maldon hospital annual report 2015 partnering with the … · 2015. 10. 27. · annual report 2015...
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MALDON HOSPITALANNUAL REPORT 2015 Partnering with the Community
Chapel Street, Maldon, Victoria 3463 P. (03) 5475 2000 F. (03) 5475 2029E. [email protected]
www.maldhosp.vic.gov.au
Contents
MISSION STATEMENTBuilding community health and wellbeing.
VISIONTo be a thriving health service contributing to a happy and healthy community.
VALUESIntegrity, Safety, Positivity, Professional and Service Driven
BOARD OF MANAGEMENTMr Gordon Carter, President – appointed 1 July 2009
Dr Helen McBurney, Vice President – appointed 1 November 2008
Mr Colin Thornton, Treasurer – appointed 1 July 2011
Mr John Fitton (Dec.), Treasurer – appointed 1 November 2004 to 21 February 2015
Mrs Barbara Ford, Board member – appointed 1 November 2003
Ms Megan Purcell, Board member – appointed 1 July 2011
Mrs Vanessa Healy, Board member – appointed 1 July 2014
Mr Garry Johnstone, Board member – appointed 1 July 2014
BOARD SuB-COMMITTEE REPRESENTATIONAudit and Risk Committee
Mr Michael Grimes (Independent Chair)
Mr Gordon Carter (Board)
Mr John Fitton (Dec.) (Board)
Mr Colin Thornton (Board / Treasurer)
Mr Geoff McLennan (Community Representative)
Mr Garry Johnstone (Board member)
Mrs Vanessa Healy (Board member)
Clinical Care committee
Dr Helen McBurney (Chair)
Mrs Barbara Ford
Ms Megan Purcell
Community Consultation Committee
Mr Gordon Carter (Board)
Mr John Fitton (Dec.) (Board)
MANNER OF ESTABLISHMENT AND RELEVANT MINISTERSMaldon Hospital is a public hospital incorporated under the Health Services Act 1998 and has a variety of programs and services funded by the State Government.
The Hon Jill Hennessy MLA, Minister for Health, Minister for Ambulance Services 4 Dec 2014 to 30 Jun 2015
The Hon Martin Foley MLA, Minister for Mental Health, Minister for Housing, Disability and Ageing 4 Dec 2014 to 30 Jun 2015
The Hon Jenny Mikakos MLC, Minister for Families and Children 4 Dec 2014 to 30 Jun 2015
The Hon David Davis MLC, Minister for Health, Minister for Ageing 1 Jul 2014 to 3 Dec 2014
The Hon Mary Wooldridge MLC, Minister for Mental Health, Minister for Community Services, Minister for Disability Services and Reform 1 Jul 2014 to 3 Dec 2014
The Hon Wendy Lovell MLC, Minister for Children and Early Childhood Development 1 Jul 2014 to 3 Dec 2014
Board of management Inside front cover
Report to the community 1
Key achievements/Our services 3
Statement of priorities 7
Regulatory compliance 10
Workforce 12
Disclosure Index Inside back cover
Financial statement attached. If the statement is not attached please contact Maldon Hospital on (03)5475 2000.
AFS - Attached Financial Statement; IF - Inside Front
Maldon Hospital acknowledges the support of the Victorian Government
ANNuAL REPORT 2015 Partnering with the Community
LEGISLATION REQUIREMENT PAGE REFERENCEMINISTERIAL DIRECTIONSREPORT OF OPERATIONSCHARTER AND PURPOSEFRD 22F Manner of establishment and the relevant Ministers IFCFRD 22F Purpose, functions, powers and duties IFCFRD 22F Initiatives and key achievements 3FRD 22F Nature and range of services provided 3MANAGEMENT AND STRUCTUREFRD 22F Organisational structure 2FINANCIAL AND OTHER INFORMATIONFRD 10 Disclosure index IBCFRD 11A Disclosure of ex-gratia expenses 10FRD 12A Disclosure of major contracts 11FRD 21B Responsible person and executive officer disclosures AFSFRD 22F Application and operation of Protected Disclosure Act 2012 10FRD 22F Application and operation of Carers Recognition Act 2012 11FRD 22F Application and operation of Freedom of Information Act 1982 11FRD 22F Compliance with building and maintenance provisions of Building Act 1993 10FRD 22F Details of consultancies over $10,000 12FRD 22F Details of consultancies under $10,000 12FRD 22F Employment and conduct principles 11FRD 22F Major changes or factors affecting performance AFSFRD 22F Occupational health and safety 12FRD 22F Operational and budgetary objectives and performance against objectives AFSFRD 22F Significant changes in financial position during the year AFSFRD 22F Statement of availability of other information 11FRD 22F Statement on National Competition Policy 10FRD 22F Subsequent events AFSFRD 22F Summary of the financial results for the year AFSFRD 22F Workforce Data Disclosures including a statement on the application of employment and conduct principles 12FRD 24C Reporting of office-based environmental impacts 5FRD 25B Victorian Industry Participation Policy disclosures 10FRD 29A Workforce Data disclosures 12SD 4.2(g) Specific information requirements 10SD 4.2(j) Sign off requirements 10SD 3.4.13 Attestation on data integrity 10SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 10SD 4.5.5 Risk management compliance attestation 10FINANCIAL STATEMENTS REQUIRED UNDER PART 7 OF THE FINANCIAL MANAGEMENT ACTSD 4.2(a) Statement of changes in equity AFSSD 4.2(b) Comprehensive Operating Statement AFSSD 4.2(b) Balance Sheet AFSSD 4.2(b) Cash Flow Statement AFSOTHER REQUIREMENTS UNDER STANDING DIRECTIONS 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements AFSSD 4.2(c) Accountable officers declaration AFSSD 4.2(c) Compliance with Ministerial Directions AFSSD 4.2(d) Rounding of amounts AFSLEGISLATIONFreedom of Information Act 1982 Protected Disclosure Act 2012Carers Recognition Act 2012Victorian Industry Participation Policy Act 2003Building Act 1993 Financial Management Act 1994
The annual report of Maldon Hospital 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.
