services and is driven research projects have included learning management. expected to enhance service capacity an analysis of the Medical Emergency The framework includes a 360 degree and sustainability, particularly in an Team system and the Intensive Care questionnaire, which has been built environment where recruitment of Unit discharge process in order to online and in-house, and completed professional allied health practitioners provide better quality care and reduce for all senior management and the is an ongoing challenge. readmissions. majority of middle and front line managers and service co-ordinators. Once again the health service flexible Central Gippsland Health Service continues The 360 degree questionnaires form service delivery model, provided to participate in the INFINITE project to part of comprehensive capability through the Australian Institute of provide government departments and development plans that include the Flexible Learning, was used to combine clinicians current data relating to the individual’s relationship to the strategic online, face to face and on the job occurrence of H1N1 influenza in Intensive plan, that is, their key responsibilities, learning. Care Units.

Dr Brian Cole (right) and staff in the Emergency Department. Interns rated their Gippsland experience highly (see Case Study next page). 6 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 efforts of the nursing staff were also commended. “Nursing Case study staff are wonderful to work with and all very professional and highly skilled,” was one of the comments made by the interns, Interns rate their Gippsland while another said: “Ample opportunity to extend my learning. experience highly Regular case discussions with Dr Cole in the ED have been Central Gippsland Health Service has been recognised as a highly valuable.” One other added: “The presence of Dr Cole preferred destination by junior doctors starting out on their was extremely helpful.” careers. The general comments included “an excellent place to gain The Health Service and specifically the Emergency Department clinical experience” and “the best thing about the rotation was awarded a special commendation on the strength of a was feeling like an efficient and accepted member of the ED survey of the 2009 intern cohort who worked in Sale as part of staff and being able to work through problems with the other their first year rotation program. staff. (We were) overwhelmed at the capacity and courtesy of emergency nursing staff.” The junior doctors, who spend their first year after completing their medical studies working in various hospitals under a Dr Cole gained a supervisor’s award, while the Emergency medical education program run through the Alfred Hospital in Department as a whole was nominated as the best rotation. Melbourne, nominated their time at Sale as one of their most Two interns work in the Emergency Department at any given outstanding experiences. time, rotating five times a year. They also work at a number of In particular they were full of praise for the supervisory work of other hospitals, including metropolitan hospitals like the Alfred. the Deputy Director of Emergency Services Dr Brian Cole, and Central Gippsland Health Service was one of only a few to the Director of Emergency Services Dr Howard Connor. The receive multiple nominations.

KEY AREA Acute Services – by the organisation’s Central Sterilising • Code Blue Department, as opposed to within • Unplanned return to Theatre within Sustainability the Dental Clinic. This has occurred seven days Goal: To provide acute care following benchmarking, identification services efficiently and effectively of relevant standards, and comparison • Deaths of the benefits or disadvantages. and within designated funding • Unplanned transfers to Critical Care and associated revenue streams This is unusual in the public dental Unit while continuing to improve system, however at Central Gippsland • Emergency Caesarean Sections quality of care. Health Service it is seen to better utilise Between July 2009 and June 2010, there As with most health services, Central capacity and to provide a high quality were 660 Limited Adverse Occurrence Gippsland Health Service has a dental service to the local community. Screening events. Of these, 4.7 % pressing need to improve the efficiency were presented to the Quality and Risk of our acute care services. While this Over recent years, the waiting time is financially challenging, the health for general courses of care has gone Working Group for further discussion and service is clear about the need to from 55 months in July 2007, to 33.88 recommendations. continuously improve the quality of months in July 2009, to the current Some examples of changes to practice as services and ensure that achieving wait time of 23.79 months in June a result included: improved efficiency supports improved 2010. quality of care. • Review of resuscitation plan to ensure improved patient involvement in During this year, a number of activities HOW DOES CENTRAL discussion about resuscitation choices have occurred that will help with these and better documentation to state aims. GIPPSLAND HEALTH why a patient is unable to be involved. • Major revision of fluid balance charts Notable among these is a new Dental SERVICE MONITOR and fluid balance documentation Facility. The new four chair facility ISSUES? practice. is now in place which houses both • Review of pain management in Wilson community and school dental services. Limited Adverse Lodge. In the lead up to placement of the Occurrence Screening • Review of patient transfer procedure building, the Dental Team has worked and discussion with Ambulance The Limited Adverse Occurrence Screening together to identify work flow and Victoria regarding escalation processes process has been in place at Central therefore processes, to ensure clients for time critical transfers. receive the services they require. Gippsland Health Service since April 2005. • Improved direct admission pathway The occurrences screened are: Significantly, the sterilising requirements for palliative patients/clients who for the Dental Service are now provided • Medical Emergency Team calls require admission to hospital.

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 7 therefore more appropriate allocation of resources required by Case study each patient. RESEARCH PROJECT FOCUSING ON This also decreased the average length of stay, freeing resources to enable treatment of those patients with more CHEST PAIN ASSESSMENT DECREASES serious conditions. WAITING TIME The project complemented another quality improvement Participation in a state wide project has resulted in dramatically project in the new Emergency Department to improve waiting reduced waiting time in the Central Gippsland Health Service times and patient flow through the department. This project Emergency Department for people with chest pain. has seen a marked reduction in waiting times for all triage categories, in line with or better than Department of Health The health service took part in the project, titled ‘Improving the Requirements. assessment of chest pain in Emergency Departments,’ as part of the Emergency Care Improvement and Innovation Clinical The health service is continuing the program of ongoing Network. education for all new nursing and medical staff and is intending to continue auditing the processes to ensure maintenance of The Central Gippsland Health Service project concentrated high quality patient care and ongoing improvement. on ensuring better education for all Department staff and developing a new risk assessment tool, resulted in an average decrease of around 100 minutes in waiting time for chest pain patients. Central Gippsland Health Service was one of 16 Emergency Departments from across the State to take part in the nine month project, with results presented at a meeting of the Emergency Care Improvement and Innovation Clinical Network. The Central Gippsland Health Service results exceeded expectations. Just under 16,000 people a year present at the Emergency Department and about a third – more than 5,000 – are there because of chest pain. Central Gippsland Health Service has a Level Two Nursery which is utilised by families Many obviously require further treatment for cardiac issues, and from across much of Gippsland. there is a comprehensive and often time consuming process that each individual needs to undertake. As well as initial The Level Two Nursery came through with flying colours when treatment, there is often a long period of observation. there was a twin baby boom in June 2010. Prior to the project the average length of stay in the Emergency Four sets of twins arrived within a week, starting on 4 June and Department as a result of chest pain was close to seven hours. all were in the Level Two Nursery at the same time. Pictured Following the project, the average was reduced to less than five from left are the mums and their new borns, Mackenzie and hours. Miranda Laskowski with mother Katie, whose partner is Jason; Ari and Darcy Cater with mum Nicole (Dad Glenn); Allison and The project has allowed better identification of the level of risk Alexis Falconer with mum Nora (Dad Peter) and Alinta and to each patient and the most appropriate treatment, and Kalana Browne with mum Roslyn (Dad is Nat.) Case study TRAINEES FIRST IN NEW HEALTH PROGRAM The five young local people who started their career through the Central Gippsland Health Service Allied Health Assistant Workforce Plan included Jacob Tilley, Dell Colcott, Emma Schroeter, Melanie Hawthorn and Marney Dee. The Workforce Innovations Project was developed when the health service successfully applied for funding through the State Government’s Workforce Innovative Grant Program. The trainees are working in a range of Allied Health services while at the same time gaining a Certificate IV qualification in Allied Health Assistant through the Australian Institute of Flexible Learning.

The program offers a great opportunity for local people, while Pictured are (standing) Jacob Tilley and Dell Colcott, and seated from left Marney Dee, helping the health service to develop a strong future workforce. Emma Schroeter and Melanie Hawthorn. With many regional health services having an enduring issue when local people access entry level vocational qualifications in with recruitment and retention of allied health staff across their own community. most of the allied health disciplines, developing a vocational education and training-qualified allied health assistant Some also take advantage of the pathways available to them to workforce has the potential to significantly enhance service progress to professional tertiary qualifications. capacity and effectiveness. The $130,000 provided by the State Government funding is It has been demonstrated that retention rates are relatively high being matched by a similar amount from the health service.

8 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 KEY AREA Care co-ordination highly co-ordinated health care and One of the difficulties for Central community support system. Gippsland Health Service is that it Goal: To enhance the health and provides a range of specialist services So, how is this being achieved? wellbeing of people with chronic and a comprehensive mix of clinical illness and/or complex health A major change project is now services at a moderate to high level care needs through access to a underway that will impact across of complexity, as well as a near highly co-ordinated health care the breadth and depth of Central comprehensive range of community and community support system. Gippsland Health Service. The desired health and community support services. Central Gippsland Health Service is outcome is best expressed in the statement, ‘Right service by the right This comprehensive integration model seeking to better align the way in person(s), at the right time, in the right has multiple entry points and it is not which care is managed for people with setting, to achieve the best outcome.’ possible to funnel all potential access chronic illness and/or complex health points into one. needs. Placing the client at the centre of service delivery will ensure they Therefore a key outcome of the Care The health service has this year defined experience a seamless, supported and Co-ordination program will be to a specific set of outcomes in a new integrated response from the health identify complex needs at any entry Care Co-ordination program to make service (and beyond), have access to sure the services provided revolve point, regardless of where that entry the services they need and will benefit point is within the system, by using a around the needs of the patient. from, and can take advantage of standardized screening tool. opportunities for early intervention and The aim of placing the client at the secondary prevention. centre of care is one of the key planks Where a complex need is identified in the Health Service’s Strategic An important by-product of this process the patient/client is referred to care Plan, developed in 2009. By aligning will be a significant improvement in the co-ordination; a comprehensive organisational structures and processes efficiency and effectiveness of service assessment at this point will decide the so that patients’ needs are considered delivery, thus providing a more efficient need for ongoing care co-ordination at every stage of their treatment, the use of financial, human and structural and a multidisciplinary, multi-service, health service is seeking to create a resources. service delivery plan. The following table from the CGHS accountability framework shows performance in the last three months of the financial year.

