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Bairnsdale Regional Health Service

Annual Report 2011-2012

Bairnsdale Regional Health Service PO Box 474 Bairnsdale VIC 3875 Telephone (03) 5150 3333 Facsimile (03) 5152 6784 Email [email protected]

www.brhs.com.au

...focusing on you

Bairnsdale Regional Health Service – 2011 - 2012 Annual Report 1

CONTENTS

Profi le 2

Services 3

President and CEO Report 4

Statement of Priorities 7

Financial Results 10

Activity Data 12

Workforce Data 13

Corporate Governance 14

Organisational Structure 17

Organisational Chart 19

Management Committees 20

Visiting Specialist sand Medical Offi cers 21

Financial Donations 22

Life Governors 24

Community Engagement 24

Our Hospitals Health Check 26

Report of Operations 27

Glossary of Terms 29

Donations/Bequests 31

Disclosure Index 32

2 Bairnsdale Regional Health Service – 2011 - 2012 Annual Report

PROFILE

Bairnsdale Regional Health Service (BRHS) provides healthcare services to more than 40,000 people across the East Gippsland Shire covering an areaof 21,000 square kilometres. Towns to benefi t from the services of BRHS include Bairnsdale, Benambra, Bruthen, Buchan, Ensay, Lakes Entrance, Lindenow, Mallacoota, Metung, Omeo, Orbost, Paynesville, Swan Reach and Swifts Creek.

• Hospital services operate from the main campus in Day Street, Bairnsdale and include acute and post-acute services, specialist consulting rooms, dialysis and oncology outpatient services, allied health outpatient services, radiology, pathology and residential aged care facilities.

• Community health services are located in both Bairnsdale and Paynesville providing outpatient allied health services, Planned Activity Group, and dental services in Bairnsdale. Outreach Planned Activity Groups are also located in Metung, Bu-chan, Bruthen, Lindenow and Paynesville.

• Outreach healthcare and education services are also provided throughout the region including allied health services at the Lake Tyers Aboriginal Trust and the Gippsland and East Gippsland Abo-riginal Co-operative (GEGAC); outreach midwifery and maternal health, district nursing and in-home palliative care.

· BRHS work is in partnerships and its services are complimented by other East Gippsland health ser-vices such as Gippsland Lakes Community Health Centre, Omeo District Health, Orbost Regional Health and our Bush Nursing Centre colleagues.

BRHS HISTORY 1887 Opening of the Bairnsdale District Hospital

1930 Opening of the Orbost Hospital

1940 Relocation of the Bairnsdale District Hospital to Day Street (current site)

1963 Training facilities for nursing built on site

1967 Extension of hospital to facilitate outpatient facilities

1975 Name changed to East Gippsland Hospital

1981 Opening of children’s ward

1986 Completion of building works incorporating radiology, pathology, pharmacy and medical records

1992 Opening of new operating theatre

1992 Bairnsdale Regional Health Service established as an entity under the Health Services Act 1988 following amalgamation of the East Gippsland Geriatric Centre and East Gippsland Hospital

1993 Amalgamation of Community Health Services into the Bairnsdale Regional Health Service

1996 Establishment of Sutherland Lodge, dementia specifi c aged care facility

2004 Establishment of Maddocks Gardens residential aged care facility

2007 Construction of the new Emergency Department and associated works

2008 Extension of the Monash Rural Clinical School

2010 Pharmacy extension completed, construction underway on Oncology

& Dialysis unit

2011 Oncology & Dialysis unit offi cially opened

2012 Monash Rural Clinical School Expansion Offi cially opened by Honourable David Davies MP

2012 DLA Piper Bairnsdale Regional Health Services Review


SERVICES

Services offered by Bairnsdale Regional Health Service include: Acute & Sub Acute HealthDialysisEmergency ServicesGeriatric Evaluation and ManagementMedicalMedical Imaging Obstetrics Oncology Paediatrics Palliative Care Pathology Pharmacy Rehabilitation Stomal Therapy Surgical Care TheatreNon – Emergency Patient Transport

Aged Care Rehabilitation Rehabilitation Physician Residential Dementia Residential High Care Residential Low Care Respite Care

Allied HealthDieteticsKoori Hospital Liaison Occupational Therapy PhysiotherapyPodiatry Social Work Speech Pathology

Ancillary Medical Library Mental Health

Community Health Adolescent Health Breast CareCardiac RehabilitationCommunity Dental Health ProgramContinence Advisory ServiceDentalDiabetes EducationHome Based Nursing Service (District Nursing) Hospital Admission Risk Program (HARP) Hospital in the Home (HITH)Needle Exchange ProgramPalliative CarePlanned Activity Group (PAG) Post-Acute Care (PAC) Pulmonary RehabilitationQUIT program – smoking cessationWomen’s Health

Visiting Specialists Audiology CardiologyDementia and Memory ServiceGastroenterology General Physician General Surgeon GynaecologyHead & Neck Surgeon Counselling Services Low Fertility ClinicLow-Vision Clinic Neuropsychology Oncologist Ophthalmologist Orthopaedic surgeonOutreach Polio Clinic (bi-annual) Paediatric SurgeonPaediatrician Rehabilitation Cardiologist Renal Physician RheumatologistUrologistVascular Surgeon


PRESIDENT AND Acting CEO REPORT

On behalf of the Bairnsdale Regional Health Service (BRHS) Board of Management (BOM), management and staff we are pleased to Present the Annual Report of Bairnsdale Regional Health Service (BRHS) for 2011 - 12.

BRHS reports on its performance in two separate documents in the 2011-12 fi nancial year. Our Annual Report reports on fi nancial and overall performance for BRHS which fulfi ls the statutory reporting requirements of the Victorian Government in accordance with the Financial Management Act 1949. This year BRHS Quality Care Report has been separated to an individual report which will outline BRHS Quality, Risk Management and Performance Improvement matters which will be issued to the community late in 2012.

2011-12 has been a challenging and reforming year for BRHS. As a result of continued feedback from community and staff regarding concerns relating to the management of the health service. The BOM commissioned an independent external review by DLA Piper Australia which was conducted by Dr Heather Wellington. The review commenced on 28th December for the purpose of assessing the quality and effectiveness of governance and management systems and leadership at BRHS, and apparent breakdown in relationships between BRHS, Senior Medical Staff Group and other key stakeholders. The review was conducted in the context of recognition and appreciation of the important contribution public health services make to individual health and community social and economic wellbeing in Rural and Regional Victoria. The report included twenty-four recommendations dealing with a range of issues. The Board accepted all of the recommendations and in the true spirit of openness and transparency publicly released an edited version of the report and recommendations. The review was a turning point in the development of the health services and identifi ed signifi cant challenges for BRHS.

The health service and Board have implemented many signifi cant changes since the December 11/February 12 review period.

- The appointment of Michele Gardner as Acting Chief Executive Offi cer (CEO) in February – July 2012 following the resignation of the former CEO.

- Successful recruitment and appointment of Therese Tierney to the permanent CEO role with commencement in July 2012.

- The appointment of Dr Scott Deller in June 2012 and Dr Mark Pritchard in March 2012 into new senior medical roles that include educational supervision of junior medical staff.

- The expansion from part-time to full-time of the Director of Medical Services role held by Dr Ka Chun Tse- The appointment of four additional experienced doctors to work in the emergency department and across

the hospital, including overnight.- The provision by the Board of additional budget for enhanced medical staffi ng and a review of the budget

for 2012-2013.- A review of the junior and senior medical staffi ng plan.- Implementation of recommendations of the Postgraduate Medical Council of Victoria to improve intern

supervision and monitor intern satisfaction.- The development of new terms of reference for an expanded Community Advisory Committee.- Improvements to Board governance and procedures, including the cessation of the Board Executive

Committee, additional governance training and enhanced reporting to staff. - The appointment by the Minister for Health of experienced medical professional and health governance

expert Dr Michael “Taffy” Jones as a delegate to the Board for a period of 12 months.- Creation of a new, non-voting Board observer role to be fi lled by a visiting medical offi cer (GP) who provides

24-hour on-call services to BRHS.- Introduction of strategies to improve internal and external communication, including regular dialogue groups

for managers and staff, and more collaborative decision making processes.- Establishment of a new Clinical/Hospital Medical Offi cer Unit to support nursing and medical staff.


