Calvary Health Care Bethlehem (PDF 524kb) - Department of Health

2010-11
Statement of Priorities
Agreement between Minister
for Health and Calvary Health
Care Bethlehem Limited

Calvary Health Care Bethlehem
Background ................................................................................................... 3
Policy directions and priorities .......................................................................... 3
Part A: Strategic overview ................................................................................. 7
Mission statement .......................................................................................... 7
Service profile ............................................................................................... 8
Strategic planning .......................................................................................... 9
Strategic priorities for 2010-11 .......................................................................... 9
Part B: Performance priorities .......................................................................... 10
Financial performance ................................................................................... 10
Service performance ..................................................................................... 10
Part C: Activity and Funding ............................................................................ 11
Accountability and funding requirements ........................................................... 12
Signature ..................................................................................................... 12
2

Calvary Health Care Bethlehem
Background
Statements of priorities are key accountability agreements between Victorian public health services and
the Minister for Health. The annual agreements facilitate delivery of or substantial progress towards the
key shared objectives of financial viability, improved access and quality of service provision. The content
and process for preparation and agreement of the annual statement of priorities must be consistent with
sections 65ZFA and 65ZFB of the Health Services Act 1988.
Statements of priorities are consistent with the public health services’ strategic plans and aligned to
government policy directions and priorities.
A statement of priorities consists of three parts:
Part A provides an overview of the objectives, priorities and outcomes the health service will achieve
in the year ahead.
Part B lists the key financial, service and access performance priorities and agreed outcome
measures.
Part C lists the activity targets and the funding provided.
Policy directions and priorities
The key policy documents and frameworks that provide direction for public health services include:
Victorian government policy
The Victorian Government’s priorities and policy directions are addressed in the Growing Victoria together
statement. Complementing this overarching vision statement is A Fairer Victoria, a whole of government
social policy action plan that addresses disadvantage and promote inclusion and participation.
In addition, the Victorian government has recently signed the Council of Australian Governments (COAG)
National Health and Hospitals Network Agreement, which commits the government to work towards some
key national targets, national activity based funding and Local Hospital Networks (LHN).
Integral to the agreement is a funding partnership between the Commonwealth and the States, for which
Funding Authorities will be established. The Commonwealth will be established as the majority funder of
public hospital services and the States will be responsible for system-wide public hospital service
planning, performance and purchasing. LHNs will be established by State governments to manage
designated hospitals and budgets and will provide services purchased by the relevant State under a “LHN
Service Agreement”.
An Independent Hospital Pricing Authority (IHPA) will be established to develop a nationally consistent
funding system, based on the national efficient price of each public hospital service. The new national
funding model will include activity-based funding classifications, costing models and block funding, to be
paid via the funding authorities in each State.
Under the agreement, a new Performance and Accountability Framework will be developed for the
National Health and Hospitals Network, including national indicators agreed to by COAG in the National
Healthcare Agreement (NHA), and national clinical quality and safety standards developed by the
Australian Commission on Safety and Quality in Healthcare (ACSQH). New National Standards will be
developed to drive improved performance, beginning with emergency departments and elective surgery.
Hospital Performance Reports and Healthy Communities Reports will report performance for LHNs and
their hospitals.
3

Calvary Health Care Bethlehem
Health system policy
Victorian health services policy and funding guidelines 2010-11
Directions for your health system – Metropolitan Health Strategy
Rural directions for a stronger healthier Victoria – Update of Rural directions for a better state of
health
Victorian clinical governance policy framework – Enhancing clinical care
HealthSMART participation policy
Program-specific policy
Because mental health matters – Victorian Mental Health Reform Strategy 2009-19
Victoria’s Cancer Action Plan 2008-2011 – Innovation in care-saving lives
Close the Gap: Indigenous Health Equality Summit – Statement of Intent
Better Faster Emergency Care – Improving emergency care and access in Victoria’s public hospitals
Improving care for older people – A policy for Health Services
Victoria's intensive care services: Future directions, 2009
Patient-centred surgery: strategic directions for surgical services in Victoria's public hospitals, 2010-
2015.
Victorian public hospital specialist clinics - Strategic framework
Future directions for Victoria's maternity services
2010-11 State Budget initiatives
Key initiatives of the 2010-11 State Budget will create capacity to meet growing demand for hospital
services and include funding to:
expand inpatient services to treat additional patients and open additional beds in acute, sub acute and
critical care services
meet demand for radiotherapy, chemotherapy, renal dialysis
invest in mental health services and support mental health service redevelopment and reform
expand palliative care, post-acute care and provide additional sub acute and transition care places
expand the Hospital Admission Risk program, including the Residential In-Reach Program, and
provide additional community rehabilitation services
treat extra elective surgery patients
support new health, aged care and community services infrastructure
increase the health workforce and support health workforce reform
provide ongoing ambulance services
4