DISCLOSuRE INDEX
MALDON HOSPITAL
ANNUAL REPORT 2015 Partnering with the Community
It is with pride that we report that the 2014/2015 financial year has been a busy and successful year for Maldon Hospital. By providing safe and high quality health care, acute, aged and community services our community has access to essential health services close to home.
This is consistent with the Maldon Hospital Board of Management’s strategic aim to continue to pursue safety and quality improvement, whilst maintaining high occupancy in its aged residential beds, expanding services to meet the community’s needs and ensuring the future viability of the hospital.
The hospital’s new strategic plan was developed through a consultative process, considering Government strategic priorities and changes in the health environment in Maldon and across the region. The Vision and Mission Statements were reviewed and, with the input of staff, the values of the organisation were revised.
The Board is committed to ensuring that Maldon Hospital makes good progress in six key strategic areas by developing and implementing actions, and monitoring progress on a regular basis. Success is only possible if an organisation has a culture where staff members are committed to maintaining high standards. Every person in our care is respected and the centre of our attention.
Again this year our staff members have worked well as a team and have demonstrated a willingness to go beyond their core duties to explore opportunities to improve and develop our care. We thank and express our appreciation to every staff member for their loyalty and commitment.
Katrina Sparrow, Director of Nursing, worked with staff to implement many changes over the last 12 months which has improved the delivery of care, increased the engagement of staff and the community, and improved the communication and reporting to the staff and Board. We thank Katrina for her great work and results achieved for the year. We also acknowledge and thank Dr Fowler for his contribution in delivering medical services and assisting in meeting the increasing accreditation standards.
Our volunteers continue to provide a wide range of services that support the organisation and bring a great deal of joy to our residents. The contribution of our volunteers is enormous, and a cornerstone of our service.
Our very successful accreditation results for Residential Aged Care, Acute and Home Care services was a reflection of the efforts of staff, management, Medical Practitioner, volunteers and the Board.
A significant focus this year has been on consumers and our community. We have implemented policies and procedures that encourage our residents and patients to direct how their care is to be provided. We have also developed strategies that inform and engage our community in the current services, significant changes and future directions.
Our Community Consultation Committee chaired by Pam Millwood has been active in providing a community perspective on many aspects of the organisation. The committee has reviewed key policies and questionnaires, improved marketing and public relations and considered service changes and strategic directions.
We acknowledge the commitment of our Board members who, as volunteers, give their time, knowledge and skills to ensure sound governance for Maldon Hospital. To fulfil their responsibilities they participate in ongoing knowledge development on how Maldon Hospital functions and the risks, standards, financial and compliance matters that need to be managed.
Thank you to Vice President Dr Helen Mc Burney who also Chaired the Clinical Care Committee, Colin Thornton, Treasurer and Board members Barbara Ford, Megan Purcell, Garry Johnstone, Vanessa Healy and John Fitton (Dec.) for their time and expertise.
It was with great sadness that John Fitton passed away in February 2015. John was an excellent contributor as a Board member who held several office bearer roles including Vice President and Treasurer. He was always available to represent the Maldon Hospital at various forums and was an active volunteer. John’s contribution was acknowledged by the Board with the awarding of a Life Governorship.
We are very positive about our future and look forward to working with our community to ensure that we continue to provide a broad range of health services that evolve with our community’s needs.
Mr Gordon Carter Board President
Mr Ian Fisher Chief Executive Officer
REPORT TO THE COMMUNITY
MALDON HOSPITAL2
Key achievements
• Allservicesparticipatedinaccreditationsurveysconductedbythirdparties,confirmingthatMaldonHospitalismeeting all standards.
• Ongoinghealthpromotionserviceshavebeenwellsupportedbythecommunity.
• AirconditioninghasbeeninstalledinJesseBowe,andWiFiisaccessibletoallresidentandpatientareas.
• Organisationalfinancialsurpluswasachieved.
• Ourpatients,clientsandresidentscontinuetobehighlysatisfiedwithourservices.
• WeestablishedtheClinicalCareCommitteeandimprovedourreportingofclinicalperformance.
Organisational Chart
CEO(Castlemaine Health)
Director of Nursing
District Nursing NUM Acute & Residential
Community / Social Support Program
Coordinator
Social Support Staff & Volunteers
Reception / Ward Clerk
Board of Management
VMO Contracted Services(Castlemaine Health)
Registered NursesEnrolled NursesPersonal Care
Workers
Activities Coordinator
ANNUAL REPORT 2015 Partnering with the Community
Acute Inpatients
The George Ray Wing provides four-bed acute inpatient
services to the Maldon community. The hospital has the
capacity to offer care to patients with low acuity medical
conditions, palliative care and convalescence.