As part of BRHS ongoing commitment to the delivery of quality care BRHS successfully maintained full accreditation by the Australian Council of Healthcare Standards during its 18 month periodic review in May 2012. This internationally recognised accreditation provides assurance to the community that BRHS service delivery meets appropriate standards.

BRHS offers a wide range of acute, primary and aged care residential services to our community and have continued to strive over the past twelve months to fulfi l its mission of leading, shaping and delivering quality health care services to our East Gippsland community. During this year of signifi cant change at BRHS the organisation has focused on operational and organisational development. It has seen improvements to our processes for patient care and assisting us to develop better ways of utilising our existing resources to focus on patient and client satisfaction and improving patient access and patient care.

Our Emergency Department has demonstrated this by signifi cant improvements in patient response times as a result of improved medical and nursing staffi ng in the last six months of 2012. It was pleasing to note that BRHS demonstrated that 95.1% of patients that arrived at BRHS by ambulance had their transfer completed within the state-wide target of 40 minutes, thus ensuring consistent performance above the state-wide benchmark of 90% throughout the past year.

In collaboration with Monash University - East Gippsland Regional Clinical School building expansion was completed in April 2012 on the $1.5m building construction and will be offi cially opened by the Minister for Health, Minister for Ageing the Hon. David Davis MP Member for Southern and Metropolitan in August 2012.

Throughout the past year BRHS has continued to focus on enhancing partnerships across the region. BRHS and Gippsland Lakes Community Health (GLCH) have continued their Joint Executive and Joint Board meetings throughout the year to ensure ongoing effective collaboration between both organisations with a focus of enhancing our patient’s journey from hospital to community. BRHS is continuing to focus on developing and strengthening its relationships with Gippsland and East Gippsland Aboriginal Co-operative (GEGAC) and Monash University Bairnsdale Campus.

The Board supported the appointment of Dr Ka Chun Tse Director of Medical Services from a part time to a full time role to enable further enhancement and development of the BRHS Medical Services and Workforce and ensure effective support for our Senior Medical staff and VMO/GPs.

BRHS, for the second time, submitted to the Department of Health a Statement of Priorities (SOP) 2011-12. The SOP’s, developed from the BRHS 2009-13 Strategic Plan, provide the framework for BRHS and a number of highlights are outlined in this annual report.

The BRHS Board and Executive were pleased to oversee the implementation of the BRHS Non-Emergency patient transport service. This service has provided a wonderful additional service to our patients that require non-emergency transport for transfer to other like hospitals in the region and Melbourne for Elective admissions and procedures.

The Department of Health and Board continued to support BRHS Master Planning activities, crucial to identifying future infrastructure needs for the next 30 years, this was completed in November 2011. The plan submitted to the Department of Health was unfortunately unsuccessful in achieving funding from the Commonwealth Health and Hospital Fund in the 11/12 funding round, however it is an important achievement to ensure the ability for BRHS to seek future funding for the continuing development of BRHS to meet the future challenges of health care delivery to our community.

BRHS were pleased to be recipients of $2m in Grant funding from the Federal budget to build new accommodation for visiting health professionals, interns and specialists. This will assist BRHS to attract and train a wider range of health professionals to the East Gippsland region. In addition BRHS was successful in receiving $70,000 from the fi rst round of the State Government Rural Capital Support Fund to assist with the upgrade to facilities and equipment.

Early in 2011 we established the inaugural BRHS Achievement Awards which were, presented at the Annual General Meeting to recognise innovation and excellence of care by our staff to BRHS patients. It recognises both clinical and non-clinical aspects of hospital work by our staff. The Clinical Award went to the My Midwives Program which allows for all care across the entire pregnancy/birth/post-partum continuum to be provided by a midwife that is known to the woman throughout the pregnancy. This Award was proudly accepted by Clinical Midwife Specialist and project coordinator Angela Kellock.




The Non – Clinical Award went to the Consulting rooms redevelopment. This award was accepted by Sue Smith Manager Consulting Rooms on behalf of the consulting room team. They were delighted to be recognised with the achievement award which acknowledged the commitment and effort that the consulting room team have invested in repositioning the consulting room service at BRHS. Since receiving this award both the My Midwives Program and the Consulting Rooms have continued to strive for excellence in service and patient care.

BRHS continues to be appreciative and very fortunate to have a dedicated supportive fundraising community and were delighted to join the BRHS Bowerbirds in celebrating their wonderful 30th anniversary. Their dedication and tireless support to BRHS has resulted in over $375,000 being raised and donated over these 30 years, with $225,000 of these funds being donated in the past 9 years. This contribution has enabled purchasing of critical clinical equipment for our patients and assisted our staff to deliver better patient care. On the 26th June, in recognition of the Bowerbirds outstanding contribution from 1982-2012 to BRHS, the Board of Management, Executive and staff celebrated with the Bowerbirds by offi cially naming the Day Street entrance and waiting room to the hospital “The BRHS Bowerbirds Waiting Area”. An offi cial plaque was presented to President of the Bowerbirds Renate Rosenhan by the Board and Acting CEO and then erected as a public acknowledgment of their 30years of dedication to the hospital.

We would like to take this opportunity to thank all of our tireless volunteers and fundraising groups who play an important role in supporting our patients and clients. Not always are they visible to the public but their warmth, generosity and dedication are intrinsic to the delivery of quality of care by the BRHS staff. BRHS celebrated volunteer week with a morning tea function at the Bairnsdale Sporting & Convention Centre, as President of the BRHS Board I was delighted to be joined by our Acting CEO, Executive members and staff to honour the hardworking commitment shown by our 250 volunteers involved in a diverse range of activities focusing on BRHS.

In May 2012 a signifi cant focus for BRHS was on managing the hospital resources during several days of signifi cant fl ooding in the East Gippsland area. The executive successfully ran an internal Incident Control room for 2 days and worked cooperatively with all the East Gippsland Emergency Services management team. BRHS received very positive feedback on the way the operation was conducted both by staff and external agencies and we were praised for our open communication and support of staff. We would like to sincerely acknowledge staff who put the health service fi rst and were willing to stay within the Bairnsdale area to ensure that service delivery, especially within the clinical area, could continue. The response from staff was commendable and very encouraging to see such support of our patients and community in a time of great need. The management of this emergency event was streamlined due to signifi cant improvements achieved during the Emergency Planning and EMERGO Training exercise undertaken at BRHS in the previous month. This was facilitated by a dedicated Emergency Planning Project Offi cer who was appointed in early 2012.

We thank our colleagues on the Board of Management and Senior Executive for their support and effective governance of BRHS throughout this challenging year. We would also like to acknowledge and sincerely thank our highly skilled staff, Medical Offi cers, VMOs and GPs for their dedicated work under challenging circumstances and giving their best to ensure that our community receives quality care of the highest order. As President of the Board I would like to take this opportunity to publicly thank and acknowledge the professional manner in which our Acting CEO, Executive team and all BRHS staff who have demonstrated professional leadership and commitment to BRHS during a time of rapid organisational change.

The Board looks forward to working with the new CEO Therese Tierney, the Executive team and all staff at BRHS in the coming year as we take seriously our responsibility to ensure our health service responds innovatively to the ongoing health needs of our community.

This Annual Report is prepared for the Minister of Health, Minister for Ageing the Honourable David Davis MP Member for Southern Metropolitan and through him, the Parliament of Victoria and the Victorian People.

