C a s t e r t o n M e M o r i a l H o s p i ta l

A Fu l l y Accred i ted Hea l thcare Fac i l i t y

Service & Quality of Care Report

2 0 0 9 / 2 0 1 0

Meals on Wheels, self funded community meals, food safety and hygiene, menu reviews and external functions.

Administrative Services: Mrs Barb Toma & Team CMH Reception, finance, purchasing and contract management, information technology, payroll / human resources, medical records / health information, policies and procedures, governance and reporting

Under each one of the tasks recorded above there are many other sub tasks and functions required to be completed on a daily, weekly and monthly basis, usually all time critical.

These teams in conjunction with Medical, Paramedical, Nursing, Clinical and Allied Health personnel produce that quality of care that Casterton Memorial Hospital is known for.

As you read through this new report format this year please consider the many individuals whom work as a team to make up the organisation of CMH and that as a team what they produce for our health population and for others from further afield is exceptional.

We trust that you enjoy the 2009/10 Service & Quality of Care Report and that it demonstrates to you our quality of care and breadth of services for our community.

Yours sincerely,

Owen Stephens Chief Executive Officer

FROM THE CHIEF EXECUTIVE OFFICER

This our 2009/10 Service and Quality of Care Report is the first year we have included detailed quality health information and improvement data within the general report of services for our organisation.

We have chosen to do this as our financial and legislative compliance report for Parliament has been produced in-house by us and already tabled in Parliament. Therefore we have more space and opportunity in this report to detail matters to you, our community, on how your organisation is performing from a quality, service and program perspective as against having 40 plus pages of financial and compliance statements.

These financial and compliance statements for the year end 2009/10 are important for our organisation to present to the public and these can be viewed in all their detail at our website www.castertonmemorialhospital.com.au.

The focus of the Service and Quality of Care Report is rightly centred around the patient, resident or client experience that they have encountered at CMH and the report in detail seeks to show you the community in a meaningful way our measurements for quality services and how we compare to our peers within the industry.

The report is about quality, safety and demonstrating how we measure that in an ever moving cycle of monitoring, review, actions and improvement.

CMH has had a successful year both financially and patient / resident and client services provision across the organisation.

This success does not just happen, or is purely based on clinical outcomes, but in part has a lot to do with how our facility is presented, maintained, managed and operated.

I wish to acknowledge on behalf of the Board of Management to the community our service teams whom ensure that our facility operates at top class 24/7 for 365 days of the year.

Environmental Services: Mrs Lois Carter & Team Cleaning, laundry, housekeeping and waste management

Maintenance Services: Mr Ross Tomkins & TeamRoutine maintenance, construction repairs, projects, home maintenance, community transport and waste disposal

Catering Services: Mr Shannon Hutchins & Team Fresh cooked meals daily for patients, residents, staff and community, internal functions, meetings and programs,

Above: CMH Chief Executive Officer, Mr Owen Stephens

i

CONTENTS

From the Chief Executive Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

Hospital Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Board of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Our Model of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Services to Our Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-5

President Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Finance & Activity Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Our Supportive Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-10

Service & Quality of Care – “Our Commitment to You” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Quality, Safety & Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Board Member Retires After 35 Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Clinical Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14

What do You Say? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Consumer Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-18

Medication Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Falls Monitoring & Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Pressure Sore Monitoring & Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Active Service Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21-22

Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23-24

Staff List 2009/10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Strategic Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1

HOSPITAL OFFICERS

Hospital Board of ManagementPresidentMr. R. DalbyVice PresidentMr. D. HuettMembersMr. T. BakerMrs. C. BrownMr. A. Bunnik*Mr. E. EdgeDr. T. HalloranMr. G. SheppardFr. A. Hayes Audit CommitteeMr. O. Stephens – CEOMr. G. Sheppard – ChairmanMrs. B. Toma – Finance OfficerMr. E. Edge – BOMMrs. C. Brown – BOMMr. R. Dalby – BOM Visiting Medical StaffDr. B. S. Coulson: M.B.B.S., D.R.O.G., F.A.C.R.R.M.Dr. M. Prozesky: M.B., ChB, (South Africa)Dr. K. E. Tan: M.B., B.S., FRACGP, DFMDr. C. A. Wilson: M.B.B.S (Monash)Dr. R. Taheri: M.B. (Mashad Uni Iran) G.P. RegistrarDr. C. Pye: M.B., B.S. (Adel), F.R.A.C.E.P., F.A.C.R.R.M, Dip R.A.C.O.G.Dr. T. D. Nguyen: M.D. (Hue Uni Vietnam) G.P. RegistrarDr. T. N. Halloran: B.D., B.Sc. (Hons)Mr. D. L. Bird: M.B., B.S., F.R.A.C.S.Mr. P. H. Tung: M.B., B.S., F.R.A.C.S.Prof. D. Healy: B.Med.Sci.,M.B.B.S. (Hons), Ph.D., F.R.A.N.Z.C.O.G., C.R.E.I.Dr. D. Cloete: M.B., BCH, M.R.C.O.G., F.C.O.G.Dr. G. Coggins: M.B., B.S., F.R.A.C.P.Dr C. De Kievit: M.B., B.S., D.R.A.N.Z.C.O.G., F.A.C.R.R.M.Dr. K. Fielke: M.B., B.S., D.R.A.N.Z.C.O.G., F.A.C.R.R.M.Dr. P. Goodman: M.B., B.S., D.A., D.Obst., R.C.O.G., F.R.A.C.G.P.Dr. J. D. Muir: M.B., ChB, D.A., F.R.C.A.Dr. T. J. Hodson: M.B., M.B.S., F.R.A.N.Z.C.O.

EmeritusDr. A. F. Floyd: M.B., B.S., D.Obst, R.C.O.G.

* Denotes resigned during year

Chief Executive OfficerMr. O. P. Stephens: B.Bus., A.C.H.S.E. Manager Nursing ServicesMs. M. Betson: R.N., R.M., C.C.N., MNsg.,FRCNA After Hours Supervisors & Nurse Unit ManagersMrs. H. Dillon: R.N., R.M. – Quality Improvement OfficerMr. S. Gill: R.N. – Nurse Unit Manager Acute CareMrs. J. Coulter: R.N., R.M. – Education Liaison Officer & Nurse Unit Manager Acute CareMrs. S. Dehnert: R.N., R.M., IBCLC – Night Duty RelieverMrs. H. Gill: R.N, ICC – Infection Control Clinical Consultant & Nurse Unit Manager Theatre & EmergencyMrs S Nolte: R.N. – Nurse Unit Manager District Nursing ServiceMs. S. Bramall: R.N., Grd Dip CH – Nurse Unit Manger Community HealthMrs. K. Sealey: R.N., – Nurse Unit Manager Residential Care Planned Activity GroupMrs. J. Annett: R.N. Division 2, Diversional Therapy Administrative & Finance OfficerMrs. B. Toma Health Information / Quality ImprovementMrs. H. Rees Catering Services SupervisorMr. S. Hutchins Environmental Services SupervisorMrs. L. Carter Maintenance Coordinator / SafetyMr. R. Tomkins Meals on Wheels Coordinator*Mrs. M. Gorman / Mrs Valinda Ross

Right: Casterton Memorial Hospital Main Entrance

2

GOVERNANCE

BOARD OF MANAGEMENT

Responsible MinistersCommonwealth Government AustraliaThe Hon Nicola Roxon MP, Minister for Health and AgeingThe Hon Justine Elliot MP, Minister for AgeingState Government VictoriaThe Hon Daniel Andrews MP, Minister for Health