Non Inpatients
The Urgent Care Department at the hospital provides care to
patients presenting with a range of conditions. The majority of
presentations receive immediate treatment from Nursing staff
and/or the Visiting Medical Officer. Patients with more complex
needs are referred to Bendigo Health and are monitored and
supported until they are transported by ambulance.
The total number of urgent presentations for 2014-15 was 103
with 71 hours of nursing time.
KEY ACHIEVEMENTS/OUR SERVICES
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun0
10
20
30
40
50
607080
Acute Occupancy %
Urgent Care: Presentations and time taken
82
86
84
88
90
92
94
96
98
100
July Aug Sep Oct Nov Dec Jan Feb Mar Apr May JunJesse Bowe House %Mountview Home %
0
4
2
6
8
10
12
14
July Aug Sep Oct Nov Dec Jan Feb Mar Apr May JunTime taken (hours)Presentations No
Residential Aged Care Maldon Hospital provides residential aged care through 12
places in Jessie Bowe House and 16 places in Mountview
Home. The residents are well supported by family, friends
and volunteers who work with the hospital staff to ensure the
residents can maintain contact with the general community
and continue to participate in activities they had enjoyed prior
to coming to live at Maldon Hospital.
Whilst living in Jessie Bowe House and Mountview Home,
residents continue to access allied health professionals, such
as physiotherapist, podiatrist, speech pathologist, dietician,
visiting geriatrician and adult mental health services. The
two residential facilities are well supported by visiting Allied
Health Professionals from Castlemaine Health together with
Maldon Hospital trained nurses who participate in a range
of education opportunities to ensure a high level of care is
maintained.
An extensive Health and Wellbeing Program is in place to
support residents socially and emotionally with activities
including chair exercises, gardening, brain gym, arts and
craft, word games, group reading, musical entertainment,
bus outings, ecumenical church service, meditation and
many more. The Health and Wellbeing Co-ordinator is well
supported by volunteers from the Maldon community who
generously offer their time to ensure our residents receive
these activities to maintain physical functioning, emotional
support and to meet their spiritual needs.
82
86
84
88
90
92
94
96
98
100
July Aug Sep Oct Nov Dec Jan Feb Mar Apr May JunJesse Bowe House %Mountview Home %
Residential Aged Care Occupancy
During the year 2014-15 the average occupancy rate for Jessie Bowe House was 96.6% and Mountview Home 97.1%.
MALDON HOSPITAL4
KEY ACHIEVEMENTS/OUR SERVICES continued
Home and Community Care Activities (HACC) HACC Adult Day Service program staff and volunteers assisted Maldon residents to participate in a range of activities for frail aged and younger people with a disability. Most programs are of short duration, with an emphasis on physical activity and social connection and wellness. In line with departmental policy, the hospital has implemented the Active Service Model (ASM). Some of these programs include strength training, pole walking, and social connection groups.
Health Promotion
Maldon Hospital has a suitably qualified staff member trained to run health promotion programs in the Maldon community. These programs range from seniors afternoons, education sessions from specialist speakers, cooking programs, walking programs and historical guided walking tours. Maldon Hospital works in partnership with the local primary school and kindergarten to promote healthy eating and dental care.
District Nursing
The Maldon Hospital District Nursing Service continued delivering home based nursing support, health education and promotion seven days a week throughout the year. The hospital nurses travel from Welshman’s Reef to Laanecoorie and Baringhup to Walmer. The District Nurses provided services for Home and Community Care clients, Veteran’s services, Hospital in the Home, Post Acute Care and Palliative Care services.
Corporate ServicesFinance, Supply, Information Technology, Laundry, Food
and Catering, Environmental and Security.
Corporate Services at Maldon are administered under contract by Castlemaine Health. The contract covers the financial management of the hospital, as well as procurement and supply of materials (including new equipment), information technology services, linen and laundry services, food preparation and catering, vehicle management, cleaning, waste disposal and security services.
Supply Services
The ordering and supply of materials is administered from Castlemaine Health; Maldon staff raise purchase requisitions for products and materials online to Castlemaine where orders are processed and delivery arranged, as well as receiving prompt advice and resolution of purchasing and supply issues.
In line with the ideals of the Strengthening Health Services project which encourages Health Services to work together wherever possible, Castlemaine Health has entered into an arrangement with Bendigo Health to provide materials management services for the purchase of medical and surgical supplies and domestic services products. This arrangement will enable Castlemaine Health to access expert advice, a broader product evaluation forum and improved pricing. This arrangement will provide a flow on benefit to Maldon Hospital.
Information Technology (IT)
The IT Department has made ongoing improvements to the reliability of services over the past year. There have been major improvements made to the network, including new fibre optic cabling allowing for faster data communications throughout the hospital. A secure Wireless network has also been installed, with access points covering the majority of the hospital, allowing staff greater freedom and flexibility with how they work and where they work. Additional laptops have been purchased to make use of this wireless network, and iPads have been introduced for staff and residents to use. A large scale project is currently underway to replace the aging server infrastructure.
The Board adopted a three year IT hardware replacement strategy and the first year of this strategy has been implemented, including the replacement of the server. An update to the Virtual Server and backup software will provide a common platform across Maldon Hospital and Castlemaine Health which enhances system maintenance including disaster recovery and business continuity capability.
Hotel Services
A small team of seven staff provide the Hotel Services to patients and residents at Maldon.