Peter Crick Michele GardinerPresident, Board of Management Acting Chief Executive Offi cer


STRATEGIC PRIORITY DELIVERABLES OUTCOME

Commence participation in the GRICS Multi Disciplinary Care (MDC) meetings and to steadily increase the number of referrals to the same.

Recruitment of a surgeon and a physician to Bairnsdale.Commencement ofimplementation of the Junior Medical Workforce Plan.

Master Planning for BRHShospital campus.The development of strategies and agreement to support the Closing the Gap strategy.Cultural sensitivity training

A plan which informs appropriateservice and facility confi guration for future needs and facilitates ease of access and transition through the facility whilst improving patient privacy.

Master Planning has been presented at a number of community forums, AGM as well as to the Community Advisory Committee, Senior Leadership team members and staff. Outcome from Federal Government funding round May 2012 was not successful in receiving funding for 2011 – 2012 year.

Demonstrate an increase in the number of referrals to the MDC meetings. Minutes to validate the same.

General Surgeon and Physician appointed.

Progress report to be completedJune 2012.

BRHS, as the lead agency forAboriginal employment in Public Health Services in Gippsland, will report on actions in line with the strategy.

Project progressing slowly. In March 2012 young Aboriginal members of the community visited BRHS for a tour to highlight Health Service employment opportunities within Gippsland.Currently exploring opportunities to support Aboriginal nursing scholarship. An Aboriginal employment plan is currently under development for BRHS.

To be included in all positiondescriptions as a key competency and to be completed by all staff annually.

New position descriptions are currently in development with the appointment of new Workforce Capability and Culture Manager (WCCM) to BRHS in February 2012.Provision of Cultural Sensitivity Training for all staff commenced in May 2012 and will be provided on an annual basis in the future.Currently, Koori Liaison Offi cer attends all staff orientation days to highlight the importance of cultural competency.

Since commencement of GRICS MDC and the completion of telemedicine at BRHS there has been an increase in referrals and an improvement in overall awareness of the MDC process of Gippsland Regional Integrated Cancer Services this will continue to be monitored over the next 12 months.

Full time General Surgeon has been appointed and this role is working extremely effectively at BRHS. Recruitment for a physician is currently continuing to be explored. The appointment of the senior medical registrar from Box Hill via Eastern Health has been a signifi cant improvement and benefi t to BRHS commencing 16 January 2012 and the appointment of full time Director of Medical Services in April 2012.

The Junior Medical Workforce Plan was approved by the Board of BRHS and implemented in January 2012. The Medical Accreditation Report (PMCV) identifi ed the requirement for improved supervision of Junior medical staff at BRHS. In 2012 signifi cant improvements occurred in Medical Staffi ng.

STATEMENT OF PRIORITIES



Development of BRHS owned non-emergency patient transport service.

To complete a review ofpreadmission clinic and theatre processes.

Development of a capability management and development framework.

Budget, monitor and action to ensure a continuation of a positive fi nancial performance whilst maintain a high quality level of service.

Improve access to ultrasound services by expanding the number of sonographers from two tothree.

Framework to be completed andadopted by health service.

Since January 2012 our review of BRHS’ management and professional development framework has commenced with the appointment of Workforce Capability and Culture Manager to ensure effective, sustainable system for BRHS in relation to staff support, development and management development.

Improved response times.

A report on fi nancial outcomes i.e. BRHS vs cost of same service by a private provider to be provided to Board of Management.

A report on the key outcomes.

A decrease in the number of surgical cancellations.

Reduction in waiting times fromtime of referral to ultrasound.

Improved fi nancial outcome for sonography service.

Signifi cant development has occurred within this area of service. A business case has been approved and the purchase of a third ultrasound unit has occurred and training is currently under way for additional sonography staff. This will ultimately provide enhanced services for the community and improve fi nancial outcomes for the sonography service.

Positive fi nancial outcome for2011/12 whilst maintaining multiple accreditation and patient satisfaction.

BRHS has continued to maintain a satisfactory fi nancial position despite an increase in medical costs from January 2012. This has been as a result of improved management of the traditionally high use of casual staff within the organisation and a reduction in sick leave across all areas since the start of 2012.

BRHS non-emergency patient transport utilisation has improved signifi cantly in the last 3 months with an extension to the criteria of patients being able to be transported. (i.e. patients to be able to be discharged back to the community and to nursing homes rather than occupy acute inpatient beds.)

Board of Management continues to receive monthly reports on the fi nancial and performance of this valuable service.

The elective surgery project has made signifi cant progress within the past 6 months at BRHS with the creation of a new elective surgery waiting list coordinator role appointed in May 2012. This has resulted in improved rigor regarding the management of preadmission and surgical cases and management of surgery waiting list.





Implementation of BRHS ICTreview

Progress towards the implementation of the BossNet clinical system.

To comply with the Departmentsdata integrity guidelines

The development of KeyStakeholder strategy.

Audit results to validate the same.

Implementation of the Key Stakeholder strategy and provide a report to Board of Management in June 2012.

Internal and external audits have continued throughout 2012.

The Wellington review commenced on 29 December 2011 and completed in February 2012 provided valuable guidance and recommendations regarding stakeholder management. Board of Management in March 2012 reviewed the Community Advisory Committee to ensure a more effective stakeholder and community involvement at BRHS.

In January 2012 new discussion forums have been established on a monthly basis with medical staff of both key GP clinics in the community to improve stakeholder discussions and involvement at BRHS. In addition written communication has occurred with all visiting medical specialists.

Report on the key outcomes.

Demonstrated advancement in the implementation of BossNet.

The elective surgery project has made signifi cant progress within the last 6 months at BRHS.

As a result there has been a signifi cant decrease in the number of hospital initiated surgical cancellations and some reduction in the number of patient initiated cancellations. Most cancellations were due to a result of patients being over their BMI criteria for surgery at BRHS. New process have been implemented to address this resulting in improved performance.


FINANCIAL RESULTS

Operating result 2011 -12 actualsAnnual Operating result ($m) 1,945 Cash management/liquidity 2011 -12 actualsCreditors 1,912Debtors 1,645

WIES activity performance 2011 -12 actualsWlES (public and private) performance to target (%) 111.76% Quality and Safety 2011 -12 actualsHealth service accreditation AccreditedResidential aged care accreditation AccreditedCleaning standards 93%Submission of data to VICNISS (%) 100%VICNISS Infection Clinical Indicators Fully CompliantHand Hygiene Program compliance (%) 65%SAB rate (OBDs) 2.9% (10,000) *Victorian Patient Satisfaction Monitor (VPSM) Overall Care = 80%Maternity 2011-12 actualsPostnatal home care 96%Access performance 2011-12 actualsPercentage of operating time on hospital bypass NILPercentage of emergency patients admitted to an inpatient bed within 8 hours 96%Percentage of non-admitted emergency patients with length of stay of less than 4 hours 89%Number of patients with length of stay in the emergency department greater than 24 hours 0%Percentage of Triage Category 1 emergency patients seen immediately 100%Percentage of Triage Category 2 emergency patients seen within 10 minutes 84%Percentage of Triage Category 3 emergency patients seen within 30 minutes 86%

* Cumulative rate to quarter 3 2011/2012. Quarter 4 data not available to date.

Financial Performance

Service Performance


FINANCIAL RESULTS

The organisation produced an operational surplus of $2,325,000 (2010/11 $1,555,000) before transfers to and from reserves, capital grants and depreciation being applied. During the year BRHS received capital purpose income of $2,085,000 (2010/11 $3,484,000) and applied a total depreciation amount of $4,123,000 (2010/11 $3,911,000). This resulted in an overall defi cit of ($142,000).