Life GovernorsBunnik, Mr Adrian Burston, Sir S.G.W.Collins, Mr Des Cowland, Mr RossFlanders, Mrs J. Floyd, Dr. A.F.Kerr, L. M. Martin, Jean McEachern, Mrs N. J. McKinnon, Mrs C.Moffatt, Mrs Margaret Nicol, Mr Robert (Bob)Ross, Mrs Janet (OAM) Sandow, Mr. P.J.Simson, C.R. & K.L. Squire, D.Thompson, Mrs. R. G. Urwin, Mr Alan

Recognised for Service and Dedication to Casterton Memorial Hospital

Mr. Roger Dalby – Building (TAFE) S AustPresidentBuilderCommittees: Internal Audit & Fabric / FacilityFirst Appointed: 2003Current Term of Appointment: 01/11/2008 – 30/06/2011

Mr. Doug HuettVice PresidentForestry / FarmerFirst Appointed: 2007Current Term of Appointment: 01/07/2009 – 30/6/2012

Mr. Graham SheppardBoard Audit OfficerSecondary College EducatorCommittees: Internal AuditFirst Appointed: 1989Current Term of Appointment: 01/07/2009 – 30/06/2012

Dr. Timothy Halloran BDS, BSc (Hons)Dental PractitionerCommittees: Quality & Internal AuditFirst Appointed: 1986Current Term of Appointment: 01/07/2009 – 30/06/2012

Mr. Terry BakerAmbulance OfficerCommittees: Quality & Fabric / FacilityFirst Appointed: 1996Current Term of Appointment: 01/07/2008 – 30/06/2011

Mr. Adrian BunnikPlumberCommittees: Fabric / FacilityFirst Appointed: 1975Current Term of Appointment: 01/11/2008 – 30/6/2010Retired: 30/06/2010

Mr. Edwin EdgeFarmerCommittees: Internal Audit & Fabric / FacilityFirst Appointed: 1987Current Term of Appointment: 01/07/2009 – 30/06/2012

Mrs Christine BrownCommunity Services SupportCommittees: Internal AuditFirst Appointed: 1999Current Term of Appointment: 01/11/2008 – 30/06/2010

Fr Andrew HayesCatholic PriestCommittees: Quality & Fabric / FacilityFirst Appointed: 2009Current Term Appointment:04/02/09 – 30/06/2011

3

OUR MODEL OF CARE

Small Rural Health Services

Casterton Memorial Hospital is classified as a Small Rural Health Service (SRHS) under the Department of Health Policy and Guidelines. This classification allows CMH a Small Rural Health Service to direct service delivery, within a budget, to that which will best meet the needs of our community.

This service and planning decentralisation of the Hospital is important for flexibility from year to year or as circumstances may alter, but also allows at the local level to identify and target community needs.

It is the role to the Board of Management to utilise information available on our local area to maximise the health gains for our community.

Demographics of Our Service Area

Casterton Memorial Hospital is situated in the northern sector of the Glenelg Shire within the township of Casterton nestled amongst rolling hills and river red gums of the Glenelg River valley. It is located on the Glenelg Highway, 359 kms west of Melbourne and 42 kms east of the South Australian border.

The Shire has a total population base of 20,871 and Casterton Rural North of the Shire has a population of 3,340. Our catchment area includes the towns of Digby, Merino and Sandford and the surrounding rural localities.

Casterton Memorial Hospital provides services to all within its population base as well as neighbouring shires. Our satellite Monash IVF clinics encompass South East South Australia, Wimmera and the Western District of Victoria. A dialysis service and a range of other visiting specialists are provided from our facility.

Our Regional Service Area & Referral Pathways

Dergholm

Balmoral

Cavendish

Ararat

Ballarat

Glenthompson

DunkeldHamilton

ColeraineCasterton

Merino

Penshurst

Heywood

Dartmoor

Nelson

PortlandWarrnambool

Geelong

MelbourneMt. GambierSA

4

SERVICES TO OUR COMMUNITY

Hospital 2009/10 2008/09

Total Multi-stay Inpatient Separations* 364 356

Total Same Day Inpatient Separations* 371 428

Bed Days* 2,928 3,372

Total WIES 458.99 452.78

% Occupancy Rate Staffed Beds 54% 62%

Average Length of Stay** 3.56 3.07

% Public Bed Days 76% 81%

% Private Bed Days 24% 19%

Obstetrics / Gynaecology 11 17

Operations / Procedures 159 216

Emergency Department Presentations 1,613 1,592

Glenelg House Residential Care

Residents Accommodated 40 41

Bed Days 10,902 10,945

Average Daily Occupancy 29.98 29.98

% Occupancy Rate Full Year 99.59% 99.95%

Planned Activity Group

Attendances 1,270 1,202

District Nursing

Home Visits 4,576 4,997

Kilometres Travelled 24,339 26,288

Community Health

Attendance (contacts) 1,556 1,479

Allied Health

Physiotherapy Attendance 1939 2,248

Speech Therapy Attendance 5 31

Dietetics Attendance 107 124

Occupational Therapist Attendance 38 46

Meals Produced

Hospital / Residential Care / Other 71,757 75,534

Meals on Wheels (HACC Assessed) 8,833 8,856

Antenatal Sessions 3 4 * Does not include newborn transfers ** Excludes Nursing Home Type Patients

Other services facilitated from Casterton Memorial Hospital through private practitioners include:

AudiologyChild Maternal Health Visiting Medical Specialists Radiology ServicesOphthalmology Services Podiatry ServicesPsychology ServicesDrug & Alcohol

Right: Maternal & Child Health Nurse, Bernadette Fitzgerald conducts an assessment on a child

5

Left: Ambulance Victoria Paramedics, Geoff Elmes and Terry Baker

Left: These children were thrilled with the free cupcake decorating provided by CMH at the Casterton Show

Right: David Richardson prepares to go and collect a client in the CMH Community Car

Right: CMH Meals on Wheels Coordinator, Valinda Ross assists volunteer Kim Bright to

place meals in her car ready for delivery.

SERVICES TO OUR COMMUNITY cont/...

6

PRESIDENT REPORT

Ladies and Gentlemen it is with great pleasure that we present to you our Service and Quality of Care Report for the Casterton Memorial Hospital for the year 2009/2010.

This was another productive year for Casterton Memorial Hospital with service targets being met, budgetary objective achieved and service levels either maintained or expanded. A small operating surplus of $41009 was recorded after additional financial costs in relation to information technology and financial management reporting systems which were implemented as required by the Department of Health.

Your Board of Management, executive team and staff are to be congratulated on again providing efficient, effective and caring service to our health population. State wide and peer benchmarking continues to show Casterton Memorial Hospital in a very strong light in comparison to its peers. We thank all staff, volunteers and service providers at Casterton for keeping up the sound and effective work.

Your Board, together with the Executive, continues with its strategic planning objectives. It has been pleasing to see a number of achievements recorded again this year including, community transport service maintenance and expansion, additional disability transport commuter bus access, Deakin Medical School funding and preparation for first medical student cohort to Casterton Memorial Hospital in January 2011, kitchen/laundry services zone up-grade, GP registrar placements at Casterton Memorial Hospital and Casterton Coleraine Medical Clinic, and master planning work progression.

Your Board of Management continues to watch closely the national health reform agenda, and as a Small Rural Health Service will seek to maximise services for its health population through improved partnerships, collaborations and referral networks that best suit the service level requirements of our local population.

We trust that this Service and Quality of Care Report presents you our public and consumers a detailed insight into much of the work that is done by our various teams across the hospital in respect of quality improvement, risk management, occupational health and safety and development of service improvements for you, our community.