ANNUAL REPORT 2015 Partnering with the Community
Food Services
Thirty two meals are provided for each meal service daily by Castlemaine Health Food Services staff. Our customer satisfaction surveys continued to demonstrate excellent results in terms of the quality of residents’ meals, and external audits again scored our service highly in terms of the strict food safety standards demanded of public hospitals.
Laundry Services
Castlemaine Health provides Laundry Services to Maldon Hospital and includes bedroom and bathroom linen, continence products and resident personal items.
Cleaning Services
Castlemaine Health provides a seven day cleaning service to facilities used by patients and residents.
Occupational Health and Safety/WorkCoverMaldon manages and monitors its Occupational Health and Safety (OH&S) system through its OH&S Committee and other relevant committees by the board and the executive. All aspects of the Maldon Hospitals OH&S is supported through the Castlemaine Health OH&S Department which has qualified and experienced staff to manage the OH&S systems.
Maldon Hospital continues to ensure that in the pursuit of excellence in providing patient and resident care, we do not jeopardise the safety or health of our employees and continue to comply with the requirements of relevant legislation and supporting regulations.
Maldon Hospital has a good record for maintaining the health of employees and addressing risks. With the guidance of the Castlemaine Health OH&S Department, the hospital has been ensuring that all staff members are supported in returning to work after an extended period of absence.
The OH&S Department has recently begun providing OH&S incident data to the Maldon Hospital via their OHS Committee on a monthly basis which allows for a more informed discussion of OHS incidents and hazards at Maldon Hospital.
The Terms of Reference of the OH&S committee have been reviewed including the membership and the reconfiguration of the Designated Work Group’s (DWG’s) to ensure better coverage, support and representation for all staff by their Health and Safety Representatives (HSR’s). During this time Castlemaine Health provided guidance in regards to all legislative requirements related to the election of HSR’s and reconfiguration of the DWG’s. This included support in the form of education and follow up throughout the nomination and election process and the organisation of initial training for the HSR’s.
Achievements
We have carried out numerous assessments and recommendations with regard to the bus and work area used for community activities at the hospital which involved consultation with staff and the OHS committee members.
Recommendations were made which resulted in:
• aproposaltohavethebusdoormechanisedinaneffort to reduce further likelihood of staff and volunteers sustaining shoulder/arm injuries from repetitive manipulation of heavy door. Maldon Hospital has now acted on this recommendation and implemented an electric door.
• researchintothecurrentrestraintsystemutilisedwithinthe bus and possible alternatives; ongoing discussion with managers and staff with regard to the review of the current policy in the transport of residents and bus ’jockey’ policy.
• reviewandsuggestionsregardingtablestobeusedin the community area and possible alternatives to current seating due to manual handling concerns.Maldon Hospital has now purchased new tables to meet recommendations. Our committed HSR’s to date continue to pursue the recommendations and discuss them regularly at OHS meetings.
0
200
100
300
400
500
600
700
800
Oct Jan Apr Jul
2014/2015 2013/2014 2012/2013
Quarter
Cos
t
0
10,000
5,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
15,000
20,000
25,000
July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun2014/2015 2013/2014 2012/2013 2014/2015 2013/2014 2012/2013
KL
Cost Cost Cost
0
200
100
300
400
500
600
700
800
Oct Jan Apr Jul
2014/2015 2013/2014 2012/2013
Quarter
Cos
t
0
10,000
5,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
15,000
20,000
25,000
July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun2014/2015 2013/2014 2012/2013 2014/2015 2013/2014 2012/2013
KL
Cost Cost Cost
Maldon Hospital Water Consumption 2104 / 2015 Maldon Hospital Electricity Consumption 2014 / 2015
MALDON HOSPITAL6
KEY ACHIEVEMENTS/OUR SERVICES continued
Proactive Approach
Maldon Hospital continues to be proactive in its approach
to the reporting of hazards and any required follow up which
facilitates a positive culture of health and safety throughout
the hospital. Once again this has lead to minimal work-related
injuries and illness and for this reporting period there has only
been one WorkCover claim lodged.
Risk ManagementMaldon Hospital has a strong commitment to managing risk
and has actively worked to increase sound risk management
practice throughout the organisation. The Risk Management
Framework aligns business opportunities and supports
managers and staff in the identification and treatment of risks
as they arise. Risk Management is overseen by the Senior
Management Team at an operational level and the Clinical
Care and Audit and Risk Committees at a Board level.
Emergency Management
Emergency Response and Recovery Planning Committee
The Emergency Response and Recovery Planning Committee
is a joint committee with Castlemaine Health and meets on a
monthly basis from October to March each year and then on
an as needs basis.
Emergency Response and Recovery Plan
The Emergency Response and Recovery Plan (ERRP)
documents the arrangements for the prevention of, response
to, and recovery from an incident, emergency or crisis that
may impact upon Maldon Hospital, its staff, the community,
stakeholders or physical assets. It is expected that knowledge
of and adherence to these procedures will ensure that all
clients, visitors and Staff are guaranteed the highest possible
standards of health and safety whilst in Maldon Hospital.
Security
Security Framework
2014 saw the development of a Security Framework to ensure
a proactive approach in the protection of patients, residents,
visitors, staff and health system assets and an appropriate
response to, and recovery from, an incident, emergency or
crisis that is the result of a security incident. The framework is
a collaborative of Castlemaine Health and Maldon Hospital.