* BRHS implemented the principals of Hospital Circular 19/2011; Accounting for income received in advance, for the fi rst time in 2011/12. This resulted in recognising an additional $564,000 of revenue of revenue that was not previously have been recognised.

Changes in Prices, Fees, Charges, Rates and LeviesThe Service charges fees for services it provides to: Aged Care Residents, Allied Health Clients accessing services through HACC and CACPs and District Nursing, as well as private patients in our main hospital. On all of these occasions BRHS charges according to schedules of fees published by the appropriate federal authority, and fees are only increased when advice is received from the appropriate Commonwealth Department.

Total Revenue 62,108 59,120 54,816 53,356 52,200Total Expenses 61,870 59,655 56,372 51,971 49,555Overall Surplus / (defi cit) 238 (535) (1,555) 1,385 2,644 Retained Surplus / (defi cit) 9,896 9,633 8,170 9,245 7,708Total Assets 68,027 67,918 65,521 66,901 48,545Total Liabilities 20,657 20,787 17,854 17,679 15,087Net Assets 47,369 47,132 47,667 49,222 33,458Total Equity 47,369 47,132 47,667 49,222 33,458

2012$000

2011$000

2010$000

2009$000

2008$000


Same Day Multi Day Total Separations

9,3374,969

14,306

21340361

000

9,3585,309

14,667

WIES

The Weighted Inlier Equivalent Separations (WIES) is the casemix instrument that is used by the Victorian Government to fund hospitals. All health services have WIES targets and funding depends on the number of WIES the organisation attains. BRHS’ WIES target for the year was 6,019 and achieved 6,118 or 99 more than target.

PublicPrivateRenalTACDVA

Target Actual Variance

5,012985263

49295

5067217

363

TOTAL 6,103 501

4,506913280

46358

Acute Sub-Acute Mental Health Other TotalAdmitted Patient

Separations

Total WIES

Total Bed Days

6,609.44 6,606.44

28,511

14,306

6,284

361 0 0

34,821

14,667

Non Admitted Patient

Outpatient Services – occasions of services (VACS and Non VACS clinics)

Acute Sub-Acute Mental Health Other TotalNon Admitted Patients

Emergency Department Presentations

Other Services – occasions of services

Total occasions of service

17,344*

15,10331,529017,160 0 47,46048,873

17,160 17,160

Admitted Patient

* Includes SACs = 7876,, Consulting room attendances, Medical, Nursing and Allied Health

ACTIVITY DATA

17,344

0 0 0

000

6,604


NursingAdministration and ClericalMedical SupportHotel and Allied ServicesMedical Offi cersHospital Medical Offi cersSessional CliniciansAncillary Staff (Allied Health) Dental Offi cersOther Dental Clinicians / Specialists

Labour Category

WORKFORCE DATA

June Current Month FTE*

2012 2011 2012 2011

June YTD FTE**

193.5573.7528.19

111.593.29

12.820.00

29.780.901.27

182.0379.6126.41

102.892.18

12.940.00

26.822.002.42

189.63 70.81 28.18 107.50 2.45 13.29 0.00 32.69 1.42 1.00

184.84 73.89 29.61 103.59 1.50 13.75 0.00 27.41 1.99 2.60

The Workforce Capability and Culture department has experienced a period of signifi cant change, growth and development over the past 12 months. The appointment of a new Manager and the development of additional roles to further support recruitment, retention and training opportunities now provide BRHS with more scope and expertise to enhance these important human resource functions. The department is also undertaking a compre-hensive review of its policies, procedures and templates to facilitate best practice. Plans for the refurbishment of its reception area is also progressing well and when complete will provide staff, volunteers and visitors with a comfortable space to access human resource information and to complete their documentation in a more private and confi dential area. In August 2011 BRHS became the fund holder for the regional “Closing the Gap” Program and a Project Offi cer was appointed to assist the 4 hospitals in the region attain a target of at least 1% of the workforce comprising Aboriginal people by 2013. An Aboriginal Employment Plan is currently under devel-opment and a number of traineeships for Aboriginal people have been developed as part of an overall strategy for BRHS to attain or preferably exceed this target. A Project Offi cer to review our current Volunteer Workforce and to investigate more opportunities to develop and extend the use of volunteers within BRHS commenced in April for a 6 month period.

Occupational Health and Safety (OH&S)The Health Service complies with all its obligations under the Occupational Health and Safety Act 2004. BRHShas in place an OH&S Policy and a Return to Work Policy which was reviewed over the past 12 months to include management of long term absences due to sickness and injury which are not work related. BRHS collects infor-mation about all OH&S incidents and the data is used to produce comprehensive reports which identify trends and assist with identifying and implementing appropriate corrective actions to protect the health and safety of all staff, patients and clients visiting our facilities.

Whistleblowers Protection Act 2001 Bairnsdale Regional Health Service is committed to the principles and intent of the Act and to the protectionof genuine whistleblowers against action taken in reprisal for the making of protected disclosures. In line with this, Bairnsdale Regional Health Service has in place a corporate policy and procedure, which complies with the Act. Disclosures made under this policy will be investigated swiftly, professionally and discretely. During the 2011/12 fi nancial year, BRHS has had no disclosures.

A copy of the Act is available for inspection from the Health Service’s library. The policy is also available to all staff on the BRHS intranet.


CORPORATE GOVERNANCE

There were four changes to the Board of Management in 2011/12 with additional members Lindley Jones, John Websdale and Appointed Delegate to the Board Dr Michael (Taffy)Jones

Philippa deVoilAppointed 2001

BA (Admin); Dip App Sc.

(Nursing) Former ExecutiveDirector of Nursing, Served on various government advisory committees. Extensive health service experience including

aged care services in public and private sectors at management and board levels. Rotarian and local volunteer.

Dr David FormbyAppointed 2008

MB BS.DCH; FRACP; FRCP; FRACMA; MHA.

Former Medical Director Princess Margaret Hospital for Children, Perth, Wangaratta Regional Hospital and Latrobe Regional

Hospital. Previous Treasurer and Chairman of the Federal Assembly of the AMA. Former surveyor with the Australian Council of Health Care Standards. Formerly Consultant Paediatrician at Princess Margaret Hospital, Latrobe Regional Hospital and Bairnsdale Regional Hospital. Past President of the Bairnsdale Golf/Bowls Club.

Tony WardAppointed 2000

B. Laws; B. Jurisprudence

Principal, Wards Barristers & Solicitors Pty Ltd. Married to Sharon, four children.

Board of Management

PresidentPeter CrickAppointed 1992

Held various bank management positions in the Gippslandregion and Tasmania over a 23 year period from 1979– 2002. Vice President of thePelicans community fundraising

committee. Signifi cant association with Freemasonry for over 40 years. Keen gardener and walker

Vice PresidentAngela HutsonAppointed 2000

BA (UM); Dip Ed; Masters in Organisational Leadership; Graduate Dip Businessin Entrepreneurship and Innovation; Grad Cert Enterprise Management; Diploma of

Frontline Management. Extensive experience in executive management and governance in the public sector. Up until May 2011 was CEO of East Gippsland TAFE.

TreasurerKen WhiteAppointed 2009

BBus; CA; GradCert FP

Chartered Accountant, Directorof Whites Accounting andTaxation Solutions. Extensive experience in public practice

accounting, taxation and business management.


Lindley JonesAppointed July 2011

DipB(FLM); Grad.Dip. Emergency Health(MICA); AdvDip MICA Paramedics; Grad.Dip.VET UniMelb; BNursing.

Extensive experience in medical emergencies, is an active

community member.

Charme SedunaryAppointed July 2010

Former offi ce manager at Slap Architects. Treasurer of the Pelicans community fundraising committee. Area of expertise is Human Resource management.

Dr Michael Taffy JonesDelegate to the Board of Management Attendance 2011/12Appointed by the Minister April 2012 for a term of 1 year.