On behalf of the Board of Management I wish to thank all staff for your work and competency throughout 2009/10, our external service providers, Ambulance Victoria team in Terry and Geoff and their support Community Officers,

to all our volunteers and fundraising groups, our Medical Officers, and of course to my fellow Board colleagues and Executive team in Owen and Mary-Anne.

2009/10 has been a productive year for your health service organisation and we look forward to continuing our sustainability and successes into 2010-2011 on behalf of this community.

Mr Roger DalbyPresidentBoard of Management

CMH Board of Management, President, Mr Roger Dalby

7

FINANCE & ACTIVITY OVERVIEW

Finance & Activity 2009/2010: The financial statements of Casterton Memorial Hospital’s annual accounts for the year ended 30th June, 2010 have been completed in accordance with the Australian Audit and Accounting Standards and the Financial Management Act 1994.

The accounts have been audited by the Victorian Auditor-General’s representative and signed off by the Auditor-General D D R Pearson on the 19th August, 2010.

The audited Annual Report, including supporting information and the facility’s compliance with staturory disclosure requirement can be found on the Casterton Memorial Hospital’s website www.castertonmemorialhospital.com.au

Finance Overview: The hospital has reported an operating surplus of $41,009 for 2009/10 financial year. This surplus is a reduction on our 2008/09 surplus and this reduction is primarily the increased Information Technology (IT) Alliance expense. The increased IT costs have been incurred as a result of unfunded expenditure on the implementation of the Department’s statewide new ‘Oracle’ finance systems and Casterton’s shared component of the SWARH’s Joint Venture equity.

Facility and grounds revaluation as at 30th June 2009 increased our unfunded capital depreciation costs from $361,680 in 2008/09 to $921,369 in 2009/10, this being the influencing factor to the overall ‘Comprehensive Surplus/(Deficit) Result For the Year’ of (-$455,628).

The current asset ratio of 1.41 is an increase from 1.31 in 2008/09. Cash and investments have been well managed, resulting in a year end cash position of $2,052,655 compared to 2008/09 balance $1,797,652. This cash increase is pleasing considering limited investment opportunities and the capital outlay on equipment and facility upgrade of $295,333 during the 2009/10 financial year.

The overall operating expenditure, exclusive of Joint venture equity, for the facility totalled $6,609,578. Salary and employee benefits costs accounted for $5,110,437 or 77.3% of this expenditure. Other non salary related costs totalled $1,499,141 and as a result of departmental prudent budget monitoring and controls, pleasingly, this is a decrease of 2.41% compared to the same figures in the 2008/09 year.

Revenues for the year totalled $7,067,052, including capital purpose revenue of $387,015. Government grants contributed $4,124,064 in operating funds and $100,000 in capital funds to total revenue. Other major revenue sources include Patient & Resident fees of $1,993,135 of which $1,436,286 is Commonwealth Residential Care payments. Donations received from community and support groups have contributed $65,272.

The Hospital’s inpatient activity met the set targets for both public and private inpatients. The net result of the Department of Veterans’ Affairs (DVA) over target activity and under target with Dialysis patients treated earned additional Department revenue totalling $18,790. Glenelg House, our 30 bed high care residential activity remained consistent with a daily occupancy rate of 29.98 and full year % occupancy rate of 99.59%. Our extensive primary care and community based services have benefited from additional program resources being provided to this area of our service and have achieved numerous successful activities throughout the year.

Overall the 2009/10 operating finanical year for Casterton Memorial Hosital has been pleasing.

We have maintained expenditure within budget and at the same time increased infrastructure, resourcing, range and scope of services provded to our community.

Five Year Financial Comparative Statement 2005/06 2006/07 2007/08 2008/09 2009/10

Total Operating Revenue 5,454,881 5,764,501 6,077,193 6,437,618 6,680,037

Total Operating Expenditure 5,415,590 5,533,898 5,894,965 6,303,840 6,639,028

Operating Surplus / (Deficit) 39,291 230,603 182,228 133,788 41,009

Capital Purpose Income 161,835 273,150 223,847 428,766 387,015

Depreciation Expense 269,889 329,756 337,352 361,680 921,369

Net Result for the Year -68,763 173,997 68,723 200,864 -493,345

Asset Revaluation increments/(decrements) 1,571,247

Capital Contribution from State Government - - 74,386 -

Share of Comprehensive Income Joint Venture 37,717

Retained Surplus/Accumulated Deficit 7,271,249 7,445,248 7,588,357 7,789,221 7,333,593

Total Assets 10,569,510 10,946,557 11,197,560 18,212,964 17,853,140

Total Liabilities 1,568,243 1,771,293 1,862,537 1,688,069 1,783,873

Net Assets 9,001,267 9,175,264 9,335,023 16,524,895 16,069,267

Total Equity 9,001,267 9,175,264 9,335,023 16,524,895 16,069,267

8

OUR SUPPORTIVE COMMUNITY

Donations received during the 2009/2010 year:

Casterton Memorial Hospital volunteers and donors have made a significant contribution to the overall success of the quality and operations of the facility. Volunteers contribute to meals on wheels deliveries, patient care, residential and day centre activities and much more. The financial support we receive enables the facility to provide updated medical equipment and much needed refurbishments. The various fund-raising committees and auxiliaries continue, year in and year out, to raise valuable funds. To these groups and the many individuals who raise funds and donate to Casterton Memorial Hospital each year, your support and sense of community is what makes Casterton Memorial Hospital the organisation it is today. The Board sincerely thanks all our volunteers, fund-raising committees and individual donors for their generous and tireless support over many years.

Fundraising Committees

CMH Friends of Glenelg House 1,126.40

CMH Hospital Card Program 7,200.00

CMH Hospital Social Club 1,000.00

CMH Ladies Auxiliary 8,691.15

CMH Murray to Moyne 10,083.25

CMH Staff Fundraising 2,118.50

CMH Wando Vale Ladies Auxiliary 1,000.00

Give Me 5 for Kids Program

5SE / Star FM $2,462.26

Casterton Rotary Club 1,000.00

Glenelg Inn 100.00

CMH Staff 454.50

Community Groups

Albion Hotel (Fun Run) 1,436.50

Casterton Apex Club 200.00

Casterton Kelpie Association 131.30

Casterton Lions Club 110.00

Coleraine & District Art Group 1,890.00

Dergholm Social Club 500.00

Wando Vale Plantation Committee 20,000.00

Community Member Support

Anderson, Beverly 10.00

Anonymous 50.00

Cook, Stewart 100.00

Delahunty, Hugh MP 300.00

Donohue, Edgar 50.00

Fraser, Bonnie 20.00

Glenelg Inn 177.00

Holmberg, W & B 50.00

Living Pure Potential 306.70

Mace, T & M 100.00

In Memory of Harold McConachy 80.00

In Memory of John Robertson 65.00

In Memory of Lancelot Bruhn 50.00

In Memory of Shirley Harvey 785.00

In Memory of Shirley Outtram 442.00

In Memory of Verna McIntosh 815.00

In Memory of Ted Reiter 70.00

Rivett, Ruth 20.00

Tait, Peter & Jo 50.00

Tapscott, Mr 20.00

Estates

Estate John Russell MacPherson Fund 1,501.25

Estate of Louisa Henty 691.27

Estate of William Jones 15.00

Total Donations $65,272.08

Left: Mr Edgar Donehue with CMH Chief Executive Officer, Owen Stephens and CMH Board President, Roger Dalby announces the Wando Vale Plantation Committee donation at the 2009 Annual General Meeting

9

Above: The successful 2010 CMH Murray to Moyne Cycle Relay Team and support crew.

OUR SUPPORTIVE COMMUNITY cont/...

Between our main 5 fundraising groups, staff fundraising and the Hospital Card Program a total of $31,219.30 has been raised in favour of Casterton Memorial Hospital improvements and activities.