Access/Equity

Waiting times for Elective Surgery by urgency category (Benchmarks CGHS Results under (average number of days) development) April May June Urgency Category 1 <30 days 15 12 10 Urgency Category 2 <90 days 35 33 33 Urgency Category 3 (Average Wait Time) <365 days 69 69 44 Emergency Department Waiting Times DoH benchmarks by triage category Triage Cat 1 (seen immediately) 100% 100% 100% 100% Triage Cat 2 (seen within 10 mins) 80% 82% 80% 88% Triage Cat 3(seen within 30 mins) 75% 85% 84% 82% Triage Cat 4(seen within one hour) Not yet targeted 69% 65% 66% Length of Stay >24hours 0 1% 1% 2% Occasions of Ambulance Bypass Reducing trend 0 0 0 Episodes of Blocked Admissions Reducing trend 0 9 41 Number of people awaiting urgent aged care placement trend 5 4 1 (Sale and Maffra combined) Number of people awaiting non-urgent aged care placement trend 15 14 2 (Sale and Maffra combined) Number of people placed in residential care, placed in non preferred location Decreasing trend 0 0 0 (e.g. Heyfield resident placed in Sale when their preference is Heyfield) Waiting time for general course of dental care 24 months 29 23.79 24.77 Waiting time for dental prosthetics 22 months 29.57 30.59 29.01

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 9 Role of Intake Worker to establish the possibility of the patient/ interdisciplinary assessment is carried out client being supported by Care Co- by a relevant multi-disciplinary team and The key responsibility of the Intake position ordination and a multidisciplinary team a comprehensive service delivery plan is to provide an efficient and effective and, if so, advising the patient/client of the developed with the patient/client being the initial point of entry for patients/clients role of Care Co-ordination. key decision maker. The service delivery entering Central Gippsland Health Service. plans are based on need and patient/client At this stage the patient is either preferences rather than program eligibility. Intake helps the patient/client begin or transferred to Care Co-ordination or, for continue their transition through their care a single service/one off presentation, to The Care Co-ordinator ensures that journey by initially identifying the patient/ the best program to meet that immediate potential for duplicated effort in the client status, whether new or existing and need. assessment and service delivery processes if the latter, confirming existing consumer is mitigated. information is current. Role of Care Co-ordinator Where appropriate a key worker is Intake also has an important role to play in The key responsibility of the care co- appointed, such as for palliative care determining program eligibility, obtaining ordinator is to develop a comprehensive, clients. Ongoing effective communication consumer consent and the information patient/client centered plan and co- between the key worker and the care required to complete Initial Contact and ordinate delivery of services to ensure the co-ordinator is an important part of the Initial Needs Identification processes. best outcome. success of this approach, as ongoing review and assessment, with appropriate One of the most important tasks at this Among other things, the Care Co-ordinator changes to the service delivery plan, may stage is undertaking the screening process takes responsibility to ensure that an need to be implemented.

Figure 3: Model and Entry and CGHS Intake Model Assessment for people presenting at HOW DOES CENTRAL Central Gippsland Health Service Entry Point GIPSLAND HEALTH (Multiple) CGHS care co-ordination model SERVICE IMPLEMENT

Entry Point Intake / Screening INFECTION (Multiple) (Telephone, Electronic, Paper based, Face-to-Face) CONTROL? Infection Control Intake / Screening Intake / Screening The Infection Control Program is Referral based on Obtain required patient/client information responsible for monitoring all aspects of identification of to complete Initial Contact, Initial Need infection risk, ranging from ensuring correct complex Identification and Consumer Consent in systems for food handling, environmental care needs conjunction with determining if there are safety, water supplies and air conditioning Chronic/Complex Care Needs systems, correct operating theatre and sterilising procedures. Care co-ordination / Intake - Chronic/complex Infection Control and Compliance Audits case management care needs identifiers Multidisciplinary team are performed annually in each clinical with or without a key • Does the client have more than area as well as at an organisational level. worker one medical condition or a chronic Results are collated and forwarded to the disease? Rural Infection Control Practice Group • Does or will the client have difficulty (RICPRAC) where they are benchmarked with activities of daily living? against other like-sized facilities across rural General Develop outcome • Does the client receive community Victoria. based, patient/ Practice Service based services? client centred, Through the Victorian Hospital Acquired • Does the client have or likely to detailed service Infection Surveillance System (VICNISS), have caring responsibilities at home delivery plan that they have/may have difficulty surgical site infections, blood stream Based on a meeting? infections, occupational blood and body comprehensive fluid exposures, influenza staff vaccination Specialist • Are there any complex family or social assessment (Adapted medical rates, haemodialysis infection events and as situation charges) issues? practitioners multi-resistant organism infections are • Other? monitored, reported on and bench marked against other Group 2 health care facilities. Service Service Care Co- The Infection Control Co-ordinators Single ordination/ are nurses with specialised training Service Case or one off who provide leadership throughout the Service Service Management presentation organisation for the prevention and Multidisciplinary Program Specific management of infections. The Infection team with or Service Control Co-ordinators report directly to the without a key Service Delivery Quality and Risk Working Party and the worker Safe Practice and Environment Committee.

10 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Hand Hygiene Compliance Hand Hygiene Compliance 100% The Australian Commission on Quality and Safety in Health Care (ACSQHC) 80% has engaged Hand Hygiene Australia 60% (HHA) to implement the National Hand Hygiene Initiative. HHA reports directly 40% CGHS to the ACSQHC. Hand Hygiene Australia 20% VIC has worked closely with all States and 0% Territories to establish a national system of outcome measures to assess the Jul 10 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Aug 10 effectiveness of the National Hand Hygiene Initiative. N.B. At the time of printing the State benchmarking result for the last reporting period due August 6th 2010 were not available. The Infection Control Team at Central The ‘Five Moments of Hand Hygiene’ those opportunities that staff miss. Gippsland Health Service monitors hand define the essential hand washing washing compliance rates. This data is opportunities on which the audit is Central Gippsland Health Service has then reported to the Victorian Hospital based. Staff are categorised according to improved its hand washing compliance Acquired Infection Surveillance System co- job description and the total number of this year in all three audit periods and ordinating centre, where it is collated and opportunities for hand hygiene that are displays a level of compliance above the benchmarked against the State average. observed are compared to the number of state average.

Medication Management Prevention of Pressure Falls Monitoring Delivering medication safely depends on Ulcers Central Gippsland Health Service continues providing the right medication to the right Pressure Ulcers result from damage to the to identify those patients who are at patient in the right dose at the right time. skin when patients are unable to move increased risk of falls in the hospital setting as well as in their home environment. Central Gippsland Health Service has freely in bed. an active program of monitoring any There are four levels of severity and Falls risk assessment tools and falls incidents that occur in relation to drug recognising the subtle changes in the minimisation plans are developed and administration. All Registered Nurses skin before it breaks down has a major continuous improvements implemented complete an annual medication influence on reducing the occurrence of in acute, community services and aged administration education program as part pressure ulcers. care. Completion of assessments and of their ongoing professional development implementation of plans continue to be and credentialing program. Central Gippsland Health Service submits audited. Pressure Ulcer Clinical Indicators six Below are the reported medication errors monthly to the Australian Council on The Falls Committee meets regularly and for the previous six months: Health Care Standards. the Falls Prevention Committee continues to monitor data related to falls, in particular ACHS Medication Incidents with Result of this benchmarking show that incidents reported. adverse outcome Central Gippsland Health Service compares Nursing staff annually complete July - December 2009 favourably with other organisations. mandatory education relating to Falls Risk Assessments as part of their ongoing ACHS Pressure Area Incidence professional development program. July - December 2009 All hospitals 0.03 The result of benchmarking through submission of Falls Clinical Indicators to the Australian Council on Health Care CGHS 0.01 All hospitals 0.08 Standards is presented below. Rate % ACHS Pressure Indicators Falls 0.0 0.01 0.02 0.03 0.04 CGHS 0.07 July - December 2009 Rate % This graph demonstrates % occurrence against total bed days for six month period .065 .070 .075 .080 .085 Rate % (medications) All hospitals .380 This graph demonstrates % occurrence against overnight occupied bed days for six month period (falls, pressure area) CGHS .390

.375 .380 .385 .390 .395 This graph demonstrates % occurrence against overnight occupied bed days for six month period (falls, pressure area)