Security Liaison Committee
The Security Liaison Committee is a consultative committee
that provides advice to the Board and Executive of
Castlemaine Health and Maldon Hospital on issues relating
to existing, new and emerging security issues within the
community that may impact on the health and safety of
hospital staff and care recipients.
The committee has membership from both hospitals as well
as Bendigo Health, Victoria Police, Mount Alexander Shire,
Loddon Prison Service, Castlemaine Community Health
Centre and contracted Security Company (WorkforceEX).
ANNUAL REPORT 2015 Partnering with the Community
Action Deliverable Status
Priority 1 – Developing a system that is responsive to people’s needs
Develop an organisational policy for the provision of safe, high quality end of life care in acute and subacute settings, with clear guidance about the role of, and access to, specialist palliative care.
Organisational policy adopted by Board of Management.
Current policies/protocols in place include:
• AdvancedCarePlanning–ProcedureandForms
• GuidelinesforcompletingMedicalPowerofAttorney
• RefusalofTreatmentCertificates
• NoticeofCancellation
• AdvancedCarePlanDirectives
Implement formal advance care planning structures and processes, including putting into place a system for preparing and/or receiving, and documenting advance care plans in partnership with patients, carers and substitute decision makers.
Advancecareplanningimplementedwithappropriate structures and processes.
ProcessandsysteminplaceforAcuteandResidentialCare.
Directives audited as part of audit schedule.
RequireACPsystemforDNSandcommunityresidents to be formalised.
Progresspartnershipswithotherservicestoimprove outcomes for regional and rural patients.
PartnershiparrangementswithCastlemaineandDistrictCommunityService(CDCHS)andCastlemaineHealthreviewedandformalised.
ParticipationinStrengtheningHealthServices(SHS)projectsforLoddonMalleeandHumeRegions.
ArrangementwithCastlemaineandDistrictCommunityServiceformalisedtocontinuetodeliver health promotion services.
CastlemaineHealthandMaldonHospitalrevisedcontract arrangements in place.
CEOonGovernanceCommitteeforStrengtheningHealthServicesandopportunitiesto share corporate services and strengthen clinical services is being progressed.
Priority 2 – Improving every Victorian’s health status and experiences
Use consumer feedback to improve person and family centred care, health service practice and patient experience.
Evidence that consumer feedback systems have lead to improved health care outcomes collated and reported to the Board.
Systemsimplementedtoimproveconsumerfeedback include:
• Expansionofsystemstoobtainconsumerfeedback.
• CommunityConsultationCommitteeactivelyinvolved in addressing consumer feedback.
• ChairofCommunityConsultationCommitteeattends Board meetings.
• BoardinformedthroughtheClinicalCareCommittee of clinical care improvements that have occurred as a result of consumer feedback.
SupportlocalimplementationoftheVictorianHealthandWellbeingPlan2011–2015throughcollaborationwithkeypartnerssuchasLocalGovernment,MedicareLocals,communityhealth services and other agencies.
ParticipationincollaborativearrangementswithMtAlexanderShire,CentralVictoriaPrimaryCarePartnership,CastlemaineHealthandCastlemaineandDistrictCommunityHealthtopromotetheVictorianHealthandWellbeingPlan2011–2015.
PartnershipwithMtAlexanderHealthyAgingCollaboration with several community and shire groups for health promotion activity.
MaldonHospitalundertookneedsanalysisandhas targeted health issues in the community
Part A: Strategic Priorities
REPORTING AGAINST THE STATEMENT OF PRIORITIES
MALDON HOSPITAL8
Action Deliverable Status
Priority 3 – Expanding service, workforce and system capacity
Develop and implement a workforce
immunisation plan that includes pre-
employment screening and immunisation
assessment for existing staff that work in high
riskareasinordertoalignwithAustralian
infection control and immunisation guidelines.
Optimise workforce productivity through
identificationandimplementationofworkforce
models that enhance individual and team
capacity and support flexibility.
ImmunisationWorkforcePlandevelopedand
implemented.
Reviewofstaffingstructureandflexiblestaffing
arrangements implemented.
Plantoachieveworkforceimmunisationtargets
has been developed.
ReviewshavebeencompletedforAdultDay
Activities,DistrictNursingandadministrative
services.
Established an agreement for additional clinical
support through a post graduate rotation in
partnershipwithCastlemaineHealth.
Priority 4 – Increasing the system’s financial sustainability and productivity
Identify and implement practice change to
enhance asset management.
Assetmanagementplanforcapitalreplacement
/ refurbishment developed.
Inconjunctionwithinternalauditorspolicies
have been reviewed and asset management
improved.
Priority 5 – Implementing continuous improvements and innovation
Drive improved health outcomes through a
strongfocusonpatient-centredcare(PCC)in
the planning, delivery and evaluation of
services, and the development of new models
forputtingpatientsfirst.
Accreditedstatusforallservicesmaintained.
Policiesandproceduresforimprovedpatient
centredcare(PCC)developedand
implemented.
Allservicesfullyaccredited.
PCCguidelineinplace.
Icon for agenda and minutes indicating an item
that reflects directly on patient/resident care
implemented.
Priority 6 – Increasing accountability and transparency
Undertake an annual board assessment to
identify and develop board capability to ensure
all board members are well equipped to
effectively discharge their responsibilities.
Demonstrate a strategic focus and commitment
to aged care by responding to community
needaswellastheCommonwealthLiving
LongerLivingBetterreforms.