This magnificent effort for our Small Rural Health Service and all involved in either organising these fundraising activities or supporting them must be commended once again.

Special note this year has been the great contribution of $20,000 from the winding up of the Wando Vale Plantation Trust after many years. On behalf of the Community we thank Mr Edgar Donehue, Mr Ross Davidson, Mr Digby Crozier and Mrs Ann Galway for voting in favour of the Casterton Memorial Hospital through this donation. These proceeds will go toward our building redevelopment for the General Services zone of CMH and therefore will have tangible affect of improving this facility for the Community.

Murray to Moyne

Our Murray to Moyne Committee has once again recorded a successful year in both fundraising activities and with their participation in the annual cycling event.

Riders Simon Povey, Stephen Mutch, Duncan Wishart, Michael Greenham, Mark Cowland, Tony McKenzie, Barb Toma and first time riders Maggie Greenham and Liam Gill cycled their way from Mildura to Port Fairy in good time to finish Casterton Memorial Hospital’s 18th consecutive and 19th ride in this event.

The experienced support crew of John Carmichael, Barry McKenzie, Wayne Annett and food connoisseur Shane Gill, capably managed the catering, driving, bike transfer and safety of the riders. A challenging, rewarding and good time was had by all.

The committee’s annual and much anticipated “Brekky on the Lawns”, with overwhelming support from the community of Casterton, this year recorded the best ever attendance and a wonderful social morning was enjoyed by all.

The committee plans events on an annual basis and works constantly over a twelve month period to raise funds under the Murray to Moyne umbrella for our facility. Events held in 2009/10 financial year included a Quiz Night, Hospital Golf Sunday, Service Club dinner, various catering roles, wood raffles and sponsorship drives.

The committee would like to acknowledge and sincerely thank their major sponsor Foodworks Casterton and our other long term supporters Bruce Clode Construction, Landmark, Robco Petroleum, Phil Pullen & Co, Elders Casterton and our new sponsor this year Fox Refrigeration.

The support from the local businesses and the Casterton community in general has again been wonderful and without their support our financial goals would not be achievable.

We thank everyone involved for their time, effort, products donated and financial support; together we have raised an amazing sum of $10,083.25 for our wonderful hospital. This sum, like our Brekky is our best ever result. Total funds raised over our 19 year history in this event now totals $126,722.26. Well done to all.

The community support for our Small Rural Health Service is amazing and each year this community support ensures that CMH can continue to improve in both its service provision and maintenance of equipment and assets essential to the operation of your Hospital.

Owen Stephens Chief Executive Officer

10

Left: Activities Person, Mrs Karen Perry, Friends of Glenelg House (FOGH) member Mrs Betty Collins, Diversional Therapist, Mrs Janice Annett and FOGH member, Mrs Margaret Wood at the 2010 Minister for Health Volunteer Awards where the Friends of Glenelg House were a finalist.

Left: CMH Chief Executive Officer, Owen Stephens thanks CMH Volunteers for all their hard work at the annual Volunteers Afternoon Tea.

Right: Glenelg House Volunteers, Matthew Kensen and Keith Edwards assist in making

donuts as a fundraiser for Glenelg House

Right: Mr Barry Richardson presents a cheque on behalf of the CMH Social Club

to Board President, Mr Roger Dalby.

OUR SUPPORTIVE COMMUNITY cont/...

11

Above: Education Officer, Judy Coulter instructs RN Division 1 staff members, Stewart Bryan and Smart Makore on

the correct technique for setting up an IV line.

SERVICE & QUALITY OF CARE – “OUR COMMITMENT TO YOU”

QUALITY, SAFETY & RISK MANAGEMENT

This section of our report is produced under required guidelines from the Department of Health Victoria and is designed to provide to you the consumer an indicator of our achievement of certain outcomes under quality of care provisions.

Areas such as Quality and Safety, Consumer and Carer participation, Continuity of Care and Health Promotion programs are to be critically reviewed each year and reported to you the public the details of our activities as a healthcare service in respect to service and quality of care outcomes.

We trust that you will observe some of our outcomes achieved for 2009/10 and also whilst reading this section of the report share in some of the patient / client feedback received during 2009/10.

This year the hospital implemented a new Incident Management system in conjunction with the Department of Health and was one of the first in Victoria to receive this new software. This new system has improved our overall capacity to accurately record, manage and analyse all risks that occur within the hospital.

Over the past 12 months, staff have continued to demonstrate their commitment to quality improvement by their pursuit of knowledge. A large number of staff have completed external education as well as accepting and implementing a range of online competencies. These courses have included Palliative Care, Rural Isolated endorsement, Accident & Emergency, Aged Care Assessment and Medication Endorsement, Fire Training and a range of other systems. The Registered Nurses Division 2, are to be congratulated on their commitment to education. Almost all RN Division 2 nurses have completed their medication endorsement, and this is contributing to a facility wide holistic approach to the care of our patients and residents. Personal Care Attendants have also shown commitment to personal development completing enrolled or registered nurse education.

The importance of Palliative Care has long been recognised by staff and ongoing education in this area ensures that patients’ and residents’ treatment is planned and delivered

This section of the report underpins our level of care and vigilance to safety for all and is important to demonstrate to you, the public, these results for your health service.

This report has been a joint effort of CMH staff all working towards providing our community with a snapshot overview of the hospital’s services and outcomes for 2009/10. We trust that you will gain from the information a sense of the level of quality and care we all strive for as a team at Casterton Memorial Hospital.

The Quality Improvement Framework, incorporating Clinical Governance and Risk Management support the hospital’s approach to providing safe and effective healthcare to our patients. Our Quality system promotes good Clinical governance practices and processes along with Risk Management principles.

sensitively and in a caring environment. Results from Palliative care surveys indicate that we continue to meet the needs of our patients and families.

Assessment and management of A&E presentations is another area where education has led to improvement in skills which in turn leads to more timely and appropriate patient management.

12

ACCREDITATION

BOARD MEMBER RETIRES AFTER 35 YEARS OF SERVICE TO CASTERTON MEMORIAL HOSPITAL

Self assessment is a major component of reviewing how well you perform and Casterton Memorial Hospital participates in a continuous quality improvement program through the Australian Council on Healthcare Standards Accreditation process. Through this process we continuously assess ourselves against comprehensive external standards and criteria based on health industry best practice which are aimed at improving quality and safety within hospitals. The ACHS Accreditation cycle is a 12 monthly process of self assessment combined with an external assessment each 2 years. This year we undertook self assessment which gave us the opportunity to ask ourselves how well we rate ourselves against each of the standards and identify our achievements as well as strength and weaknesses. From this we develop and

Mr Adrian Bunnik was appointed to the Casterton Memorial Hospital Board of Management in 1975 and has served on numerous Hospital Committees over the years from Finance, House & Works, Project Control Groups and the Board.

He was elected Board President for the year 1981/82 and was awarded Life Governor status in 1993 in recognition of his commitment to the Board and Hospital.

Mr Bunnik considered carefully seeking reappointment in the 2010 appointment round, however has decided after due consideration to retire from the Board of Casterton Memorial Hospital.

A Farewell Dinner was held for Mr Bunnik in April, recognising his achievements during his 35 years as a Board Member of Casterton Memorial Hospital.

implement an action plan based on improvement needs we have identified.

The Australian Council on Healthcare Standards is not the only Accreditation body that we are assessed by. We undertake a range of external Accreditation and Quality audits through bodies such as Home & Community Care, Infertility Treatment Authority, Bendigo Radiology, Department of Health Drug & Poisons Unit, Food Safety audits, Department of Veteran Affairs and the Aged Care Standards Agency.