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 11 credentialing and privileging Regular monitoring and management of Clinical Governance processes? incidents takes place within the Quality structure 10. Can we demonstrate consumer Department. Significant reported incidents involvement? are tabled at the fortnightly meeting of Review of Clinical Risk 11. Are there manageable Clinical the Quality and Risk Working Party, with Management auditing, benchmarking and specified reporting to the Quality and Risk Risk management is an essential ingredient monitoring tools? Committee. of good corporate and clinical governance. 12. Are there clearly defined roles and This enables the organisation to conduct Increasingly, health service providers responsibilities by all staff within the trend analysis on incidents reported under are being asked to show evidence of a healthcare environment? systematic approach to the identification, certain categories. analysis, evaluation, treatment and ongoing 13. Does the organisation adequately monitoring of risks. demonstrate compliance with Revised ‘Key Ages and legislation? The application of a systematic approach Stages’ framework to the management of risk assists in The review was extensive and obtained achieving Central Gippsland Health input from the Board, a broad cross Implementation of the revised Key Ages Service’s strategic objectives and section of clinical and non-clinical staff and and Stages framework for Maternal and compliance with statutory obligations. the consumer consultative committee. Child Health Services has occurred over In line with the values and key priority the past six months, which has included To help ensure continual improvement in areas within the Central Gippsland Health the areas of clinical governance and overall Service strategic plan a number of key significant staff education and revision of health service delivery accountability, the outcomes were achieved. existing processes. executive team at Central Gippsland Health Service undertook a full review of its The existing quality committee structure The new policy framework is based on clinical risk management and compliance was streamlined to ensure appropriate aspects of child health and wellbeing, processes, along with its capacity to cross representation with integrated and learning and development and safety that provide clear and accountable activity accountable reporting processes between reports to the Department of Health, the committees. are essential to children’s futures and Board, staff and the community. recognises the vital role that Maternal and An organisational accountability framework Child Health nurses can play during their In the context of recommendations from was developed which clearly reflects the the Victorian Auditor General’s Office on key priorities of the Central Gippsland regular consultations with young children Patient Safety in Public Hospitals (2008) Health Service strategic plan, through the and their families. and on review of literature relating to development of key indicators for health national and international frameworks service delivery in the areas of finance, Stomal Therapy support for clinical governance and systems of access/equity, quality, organizational accountability, an overall appraisal of the culture, health outcomes, community group established Central Gippsland Health Service quality well being, clinical governance and A stomal therapy support group was committee structure, reporting processes sustainability. and legislative compliance systems were established by Central Gippsland Health undertaken. The review included 13 key A legislative compliance framework Service early in the reporting period. points for consideration: supported by a legal health peak body group was adopted and integrated with the After an initial ‘Meet and Greet’ in 1. Can staff identify a clinical risk when quality committee framework to ensure August 2009, the group was formed it occurs? validity of compliance through regular and has since proved a valuable auditing schedules. 2. Do staff effectively report and record support process for those involved. clinical incident data? Benchmarking opportunities with like-sized Like many medical conditions, there health services were also developed. 3. Are incident investigations effective? are often quite a lot of people with the 4. Are responses to prevent incidents condition who perhaps are not aware from recurring effective and are they Clinical Governance that others are dealing with similar evaluated? issues. 5. Does the leadership support a Quality The purpose of a support group was to culture of open disclosure and Closing the gap between the clinical effective response to performance care that is provided and best practice bring together people who can assist problems? each other and learn about the other 6. Does the organisation have a support systems in place. transparent service capability/ Safety Stomal therapy is planned following accountability framework? Ensuring the wrong things happen to patients less frequently (reactive) a careful assessment which typically 7. Is the committee structure, Identifying weak processes that includes consultation with the treating systems and processes clearly represent an unacceptable level of risk defined, is there appropriate of patients experiencing an adverse physician and/or surgeon. There is a clinical representation and do event while they are receiving range of support and services available, representatives understand their care (proactive) including self-management options, role? which take into account the client’s daily 8. Is there ready access to clear, Incident Reporting routines, reactions to changed body evidence based clinical procedures? Central Gippsland Health Service promotes image and capacity to self-manage all 9. Do we have appropriate a robust incident reporting system. or part of their stoma care.

12 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Victorian Patient Satisfaction Monitor June 2009 - December 2009 84 82 CGHS 80 Like Hospitals 78 76 74 72 70

Treatment Overall Care

Access & Admission Patient Information Physical Enviroment Discharge & Follow Up Consumer Participation Complaints Management Central Gippsland Health Service participates in the Victorian Patient Satisfaction Monitor run by the Department of Health. This allows organisations to compare their performance with similar size/type hospitals across Victoria. It is pleasing that Central Gippsland Health Service is typically performing above the B Category average. The following graph shows performance in key satisfaction indicator areas for the period June 2009 to December 2009, the most recent data available. Central Gippsland Health Service had: 200 participants (sample size), 540 prospective participants (sent a questionnaire), 36.9% response rate, 37.4% response rate for same category hospitals.

• in October 2009. This group has about the range of available services and Consumer, carer agreed to provide the major consumer highlighting new programs; staffing profile; and carer input into the organisation’s and evidence of the health service’s self and community Care Co-ordination project. sufficiency. As much of this information as is available is being included in this report. participation • The establishment of the inaugural Consumer Advocate in late 2009. A revised Accountability Framework has Governance been developed with the support of the • The creation of a consumer Central Gippsland Health Service has Board of Management and as part of the representative member on the detailed the importance of consumer and new Strategic Plan. organisation’s Quality and Risk carer participation in the organisation’s Committee, which is a subcommittee This framework enables accountability Strategic Plan 2009, which requires that to the Board of Management. This and transparency on a number of fronts, services are person centred. including to various funding bodies, local came into effect in April 2010. government and more importantly to the In the 2008 EQUIP Accreditation, Central • The establishment of an Aboriginal community. The framework responsibilities Gippsland Health Service achieved and Torres Strait Islander Advisory have been assigned to the various “Moderate Achievement” against Committee occurred in May 2010, Committees within the organisation’s Standard 2.4, which required that “the following open consultation with the Quality Structure, ultimately reporting governing body is committed to consumer relevant local community. A member through to the Board of Management. participation.” Since development of the from this group will also participate in new Strategic Plan, the health service is the Central Gippsland Health Service moving to improve that rating with the Health care and treatment Consumer and Carer Consultative creation of new systems and consumer As indicated above, Central Gippsland Committee. groups. Health Service emphasizes the importance Smaller community and service specific of providing services that are person As well as the Board of Management, advisory groups and working parties, centred. whose seven members meet on a monthly such as the Loch Sport and Rosedale basis, consumers and carers are now This is most evident in the major Care Co- Community Health Centre Advisory ordination project that commenced across further represented on key governance Committees; the Meals on Wheels groups including: the organisation in August 2009 and is Consumer Reference Groups; and others ongoing. This project seeks to ensure the • The Central Gippsland Health Service also provide input. right service by the right person(s), at the Consumer and Carer Consultative right time, in the right setting, to achieve Committee – current membership Accountability the best outcome. of 12 community members which During the year, there was consultation It is lead by a Project Steering Committee meets monthly. This Committee has with the Consumer and Carer Consultative which includes members from across agreed to lead the organisation’s Committee seeking their input into this the organisation’s continuum of care as Community Consultation process Quality of Care Report. well as a representative from the Central which will be a major component of The Committee called for various Gippsland Health Service Consumer and the comprehensive needs assessment information to be reported, including Carer Consultative Committee. to inform future service delivery plans. waiting times – for elective surgery and Central Gippsland Health Service has • The Central Gippsland Health Service emergency department– and how Central also facilitated a two year, Improving Care Chronic Disease Network – current Gippsland Health Service benchmarks for Older People project. The resulting membership of eight people who with other services; statistics benchmarked Functional Design Toolkit and related have met on a monthly basis since its with other services; feedback from the strategies has and will influence care co- inception patient satisfaction survey ; information ordination practices into the future. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 13 Consultative Committee, Mr Murray has formal and regular Case Study access as required to the Chief Executive Officer and the Board CONSUMER ADVOCATE POSITION President and participates on relevant committees and project teams such as the Quality and Risk Committee and the Care TRIALLED BY HEALTH SERVICE Co-ordination Project Steering Committee. Central Gippsland Health Service appointed a Consumer Advocate during the year to assist with a pilot community engagement program. Alan Murray, a long term volunteer of the health service, agreed to the role which now sees him actively support individuals, families, groups and communities to help them access the health services they need. His specific tasks are to provide direct advocacy for individuals and groups within the community. This may include providing information about services, facilitating feedback to staff and Board regarding consumer issues, both positive and negative, and assisting in quality improvement processes. Mr Murray has also had input into agency policies to ensure consumer issues receive priority. The role is being piloted as the health service explores ways in which it can continue to improve its services. Caption: Alan Murray (centre) who has taken on the role as Community Advocate is As well as participating on the Consumer and Carer pictured with CEO Frank Evans and Director of Nursing Bronwyn Beadle.