AnnualBoardassessmentusingAustralian
CentreforHealthCareGovernancepackage
implemented.
Annualreviewofstrategic/serviceplanto
review community needs and service
strategies.
Assessmentcompleted.
Newstrategicplancompletedandactionsto
meet key strategic goals, including aged care
needs, have been implemented.
Priority 7 – Improving utilisation of e-health and communications technology
Ensure local Information and Communications
Technologystrategicplansareinplace.
InformationandCommunicationsTechnology
PlanadoptedbyBoardofManagement.
FundingforWiFireceivedandimplementedto
provide access for patients and residents, and
as a foundation for ehealth applications.
Workcommencedonanintranetplatform.
Part A: Strategic Priorities Continued
REPORTING AGAINST THE STATEMENT OF PRIORITIES continued
ANNUAL REPORT 2015 Partnering with the Community
Safety and quality performance
SOP Measure Target 2014-15 actual
Patient experience and outcomes
Victorian Hospital Experience Survey Full Compliance Full Compliance
Governance, leadership and culture
Patient Safety Culture 80 Achieved
Safety and quality
Health service accreditation Full compliance Full Compliance
Residential aged care accreditation Full compliance Full Compliance
Cleaning standards (Overall) Full compliance Achieved
Cleaning standards (AQL-B) 85 Achieved
Cleaning standards (AQL-C) 85 Achieved
Submission of data to VICNISS Full compliance Full Compliance
Hand hygiene (rate) – quarter 2 75
Overall 92Hand hygiene (rate) – quarter 3 77
Hand hygiene (rate) – quarter 4 80
Health care worker immunisation – influenza 75 73.5
Financial sustainability performance
SOP Measure Target 2014-15 actual
Finance
Annual Operating Result ($m) $0
Not available. Refer to AFS.Creditors <60 days
Debtors <60 days
Asset management
Basic Asset Management Plan Full compliance Full compliance
Funding type Target 2014-15 Activity Achievement
Small Rural
Small Rural Acute 75 107
Small Rural Residential Care 10,125 9,934
Small Rural HACC 6,523 6,258
Part B: Performance Priorities
Part C: Activity*
*Activity achievement is subject to confirmation.
MALDON HOSPITAL10
REGULATORY COMPLIANCE
Attestation for Compliance with the Ministerial Standing Direction 4.5.5.1 – Insurance
I, Ian Fisher, certify that Maldon Hospital has complied with Ministerial Direction 4.5.5.1 – Insurance.
Attestation for Compliance with the Australian/New Zealand Risk Management Standards
I, Ian Fisher, certify that Maldon Hospital 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 executive to understand, manage and satisfactorily control risk exposures. The audit committee verifies this assurance and that the risk profile of Maldon Hospital has been critically reviewed within the last 12 months.
Attestation on Data Integrity
I, Ian Fisher, certify that Maldon Hospital has put in place appropriate internal controls and processes to ensure that reported data reasonably reflects actual performance. Maldon Hospital has critically reviewed these controls and process during the year.
IAN FISHER Chief Executive Officer
12 July 2015
Ex-Gratia
Maldon Hospital made no ex-gratia payments for the year ending 30 June 2015.
Protected Disclosure Act 2012
The Whistle Blowers Act 2001 has been replaced by Protected Disclosure Act 2012. The Act enables people to make disclosures about improper conduct within the public sector without fear of reprisal. The Act aims to ensure openness and accountability by encouraging people to make disclosures and protecting them when they do. Maldon Hospital has received no complaints under this Act in the 2014/2015 financial year.
Compliance with Building and Maintenance Provisions of Buildings Act 1993
All building works have been designed in accordance with the Department of Health’s Guidelines and comply with the Building Act 1993 and the Building Code of Australia 1996.
Victorian Industry Participation Policy Act 2003
During the year there were no contracts completed at Maldon Hospital to which the VIPP applied.
Statement on National Competition Policy
Maldon Hospital complied with all Government policies regarding neutrality requirements with regards to all tender applications.
Accreditation
At Maldon Hospital we have full accreditation with Australian Council on Healthcare Standards (ACHS) until 30 November 2016 for our Acute services. We acquired Aged Care accreditation for a further three years in March this year for Jessie Bowe House. Mountview Home continues to be accredited until June 2016. We also obtained Community Care Common Standards accreditation in September for a further three years for Adult Day Service and District Nursing Service.
ANNUAL REPORT 2015 Partnering with the Community
Food Safety Audit
External Food Safety Audit conducted by ‘Derek Wilson Audit Services’ 2015, resulted in 100% compliance audited with no recommendations for improvement made. This is a reflection of the high standard of work produced by the Hotel Service Staff contracted from Castlemaine Health.
Cleaning Audit
An External Cleaning audit was conducted in July 2015 by COGENT Audit Systems. The overall score for High Risk areas was 89.7% and Moderate Risk 89.5% with a comment from the auditor ‘the results of the audit indicate that the cleanliness of Maldon Hospital is of a very high standard’.
Freedom of Information applications
All applications were processed in accordance with the provision of the Freedom of Information Act 1982, which provides a legally enforceable right of access of information held by Government agencies. Castlemaine Health provides a report on these requests on behalf of Maldon Hospital to the Department of Justice.
Freedom of Information requests can be submitted to the Chief Executive Officer, Castlemaine Health, PO Box 50, Castlemaine 3450. Application forms are available on the website www.castlemainehealth.org.au, or by phoning 5471 1555. Application charges and fees apply ($25.70).