Doug VickersAppointed July 2011

Dip Edu & Grad Dip Edu

Principal, Bairnsdale West Primary School Heavily involed within the community sporting groups.

John WebsdaleAppointed July 2011

Dip BMan MonUni;

Director Corporate and Economic Development with East Gippsland Shire. Has 30 years experience in Local Government specialising in Corporate Services and Governance Functions

Board of Management Attendance 2011/12 For 2011/12 period there were only 10 meetings held this year not the usual 11. This is because the meeting for May and June were combined and held on the one night in June.

Peter Crick 9/10

Philippa deVoil 7/10

David Formby 6/10

Angela Hutson 9/10

Charme Sedunary 7/10

Tony Ward 7/10

Ken White 10/10

John Websdale 6/10

Lindley Jones 10/10

Doug Vickers 9/10




Finance, Audit and BusinessDevelopment Committee The Finance, Audit and Business Development Committee is a sub-committee of the Board of Management. The Committee assists the Board infulfi lling its governance responsibilities relating to and including, the accounting and fi nancial reporting processes, external and internal audit functions, the risk management system and legal and regulatory requirements. The Committee meets quarterly.

Board Committee members during 2011/12 were: Ken WhiteDoug VickersJohn WebsdaleTony Ward

Community Advisory CommitteeThe Community Advisory Committee is a sub- committee of the Board of Management. The Committee provides mechanism for local community involvement in the BRHS strategic planning process and local health service delivery. The Committee meets quarterly.

Board Committee members during 2011/12 were: Peter CrickAngela HutsonLindley Jones

Clinical CredentiallingCommitteeThe Clinical Credentialling Committee is asub-committee of the Board of Management. The Committee is responsible for assessing the professional expertise, competence, reputation and authenticityof the qualifi cations of medical staff seeking appointment or re-appointment to the medical staff of BRHS. The Committee meets as required.

Board Committee members during 2011/12 were: Peter CrickLindley JonesAngela Hutson

Quality Audit CommitteeThe Quality Audit Committee is a sub-committee of the Board of Management. The Committee oversees progress of the strategic quality plan and monitors each dimension of quality, safety, effectiveness and appropriateness to ensure an organisational wide quality program and culture exists.

Board Committee members during 2011/12 were: Philippa deVoilPeter Crick Charme SedunaryLindley JonesDoug Vickers


ORGANISATIONAL STRUCTURE

Chief Executive Offi cer, Directors and Associate DirectorsMichele Gardner

RNCC; Grad Dip HC; MRCNA; MAIJA; AFACHEM; AFAIM; MAHSFMA; MAICD;

Primary Position - Director Clinical(Nursing) & Corporate Service October

Acting Chief Executive Offi cer February 2012 - July 2012

The Chief Executive Offi cer (CEO) is responsible for the effective operation of the Bairnsdale Regional Health Service (BRHS) for the integration of services to provide a seamless continuum of care to the community, for the general direction of all business and affairs of the BRHS and MDHSS as a whole, and for advising and making recommendations to the Board of Management with respect to these activities.

The CEO BRHS is also CEO of Mallacoota District Health and Support Service (MDHSS) via consent by the Committee of Management MDHSS and agreement by the Board of Management BRHS.

Wayne Sullivan

Chief Executive Offi cer

Former Chief Executive Offi cerMaster of Business; Grad Dip Health Science (Administration); Grad Dip Nursing (Community Health); RN Div 1; Cert of Geron- tology; Diploma AICD Company Director’s Course; FACHSM; CHE; GAICD.Resigned February 2012

Vicki Farthing

Former Director of Nursing

RN; Stomal Therapist; BA Nursing; Grad Dip Health Informatics; Masters, Health Management; FRCNA; Resigned October 2011

Megan Morse

Former Director Allied & Community Services

B.Pod (Hons); M.Ed. (Ed & Tr); MBA; Grad Cert H.EcResigned 28th June 2012

Ka Chun Tse

Director of Medical ServicesMBBS, MHM, MPH, AFACHSM

The Medical Services Directorate at BRHS supports the operation, development and planning of the medical workforce, Medical imaging

department and Pharmacy.It also contributes to the quality of care and clinical framework of the Health Service, and works collaboratively with Monash University, Medicine, Nursing and Health Science, East Gippsland Regional Clinical School to promote medical student placements in Bairnsdale.


Janet Burton

Associate Director Corporate Services & Business Development

Master of Business Administration

This position contributes to the fi nancial operations ensuring the operational practices are consistent with the Public Sector Management Act 1994 and the Financial Management Act 1998. Monitors, evaluates and reports on business and organisational performance. Leads and oversees contractual and procurement activities. Oversees Facilities; Environmental & Catering Services; Medical Records; Fundraising and Community Engagement. Assists with implementation of the strategic plan and Identifi es Innovative business development opportunities.

Kim Turner

Primary Positon - Clinincal HMO Coordinator

Acting Associate Director Clinical (Nursing) Services February 2012 July 2012

Provide leadership and support to Nurse Managers within the Clinical Directorate, ensuring the delivery of contemporary, effective and effi cient nursing and clinical services and the continuity of care of BRHS clients. To develop and implement new services and/or programs for the provision of optimum client care and to participate in various projects including writing of submissions to promote contemporary nursing/clinical practice.

Bernadette Hammond

Primary Position - Associate Director Clinical (Nursing) Services

Acting Director Clinical(Nursing) & Corporate Service February 2012 July 2012

To provide leadership in conjunction with the executive and CEO, to achieve the organisation s Vision, through the planning and delivery of quality Clinical and Corporate Services. The position will ensure leading practice in nursing care, service delivery and effi ciency throughout the organisation as well as specifi c nursing program delivery. The role also has a governance component which ensure excellence in nursing practice and standards throughout the organisation and the need for accuracy of the information provided and the understanding of the Health Service Agreements.

Tanya Murray

Primary Position - Clinincal HMO Coordinator

Acting Associate Director Clinical (Nursing) Services February 2012 July 2012

Provide leadership and support to Nurse Managers within the Clinical Directorate, ensuring the delivery of contemporary, effective and effi cient nursing and clinical services and the continuity of care of BRHS clients. To develop and implement new services and/or programs for the provision of optimum client care and to participate in various projects including writing of submissions to promote contemporary nursing/clinical practice.


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MANAGEMENT COMMITTEES

Bairnsdale Regional Health Service (BRHS) considers committees to be an excellent formal communication tool and has an active committee meeting structurein place to provide communication support.

BRHS Management Committees support our role through the exchange of ideas, decision-making, investigation of events, assessment and review of patient care and services, consideration of reports, ensuring legislative or funding requirements are met and overseeing the implementation of plans or policy.

All our committees have ‘Terms of Reference and Membership’, which set out the role and function of the Committee. Membership for each committee is appropriate for the role and function it performs.

The Board sub-committees as listed on page 15.

• Finance, Audit and Business Development Committee

• Quality Audit Committee

• Medical Credentialling Committee

• Community Advisory Committee Report directly to the Board.

All clinical and non clinical committees at BRHS report to the Board through our peak committee, the BRHS Quality Management Committee. These committees are listed below. • BRHS Quality Management Committee

• Theatre/Anaesthetics & Surgery Committee

• Obstetrics & Neonatal Committee

• Emergency Department & Medicine Committee

• Pharmaceutical/Transfusion/Infection Prevention Committee

• Maddocks Gardens Continuous Improvement Committee

• Ambulatory Care Committee

• Information Management Committee

• Corporate Services Committee

• Occupational Health & Safety Committee

• Human Resources Committee

During the year each committee has reviewed itsTerms of Reference and Membership.

The Occupational Health & Safety Committee continues to function within the scope of the Occupational Health & Safety Act.

All committee meetings are minuted and available to staff through the intranet.