KEY AREA

CGHS Chief Executive Officer Frank Evans, left, raises the Australian flag while Aunty Irma Pepper raises the Aboriginal flag during NAIDOC week. (Inset) The small plaque between the two flagpoles which form part of the permanent display. Koori wellbeing is a significant group within the health the single most important first service catchment because of the step to enhancing the health and Goal: To receive direction from enduring health inequities that exist wellbeing of local Aboriginal and our Koori communities about in comparison to the non-Aboriginal Torres Strait Islander community what is required of CGHS to population. members was to meet with enhance Koori health and them and listen to them. This wellbeing. A range of significant activities have consultation occurred during May, recently occurred which aim to support with eight local people attending. In the 2006 census, 432 people in the local Aboriginal and Torres Strait A range of strategies was identified the Wellington Shire reported to be Islander community members. an Aboriginal or Torres Strait Islander, for action, including establishing which equated to 1.07% of the total • Listening to the local community: an Aboriginal and Torres Strait Shire population and compares to Throughout the strategic planning Islander Advisory committee to 0.6% for all of Victoria. This population consultations, it was identified that Central Gippsland Health Service, 14 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 which meets on a quarterly basis. employee survey, in order to • Linkages: Consolidate engagement In addition to this, a member of ascertain the percentage of staff and networking with the local this Committee will now join the who are Aboriginal or Torres Strait community with, for example, organisation’s Consumer and Islander. This information will involvement in community Carer Consultative Committee. provide a baseline on which to meetings at Ramahyuck District • Flying the Flags: During NAIDOC measure future efforts in recruiting Aboriginal Corporation. Week 2010, Central Gippsland Aboriginal and Torres Strait • Cultural Awareness for staff: Health Service raised both the Islander community members. As embed this into the employee Australian Flag and the Aboriginal well as this, an Aboriginal trainee orientation program. Flag at a ceremony at the front has now been recruited. • Symbols: such as local artworks. of the main campus of the health • Regional engagement in • Recruitment: seek to increase service. This was attended by the Closing the Health Gap the percentage of Aboriginal and Board members, staff, and many Committee: Central Gippsland Torres Strait Islander employees members of the local community. Health Service is taking advantage so that it at least equals the The health service’s newly formed of a National, State and Regional population percentage of 1.07%. “Closing the Gap” project to Aboriginal and Torres Strait • Welcome to Country/ advance the strategic objectives Islander Advisory Committee Acknowledgement of Country: with regard to Koori wellbeing. supported the event. Develop the wording and • Aboriginal Workforce: Central Activities which have been planned or procedure so that this is routinely Gippsland Health Service has at the very least considered include the stated at relevant activities across conducted an agency wide following: the health service.

KEY AREA Culturally and Malta, India, Scotland, Lancashire • CALD portfolio: A community – England, Romania, Germany, services assessment officer has Linguistically Diverse Latvia, Tanzania, Holland, China, worked under a Cultural and backgrounds Australia, and the local Gunai/ Linguistically Diverse portfolio Kurnai peoples. The participants which has enhanced the Goal: Ensure people from tasted dishes from around the awareness amongst other staff, as culturally and linguistically diverse world, including Meatballs from well as developed strong linkages backgrounds experience equitable Sweden, Piragi from Latvia, Curry to clients who have particular access to services to maximise from India, Aussie Pizza and Pies needs in relation to their cultural or their health and wellbeing. from Australia, Puddina from linguistically diverse backgrounds. Malta, Oatcakes and Cheese from A significant number of people from • CALD Workforce: Central Gippsland Scotland, Pineapple and Cashew Culturally and Linguistically Diverse Health Service has conducted an Dessert from Tanzania …and backgrounds, commonly known as agency wide employee survey, in much more! order to ascertain the percentage CALD, live in the Wellington Shire and it of staff who come from a cultural is very important that Central Gippsland • Proper use of Interpreter Services: or linguistically diverse background. Health Service supports access to A number of staff have attended This information will provide a services and maximises their health either Interpreter Training or baseline on which to measure and wellbeing. Cultural Awareness training, which was provided on-site by Gippsland future efforts in recruiting CALD Multicultural Services. community members. For many of the CALD population, the increasing complexity of their • Networking: Central Gippsland Listening to the local community is an service needs is compounded by a Health Service has developed a important element of this strategy and decreasing proficiency in language as close relationship with Gippsland planning is in place for a consultation they age. It is important that the health Multicultural Services. This has and meeting in coming months. This will service engage with this community will support future efforts. inform ongoing work. to enable their needs to be articulated and subsequently addressed through service delivery planning.

Activities towards achieving this important goal to date have been:

• Staff awareness raising: approximately 40 staff attended a BYO lunch to “Celebrate our Diversity”. Most brought a plate of food to share from their cultural background. Some also came in traditional dress. It was a lovely time in which those who attended learned how to say hello from Staff enjoy a culturally diverse meal, during a luncheon to celebrate diversity. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 15 Case study YOUNG, AGED CONNECT THROUGH NEW PROJECT A new project that will encourage greater connection between residents of aged care facilities and the broader community has started at Central Gippsland Health Service. The service received funding through the State Government’s Department of Health to run a project called ‘Count Us In’ which will help develop social connections for residents of Wilson Lodge in Sale. The project includes activities involving residents, local school children and community clubs through a program of gardening, artworks and other activities. As well as enhancing the grounds and environment of Wilson Lodge, the project will provide opportunities for residents to participate in community activities. The project will encourage social connections through contact with local community centres, schools and volunteer organisations. The project will have five key activities. They include creation of a ‘Tree of Life’ mosaic by a local primary school art group in conjunction with residents that will enhance the Wilson Lodge Garden, while another part of the project will develop a sensory Work started on an irrigation system for the new gardens, with support from local garden and an ergonomically safe ‘conservation pit’ modelled businesses including Noel Cleal and his partner from Bobtrucks Mini Diggers, Stratford. on the one at the Stratford Garden for Humanity. Noel generously donated his time and equipment to dig the trenches for the new plumbing. Another part of the project will involve the Aboriginal community producing a weatherproof work of art depicting the vegetable garden with a Culturally and Linguistically Diverse history of indigenous people in this area, while a life journey (CALD) component, which will involve people from different component will develop story telling among the residents. cultural backgrounds. The result should be a diverse vegetable The other component of the project is development of a garden with, for example, Asian and European sections.

KEY AREA Business Units manner; be adequately resourced developments in both areas. to ensure continued production Goals: To develop and protect capacity and maintain or enhance A detailed maintenance program profit centres to enable the their competitive advantage; maintain and equipment register has been generation of discretionary funds existing and acquire new contracts developed for the Linen Service, which that can be targeted to address where production capacity can meet has also secured a major contract with Parks Victoria for a further three years priority needs. need; and maintain and enhance their reputation as a provider of high quality and expanded the business further into Background services and products. the hospitality industry. Central Gippsland Health Service Outcomes A review of the energy and water includes two major business units, usage has started to determine where The financial year has been a efficiencies can be achieved. the Sale Linen Service and Central particularly challenging year for both Gippsland Health Service Medical Business Units. The profit margins In the Medical Imaging Department, Imaging. The two business units in the Linen Service have been accreditation was achieved and generate a significant net financial challenged due to the increasing costs improvements have commenced benefit for the health service. of energy and water and the Medical to the physical environment of the Imaging business is being challenged Medical Imaging department. As well, A number of key outcomes have been as competitors enter the local market. the health service has developed a identified to ensure these businesses long-term replacement program for all can operate in a safe and appropriate However, there have been significant major equipment.

16 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 The health service believes it will be of benefit to clients. Bulk Case study Billing simplifies the process for patients because the Unit claims the fee direct from Medicare, which means the patient MEDICAL IMAGING EXTENDS BULK does not have to pay first, and then make the claim back from BILLING Medicare. The Medical Imaging Unit at Central Gippsland Health Service The Bulk Billing applies only to general and dental radiology, extended bulk billing to all its general radiology patients from not higher level services such as Ultrasound, CT Scans and February 2010. Nuclear Medicine. Until that time only pensioners and healthcare card holders Central Gippsland Health Service has invested in high quality were bulk billed for their services. The opportunity for the Unit equipment to ensure that patients can have tests locally that to bulk bill was first considered late in 2009 when the Federal are at a comparable level to Melbourne Hospitals; however, Government introduced an incentive to bulk bill. It is in keeping if it bulk bills for these tests it cannot continue to provide with the health service values of social justice and after an the high standard of equipment locally. All fees raised are internal evaluation, it was decided to implement the bulk bill channelled back to the health service for the overall benefit of system from February. the community.

KEY AREA Building Infrastructure Works in Planning needs to be recognised that these works are only an interim step, as a new building Immediate objectives in planning or Goal: To meet our short to is required if Central Gippsland Health just underway are to develop a Patient medium term infrastructure Service is to meet future certification Services Area; and improve the physical requirements and to position and accreditation requirements. The environment of the Medical Imaging ourselves to receive the major concept drawings for the upgrade have Department. capital funding required to meet been produced and enable increased our long term needs. The objective of developing a Patient bathroom and bedroom space with no Services Area involves redeveloping the bed reductions. It is expected that this A significant challenge for public health old Dental Facility. The development will development will be completed late in the services is to maintain, upgrade and enable an improved admission process 2010 calendar year. replace building infrastructure. The and centralise access to a range of services Department of Health regional office Sale and Maffra campuses require across the health service. Specifically, it senior managers are aware of these significant capital investment in will also improve access to a range of key developments and are interested in building infrastructure. The Loch Sport services such as Pharmacy and Cardiology. working towards a sound long term facility also needs improvements if it is Works have commenced on the solution for Maffra. To this end, Central to provide the base for services in that improvement of the Medical Imaging Gippsland Health Service has been community for the next 5 -10 years. department. The work has focussed on working on a strategic business case for Sale Campus the improvement of waiting room areas, a major development at Maffra, with a final new ultrasound room and improvements draft completed in July 2010. During 2009/10, Dental Health Services in air conditioning. Further work will be Victoria commissioned the building of a completed to modernise the facility and Loch Sport Facility relocatable four chair dental clinic. The enable better customer flow. The Wellington Shire Council has sought building arrived on site in April and has Another important activity in 2010/11 is funding from the Commonwealth been in service since May 2010. The Government to undertake a significant facility provides the community with two development of a current Master Plan, which will assist with securing major capital upgrade to the Loch Sport facility that additional Dental Chairs and enables the funding from the Department of Health. would meet the needs of the community consolidation of the School Dental and The process of master planning is being for the coming decade. If successful, the Public dental services. informed by a comprehensive needs project should be completed by mid 2011. A $1.4 million upgrade of the Monash assessment and detailed service planning, If the submission is unsuccessful Central University School of Rural Health building including demand projections. Gippsland Health Service will need to was completed in March 2010. This work with the Council to access alternative upgrade facilitates an increase in the Maffra campus funding. number of undergraduate medical and The Maffra campus has very old other health related students. It has also infrastructure: nearly 50% of the facility is improved and increased the space for no longer used and an upgrade is needed. Central Gippsland Health Service learning The upgrade works have been in the services staff. planning stage for a number of months. It

