Contents Who we are 2 Quality of Care report 2 Board Chairs Report 3 CEO Report 3 Introduction/Strategic Plan 4 Key areas Population health planning 4 Workforce capability 5 Acute Services – Sustainability 7 Care Co-ordination 8 Consumer, Carer and Community Participation 10 Koori Wellbeing 11 Cultural and Linguistic Diversity 12 Business Units 14 Building Infrastructure 15 Energy Efficiency 15 Our History 16 Governance 16 Board of management 16 Executive Staff 17 Workforce data 17 Overview of Services 18 Our Structure 20 Community Support Groups 21 Senior Personnel 24 Statutory Information 27 Service Level 29 Report of Operations 29 Statement of Priorities 31 Disclosure Index 33 Financial Statements Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 ' Who we are Quality of Care Report Central Gippsland Health Service (CGHS) is the major provider Central Gippsland Health Service is committed to quality and of health and residential aged care services in the Wellington excellence with the client/patient at the centre of care. Shire. In line with the Central Gippsland Health Service strategic plan It serves an immediate population of 42,000 in Central Gippsland, while acute specialist services reach a wider the health service reviews and improves on its existing quality community in East Gippsland and parts of South Gippsland. framework to ensure systems which embed a quality culture of continuous improvement across the organisation and At your service also processes of engagement from clinical and non clinical Central Gippsland Health Service has 80 acute beds; disciplines, consumers and other key stakeholder groups. approximately 180 high and low care residential aged care beds, The quality team is an integral part of Central Gippsland as well as 19 independent living units. Health Service and is central to the Quality and Risk Working Acute services include a 24 hour, seven day a week emergency Party which meets fortnightly to identify and monitor issues department, operating theatres, day procedure unit, oncology relating to patient/client safety and quality of service. and dialysis services. The Quality and Risk Working Party reports to the Quality and Risk Committee which meets bi-monthly, has Board The Health Service comprises: and consumer representation and reports directly to the Acute Services situated at Sale, Maffra and Heyfield; Community Board of Management. Three community and consumer Services provided throughout the Shire of Wellington specifically participation groups work with us to enable community and at Maffra, Sale, Heyfield, Rosedale and Loch Sport; and consumer perspectives to be at the centre of our continuous Residential Aged Care Services at Sale, Maffra and Heyfield. improvement efforts. Our services Comprehensive accountability reports relating to performance Population Served approximately 42,000 and legislative compliance are presented to the Board on a monthly basis. Emergency attendances 16,252 Inpatient services 12,230 Current Accreditation Status The Acute and Community Services of Central Gippsland Community Services hours of service 121,192 Health Service are currently accredited with the Australian Allied Health acute services attendances 4,493 Council on Healthcare Standards. People A full, organisation-wide survey was held in 2007, when Central Gippsland Health Service gained full accreditation 652 Full Time Equivalent employees valid for four years. Approximately 1,127 people employed, including casual, part A site visit, which is called a Periodic Review, was conducted time and full time active employees at 30 June 2011. in October, 2009. This determines ongoing accreditation Assets and Revenue status, reviewing mandatory standards as well as reviewing the progress of recommendations made at the organisation- $56m in Net Assets wide survey held in 2007. $54m in Buildings A self assessment report was sent to the Australian Council $5m in Plant & Equipment on Healthcare Standards in August, 2010 providing detail $70m in Revenue and Budgeted operations on continuous quality improvement under the three main functions of the framework. Central Gippsland Health Service is due for a further accreditation review in August 2011 against the ACHS Equip 5 standards. Our Aged Care Facilities – Laurina Lodge, Wilson Lodge, Stretton Park and McDonald Wing – all hold current Aged Care Accreditation. ( Central Gippsland Health Service ANNUAL QUALITY OF CARE REPORT 2011 Report by Chair, Board of Management Our Partners Year in Review One of our key strengths lies in our ability to work with our various partners in the delivery of clinical services, other support It is with pleasure that we present the Central Gippsland Health services, research and education. Our ongoing relationship with Service 2010/11 Annual Report. our neighbours at Bairnsdale Regional Health Service, Latrobe Regional Hospital and Monash University continue to enable Our Strategic Plan us to achieve economies of scope and scale in our delivery This has been the second year of implementation of the of clinical services through various shared arrangements. In Strategic Plan and considerable progress has been made to particular, our ability to offer a range of quality specialist services assess our local population health needs to enable us to direct is enhanced through these partnerships and we will continue our health services appropriately in the future. Furthermore, a to pursue innovative opportunities to attract and work with the great deal of work has been done to streamline and coordinate specialist workforce we need. our services to optimise the quality of care our patients receive. In particular, people with chronic illness will benefit from these Thank you improvements through better linkages across the health service It has been another challenging and exciting year for Central and more seamless access to the range of specialist services Gippsland Health Service and we acknowledge and thank the they require. dedicated staff, our volunteer workforce, committee members, and the leadership and management team for their continued Central Gippsland Health Service’s workforce capability is integral commitment and excellent work. to the delivery of the Strategic Plan and it is pleasing to note that significant inroads have been made to identifying, building and We also acknowledge our Board members who have left or attracting staff with the right mix of skills and experience to meet retired this year. In particular, Mr John Lawrence who has served the future needs of the health service. The resulting capability on the Board since 2006 and whose term expired on 30 June framework provides a tremendous foundation for our continued 2011. John did not seek reappointment and we acknowledge his delivery of high quality, relevant health services and we significant contributions over the past five years, in particular his acknowledge the efforts and leadership of our Chief Executive thoughtful input into the strategic direction of the health service Officer, Dr Frank Evans, in this achievement. and passionate stance towards addressing disadvantage and community access issues. John’s business acumen and strong Maffra Hospital belief in social justice were much appreciated and have greatly The Board is delighted with the recently completed upgrade of assisted in the advancement of our health service. the McDonald Wing at the Maffra hospital which has resulted We also acknowledge and thank Ms Angela Todd who was in refurbishment of residents’ rooms; enhanced bathroom appointed in 2008 and resigned early in the 2011 calendar year. and toilet facilities and improved heating, cooling and other The Board sincerely thanks her for her valued contributions. amenities to ensure greater staff, patient and resident comfort. Other members of the Board during the year ended 30 June The project was delivered within budget and would not have 2011 were Mr John Sullivan (Chair until December 2010, been possible without the generous contribution from the Clyne now Deputy Chair), Mr Glen Stagg, Ms Helene Booth and Ms Estate fund. Elizabeth Thomson. Koori Traineeships My own appointment and that of Mr John Sullivan and Mr We were pleased to have funding approved for a significant Glenn Stagg also expired this year but each of us has been successfully reappointed for another term. We all look forward to Aboriginal traineeship program earlier this year and even more welcoming four new Board members who have been appointed thrilled to have successfully recruited six Allied Health Assistant to commence in 2011/12. trainees to our Community Services area in June. We look forward to supporting these young people in their exciting endeavour and shall watch their progress over the next 18 Catherine Greaves months with great interest. Board Chair Chief Executive Officer’s Report of our volunteers, many of whom contribute year after year. This includes our hospital and health centre auxiliary members, who The past year has seen Central Gippsland Health Service make work hard to raise important funds for equipment to meet the considerable progress toward the implementation of its strategic needs of our patients, residents and clients. plan. This report has been formatted to enable you to follow our progress during what has been a very challenging year. Last year we established a consumer health advocate role. The role, in addition to supporting people to have their issues heard The report incorporates our Quality of Care report, which is or needs met has helped