We are committed to meeting these standards and practices and we continually strive to improve our care, services, and practices to ensure that they remain safe and effective.

Above: Mr Stephen Koci and Ms Gillian Walster, Aged Care Standards Accreditation Agency, report on

their findings during their visit to Glenelg House

Above: Ms Mary-Anne Betson, CMH Manager Nursing Services and Mr Roger Dalby, CMH Board President show Minister for Health, Mr

Daniel Andrews MP the new digital imaging system at CMH

Above: Mr Adrian Bunnik

13

CLINICAL GOVERNANCE

According to the Australian Council on Healthcare Standards 2004, Clinical Governance is defined as ‘the system by which the Governing body, managers and clinicians share responsibility and are held accountable for patient care, minimising risks to consumers and for continuously monitoring and improving the quality of clinical care’.

In 2009 the Victorian Department of Health requested that health facilities review their Clinical Governance systems based on the “Victorian clinical governance policy framework – A guidebook” We are in the process of reviewing our policy and systems and have already made improvements to our overall governance systems.

According to the Department of Health, “Victorian Clinical Governance Policy Framework - A guidebook” there are 9 required elements to an effective clinical governance framework. These are;

DHS required Element Our system Improvements Undertaken

Priorities and Strategic direction are set and communicated clearly.

We have a facility wide Strategic plan, endorsed by our Board of Management which is clearly distributed to our staff members and our community

We have moved the time frame of our Strategic plan to two yearly to allow extra time for effective completion of strategies.

Planning and resource allocation supports achievement of goals

Resources are allocated by the Board of Management to progress each aspect of the plan where appropriate.

Two yearly completion time frames allow more effective allocation of resources required.

The culture is positive and supports patient safety and quality improvement initiatives.

We have very active committee structure to promote staff participation and an annual quality improvement plan. We participate in external Accreditations that monitor our quality systems.

Active Service Model implementation with commencement of PAG community committee.

Legislative requirements are complied with.

Health Legal Legislative update service. Inclusion of Aged Care Legislative sections into suite to ensure full coverage of required Legislation.

Organisational and committee structures, systems and processes are in place.

Comprehensive suite of Policies and Procedures / guidelines that guide and support work practices across the spectrum of hospital operations.

Move to PROMPT system to manage development.

New Unplanned Birthing Policy.

New Stroke Management Policy.

Measure performance and monitor quality and safety systems within the service.

Comprehensive suite of audits, quality indicators, feedback surveys, complaint mechanisms, Risk Management systems, Infection Control systems, Incident management systems, essential service and preventative maintenance systems to monitor safety and performance across the spectrum of hospital operations.

Newly developed internal clinical review process to complement existing clinical screening program.

Increased microbiological testing of equipment.

New Incident Management system to review, monitor and analyse hospital incidents.

Report, review and respond to performance to support continuous improvement of quality and safety within the service.

Monthly Governance reports to the Board of Management detailing quality indicators across clinical, financial and operational areas.

Current review of quality indicator and audit suite and how these are effectively being communicated to the Board of Management and staff members.

Roles and responsibilities are clearly defined and understood by all.

Comprehensive suite of position specifications, orientation programs, duty statements and credentialing systems.

Implementation of E-learning competencies.

Continuity of care processes ensure there is continuity across service boundaries.

Effective referral systems in place. Appointment of additional Community Health personnel.

Review of referrals to and from PAG in line with Active Service Model Philosophy underway

14

CLINICAL GOVERNANCE cont/...

WHAT DO YOU SAY?

The Board of Management provides oversight of the Quality and Risk Management system, receiving reports and information on the hospital’s Clinical Governance, Quality, Risk Management, Infection Control and Safety programs to ensure that all risks are identified, communicated and acted upon. The Quality Committee is responsible for the overall monitoring and management of the Quality and Risk Management system.

The Credentialing framework manages checking of Scope of Practice, Qualifications, Registration, training and experience. These are regularly checked to ensure that all staff are suitably qualified to carry out their roles professionally and effectively. Regular competency checking/education is also undertaken in areas of CPR, Medication administration, Blood Transfusion, Dialysis, Cannulation, Advanced Life Support, Minimal Handling, Food Safety, Fire, just to name a few.

We are presently participating in a trial of e-learning packages through the Victorian Managed Insurance

We receive feedback from our clients in a variety of ways, including formal and informal. We actively seek our clients opinion of our care and services through service surveys, satisfaction questionnaires, Comment/Suggestion forms and Complaints. We value this feedback be it positive through compliments or improvement suggestions or through complaints.

Feedback forms be they compliments/suggestions or complaints are widely available throughout CMH and we regularly inform our clients of how to leave a compliment/comment/suggestion or indeed how to make a complaint.

We will respond to complaints in a timely manner and will work to resolve complaints to the satisfaction of all involved. We regularly review comments and complaints to identify where we can improve. This graph shows the number of formal/informal complaints that were received in 2009/10.

During 2009/10 we implemented the National Open Disclosure Standard throughout the facility. This standard is about effectively communicating with patients and their family when an incident that may have resulted in harm or injury has occurred. This is not a new concept to us, we believe that open communication of actual and potential events is beneficial to all and strengthens relationships with our community.

Above: CMH Board of Management oversee the Quality and Risk Management Systems at CMH

Authority to determine the level of interest for small rural hospitals in this learning method and assist with defining the overall E-learning strategy for VMIA.

Resident/Patient

Complaints Recieved 2009/2010

Clinical Treatment

Catering

Staff

1

1

1

1

15

Satisfaction surveys are used to ask our clients what they think of us and the services we provide. We use a range of surveys that most departments use and that you may already be aware of. Examples of these may be District Nursing survey, Home Maintenance service surveys, Meals on Wheels and the satisfaction surveys on discharge from hospital. Results of these surveys are used to plan, deliver and improve our range of healthcare and services.

The graph below shows results from the Victorian Patient Satisfaction Survey which is run by the Department of Health. All Victorian public hospitals participate in this program. Survey results give the Department of Health insight into how our patients see the quality of their hospital care. It also gives us an opportunity to benchmark our own results with other like sized hospitals and identify improvement opportunities. This year our overall Score of 89 remains the third highest score we have achieved since the VPSM inception in 2002. Thanks to all who have completed the Victorian Patient Satisfaction Monitor to date.

CONSUMER SATISFACTION

CMH - Benchmark Data - Individual Care Index

Overall Care Index

50 70 80 90 100

7884

87

76

77

80

83

81

85

89

82

88

Discharge & Follow Up

Physical Environment

Complaints Management

Treatment & Related Information

General Patient Information

Access & Admission

79

82

77

84

88

82

86

91

81

State Average CMH“D” Hosp Av.

Access & Admission

General Patient

Information

Treatment & Related

Information

Complaints Management

Physical Environment

Discharge & Follow Up

Overall Care Index

State Average 77 82 79 80 76 77 78

“D” Hosp Av. 82 88 84 85 83 81 84

CMH 81 91 86 88 89 82 87

Comments from Patient Questionnaires

“Impressed with the overall care and concern by all the hospital staff. Thank you.”

“Staff wonderful. Meals lovely. A very quiet environment to be in to rest and recuperate.”

“I am more than happy with the treatment I received while a patient. Everyone responded

to my requirements without question.”

“My stay was very good. The care etc at this hospital is excellent, second to none. No

complaints whatsoever. Very caring, warm staff and volunteers. It was a privilege to be here.”

Above: RN Division 1, Vanessa Markham discusses patient care with Dr Tim Nguyen.