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 17 Case study New Community Dental Clinic arrives The capacity to tackle public dental waiting lists was significantly enhanced during the year, with the completion of a new Community Dental Clinic. Central Gippsland Health Service has been keen for some years to improve the facilities and therefore throughput of public patients. Together with Dental Health Services Victoria, a plan was developed whereby a four chair dental building could be incorporated into the Sale campus of the health service. A $750,000 pre-constructed building was trucked down from Shepparton and manoeuvred into position in a pre-prepared area adjacent to the Community Rehabilitation Centre. Services were provided from the building from late May. Health Minister Daniel Andrews turns the first sod on the site for the new Dental building November 2009, then in April 2010 the building was placed in position. It houses the Central Gippsland Health Service Dental Team, which has been operating for many years from a two chair facility in the old outpatients’ area of the health service’s Sale campus and also at the School Dental facility at Guthridge Primary School. The new facility is also home for the Dental Laboratory. The Dental Program provides a range of public dental services for eligible clients, including diagnosis and treatment of oral health issues. Even prior to the new building, the Dental Staff Team had worked very hard and reduced the waiting list for general dental work from 37.95 months in April 2009, to 28 months late in this financial year.

KEY AREA Energy efficiency • Increase and/or improve the subject of a Level 3 audit which will efficiency and effectiveness of determine the cost benefit in detail. Goals: Our goal is to significantly recycling. This information will be translated into improve our energy related To this end the health service is a project plan that the health service performance and to engage engaging an energy consultant to will seek to have funded through the in activities that will support review short, medium and long term upcoming energy efficiency funding substantial and long-lasting options for energy sustainability rounds. reductions in energy use and and waste management, so that Concurrently, Central Gippsland Health the health service is in a position generation of waste. Service is working with senior officers to take advantage of State and Central Gippsland Health Service Commonwealth project funding from the Department of Health in the recognises that energy management opportunities for energy efficiency and energy efficiency portfolio to ensure is integral to its business practices waste management grants. they are aware of the planned work and decisions. The health service and to gain their in-principle support of is committed to environmental An external consultant will complete an the steps being taken. stewardship and community energy-wise audit and environmental responsibility though delivery of health sustainability review in July 2010. The Central Gippsland Health Service has Next Steps services in line with the Department of received Expressions of Interest and The purpose of the current work is to Human Services’ strategic approach to prices from three companies with the ensure that the organisation is project energy management. appropriate credentials and capability ready for Commonwealth and State funded projects which will target increased Central Gippsland Health Service is to undertake a Level 2 energy efficiency audit, which is planned for efficiencies and renewable energy exploring opportunities to: later in 2010. opportunities. • Reduce energy and water usage As well the health service is integrating and costs; A Level 2 audit is designed to identify all potential areas of improvement and energy management into its organisational • Reduce greenhouse gas emissions; in particular, those where investment policies, decision making and culture to • Increase renewable energy will likely produce a timely payback. ensure the most efficient use of energy production and/or use; and These areas will subsequently be the and minimisation of waste.

18 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Health Service in 1999. As well, the has total revenues of more than $70 Our History Heyfield Hospital, Stretton Park and Laurina million. Lodge Hostel became associated by The Gippsland Base Hospital, forerunner The organisation serves the immediate management agreement with the Central to the current Central Gippsland Health population in Central Gippsland, while Gippsland Health Service. Service, was established more than 140 acute specialist services reach a wider years ago. Central Gippsland Health Service is community in East Gippsland and parts of In the intervening years, various other responsible for the majority of acute and South Gippsland. service entities were established in the residential aged care as well as a wide range of community services throughout surrounding districts of what is now the Wellington Shire, excluding YArram and Governance Wellington Shire. district. Central Gippsland Health Service is a Body These included home and community Corporate listed in the Victorian Health The health service provides management services, community health centres Services Act 1988 and operates under the and corporate services to two not-for-profit provisions of this Act. and maternal and child health centres private facilities, Stretton Park Hostel Inc established by municipalities based in and and Heyfield Hospital Inc. These facilities The Minister responsible for the around Maffra, Sale and Rosedale in the have acute and aged care services as well administration of the Victorian Health 1970s. as 19 independent living units. Services Act during the reporting period was the Minister for Health, The Hon. Through a series of amalgamations, the More than 900 staff members occupying Daniel Andrews, M.P. Gippsland Base Hospital, Maffra and more than 600 full time equivalent District Hospital, the JHF McDonald positions are employed by Central The registered office of Central Gippsland Nursing Home and Evelyn Wilson Nursing Gippsland Health Service, which is also Health Service is 155 Guthridge Parade, Home became the Central Gippsland supported by some 600 volunteers and Sale, 3850. Telephone (03) 5143 8660.

Board of Management

The Board members are:

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

Kevin Young: A chartered Helene Booth: Helene brings Dr Angela Todd: Angela is accountant and company a strong finance background as a Chiropractor with the Todd auditor, Kevin is a board a partner in Booth Cartledge Chiropractic Wellness Group. member of West Gippsland Accountants in Sale. Catchment Management Authority and treasurer of Seaspray Reserves Committee of Management. Kevin retired from the Board of Management on 30th June, 2010 at the expiration of his term. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 19 Executive Staff As at 30th June 2010 Chief Executive Officer Frank Evans Director Medical Services Dr Ka Chun Tse Director of Nursing Bronwyn Beadle Director Community Services Mandy Pusmucans Director Corporate Services Michael Clamp

Solicitors Pictured receiving their 25 year service awards are, from left, Judith Ripper, Joy White, Dr Rob McKimm, Lynette Hughes, Denis Robertson, Tracie Collis, Debbie Kardinaal, Jennifer Lees, and Heather Tancred. Those unable to attend included Dr Milstein and Associates John Bergin, Christine Crouch, Lynette Emphield, Dr Roger Malouf, Dr Rob Melville, Dr Ian Ronchi, Dr Andrew Watt and Bill Kee and Associates Ann Payne. Lucy Hunter A large number of staff at Central Lynette Hughes, Debbie Kardinaal, Jennifer Gippsland Health Service have been Lees, Dr Rob McKimm, Judith Ripper, Banker recognised for 25 years of service. Denis Robertson, Heather Tancred, Joy Seventeen staff from a wide variety of White, Dr John Bergin, Christine Crouch, National Australia Bank Limited professions and areas of the health service Lynette Emphield, Dr Roger Malouf, Dr Rob were recognised with service awards. Melville, Dr Ian Ronchi, Dr Andrew Watt The long-serving staff included Tracie Collis, and Ann Payne. Workforce data

Labour Category Female % Male % TOTAL FTE Administration & Clerical 85 10.35% 11 1.34% 96 76.84 Ancillary Support Services 45 5.48% 8 0.97% 53 37.41 Hospital Medical Officers 13 1.58% 13 1.58% 26 13.00 Hotel & Allied Services 161 19.61% 51 6.21% 212 134.93 Medical Officers 2 0.24% 14 1.71% 16 13.36 Medical Support Services 48 5.85% 12 1.46% 60 49.32 Nursing Services 336 40.93% 22 2.68% 358 232.36 Total 690 84.04% 131 15.96% 821 557.22 Labour Category Female % Male % TOTAL FTE Central Gippsland Health Service 690 76% 131 14% 821 557.22 Heyfield 53 6% 4 0% 57 36.29 Stretton Park 28 3% 2 0% 30 20.36 Total number of staff employed 771 85% 137 15% 908 613.86 by the Whole Network

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.