One request was received under Freedom of Information in 2014/15. All requests were processed within the required timeframes.
Fees Charged for Service
All fees and charges charged by Maldon Hospital are regulated by the Commonwealth Department of Health and Ageing and the Hospitals and Charities (Fees) Regulations 1986, as amended and as otherwise determined by the Department of Human Services, Victoria. Policies and procedures are in place for the effective collection of fees owing to the service.
Ethical Standards
The Board of Management promotes the continued maintenance of corporate governance practice and ethical conduct by the Board members and employees of Maldon Hospital. The Board has endorsed a Code of Conduct which applies to Board Members, officers and all employees.
Pecuniary Interests
Members of the Board of Management of Maldon Hospital are required to notify the President of the Board of any pecuniary interests which might give rise to conflict of interest in accordance with Maldon Hospital Board’s Code of Conduct.
Tax Deductible Gifts
Maldon Hospital Health is endorsed by the Australian Taxation Office as a Deductible Gift Recipient. Gifts to Maldon Hospital as a Public Health Service qualify for a tax deduction under item 1.1.1 of Section 3-BA of the Income Tax Assessment Act 1997.
Disability Act 2006
Maldon Hospital has been incorporated in the Access and Inclusion Plan developed by Castlemaine Health that incorporates requirements of the Disability Act 2006.
Statement of Merit and Equity
Maldon Hospital ensures a fair and transparent process for recruitment, selection, transfer and promotion of staff. It bases its employment selection on merit, and complies with the relevant legislation. Policies and Procedures are in place to ensure staff are treated fairly, respected and provided with avenues for grievance and complaint processes.
Availability of Other Information
Maldon Hospital confirms that it retains additional information specified in Financial Reporting Direction 22F and that this information is available to the relevant Ministers, Members of Parliament and the public on request (subject to the provisions of the Freedom of Information Act 1982, if applicable).
Carers Recognition Act 2012
Maldon Hospital has taken all practical measures to comply with its obligations under the Act.
Disclosure of Major Contracts
There were no contracts greater than $10 million entered into during the year ended June 2015.
MALDON HOSPITAL12
Staff Analysis as at 30 June 2015*
Year ending 30 June 2015 FTE
WorkCover*
One WorkCover claim was lodged for this reporting period.
*Data supplied by CGU and correct as at 27 June 2015
ConsultanciesThere were no consultancies of more than $10,000 for Maldon Hospital in the year 2014/15.In 2014-15, Maldon Hospital engaged two consultancies where the total fees payable to the consultants were a total of $8,619.08
FULL TIME PART TIME CASUAL TOTAL
Medical 0% 0% 1.5% 1.5%
Nursing 6.5% 47% 31% 84.5%
Clerical 0% 3% 1.5% 4.5%
Personal Care Workers/ Recreational Workers 0% 3% 6.5% 9.5%
Total 6.5% 53% 40.5% 100%
*Percentage of total headcount
InsuranceYear
Remuneration or Wages 1
Premium Paid
inc GST 2
Claims Costs Paid
Average Premium
Rate 3
Weighted AverageIndustryRate 4
Days CompPaid 5
Time LostClaims 6
Total StandardClaims 7
2010/2011 $1,726,127 $48,000 $0 2.78% 3.24% 0 0 0
2011/2012 $1,656,493 $50,135 $0 3.03% 3.61% 0 0 0
2012/2013 $1,845,282 $51,666 $0 2.80% 3.30% 0 0 0
2013/2014 $1,976,590 $52,334 $0 2.65% 3.06% 0 0 0
2014/2015 $2,055,968 $49,808 $33,006 2.42% 2.75% *97 1 2
1. 2014/2015 premium may be subject to adjustment in October 2015 when remuneration has been confirmed2. Actual Premium paid by Maldon Hospital is exclusive of GST3. Average Premium Rate is the premium amount paid as a percentage of remuneration4 Weighted Average Industry Rate is calculated by WIC Code and remuneration distribution across workplaces by VWA5. Days Comp Paid is the VWA Days only, and excludes employer under excess days (1st 10 days lost)* Numbers fluctuate due to claims in each year remaining open/active and continuing to accumulate lost time days6. Time Lost Claims reflect claims with either full or partial lost hours7. Total Standard Claims are claims that have either exceeded 10 days lost time and/or have medical expenses incurred above
employer excess amount
WORKFORCE
Labour category Month ending June FTE June YTD FTE
2014 2015 2014 2015
Nursing 24.20 23.80 22.3 23.29
Administration and Clerical 1.50 1.58 1.12 1.13
Hotel and Allied 1.62 1.99 1.72 1.99
Medical support 0.23 0.00 0.20 0.00
Total 27.55 27.37 25.34 26.41
Contents
MISSION STATEMENTBuilding community health and wellbeing.
VISIONTo be a thriving health service contributing to a happy and healthy community.