BRHS Board Quality Audit Committee

Quality Management Committee

Ambulatory CareCommittee

Maddocks Gardens Continuous Improvement

Committee

Pharmaceutical / Transfusion / Infection Prevention Committee

Emergency Department & Medicine Committee

Obstetrics & Neonatal Committee

Theatre / Anaesthetics & Surgery Committee

Information Management

Committee

Corporate Services Committee

Occupational Health & Safety Committee

Human ResourcesCommittee

Clinical Committees Corporate Committees


CardiologistsDr David BertovicDr Justin MarianiDr Meroula RichardsonDr James ShawMr Andrew Taylor

Head, Neck, Nose & ThroatProf Andrew SizelandMr Guilermo Hurtado

GastroenterologistsDr David IserDr Jeremy Ryan

General SurgeonsMr Adrian AitkenMr Anamitra SarkarMr Clem SmithMr Servaise de Kock

GynaecologistsDr Robert McKimm Dr Michael Sedgley Dr Gareth Weston

NephrologistsDr. David HookeProf David Power

OncologistsDr John Scarlett

OpthalmologistDr Pradeep Madhok

Orthopaedic / LegalDr Stan O’Loughlin

Orthopaedic SurgeonsMr Andries DeVilliersMr Peter Rehfi schMr Warwick Wright

Paediatricians Dr Peter GossDr Jo McCubbinDr Austen Erasmus Dr Sylvia Welgemoed

Paediatric SurgeonsMr Chris KimberMr Neil McMullen

PhysicianDr Krishna Mandaleson

Rehabilitation PhysicianDr David McConachy

RheumatologistsAssoc Prof Peter Ryan

UrologistsProf Mark FrydenbergDr Jeremy Grummet

Vascular SurgeonMr Peter Milne

Visiting Medical Offi cersDr Andrew RutherfordDr Daniel OtuonyeDr Daryl SmithDr David McConvilleDr Elizabeth BoydDr Graham BromwichDr John UrieDr Poh NgDr Myles Chapman (Field Emergency Medical Offi cer)Dr Naveen Joshi Dr Peter Lindstedt Dr Peter WorboysDr Phillip SewellDr Ross de SteigerDr Sema YilmazDr Sue GeorgeDr Tomasz GrabinskiDr Wanda Wysocka-Grabinska

VISITING SPECIALISTS AND MEDICAL OFFICERS AT BRHS

Senior Medical Offi cersDr Scott DellerDr Mark PritchardDr Hulme Hay

Director of Medical ServicesDr Ka Chun Tse

Gippsland Lakes Community Health District Medical Offi cers serving the Hospital in the Home Program.

Cunninghame Arm Medical Centre District Medical Offi cers serving the Hospital in the Home Program.


FINANCIAL DONATIONS TO BRHS 2011/2012

Bequests and EstatesAnonymous $30.00Erica Cromwell Trust $4,975.24Estate of Arthur Martin $21,304.00Estate of John Musgrove $255,882.38LJ Snowball $50.00

Fundraising Bower Birds $15,275.00Chocolate Sales $1,312.04Flower Auxiliary $4,000.00Kiosk Auxiliary $21,378.68

Business Sector Bairnsdale Racing Club $1,199.00Bulmers Gifts $2,300.00East Gippsland Community College $25.00Foodworks Paynesville $98.92Freemasons Victoria $17,000.00G-Tec Gippsland Technical College $220.00GW Arthur & Associates Pty Ltd $620.95Hibbert & Hodges Lawyers $100.00I & F Automotive Engineers $100.00Latrobe Community Health Service $2,273.75Masonic Centre Committee $17,000.00Monash Rural School of Health $1,510,000.00Noamunga Pty Ltd $200.00Paynesville Medical centre $46,806.74Regional Health Care Group $10,620.00Ritchies Store $391.29Royal Childrens Hospital $91.69Sperti Concreting Pty Ltd $600.00Swifts Creek Bakery $50.00Tyco Healthcare $2,704.76

Community Groups Apex Club of Bairnsdale $3,500.00Bairnsdale & District Arts Society $120.00Bairnsdale & District Palliative Care $2,136.36Bairnsdale Golf Club $3,000.00Bairnsdale Palliative Care Volunteers $2,272.00Bairnsdale Past Nurses Association $682.17Bairnsdale Secondary College $140.10Johnnos Outreach Centre $1,400.00Lions Club of Lakes Entrance $500.00Lucknow Junior Football Club $459.00Metung Bloodhounds $7,000.00Paynesville Hospital Auxiliary $1,200.00Paynesville Uniting Church $2,500.00

Riviera Triathlon Club $5,000.00St Marys Parish $500.00

Individual A & K Van Der Kaap $50.00A & T Grassby $50.00AJ Stewart $35.00Albert Rodd $50.00Alistair Mailer $200.00Andrea Johnson $45.00Andrea Newman $10.00Anonymous $292.30AT Williamson $70.00Bill Barry $30.00BJ Saunders $50.00Brian & Wendy Cottam $50.00Bridie Cornall $35.00Bruce Hailey $1,000.00Bruce Halley $100.00C Felkel $25.00C Storer $20.00CA Blackney $20.00Carol Johnson $100.00CF Cannington $50.00Charles Paterson $50.00Chris Jordan $35.00Colette Maraczy-Lanley $13.10Coral & John Gascoigne $100.00Craig Armistead $40.00D & B Allerding $25.00D Johnson $70.00David & Glenda Mitchell $100.00Davidson Family $50.00De Kock Private Inpatient Fees $44,885.65Deller Private Inpatient Fees $1,764.35Dialysis Education Fund $1,737.00Diane, Florance & Marjorie Simpson $70.00Dinali Perera $20.00Don Johnstone $50.00Donald McFarlane $50.00Dorothy Den Houting $100.00Dr AL White $50.00E Spicer $35.00Eleanor Mauger $35.00Elizabeth Strang $100.00Elsbeth White $100.00Fay Dawson $100.00FM & SM Garden $200.00G & J Wilesmith $10.00GA & JM Van Den Bogaart $50.00


Geoff & Wendy Jones $20.00Gerald Bridger $100.00Gwen Bradbury $4.65Gweneth Cooper $1,200.00HJ Kilpatrick $50.00In Memory of George Sumner $130.00J & R Reggardo $50.00Jan & Paul Jansen $100.00Jenny Hartwell $100.00JF & AR Cox $50.00JG Sedgley $35.00Johanna Arden $50.00John & Beryl Camilleri $100.00John O’Loughlin $100.00Judy $50.00Julia Trezise $500.00Juliette Wenn $15.00June Weller $250.00June Wilson $20.00Kemble Miller $50.00Kevin & Jenny Eckhardt $500.00KM Porter $100.00Leah Camm $500.00Linda Callahan $35.00Locum Surgeon Private Inpatient Fees $52,498.00Lois Botsman $35.00Lorna Griffi n $50.00Lorraine Wallace $50.00M & P Bexley $35.00Maria Parente $100.00Mary Farrell $50.00Melanie Rice $50.00MP & AY Pritchard $2,000.00Mr & Mrs A Dicello $20.00Mr & Mrs Currie $100.00Mr & Mrs DJ Davies $25.00Mr & Mrs Fisher $50.00Mr & Mrs JW Bright $35.00Mr & Mrs K O’Connor $35.00Mr & Mrs L Barr $35.00Mr & Mrs N Hengstberger $35.00Mr & Mrs P Berlingeri $50.00Mr & Mrs P Neal $578.15Mr & Mrs Trybus $50.00MR Edsall $500.00Mrs KM Kennedy $50.00Mrs Niedermann $20.00Murray Cox $2,500.00Noel Bedford $35.00P & H Bowman $50.00