20 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 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 Discharge Planning Cystic Fibrosis Dialysis Ear, Nose and Throat Infection Control Audiology Emergency Dermatology Stomal Therapy Wound Specialist Medicine Lithotripsy Management Specialist Surgery Gastroenterology Professional Development General Practice Urology Food Services Hospital in the Home Orthopaedic Surgery Pharmacy Obstetrics and Gynaecology Renal Medicine Environmental Paediatrics Fertility Breast Care 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 Hostel Heyfield – Laurina Lodge Nursing Home Heyfield – Laurina Lodge

Community Services Allied Health to both the Community Health and Home Support and Service Home Nursing Acute and Community Partnerships Co-ordination Settings Physiotherapy Counselling Home Care District Nursing Occupational Therapy Community Health Nursing Personal Care Palliative Care Podiatry and foot care Respiratory Educator Respite Care Hospital in the Home Dietetics Diabetes Educator Delivered Meals Grief and Loss Support Speech Therapy Maternal and Child Health Property Maintenance Social Work – Acute Volunteer Program (CAVA) Planned Activity Groups Koori Liaison Special Projects Intake Child Services Community Dental Program Service Co-ordination School Services Community Transport Discharge Planning Post Acute Care

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

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 21 Overview of Services

Corporate 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 Account Receivable Industrial Relations Asset Management Health Records Reception Occupational Health & Safety Building Maintenance & Information Technology Admissions Risk Management Development Information Technology Applications Payroll Staff records New Capital Works Information Technology Payroll WorkSafe/Return to Work Environmental Services Salary Packaging Porters Infrastructure Security Medical Library Supply Services Supply Fleet Management Accommodation Management Food Services and Catering

Administration Strategic Planning Business Units Major Projects Medical Imaging Public Relations Home Support Services Fundraising Linen Service Government Relations Food Services Organisational Policy Development Quality Management

22 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Structural Framework

Board of Management

Quality & Risk Committee Chief Credentialing Committee Consumer Consultative Executive Audit Committee Committee

Learning Services Medical Nursing, Midwifery Library Community Corporate Services & Aged Care Services Services Medical Imaging

Medical Services Operations/Access Allied Health Human Resources Medical Staff Hospital Co-ordinators Dietetics Recruitment Visiting Medical Discharge Planning Health & Safety Officers Koori Hospital Liaison Work Cover Medical Student Acute Inpatient Units Occupational Therapy Liaison (Monash) Medical Unit Physiotherapy Surgical Unit Podiatry Switchboard & Women’s & Children’s Unit Speech Therapy Admissions Pathology Maffra Campus Social Work & Outpatients Heyfield Hospital Medico - Legal Finance/Payroll Pharmacy Home Nursing - including Clinical Governance Palliative Care District Nursing Information Emergency Department Hospital in the Home Technology

Critical Care & Ambulatory Services Home Support & Service Facilities Management Critical Care Unit Co-ordination Cardiology Home Care Oncology Personal Care Supply Dialysis Respite Care Delivered Meals Property Maintenance Food Services Surgical Suite Services Planned Activity Groups Operating Theatre Intake Central Sterilising Supply Dept Environmental Services Service Co-ordination Day Procedure Unit Community Transport Pre Admission Linen Service Community Health & Partnerships Clinical Nurse Consultants Counselling Infection Control Medical Records Community Health Nursing Privacy legislation Wound Management Respiratory Educator Diabetes Educator Residential Aged Care Services Volunteer Program (CAVA) Wilson Lodge Special Projects Stretton Park Maternal & Child Health Maffra Campus Community Dental Program Heyfield Campus

Facilitating Partner For: Quality Wellington Primary Care Partnership Gippsland Regional Palliative Care Consortium

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 23 Melbourne. We wish them all the very best While they will still have some involvement Support groups in their new home. Thank you, Norm for all and are more than likely to saddle up for your hard work for the Auxiliary. the next ride later this year, the couple are Maffra Hospital Ladies taking the opportunity to join the ‘Grey In closing we would like to thank the Auxiliary Nomads’ and enjoy some travel around health service staff and the general the countryside, although will still be It is my pleasure to present this report for public for their support, and of course all available to assist. the year 2009 – 2010. A faithful band of members and volunteers. 15 members continue to work to support The original ride was organised through our local hospital. Elva Doolan-Jones President. the Lamplighters, a community support We raise funds to provide items, both to group for the health service. Mrs Jackson enhance the comfort of residents and to DONATIONS was instrumental in its establishment, after assist the nursing staff. Central Gippsland Health Service gratefully taking part in the Murray to Moyne, a long running fundraising event from the Murray The Annual Oaks Day Luncheon continues acknowledges the support of individuals, River to Moyne on the south west coast to be the highlight of our fundraising and families and organisations who gave of Victoria. The bike trail to Lakes Entrance is well supported by members of the donations of cash or equipment during the had only recently opened providing an community. More than 80 attended the past year. opportunity to develop a ride for local 2009 Oaks Day luncheon including a Because of issues which may arise due to fundraising purposes. number of ladies from Stretton Park. the Privacy Act, we have chosen not to list Nowadays the journey is from Sale to We are grateful to members of the personal names in this report. Lake Tyers, after some changes to the trail, community who support us through the Total contributions received although the length has stayed the same; I.G.A. Community Benefits Scheme which 2009/2010: around 185 kilometres on the first day and raised $3,412.47. General Donations $5,720.00 165 kilometres on the return trip. Most Some of the items purchased this year people ride it as a relay event, although are Roho cushions ($3,140.00), Procair Ward Specific and some hardy souls take part as individual overlay system ($3,580.00), and a Nurse Restricted Purpose riders. call sensor beam ($2,571.80). Donations $117,914.21 The ride has raised in excess of $100,000 We also cover the cost of bus hire for Clyne Estate (Bequest) $69,722.10 since it first began, and it has not stopped monthly outings for the residents of yet. Central Gippsland Health Service McDonald Wing. Three deck chairs were Fundraising Health Promotions Officer Renee Heath provided for the use of residents on these has taken on the role of main organiser outings. A further $200.00 was spent on INVOLVEMENT IN BIKE for this year’s event, which will be held in potting mix and fertiliser for re-potting in November 2010. the courtyard garden. RIDE ENDS ON A HIGH After 17 years, local couple Mary and Les The Jacksons are full of praise for the Thanks are due to all members who so Jackson have bowed out of their direct many people who took part in and helped willingly support our fundraising functions involvement in the annual fundraiser event support the ride over the years. and take their turn delivering Meals on for the Central Gippsland Health Service, Wheels. Pictured inspecting a Glide Video Laryngoscope, a the Sale to Lakes Bike Ride. device used to view the vocal cords and airways when Many thanks to our Treasurer, Pat intubating patients in preparation for surgery, are from The Jacksons ended their involvement as McKenzie for so capably keeping track left, Mary Jackson, Associate Nursing Unit Manager the main organisers of the ride on a high, of our finances and to President Lennie Heather Ronchi, Les Jackson and GP Anaesthetist with a donation of $12,000 to purchase a Stammers for leading the Auxiliary. Antony Wong. The item was purchased with funds new piece of equipment for theatre. raised in the annual bike ride. Lennie Stammers President Friends of Central Gippsland Health Service Sale Campus (formerly Gippsland Base Hospital Auxiliary) Once again it has been another busy year for our Auxiliary. Gift wrapping for Father’s Day, Christmas and Mothers Day are held in the Gippsland Centre, Sale and raffles too. Thank you to them for their wonderful support. We held another Bingo and Raffle night at Sale Greyhounds in June. Thanks to all the General Public for their donations. As well, Ritchies (IGA Supermarket) donations come in each month. All members were sorry to hear our Secretary Norm Murray and wife Ann were leaving Sale, although pleased they were moving to live with their son closer to 24 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 DONORS URGE OTHERS TO FOLLOW SUIT A long term Sale couple who have made a major donation to the Central Gippsland Health Service this year has urged other people to consider doing the same. Bill and Mavis Jennings decided to bestow a stunning $25,000 to assist with the purchase of a CTG Machine for the Women’s and Children’s Unit, as a mark of their respect for local nurses and their high esteem for the work of the health service. The couple, who moved to Sale in 1958 to work as teachers at the then Sale Technical School, was initially reluctant to publicize the donation but felt it might encourage others to think about their support for the health service. The Jennings felt moved to make the donation because they believed the health service did a “wonderful job.” Mr Jennings is a past President of the Board in 1977-1979. The very generous donation by the Jennings’ was most welcome. It has helped purchase an essential piece of equipment that measures the foetal heartbeat during pregnancy, as well as measures contractions and monitors the Bill and Mavis Jennings admire the new machine they helped to fund, with Clinical Nurse Specialist midwife baby’s heart rate during contractions. Maree Cooper.