16

INFECTION CONTROL

Monitoring Infection Control risks within the hospital is an ongoing routine for our Infection Control Co-ordinator. The role of the Infection Control nurse is to manage infection surveillance and management programs to minimise transmission of infection risk and maximise infection prevention practices of staff and the community.

1915

86

64

0

10

Acute

2006/07

2007/08

2008/09

2009/10

Glenelg House

Acquired Infec�on Rates

20

30

40

50

60

70

47

40

29

Infection Monitoring Data Collection The Infection Control nurse collects information on a large range of infection management and prevention based data. Examples of the types of information collected include, Hospital acquired infection rates, Surgical site infections, immunisations, Occupational Exposures, effective use of antibiotics, Hand cleaning rates, Sterilisation compliance, Microbiological testing of water and equipment, waste management practices, staff education, and Environmental cleaning audits. This data is used to monitor, compare and improve safety and quality of our healthcare services.

During this year improvement activities included development of a Residential Care infection control auditing process, broadening of antibiotic surveillance audits, updating of Outbreak management plans, development of an annual business plan,

Keeping our Hospital Clean We have a very dedicated and caring Environmental Services staff who take great pride in the cleanliness of our hospital. We are often complimented on how clean our ward and general service areas are kept.

We participate in the Department of Health Cleaning Standards where functional areas of the hospital are audited based on set standards of cleanliness. The Department of Health have set a minimum standard of cleanliness that all hospitals must meet for both High risk areas like Operating Theatres and Sterilizing areas as well as less risky areas such as clinical areas and wards.

Cleaning audits results for CMH, shown below, clearly demonstrate the high standard that we set ourselves. We have continually met and have exceeded all standards set.

Comments from Patient Questionnaires

“The hospital is to be congratulated by its cleanliness and very wonderful staff ”

“Very clean at all times”

“Couldn’t be cleaner or better in any way”

“Like a hotel”

“Hospital lovely, clean and friendly. Well Done.”

97 90 9785

9785

0

20

40

60

80

100

Very High Risk Area High Risk Area Moderate Risk Area

July 2010 Audit Acceptable Quality Level

External Cleaning Audit Results 2010

17

INFECTION CONTROL cont/...

Hand Hygiene It is widely accepted that the best method of reducing or controlling the risk of infection within hospitals and the community is good hand hygiene practices. Simple and thorough hand hygiene has been shown to significantly reduce the risk of infection.

The Victorian Department of Health and Victorian Quality Council implemented a joint project in 2006/7 to implement a hand hygiene monitoring system into Victorian health services which has now become the National Hand Hygiene Initiative. We submit hand hygiene compliance data three times a year. Compliance is audited on the five moments of Hand Hygiene, these are;• Prior to patient Contact• Post Patient Contact• Prior to a procedure• Post procedure• Post contact with patient surrounds.

CMH have improved distribution of hand hygiene stations throughout the hospital for use by staff and community alike.

The graph below is extracted from Victorian Patient Satisfaction Monitor results.

Disinfection and Sterilisation Appropriate Sterilisation is another method of managing the risk of Infection. We regularly assess ourselves against the AS4187 Australian Standard for Sterilisation and Disinfection Management. We have consistently achieved high results as compared to Best Practice scores.

Immunisation CMH provides initial employment immunisations to staff to help prevent the transmission of infection to patients and residents who are more vulnerable. This year our Flu Vaccination program immunised 89% of staff which is a very high result. Only a few staff were unable to receive the vaccine due to allergies. Eligible patients and all residents are also offered the vaccine.

88%

0%

20%

40%

60%

80%

100%

Jun-Dec 2009

During your stay, were you aware of the hospital’s hand cleaning policies/procedures?

Yes

No

12%

Aggregate Hand Hygiene Compliance Rate

200868% 68%

67%

2009

2010

Above: Personal Care Attendant, Dianne McKinnon putting good hand hygiene into practice

AS4187 Sterilisa�on & Disinfec�on

Apr-10

Best Prac�ce2010

0%

20%

40%

60%

80%90% 85%

100%

18

INFECTION CONTROL cont/...

Food Safety Standards Catering Services have in place comprehensive policies and procedures to guide staff work practices to minimise risk. Safe food handling training and an annual Food Safety audit is carried out by external auditors. Microbiological testing of surfaces within food preparation areas is also carried out regularly by the Glenelg Shire Environmental Health Officer. A Food Safety Plan is in place and is updated regularly.

Waste Over 2009 and part of 2010, we completely changed our Waste Management procedures to help maximise recycling and improve waste segregation practices. The entire system of waste from initial generation to collection and disposal was reviewed. Improvements to the system were implemented in relation to segregation, collection points, work practices, storage and disposal processes. It is hoped that this new system will reduce our overall waste production whilst improve our recycling opportunities.

Above: CMH Catering Supervisor, Mr Shannon Hutchins monitors the

temperature of food before being served.

MEDICATION MANAGEMENT

Comprehensive competencies are undertaken by staff throughout the year in relation to our Medication administration policies and practices. Internal audits are carried out regularly to test application of hospital processes. External audits are also undertaken by the Pharmacist, again to measure compliance to hospital processes. The risk of medication incidents in hospitals is acknowledged as not uncommon due to the high amount of medications administered and the frequency of this administration. Medication Incident data is collected to assist in analysing reasons and causes of errors and omissions. Data is reported to staff and the Board of Management to enable oversight and monitoring. We actively encourage our staff to fully report all incidents that occur so that they can be investigated and improvements made. Introduction of the Victorian Health Incident Management System has made this process much easier for staff to undertake and for clinical staff to interpret.

Above: Maintenance Supervisor, Mr Ross Tomkins, Infection Control Nurse, Mrs Heather Gill and Quality Improvement

Officer, Mrs Heather Rees undertake a waste audit at CMH

12

16

0

5

10

15

20

Medica�on Incidents

Total Reported Medica�on Incidents including Non Errors

2008/09

2009/10

*There have been no injuries or adverse outcomes sustained by a patient as a result of any reported Medication Incident.

19

Above: Healthcare Attendant, Frank McInerney and Activities Person, Karen Perry assist Glenelg House Residents during their exercise class

FALLS MONITORING AND PREVENTION

Falls can happen at any age, however the frequency and severity of fall-related injuries increases with age especially for people over 65. Research has shown that about 33% of people aged over 65 fall each year, of these fall, between 10-20% results in a serious injury, such as a fracture. Many other falls may not actually cause an injury but may decrease a person’s confidence in going about their daily routines which can affect independence and quality of life.

Falls are also a major cause of hospitalization in the elderly whilst falls in hospital are also a major cause of increased resources and length of stay in an inpatient episode.

Balancing a patient’s right to be as independent as possible whilst minimising the potential of a fall is quite an undertaking. Patients are assessed at admission to identify possible risk factors and these are managed with practical interventions like hip protectors, good lighting, proper footwear and continence management to minimise the risk of injury should a fall occur. We report and closely monitor all falls and those instances of patients found on the floor. Patients are referred to Primary Care groups like Strength and Balance group, Well for Life programs, Walking Groups to continue to assist in implementing strategies to reduce further risk of falls at home.

The Physiotherapist undertakes regular exercise classes in Glenelg House with those residents able to participate, with a view to maintaining dignity, independence and mobility.

The graph to the right shows the rate of falls for Acute along with rate of falls with Fracture. Whilst screening and risk assessment programs identify the risk of falls, patients will continue to fall despite this, however minimising the risk of major injury from a fall can be and is a major focus. Implementation of minimising strategies helps to reduce major injury should a fall occur. Both the hospital and Glenelg House are working hard to reduce the overall rate of reported falls/found on floor and continue to implement preventative and harm minimisation strategies.