VALUESIntegrity, Safety, Positivity, Professional and Service Driven
BOARD OF MANAGEMENTMr Gordon Carter, President – appointed 1 July 2009
Dr Helen McBurney, Vice President – appointed 1 November 2008
Mr Colin Thornton, Treasurer – appointed 1 July 2011
Mr John Fitton (Dec.), Treasurer – appointed 1 November 2004 to 21 February 2015
Mrs Barbara Ford, Board member – appointed 1 November 2003
Ms Megan Purcell, Board member – appointed 1 July 2011
Mrs Vanessa Healy, Board member – appointed 1 July 2014
Mr Garry Johnstone, Board member – appointed 1 July 2014
BOARD SuB-COMMITTEE REPRESENTATIONAudit and Risk Committee
Mr Michael Grimes (Independent Chair)
Mr Gordon Carter (Board)
Mr John Fitton (Dec.) (Board)
Mr Colin Thornton (Board / Treasurer)
Mr Geoff McLennan (Community Representative)
Mr Garry Johnstone (Board member)
Mrs Vanessa Healy (Board member)
Clinical Care committee
Dr Helen McBurney (Chair)
Mrs Barbara Ford
Ms Megan Purcell
Community Consultation Committee
Mr Gordon Carter (Board)
Mr John Fitton (Dec.) (Board)
MANNER OF ESTABLISHMENT AND RELEVANT MINISTERSMaldon Hospital is a public hospital incorporated under the Health Services Act 1998 and has a variety of programs and services funded by the State Government.
The Hon Jill Hennessy MLA, Minister for Health, Minister for Ambulance Services 4 Dec 2014 to 30 Jun 2015
The Hon Martin Foley MLA, Minister for Mental Health, Minister for Housing, Disability and Ageing 4 Dec 2014 to 30 Jun 2015
The Hon Jenny Mikakos MLC, Minister for Families and Children 4 Dec 2014 to 30 Jun 2015
The Hon David Davis MLC, Minister for Health, Minister for Ageing 1 Jul 2014 to 3 Dec 2014
The Hon Mary Wooldridge MLC, Minister for Mental Health, Minister for Community Services, Minister for Disability Services and Reform 1 Jul 2014 to 3 Dec 2014
The Hon Wendy Lovell MLC, Minister for Children and Early Childhood Development 1 Jul 2014 to 3 Dec 2014
Board of management Inside front cover
Report to the community 1
Key achievements/Our services 3
Statement of priorities 7
Regulatory compliance 10
Workforce 12
Disclosure Index Inside back cover
Financial statement attached. If the statement is not attached please contact Maldon Hospital on (03)5475 2000.
AFS - Attached Financial Statement; IF - Inside Front
Maldon Hospital acknowledges the support of the Victorian Government
ANNuAL REPORT 2015 Partnering with the Community
LEGISLATION REQUIREMENT PAGE REFERENCEMINISTERIAL DIRECTIONSREPORT OF OPERATIONSCHARTER AND PURPOSEFRD 22F Manner of establishment and the relevant Ministers IFCFRD 22F Purpose, functions, powers and duties IFCFRD 22F Initiatives and key achievements 3FRD 22F Nature and range of services provided 3MANAGEMENT AND STRUCTUREFRD 22F Organisational structure 2FINANCIAL AND OTHER INFORMATIONFRD 10 Disclosure index IBCFRD 11A Disclosure of ex-gratia expenses 10FRD 12A Disclosure of major contracts 11FRD 21B Responsible person and executive officer disclosures AFSFRD 22F Application and operation of Protected Disclosure Act 2012 10FRD 22F Application and operation of Carers Recognition Act 2012 11FRD 22F Application and operation of Freedom of Information Act 1982 11FRD 22F Compliance with building and maintenance provisions of Building Act 1993 10FRD 22F Details of consultancies over $10,000 12FRD 22F Details of consultancies under $10,000 12FRD 22F Employment and conduct principles 11FRD 22F Major changes or factors affecting performance AFSFRD 22F Occupational health and safety 12FRD 22F Operational and budgetary objectives and performance against objectives AFSFRD 22F Significant changes in financial position during the year AFSFRD 22F Statement of availability of other information 11FRD 22F Statement on National Competition Policy 10FRD 22F Subsequent events AFSFRD 22F Summary of the financial results for the year AFSFRD 22F Workforce Data Disclosures including a statement on the application of employment and conduct principles 12FRD 24C Reporting of office-based environmental impacts 5FRD 25B Victorian Industry Participation Policy disclosures 10FRD 29A Workforce Data disclosures 12SD 4.2(g) Specific information requirements 10SD 4.2(j) Sign off requirements 10SD 3.4.13 Attestation on data integrity 10SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 10SD 4.5.5 Risk management compliance attestation 10FINANCIAL STATEMENTS REQUIRED UNDER PART 7 OF THE FINANCIAL MANAGEMENT ACTSD 4.2(a) Statement of changes in equity AFSSD 4.2(b) Comprehensive Operating Statement AFSSD 4.2(b) Balance Sheet AFSSD 4.2(b) Cash Flow Statement AFSOTHER REQUIREMENTS UNDER STANDING DIRECTIONS 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements AFSSD 4.2(c) Accountable officers declaration AFSSD 4.2(c) Compliance with Ministerial Directions AFSSD 4.2(d) Rounding of amounts AFSLEGISLATIONFreedom of Information Act 1982 Protected Disclosure Act 2012Carers Recognition Act 2012Victorian Industry Participation Policy Act 2003Building Act 1993 Financial Management Act 1994
The annual report of Maldon Hospital 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.
DISCLOSuRE INDEX
MALDON HOSPITAL
MALDON HOSPITALANNUAL REPORT 2015 Partnering with the Community
Chapel Street, Maldon, Victoria 3463 P. (03) 5475 2000 F. (03) 5475 2029E. [email protected]
www.maldhosp.vic.gov.au