Paterson $30.00Paul Simpson $100.00Peter Le Maitre $100.00Rhonda O’Toole $35.00Ria Nieuwland $20.00Richard Fincher $35.00Richard Randall $50.00Robert Hadden $50.00Russell & Beth Hansford $100.00S Kidston $50.00Shirley Harman $20.00Sizeland Private Inpatient Fees $5,347.34Surgeon Private Outpatient Fees $5,162.70Sylvia Anderson $1,000.00Tammy Gilmore $20.00Tim Biles $200.00Tony Di Palma $50.00Ursula Plunkett $50.00V Bush $50.00William Govett $50.00Day Centre Fundraising $808.40GRAND TOTAL $2,095,615.71


LIFE GOVERNORS

1946 W O’Doherty1946 A O’Leary1947 FH Redman1947 Mrs V King1947 Mrs Jean Lafsky1947 Mrs E McLaren1948 Glynn D Timmins1950 FL Johnston1950 W Thatcher1951 Mrs Judy Beatty1951 John Spirason1953 Mrs Betsy Cathcart1953 Mrs Jean Loud1954 S Telfer1954 Ian Thatcher1954 Leonard Rule1955 CR Holman1955 Ben Ogden1955 Mrs Anne F Ikin1955 Arthur Winter1955 Mrs Flora Brumby1957 Mrs B Watson1959 Mrs Margaret Latimer1959 Mrs Phyllis Rodgers-Wilson1961 Rev Canon GFD Smith1963 Mrs Isabel (Doris) Savige1965 Thomas Hansen1965 PJ Thompson1968 Victor Cole1968 Dr Thomas O’Beatty1968 Mrs Mary Nicholls1969 Mrs M (Peg) Bailey1969 Joe Alvin1970 Rex Foard1970 Kenneth Beynon1972 Miss Eileen O‘Leary1972 William Rodgers-Wilson1973 Gordon Arthur Henry Smith1974 Clement John Sharp1975 Miss Margaret McIntyre1976 Mrs Margaret Sheehan1979 William McCallum1979 Robert Bosworth1987 DM Yeates1992 Alan Glass1992 Mrs Thelma Glass1992 Ron Nation1992 Albert Rodd1992 Mrs May Winnett1993 Ian Campbell

1993 Brian Hopkins1993 Peter Engel1993 Robert Mansell1993 Milton Murphy1993 GJ Foard1993 Ewan Logan1993 Helen M Schutt (Trust)1993 Mrs GF Barter1993 LG Tipper1993 J Siggins1993 Miss JH Scott1993 FH Ray1993 J Parker1993 Rev DM Muller1993 Mrs DM Mitchell1993 W Meade1993 J Leatham1993 Mrs E Ingle1993 EGR Horsfi eld1993 Miss JH Holford1993 JW Hawksley1993 Mrs Patricia Evans MBE1993 WH Elridge1993 Mrs J Court1993 HN Cox1993 KL Cook1993 M Campbell1993 Mrs MA Cameron1993 AE Boucher1993 W Bills1994 Derek Dahlsen1994 Ray Holloway1994 Mrs P Lane1994 T Grass1994 Mrs A Grass 1995 Ms T Gillies1995 Dr F Malatt1996 Mrs K HeathPre2006 Mr E DahlsenPre2006 Mr T EagerPre2006 Mr WH EldridgePre2006 Mr R GregoryPre2006 Miss JH HolfordPre2006 Mr P LayPre2006 Mrs R MarshPre2006 Mrs M McRaePre2006 Mrs M Winnette2008 Dr James Evans2008 Mr Michael Padula2012 Mr Tony Ward

Community EngagementCongratulations on a wonderful achievement for over $375,000 donated to BRHS over these 30 years. Also an incredible achievement with $225,000 of the $375,000 being donated in the past 9 years. Your strong commitment to BRHS and the East Gippsland community is evident by the many events that the Bower Birds organise each year. For example; catering key events, special luncheons such as the Oaks Day function, regular raffl es and BBQs, Mother s day and Christmas stalls in the main street. The Board of Management, Executive team and staff are proud of your outstanding contribution, dedication and commitment to improving the quality of care for our patients. The funds that you have raised have ensured the purchase of critical clinical equipment which has improved the outcomes of our patients over the past 30 years. As we celebrate with you at your 30th anniversary we sincerely thank you for your hard work and tireless volunteer commitment to BRHS. our heartfelt thanks for helping us make our patients journey a better one and for role modeling a true community spirit to demonstrate to our future generations the importance of volunteering for the community’s good.

Bower Birds

Bairnsdale Regional Health Service – 2011 - 2012 Annual Report 25Bairnsdale Regional Health Service – 2012 Annual Report 25


Like people, Health Services need checkups to make sure all is well. In Hospitals these checkupsare called accreditation. There are various types of accreditation (health checkups) that BRHS undergoes regularly with various external organisations such as:

- Postgraduate Medical Council Victoria – to check if we provide suffi cient experience, education, training, supervision, evaluation, support and a safe working environment for training doctors in their fi rst year.

- BRHS underwent an extraordinary visit conducted by PMCV in November 2011 where a number of medical staffi ng issues were required to be addressed. On 14th June 2012 a follow up review visit BRHS received very positive feedback regarding the signifi cant improvement’s that had occurred at BRHS in a short period of time remains successfully accredited and will be reviewed again in 2013.

- Aged Care Accreditation Agency – During 2011/12 year a number of unannounced and announced visits from the Aged Care Accreditation Agency with the two of the 44 Aged Care Standards identifi ed as being un met in November 2012. However these were rapidly addressed with signifi cant staffi ng and infrastructure increases as well as implementation of a new Aged Care organisational structure.

The Maddocks Gardens Aged Care Facility was award full accreditation in 2009 and will undergo review again in September 2012.

- Medical Imaging was reviewed in April 2011 and received full accreditation from the National Association of Testing Authorities (NATA) and the Royal Australian and New Zealand College of Radiologists (RANZCR) indicating safe practice for staff and patients. Recommendations were minor and all have been met.

- In 2012 a team of external surveyors visited the hospital from the Australian Council on Healthcare Standards for periodic review. They reviewed our patient care, service provision, safety and business processes. We maintained full accreditation and with all recommendations from previous survey’s having been addressed and one new recommendation provided as a result of this survey.

- Positive feedback has been received on the improvements made in relation to quality of patient care services at BRHS.

- BRHS volunteered itself to be assessed against the New National Health Standards, in preparation for their mandatory implementation in all health services in 2013.

BRHS are due to go for full accreditation in May 2014.

OUR HOSPITALS HEALTH CHECK


REPORT OF OPERATIONS

Responsible bodies declarationIn accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for Bairnsdale Regional Health Service for the year ending 30 June 2012.

Peter CrickPresident, Board of Management

Bairnsdale30 August 2012

Summary of factors affecting operationsThe employment of a fulltime surgeon at BRHS for the 11/12 fi nancial year has had a positive result on improving waiting list on managing surgical wait list demand, however due to the requirement of signifi cant catch-up on patient procedures has resulted in 11.6% above WIES target

Events subsequent to balance dateAt the date of this report, Management has identifi ed that the determination by VAGO in this fi nancial year that Grants in Advance received must be recorded as income in the year received in 2011/12 which will result in a positive income result this year, however will result in a defi cit position for the next reporting period of 2012/13 as items will be expensed with no income recorded against them, which will result in a material impact in the next reporting period,

Attestation on Compliance with Australian/New Zealand Risk Management StandardI, Peter Crick, certify that the Bairnsdale Regional Health Service has risk management processes in place consistent with the Australian/New Zealand RiskManagement Standard and an internal control system is in place that enables the executive to understand, manage and satisfactorily control risk exposures. The Finance, Audit & Business Development committee verifi es this assurance and that the risk profi le of the Bairnsdale Regional Health Service has been critically reviewed within the last 12 months.

Peter CrickChair of Board

Bairnsdale30th August 2012


REPORT OF OPERATIONS cont.