Members of the Lions clubs that raised money came together to make the presentation to the Maffra Campus of Central Gippsland Health Service. LIONS CLUBS PROVIDE Newry, Heyfield, Wellington-Latrobe, medication for up to 24 hours, to provide Maffra, Loch Sport, Briagolong and District, constant relief from pain and nausea. COMBINED SUPPORT Stratford, Sale and Longford clubs worked for months and the fruits of their efforts The clubs joined together and raised A combined effort by nine local Lions clubs were realized when they provided funds $3,800.00 after hearing a presentation resulted in a substantial donation to the for the purchase of a syringe driver. by a health service representative. The Central Gippsland Health Service, Maffra The item is an important piece of medical syringe drivers cost $2,500.00, while the Campus for purchase of equipment. equipment that, once set, automatically remaining money will go towards purchase Members from the Macalister Valley delivers a measured continuous dose of of other items for palliative care. Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 25 Executive staff as at Dr G Ivanoff Paediatric Cardiologist Dr CJ Jarman Dr L Fong 30 June 2010 Dr B Johnston Paediatric Rehabilitation Physician Chief Executive Officer Dr CA Martin A/Prof H Rawicki Dr Frank Evans Dr RH Melville Paediatricians Locums Director Medical Services Dr Ka Chun Tse Dr A Miller (retired Dec 09) Dr S Beggs Dr R Diplock Director of Nursing Dr DA Monash Bronwyn Beadle Dr IC Nicolson Dr M Marks Director Community Services Dr C O’Kane Dr S O’Dea Mandy Pusmucans Dr R Nandha Dr G Roberts Director Corporate Services Dr AC Richards Paediatric Surgeons Michael Clamp Dr H Stanley Mr C Kimber Senior staff Dr P Stevens Mr N McMullin Dr F Sundermann Pathologists SENIOR MEDICAL & Dr LA Waters Dr B Morrison Dr NR Sonenberg DENTAL STAFF 09/10 Dr AJ Watt Dr PJ Van der Hoeven Anaesthetist Consultant Dr SJ Williams Physicians Dr G Rooke Dr AJ Wright Anaesthetists GP Dr H Connor General Practitioners Consultant Dr N Atherstone Dr V Das Dr A Hughes Dr N Fuessel Dr K Mandaleson Dr D Mudunna Dr J Lancaster Dr RW Ziffer IVF/Gynaecology Dr R Nandha Radiologists Dr JM Talbot Dr C O’Kane Dr R Bain Dr G Weston Dr A Wong Dr R Brownlee Dermatologists Nephrologist Dr T Kulatunge Dr C Baker Prof D Power Dr G Savarkudele Dr D Gin Prof R Langham Dr K Stribley Dr J Horton Nuclear Medicine Physician Dr A Zammit Dr A Mar Dr Y Jenkin Surgeons General Dr R L Nixon Obstetricians & Gynaecologists Mr A Aitken Dr D Orchard Dr R Guirguis Mr I McN Miller (retired Dec 09) Director Medical Services Dr RJ McKimm Dr K C Tse Mr A Sarkar Dr Anu Sarkar Surgeon (Locum) Echo Cardiologist Obstetricians GP Dr J Gutman Mr I Farmer Dr C O’Kane Emergency Medicine Surgeon Upper GI Senior Medical Officers Dr AJ Wright Mr S Banting Dr B Cole Ophthalmologist Surgeon Vascular Dr A Richards Mr A Amini Mr N Roberts Forensic Medical Officer (Affiliated) Oral Maxillofacial Surgery Urologist Dr R Hides Dr S R Hookey Assoc Prof M Frydenberg General Practitioners Orthopaedic Surgeons Mr P McCahy Dr Y Ahmad Mr A De Villiers Dentists Dr S Anderson Mr P Rehfisch Dr R Cox Dr M T Baker Mr P Smith Dr JJ Gibson Dr F Begum Otorhinolaryngologists (ENT) Dr JM Bergin Dr R Malouf Mr M Campbell Dr A Burk Dr B Pedrotti Dr. J Bvirakare Mr PJ Guiney Dr T Ranten Dr P Dandy Mr. B Cook Dr I J Ronchi Dr LJ Derrick Paediatricians Dr O Husodo Dr RJ Hides Dr A Erasmus Dr J Roberts 26 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 ACUTE SERVICES Nursing Unit Manager, Emergency Community Health and Louise Vuillermin Partnerships Manager Director Critical Care and Ruth Churchill Emergency Services CLINICAL SUPPORT Dr Howard Connor Home Support and Service SERVICES Co-ordination Manager Deputy Director of Belinda Greening Emergency Services Infection Control Officer Dr Brian Cole Cathy Mowat CORPORATE SERVICES Head of Anaesthetics Wound/Stomal Therapy Financial Manager Dr Gary Rooke Anne Payne Daryl Cooper Head of Aged Care MAFFRA CAMPUS Engineering Services Manager Dr Krishna Mandaleson Rod Cusack Health Service Manager Director Pharmacy Sonya Hanratty Environmental Services Manager Annabel McNally Geoff Brown Nursing Unit Manager Deputy Director of Nursing and Karen Llewellen; Kylie Barnes Food Services Manager Quality Improvement Manager David Askew Dianne Matcott HEYFIELD Health Information Manager Hospital Co-ordinators (including Laurina Lodge) Heather Rowell Wendy Harwood; Neville Nicholas; Therese Health Service Manager HMO Manager Smyth; Judy Niziolek; Cathy Teed; Janny Anne Woollard Hannah Cole Steed; Michael Hams; Sue Shadbolt Nursing Unit Manager Information Technology Manager Jon Millar SURGICAL SERVICES Jo Ollier Nursing Unit Manager, Surgical Payroll Manager Gary McMillan RESIDENTIAL AGED CARE Raquel Kenney Nursing Unit Manager, WILSON LODGE NURSING HOME Supply Manager Perioperative Services Cindy Dunnett Nursing Unit Manager Sally Relph Sue Ingrouille WORKFORCE CAPABILITY OBSTETRIC/PAEDIATRIC STRETTON PARK HOSTEL AND LEARNING UNIT General Manager Nursing Unit Manager, AND INDEPENDENT Denise McInnes Obstetrics and Paediatrics LIVING UNITS Librarian Moira Tulloch Care Manager Helen Ried Robyn Cotterill MEDICAL SERVICES BUSINESS UNITS Nursing Unit Manager, Critical Care, COMMUNITY SERVICES Business Unit Manager Medical Dialysis, Cardiology, Oncology Home Nursing Manager Imaging Jenny Dennett Mary Hartwig Michael Coleman Nursing Unit Manager, Medical Allied Health Manager Sale Central Linen Service Supervisor Sue Roberts Maureen Wilson Sue Jenner

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 27 Statutory Information Building Act 1993 As at June 30, 2010, fire risk audits had been completed for all Central Statutory Compliance Compliance Gippsland Health Service occupied Central Gippsland Health Service is a Central Gippsland Health Service residential care facilities. public hospital listed in Schedule 1 to complies with the Standards for Publicly Central Gippsland Health Service installs the Health Services Act 1988 (the Act). Owned Buildings (the guideline). Central and maintains fire safety equipment in Central Gippsland Health Service is an Gippsland Health Service controls nine accordance with building regulations and incorporated body under and is regulated (9) properties, six (6) residential care regularly conducts audits. The upgrading by the Act. The Victorian Minister for and three (3) non-residential care. of fire prevention equipment in buildings Health during 2009/2010 was The Hon. is also undertaken as part of any general Daniel Andrews. All new work and redevelopment of existing properties is carried out to upgrade of properties where necessary Reporting Requirements confirm to current building regulations and is identified in maintenance inspections. The information requirements listed in the (1994) and the provisions of the Financial Management Act 1994 (the Act) Building Act 1993. The local authority Central Gippsland Health Service the Standing Directions of the Minister for or a building surveyor issues either a requires building practitioners engaged Finance under the Act (Section 4 Financial Certificate of Final Inspection or an on building works to be registered and Management Reporting) and Financial Occupancy Permit for all new works or to maintain registration throughout the Reporting Directions has been prepared upgrades to existing facilities. course of the building works. and are available to the relevant Minister, Members of Parliament and the public on Non residential Residential request. Loch Sport CHC 1 Objectives, functions, powers and duties of Community Care 1 Central Gippsland Health Community Rehabilitation Centre 1 Service The principal objective of Central Heyfield Hospital 1 Gippsland Health Service is to provide public hospital services in accordance with Laurina Lodge 1 the Australian Health Care Agreement (Medicare) principles. In addition to these, Maffra Hospital 1 Central Gippsland Health Service has set other objectives which encompass the Stretton Park 1 shared vision, core values and strategic directions of the organisation. Sale Acute 1

Competitive Neutrality Wilson Lodge 1 Central Gippsland Health Service supports the Victorian Government’s policy statements as outlined in Competitive Act 2003, a summary of the extent Neutrality; a statement of Victorian Consultancies engaged of contractual costs for consultants is Government policy. Competitive Neutrality during 2009/2010 outlined. is seen as a complementary mechanism A number of consultants were contracted to the ongoing quest to increase operating During 2009/2010 there have been nil to work for Central Gippsland Health efficiencies by way of benchmarking and contracts commenced or completed Service in 2009/2010. As required by embracing better work practices. under the Victorian Industry Participation the Victorian Industry Participation Policy Policy Act 2003. Freedom of Information A total of 89 requests under the Freedom 2009/2010 2008/2009 of Information Act were processed during the 2009/2010 financial year. Number of consultants used to a Requests for documents in the possession 0 0 of Central Gippsland Health Service are value greater than $100,000 directed to the Freedom of Information Total cost of consultants used to a Manager, and all requests are processed 0 0 in accordance with the Freedom of value greater than $100,000 Information Act 1982. Number of consultants used to a 4 1 A fee is levied for this service based on the value less than $100,000 time involved in retrieving and copying the Total cost of consultants used to a requested documents. $38,299 $7,200 value less than $100,000 Central Gippsland Health Service nominated officers under the Freedom of Information Act are: Principal Officer Dr Frank Evans, Chief Executive Officer

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

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 29 REPORT OF OPERATIONS KEY PERFORMANCE INDICATORS Service Level Central Gippsland Health Service provides services throughout the Wellington Shire. The population of the total area is approximately 40,000.

Activity Data Acute Sub Acute Total Admitted Patient Separations Same Day 6,435 6,435 Multi Day 5,490 300 5,790 Total Separations 11,925 300 12,223 Emergency Surgery 431 Elective Surgery 3,795 Total Surgical Occasions 4,226 Babies Delivered 502 Total WIES 7,307.06 Total Bed Days 32,113 Non Admitted Patient Emergency Department Attendances 16,059 Community Services Hours delivered by home and Community 78,746 Care Services Meals Delivered 21,574 Hours of Service to externally funded 13,402 Community, Aged Care package clients Palliative Care contacts 8,223 Primary Health Hours of Service 7,961 Allied Health acute services attendances 3,878 as at 30 June 2010 Report of Operations Responsible Bodies Declaration as at 30 June 2010 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 2010.