0

10

2004/05

Falls Falls with Fracture

2005/06 2006/07 2007/08 2008/09 2009/10

Acute Falls Data

20

30

40

50

60

20

PRESSURE WOUND MONITORING AND PREVENTION

As part of the Barwon South West Regional Wound Group CMH staff liaises and undertakes continual education on wound management. Product selection and wound management is supported through this liaison.

All hospital mattresses are now categorised as “Pressure” reducing mattresses and have assisted us in the ongoing management and prevention of Pressure wounds. We have managed to reduce the incidence of pressure ulcers forming as an inpatient or resident and rates remain low. This is pleasing when taking into account the frailty of some of our Glenelg House residents. Risk assessments have been updated and reduction strategies are used to improve the overall numbers of pressure areas developing. We participate in quarterly data collections of pressure area incidence to the Department of Human Services which also allows us to compare ourselves to other like size facilities and identify improvement opportunities.

1st Quarter 09/10 2nd Quarter 09/10 3rd Quarter 09/10

Level of Acquired Pressure Ulcer Comparisons

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.18% 1.21%1.28%

0.80%

1.26%

0.90%

0.00%

0.90%

0.50%

CMH Rate

Statewide Group Rate

Peer Group Rate

1st Quarter 09/10 2nd Quarter 09/10 3rd Quarter 09/10

Propor�on of Pa�ents with Risk Assessment

80%

85%

90%

95%

100%100% 100% 100%

89%

91%

88%

91% 91%

96%

CMH Rate

Statewide Group Rate

Peer Group Rate

21

ACTIVE SERVICE MODEL PHILOSOPHY

The Active Service Model is an initiative of the Victorian Department of Health. It aims to support clients of Home & Community Care Services (HACC) to live as independently and autonomously as possible. HACC Agencies will implement the five basic principles of the Active Service Model into their day to day routines. These principles are;

• People wish to remain autonomous

• People have the potential to improve their capacity

• People’s needs should be viewed in an holistic way

• Home & Community care services should be organised around the person and his or her carer, that is, the person should not be slotted into existing services.

• A person’s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carers and families; support workers and between service providers.

CMH and the Primary Care Services have developed a plan of actions in order to implement this Active Service Model. To date we are looking at Goal centred Care Planning for Planned Activity Groups (PAG) as well as setting up a community based PAG committee.

Our Primary Care Services and specifically District Nursing and Planned Activity Group staff are committed to implementing this philosophy into their day to day routines. They will continue to support and encourage a person centred approach in planning and improving care outcomes with particular emphasis on promoting care goals, enhancing independence and improving capacity.

A practical example of how this approach can enhance and improve independence lies with members of our Planned Activity Group. Janice Annett and her team of volunteers do a great job working with their clients to improve their independence as well as providing much needed social support.

Some of the clients had mentioned that they rarely made sauces or cakes anymore because they often made too much and there would be leftovers which would go to waste and this was something that they really missed doing.

Janice scoured her cookbooks at home and came up with a solution so that her clients could easily make these items for themselves at home. Much practice and fine tuning took place at the Planned Activity Group with lots of laughter and hilarity at ‘the flops’ but eventually recipes were ‘fool proofed’ and perfected. Now clients report that they often make white sauce in a jug and cake in a mug at home for themselves – all in the Microwave!

Consumer, Carer and Community Participation Consumer participation is integral to all service delivery at CMH. To meet the community’s needs CMH provides forums in aged and community care to identify culturally diverse individuals and groups in conjunction with our annual Cultural Diversity Plan as well as the many and varied Health Promotion programs on offer at CMH.

Above: Planned Activity Group clients, Mrs Val Hooper and Mrs Marjorie Staats making biscuits in the Day Centre kitchen.

Right: RN Division 1, Vanessa Sheahan tastes some traditional Zimbabwean food cooked by fellow RN Division

1, Muza Makore during Cultural Diversity Week.

22

ACTIVE SERVICE MODEL PHILOSOPHY cont/...

In support of the Active Service Model initiative CMH has strengthened and provided additional resources to its existing model of care for support of members living within our community. This model which incorporates the following services;

• District Nursing

• Planned Activity Group

• Meals on Wheels

• Home Maintenance Program

• Community Transport Program

• Visiting Allied Health Services Personnel

• Health Promotions and Activities

In coordination with and underlying many of these program objectives is the intense work conducted by our Community Health team in coordinating many health promotion programs throughout the year and actively informing, educating and demonstrating to our health population ways to improve health, lifestyle and participation in being part of an active service philosophy. From the list below you can see that it has been an extremely busy year for Sheila and Paula in keeping the community active and switched on to the right health messages.

Some of the activities covered in 2009/10 included;

• Strength and Balance Group

• Diabetes Support Group

• Walking Group

• Fresh Fruit Program

• “Count Us In” – Social Inclusion Program

• “Go For Your Life” – “Get a Taste of This”

• Little Nippers Program

• Positive Body Image Program

• Men’s Health Event – “Pitstop with Parkin”

• Food Cents Program

• Make a Move

At CMH we also have an active Day Centre (Planned Activity Group) catering to the social and activity needs for members of our community, Janice and her team of volunteers are commended on their tireless work in support of our community through this program.

Clients this year have been on a variety of different outings in the district including Seniors’ Day, Winter Christmas Dinner, Church luncheons, concerts at Edgarley and visiting other Planned Activity Groups. Activities within the centre vary from visiting musicians, cooking to make sauces and custards in small quantities, pet visits ranging from dogs and cats to ferrets and the annual football tipping competition.

Above: Community Health Nurse, Mrs Paula Layley-Doyle, with Diversional Therapist, Mrs Janice Annett and Activities Person, Mrs

Karen Perry with their display on the activities held at CMH through the “Count Us In” Social Inclusion Program for Glenelg House Residents.

Above: Mr Michael Betinsky and Mr John Rooke attended the “Pitstop with Parkin” Men’s Health event organised by CMH

and are pictured with Guest Speaker David Parkin.

Above: CMH Planned Activity Group clients get into the spirit of St Patricks Day

23

HUMAN RESOURCES

During the 2009/10 year CMH employed 109 staff (full time, part time and casual) across the following labour categories.

Labour Category 2009/10 FTE 2009/10 FTE 2008/09 FTE Change

Nursing 56 37.64 40.42 -2.78

Administration & Clerical 9 8.74 7.64 1.1

Hotel & Allied Services 43 26.88 24.44 2.44

Ancillary Staff (Allied Health) 1 0.59 0.59 0* FTE – Full Time Equivalent

Labour Category JUNECurrent Month FTE

JUNEYTD FTE

Nursing 37.03 37.64

Administration & Clerical 6.7 8.74

Hotel & Allied Services 27.43 26.88

Ancillary Staff (Allied Health) 0.59 0.59

Education & Training Continuing education and skill development are essential in the changing face of healthcare. During the past 12 months CMH continued to support and encourage staff to increase their knowledge and skill base.

Education is provided both internally and externally through lectures, seminars and conferences. This year a total of 1225 education hours were clocked by staff attending external conferences.

This year will see the implementation of the new online learning system SOLLE (Southwest OnLine Learning and Education). The system will allow staff to enrol and complete courses online. It will also keep track of results and alert staff when they next need to complete a course. Courses currently available are Fire Training, Medication Administration, Elder Abuse and Restraint Minimisation.

Occupational Health & Safety Occupational Health and Safety continues to play a major role at CMH. The OH&S Committee which comprises of representatives from the different service areas and management meet regularly to discuss and address any concerns and issues that may arise. Staff are continually encouraged to act and work in a safe manner and to report any incidents or near misses. Through the operation of the OH&S committee, staff education and incident reporting CMH is ensuring the safety of staff, patients and visitors.