Building Act 1993Bairnsdale Regional Health Service complies with the building and maintenance provisions of the Building Act 1993.

ConsultanciesThere were 29 consultancies in this fi nancial year (3 in 10/11), these consultancies included: DLA Piper BRHS review, Communications and Community review, Board Communications Consultant, Aged Care Review. These consultancies cost $451,412 with No consultancy costing more than $100,000.

*excluding GST

National Competition PolicyIn accordance with the national competition principles agreed by the Federal and State Governments in April 1995, Bairnsdale Regional Health Service has implemented policies and programs to ensure compliance with the National Competition Policy.

These programs and policies include:• The benchmarking of signifi cant business activities

against other agencies of a similar size and nature;• Examination of each business activity to establish

the benefi ts or otherwise of applying market contestability; and

• Tendering for the provision of services where appropriate.

Victorian Industry Participation Policy Act 2003BRHS did not commence or complete any contracts to which the VIPP Act 2003 would apply.

Freedom of Information Act 1982The Freedom of Information Act 1982 (the FOI Act) gives people the right of access to information held by Bairnsdale Regional Health Service and applicationsfor access to information and records are processed in accordance with the FOI Act by the Health Information Manager under delegation from the Director of Medical Services.

Health Services charge a fee for Freedom of Information (FOI) requests in accordance with the guidelines set by the Department of Justice. Fees for Medico-Legal requests are also received. The revenue for this fi nancial year is $2,581.70. The Freedom of Information Application Fee is waived for those applicants holding a health care card

Attestation on Data IntegrityI, Michele Gardner, certify that Bairnsdale Regional Health Service has put in place appropriate internal controls and processes to ensure that reporteddata reasonably refl ects actual performance. The Bairnsdale Regional Health Service has critically reviewed these controls and processes during the year.

Michele GardnerAccountable Offi cer

Bairnsdale30th August 2012

Consultancy Details < $100,000

Total $ of Consultancies

29

$ 451,412*

Number of Consultancies

Number of Consultancies > $100,000 0

Freedom of InformationMedico-Legal

Number ProcessedType of request

Total

100113

213


GLOSSARY OF TERMS

AccreditationTo audit and give credentials to.

Acute CareCare that is generally provided for a short period oftime to treat a certain illness or condition.

CardiacRelating to, situated near, or acting on the heart.

ChemotherapyA type of pharmacotherapy used in the treatment orcontrol of disease, particularly cancer.

DementiaA usually progressive condition marked by thedevelopment of multiple cognitive defi cits.

DialysisThe process of removing blood from an artery (as ofa kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein – also called hemodialysis.

DieteticsThe science of diet and nutrition.

DVADepartment of Veterans’ Affairs.

GastroenterologyA branch of medicine concerned with the structure,functions, diseases, and pathology of the stomach and intestines.

GeriatricA branch of medicine that deals with the problemsand diseases of old age and aging people.

GovernanceThe way in which decisions important for the future oforganisations are taken, communicated, monitored and assessed. It includes the processes an organisation has for holding managers accountable and measuring performance.

HACCHome and Community Care

HARPHospital Admission Risk Program that enhances anddevelops preventive models of care focused on people with chronic and complex conditions to prevent inappropriate emergency presentations or admissions.

HiTHHospital in the Home. The provision of hospital care inthe comfort of the persons own home.

InternA physician gaining supervised practical experience ina hospital after graduating from medical school.

LAOSLimited Adverse Occurrence Screening is a programthat provides rural hospitals with a cost effective way of improving systems and quality of care. It doesthis by providing anonymous, non-confrontational general practitioner (GP) peer review of selected patient records with the involvement of the treating GP. This independent medical review may be otherwise diffi cult to obtain the small hospital of a rural community.

MidwiferyThe act of assisting at childbirth.

Nosocomial (as in VICNISS)Acquired or occurring in a hospital

ObstetricRelating to, or associated with, pregnancy andchildbirth.

Occupational TherapyTreatment aimed at assisting people overcomelimitations caused by injury or illness, enabling people to participate in the activities that have meaning to them.

OncologyA branch of medicine concerned with theinvestigation, diagnosis and management of people with cancer.

OphthalmologyA branch of medical science dealing with thestructure, functions, and diseases of the eye


OrthopaedicA branch of medicine concerned with the treatmentof the musculoskeletal system.

PaediatricsA branch of medicine dealing with the development,care, and diseases of children.

PAGPlanned Activity Group

PalliativeA concept of care which provides coordinatedmedical, nursing and allied services for people who are terminally ill, delivered where possible in the environment of the person’s choice, and which provides physical, psychological, emotional and spiritual support for patients and for patients’ families and friends.

PathwayClinical pathways are standardised, evidence-basedmultidisciplinary management plans, which identify an appropriate sequence of clinical interventions, time frames, milestones and expected outcomes for an homogenous group of patients.

PhysiotherapyThe treatment of disease by physical and mechanicalmeans such as massage, regulated exercise, water, light, heat and electricity.

PodiatryThe medical care and treatment of the human foot.

Pressure Ulcer/AreaAn area of skin that has been damaged due tounrelieved pressure.

RadiologyA branch of medicine concerned with the use ofradiant energy (as X-rays or ultrasound) in the diagnosis and treatment of disease.

RegistrarAn admitting offi cer at a hospital

RenalOf or relating to the kidneys or the surrounding area

Social WorkSocial work is committed to the pursuit of social Justiceand addresses situations of personal distress and crisis. Social work is informed by an understanding of human development and behaviour and of complex social structures and processes.

Speech PathologyThe study and treatment of human communicationdisorders including disorders of speech, language and swallowing.

StomaAn artifi cial permanent opening especially in theabdominal wall made in surgical procedures.

Sub-acute careGoal-oriented interventions aimed at assessing andmanaging often complex conditions to maximise independence and quality of life for people with disabling conditions.

TACTransport Accident Commission

VICNISSVictorian Nosocomial Infection Surveillance System

VWAVictorian Workcover Authority (now known asWorkSafe Victoria)

WIESWeighted Inlier Equivalent Separations – Unit ofpayment for acute admitted care.

WorkSafe VictoriaFormally Victorian Workcover Authority

Source: Merriam Webster Medical Dictionary (online); Pocket Macquarie Dictionary; Stedman’s Medical Dictionar


DONATIONS AND BEQUESTS

The generosity of the community by their fi nancial donations and volunteer support, to Bairnsdale Regional Health Service enables us to provide equipment, amenities and care that would normally be beyond our budg-etary scope.

As a result of these generous donations we have been able to purchase many signifi cant pieces of clinical equipment this year, such Treatment Chairs for Oncology and Dialysis, Syringe Pumps for our Palliative Care Pa-tients, Lifting machines for all of the ward areas to assist the patients and staff, Electronic Blood Pressure machines for our Dialysis patients, Pressure relief cushions for our patients for Rotamah Gabo and Fraser wards. Humi Crib for management of our Newborn babies and Warming cabinet for our theatre area. These are an example of some of the items that BRHS during the past year have been able to purchase to improve our patients journey and support our staff to deliver quality care to the East Gippsland community. Our heartfelt and sincere thanks to everyone who has generously contributed during. 2011/2012

To make a donation, call the BRHS Cashier on 5150 3333 and make a donation by credit card over the phone or by completing the form below and sending it to BRHS Fundraising and Community Engagement, PO Box 474, Bairnsdale VIC 3875.

First name Surname

Company name

Address Suburb P/code

Hm phone Other phone

Email

All donations over $2 are tax deductible.

I would like my donation to support the: Please accept my contribution of (circle):

Purchase of equipment $1000 $500 $250 Other Specifi c equipment as arranged with BRHS

bairnsdale regional health service annual report · 2013-06-12 · sop’s, developed from the brhs...

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