John Sullivan Sale, Victoria Board President 30 August 2010

SUMMARY OF FINANCIAL RESULTS 2009/10 2008/09 2007/08 2006/07 2005/06 2004/05 Total Expenses 74,239 65,605 60,482 56,818 54,320 54,245 Total Revenue 70,028 65,161 59,286 57,732 55,752 52,503 Operating Surplus/(Deficit) (4,211) (444) (1,196) 914 1,432 (1,742) Accumulated Surplus (Deficit) (9,956) (5,745) (5,301) (4,105) (5,019) (6,175) Total Assets 73,416 77,797 63,660 64,487 62,998 51,684 Total Liabilities 13,082 13,252 12,579 12,682 12,107 13,058 Net Assets 60,334 64,545 51,081 51,805 50,891 38,626 Total Equity 60,334 64,545 51,081 51,805 50,891 38,626

30 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 Summary of Operational and Budgetary specific items of $0.9 million and a Net Result loss for the year of $0.4 million Objectives The service recorded a net loss from continuing operations before Summary of factors that have affected capital & specific items of $0.7 million (2008/09 $1.7 million the Operations for the Year surplus). After taking into account capital & specific items the net result was a loss of $4.2 million (2008/09 $0.4 million loss) The results of the service during the reporting period have been affected by the following factors : The Health Service budgeted for a net surplus before capital & • Changes in employee factors that resulted in increase in employee costs. Revenue Indicators Average Collection Days • Significant sick leave 2009/10 2008/09 • Changes to land & building revaluation methodology that Private Inpatients 27 54 resulted in large increase in depreciation. TAC Inpatients - - • Significant decrease in business unit income. Victorian Workcover Inpatients 42 43 • Significant increase in medical related costs. Other Compensable Inpatients 44 46 Events Subsequent to Balance Date Nursing Home 7 8 At the date of this report, management is not aware of any events that have occurred subsequent to balance date that may have a Community Services 25 26 material impact on the results of the next reporting period.

Patient Debtors Outstanding as at 30 June 2010

Under 30 Days 30-60 Days 61-90 Days Over 90 Days Total 30/06/10 Total 30/06/09 $’000 $’000 $’000 $’000 $’000 $’000 Private Inpatients 70 5 1 1 77 55 TAC Inpatients ------Victorian Workcover Inpatients - - - - - 6 Other Compensable Inpatients ------Nursing Home 11 5 1 1 18 34 Community Services 52 9 3 - 64 52 Total 133 19 5 2 159 147

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. TheCentral Gippsland Health Service has critically reviewed these controls and processes during the year.

Frank Evans Sale, Victoria Accountable Officer 30 August 2010 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.

Frank Evans Sale, Victoria Accountable Officer 30 August 2010

Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 31 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 Page Reference Ministerial Directions Report of Operations Charter and purpose FRD 22B Manner of establishment and the relevant Ministers 19 FRD 22B Objectives, functions, powers and duties 28 FRD 22B Nature and range of services provided 21 Management and structure FRD 22B Organisational structure 23 Financial and other information FRD 10 Disclosure index 32 FRD 11 Disclosure of ex‑gratia payments Financial Report 40 FRD 21A Responsible person and executive officer disclosures Financial Report 2 FRD 22B Application and operation of Freedom of Information Act 1982 28 FRD 22B Application and operation of Whistleblowers Protection Act 2001 29 FRD 22B Compliance with building and maintenance provisions of Building Act 1993 28 FRD 22B Details of consultancies over $100,000 28 FRD 22B Details of consultancies under $100,000 28 FRD 22B Major changes or factors affecting performance 31 FRD 22B Occupational health and safety 20 FRD 22B Operational and budgetary objectives and performance against objectives 31 FRD 22B Significant changes in financial position during the year 31 FRD 22B Statement of availability of other information 29 FRD 22B Statement of merit and equity 20 FRD 22B Statement on National Competition Policy 28 FRD 22B Subsequent events 31 FRD 22B Summary of the financial results for the year 30 FRD 22B Workforce Data Disclosures 20 FRD 25 Victorian Industry Participation Policy disclosures 28 SD 4.2(j) Report of Operations, Responsible Body Declaration 30 SD 4.5.5 Attestation on Compliance with Australian/New Zealand Risk Management Standard 31 Financial Statements Financial statements required under Part 7 of the FMA SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements Financial Report 10 SD 4.2(b) Comprehensive Operating Statement Financial Report 5 SD 4.2(b) Balance Sheet Financial Report 6 SD 4.2(b) Statement of Changes in Equity Financial Report 7 SD 4.2(b) Cash Flow Statement Financial Report 8 SD 4.2(c) Accountable officer’s declaration Financial Report 2 SD 4.2(c) Compliance with Ministerial Directions SD 4.2(d) Rounding of amounts Financial Report 10 Legislation Freedom of Information Act 1982 28 Whistleblowers Protection Act 2001 29 Victorian Industry Participation Policy Act 2003 28 Building Act 1993 28 Financial Management Act 1994 28

32 Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2010 • seamless: coordinated, integrated and timely • work within an intersectoral and collaborative provision of person centred care; framework to maximise benefits for our • capable individuals and teams working within community; appreciate the positive impact on structures and processes that support quality organisational and community capacity that outcomes and continuous improvement; comes from diversity. • facilities and equipment that enable the People – Respect and support. provision of efficient, effective and sustainable In doing so we will: service delivery; and • strive to provide an environment that assists our • a workforce that places a very high value on staff to: excellent customer service and client/patient • achieve their personal goals and objectives; advocacy. • live ethically within their personal value Our Vision: system; and All correspondence to: Caring – Support, compassion and • enthusiastically support CGHS to achieve A safe and healthy community where everyone tolerance. To do this we will: our strategic and service delivery goals and Executive Office feels they are valued, supported and have the • be welcoming, caring, supportive, share objectives. Central Gippsland Health Service knowledge freely and support learning in every opportunity to participate. Social issues have been • develop a workplace where people are enabled 155 Guthridge Parade addressed through the joint efforts of community setting; to: Sale, Victoria 3850 and supporting agencies. • relate to our community with tolerance and • be efficient and effective; compassion; • put forward ideas and participate in decision Telephone: 03 5143 8660 Our Mission: • assist our community to understand their rights making; Fax: 03 5143 8633 and responsibilities and have access to genuine • be creative and innovative; and Email: [email protected] Our Mission is to provide health and community complaints resolution processes; • develop their learning and career in a manner services that will best meet the current and future consistent with their strengths and interests. Should the financial statements not be included needs of our community. • support our community to identify the need for and make decisions relating to the • foster very high levels of staff capability and with this copy of the annual report, a copy can In doing so we will focus on: development, delivery and evaluation of satisfaction. be obtained by contacting the Central Gippsland • supporting community identified need and services; Health Service, telephone 03 5143 8600 or by genuine community participation; email to [email protected] • placing our clients/patients and community at the centre of our work; • supporting individuals, groups and communities to maintain and improve their health and wellbeing and minimise the negative impact of chronic disease and injury; • Integrating and co-ordinating our services within an interdisciplinary service delivery model; • allocating and using our resources effectively and efficiently; Dargo • achieving through collaboration and partnerships; Licola • being creative, innovative and open to discovery. Our Values In achieving our goals and objectives we will develop an organisational culture that supports: BriagBriagolongolong Social Justice - equity of outcome. To do this we will: To Sydney • focus on achieving equality of outcome for Heyfield StratforStratford individuals and groups; Maffra • understand the impact of poverty and Loch Sport disadvantage on behavior and health status; • support affirmative action for the disadvantaged and marginalised amongst us; Rosedale Sale • ensure our fees policy takes into account ability To Melbourne LongforLongford Golden Beach to pay; Gormandale • support harm minimisation and targeted community support programs; and Seaspray • be compassionate, tolerant and embrace diversity. Honesty, transparency and integrity. To do this we will: • set and model standards of behaviour YaYarrramram consistent with the Victorian public sector code PoPorrtt Albert of conduct; To Melbourne • embrace open disclosure and provide meaningful and clear information to our stakeholders; and • support ethical leadership development at all levels of the organisation. Quality – Excellence with the client at the Melbourne centre. To do this we will: • embed a quality culture of continuous improvement across the organisation such that our clients’ experience with CGHS is characterised by the following: Blank Sale Maffra Heyfield All Correspondence Acute Care Services 48 Kent Street 14 Licola Road Chief Executive Officer 155 Guthridge Parade PO Box 313, Heyfield VIC 3858 Central Gippsland Health Service Sale VIC 3850 Maffra, VIC 3860 Telephone 03 5139 7979 AnnuAl QuAlITY OF CARE REpORT 155 Guthridge Parade Telephone 03 5143 8600 Telephone 03 5147 0100 Facsimile 03 5139 7922 Sale Victoria 3850 Facsimile 03 5143 8633 Facsimile 03 5147 0152 Telephone 03 5143 8660 Community Services Facsimile 03 5143 8633 Email [email protected] Telephone 03 5143 8800 Facsimile 03 5143 8890 Wilson Lodge Nursing Home 2010 Telephone 03 5143 8540 Facsimile 03 5143 8542 www.cghs.com.au