Workcover CMH was free from serious injury or death in 2009/10. No new Workcover claims were registered in the year and hence the premium was lower. The indicative performance rating was 87.9% which means that the claims costs compared to remuneration is 12.1% better than the average for the industries in which CMH operated in the last 3 years.

Criminal Record Checks Aged Care legislation requires mandatory criminal record checks for all employees every three years. All staff and volunteers at CMH have current police checks.

Victorian Health Incident Management System (VHIMS) 2009/10 saw the implementation of the Victorian Health Management System, an online reporting tool. All clinical and OH&S incidents are now reported online providing a more streamline process for incident reporting and management.

24

HUMAN RESOURCES cont/...

Years of Service CMH recognises years of service. During 2009/10 the following years of service were recognised:

5 YearsMichael Betinsky

Mark NolteDeborah Sealey

10 YearsKaren Perry

15 YearsAlison Jenkins

20 YearsPauline Carmichael

Judy CoulterHeather Gill

Employee of the Year Each year CMH recognises a staff member that has contributed to the reputation and success of CMH. This year the award was presented to Barb Toma for her outstanding contribution and dedication to CMH in administrative and financial operational management since she commenced in May 1988, together with her energy and drive with fundraising support through her role with the Murray to Moyne Cycle Relay team.

Above: CMH Chief Executive Officer, Owen Stephens, presents Mrs Barb Toma with the 2009 Employee of the Year award.

Left: A Board recognising CMH Employee of the Year winners since its introduction in 1997 has been put on display in the Hospital

Above: Glenelg House Staff congratulate CMH Trainee, Brittnee Tait (sitting), on completing her School Based Traineeship and being awarded with the Westvic Excellence Award for 2010

Comments from Patient Questionnaires

“Always lovely staff, friendly faces and great care.”

“Staff very friendly, supportive and helped wherever possible.”

“The kindness and understanding of all staff was wonderful”

“The service from all personnel in the hospital was above standards. Atmosphere delightful.

Staff outstanding in all areas.”

“All staff were more than helpful in their duties, caring and thoughtful. It is always a pleasure to come to this hospital.”

25

Above: Personal Care Attendant, Dianne McKinnon and RN Division 1, Vanessa Sheahan got into the spirit of Christmas when

Santa made a visit to the Glenelg House Christmas Party.

Above: Shannon Hutchins shows Frank McInerney how to make fresh pasta as part of the Staff Health Month Activities in 2009.

STAFF LIST 2009/10

RN Division 1Betson, M.Bryan, S.Carlin, N.V.Cottier, E. *Coulter, J.M.Dehnert, S.D.Dillon, H.V.Farquharson, J.L.Gartlan, D.A.Gill, H.L.Gill, S.M.D.Gunning, P.S.Jenkins, A.J.Kettle, L.J.Makore, M.Makore, S.Makwati, O.Marimi, T.M.Markham, V.M.Matthews, J.A.McEachern, B.M.Nolte, S.J.O’Connell, M.P.Perry, A.K.Rees, C.M.Sealey, K.Sheahan, V.J.Taylor, A.C.

Community HealthBramall, S.N.Layley-Doyle, P.L.

Planned Activity GroupAnnett, J.M.

PhysiotherapistFleming, K.D.

RN Division 2Bogie, R.M.Bowman, I.T.Bryan, B.H.Condon, C.A.Gill, S.M.Gledhill, K. *Hamill, J.K.Johnson, C.Johnson, K.M.Jones, N.Kirby, H.M.Landwehr, N.K. *Lewis, J.L. *McArlein, K.M.Michau, R.Nesbitt, D.A.Norris, J.M. *Russell, M.Sealey, T.M. *Tait, P.M.Tibbles, W.K.Widdicombe, A.J.Wombwell, S.M.

Nursing Attendants / Personal Care WorkersBeever, A.Makore, G.McGrath, J.A.Pohlsen, S.W.Sealey, T.B.Steenholdt, L.J.Zippel, W.J.

Healthcare AttendantMcInerney, F.

Diversional TherapyGibbs, L.M.McKinnon, D.R.Perry, K.M.Telley, D.I. *

MaintenanceMalone, W.J.Naylor, M.L.Richardson, D.J.Tomkins, R.W.

Environmental ServicesBunik, I.Carter, L.M.Edwards, K.D.Harvey, E.T.Louden, D.J.McDonald, B.A.J.Reilley, R.F.Smith, C.L.Swann, C.E.Witty, P.A.

CateringBaugh, S.Chaffey, W. *Dickinson, S.L. *Gorman, M.M. *Hutchins, S.Kent, B.A. *Murphy, J.L.Murrell, H.J.Nadan, A.M.Naylor, J.H.Nolte, M.R.Norman, J.J.Northcott, C.J.Ross, V.L.Sealey, D.J.Southern, D.L.Talbot, P.J.Twardowski, G.M.

AdministrationBandel, G.M.Betinsky, M.J.Carmichael, P.G.Davis, S.S.Hulm, L.S.Macdonald, A.M.Rees, H.D.Stephens, O.P.Toma, B.G.

To provide appropriate Health, Aged Residential and Primary Care services to Casterton and district and seek to improve access for rural consumers to healthcare and related services.

To ensure that our services will be supported by appropriate resources and subject to ongoing population health planning, standards, risk management and quality improvement assessment.

GOVERNANCE CORPORATE & CLINICAL

• Maximise financial sustainability / administrative efficiency.

• By two Clinical Governance workshops. Staff and Board.

• On-going active participation in Area Based Planning for the Great South Coast sub-region.

• Continued Board education in-house and State level.

• Develop public information and communication strategy.

• Two new Board members to enhance current skill mix.

QUALITY IMPROVEMENT / RISK MANAGEMENT

• Maintain Aged Care accreditation 12/09.

• OH&S, legislative compliance and on-going risk assessment.

• Review and rationalise quality audits and safety checks.

• ACHS accreditation, the next plateau of achievement in 2011.

• Expand existing benchmarking models relevant to CMH.

• Agreed bipartisan medical staff communication and input policy / process.

HUMAN RESOURCES

• Ensure skills and competency to all service disciplines.

• On-going system of recruitment and workforce management.

• Increased education and training from external presenters.

• Map CMH workforce composition, current future needs.

• Senior personnel succession planning dialogue and planning.

• Improve and develop volunteer supports.

PHYSICAL FACILITIES / ASSETS

• General services zone redevelopment.

• Engage in next master planning exercise.

• Investigate supported accommodation models.

• Refreshed IT infrastructure SWARH and CMH.

• Assets and infrastructure capacity and fabric review.

• Review environmental control systems efficiency and effectiveness.

SERVICES DEVELOPMENT

• Detailed community survey on services and perceived population health needs.

• Increased health promotion and activities programs.

• Implementation of positive links program (Glenelg House) and broader community social inclusion for and with residents.

• Sustain existing mental health personnel and improve networks.

• Implementation and review for expansion CMH community transport service.

• Continue advocacy for air-strip up-grade 24/7 retrieval access.

CASTERTON MEMORIAL HOSPTIAL VISION STATEMENTAND TWO YEAR OVER-ARCHING STRATEGIC PLAN 2009–10

STRATEGIC OBJECTIVES & KEY PERFORMANCE INDICATORS

26

Caster ton Memor ia l Hosp i t a l63 - 69 Russe l l St r ee t , Ca s te r ton V ic 3311

Ph : 03 5554 2555 Ema i l : ma i l@cmh .or g . au Webs i te : w w w.ca s te r tonmemor ia lhosp i t a l . com . au