Calvary Health Care Bethlehem
Investment Policy Guidelines for Victorian Public Hospitals
The Government continues to promote the prudent management of the financial assets and liabilities of
Victorian public hospitals. While the hospitals have a primary responsibility for the effective delivery of
health care to the public, the Board also has a fiduciary responsibility in managing the financial assets
held by the hospital on behalf of taxpayers, donors, residents and employees.
The Guidelines set out the roles and responsibilities of the hospital Board and management in:
Understanding the legislative framework and Victorian public hospital guidelines governing
investments
Understanding the key stakeholder interests in managing a hospital’s investment monies
Setting investment policies and objectives that align to the various stakeholder interests
Understanding the risk management approach being adopted by management in managing these
investments.
The Guidelines also provide an illustrative set of authorised investments and risk limits that the Board may
adopt, including the prohibition of leverage, direct derivatives, hedge funds and structured investments as
well as sample investment reporting that the Boards should be reviewing on a regular basis.
Health services are required to assess their current approach to managing investments against these
guidelines and address any deficiencies. The checklist included in the guidelines should be completed
and provided to the Board on an annual basis, as assurance that appropriate practices are in place.
Data Integrity
Accurate data is critical for maintaining public confidence in the health system, health service performance
monitoring, and health system performance reporting, policy and planning.
Public health service boards are accountable for the accuracy of reported data. Boards are expected to
make data integrity the responsibility of their Audit Committee, and ensure that data accuracy is subject to
appropriate controls, including regular internal audit.
A number of initiatives were implemented in 2009-10 to strengthen data accuracy at Victorian health
services, including:
Independent system-wide audits were completed at every hospital reporting elective surgery and
emergency department data
Six random spot audits were undertaken at selected health services
The Elective Surgery Access Policy was updated to provide clear direction to health services on the
active management of elective surgery patients
A Director of Data Integrity was appointed to co-ordinate the audit program and investigate complaints
about public hospital data
A data attestation statement is required from the accountable officer in each health service’s annual
report
Data definitions and reporting standards have been clarified
To ensure continuing integrity, the Minister for Health announced the introduction of a rolling three year
audit program for elective surgery waiting list and emergency department data. From 2011, every public
hospital will have each data collection audited at least once in each three year period. Audits will cover
data accuracy, and health service compliance with policies and business rules.
5

Calvary Health Care Bethlehem
In 2010-11 public health services are required to:
Complete implementation of security improvements for elective surgery and emergency department IT
systems, including implementation of unique user identity and password controls, and the activation of
transaction logs
Implement recommendations from system-wide and spot audits, and from the Auditor-General’s report
titled Access to Public Hospitals: Measuring Performance, April 2009
Make a data attestation in the health service’s annual report
Comply with the Standing Direction of the Minister for Finance titled Information Collection and
Management.
6

Calvary Health Care Bethlehem
Part A: Strategic overview
Mission statement
Calvary Health Care Bethlehem (CHCB) Mission Statement:
To bring the healing ministry of Jesus to those who are sick, dying and in need through "being for others":
In the Spirit of Mary, standing by her Son on Calvary;
Through the provision of quality, responsive and compassionate health and aged care services;
Based on Gospel values; and
In celebration of the rich heritage and story of the Sisters of the Little Company of Mary.
At CHCB our Vision as a Catholic Health, Community and Aged Care provider, is to excel and be
recognised, as a continuing source of healing, hope and nurturing, to the people and communities we
serve.
Our Values are encompassed in the “Spirit of Calvary”
We welcome you and care about your experience at Calvary
We go out of our way to support each other and help the people we serve
We provide quality compassionate care for the whole person
We listen and learn so that we can get better at what we do
We celebrate our successes and are proud members of the communities in which we work
We recognise and promote the value of high performance
We protect and develop our resources and environment
As part of the consultation process surrounding the National Health Reforms, CHCB considers the
following principles as important to achieving its Vision:
The ongoing role of CHCB as a Catholic health service, respecting our own ethical principles and
governance arrangements.
That CHCB is able to freely pursue its Mission through the provision of quality, responsive and
compassionate health care.
Where existing services are provided and new ones proposed that CHCB is treated equitably so that
our long term role in service delivery is in no way diminished.
That we ensure that our relationship with government and insurers is underpinned by a maximum
transparency of funding and clearly defined performance expectations.
That CHCB is free to act commercially as it considers its strategy and makes operational decisions.
7

Calvary Health Care Bethlehem
Service profile
CHCB is a not for profit, subacute hospital and is a service of the national organisation, Little Company of
Mary Health Care. CHCB is recognised as a provider of specialist palliative care and a state-wide
specialist in progressive neurology, in particular Motor Neurone Disease, Huntington’s Disease and
advanced Multiple Sclerosis. Our interdisciplinary, specialist model of care provides high quality,
compassionate care in a range of settings. Our interdisciplinary teams include specialist medical, nursing,
allied health, pastoral care and bereavement with the support of trained volunteers. All patients are
admitted for pain and symptom management, restorative care, respite care or end of life care.
Our service was accredited by the Australian Council of Hospital Standards in 2009 and received four
year accreditation.
The 70 bed subacute inpatient facility receives GEM (Geriatric Evaluation and Management) and palliative
funding and provides two 20 bed palliative/GEM wards and a 30 bed progressive neurology ward. CHCB
is an aging facility in poor physical condition which poses challenges for CHCB’s financial and operational
sustainability, in addition to our reputation as a specialist provider. The configuration of the site is not
suited to the delivery of modern health services and optimal patient experience and hinders development
of our model of care and expansion of services. In addition, there is a high cost of repair and
maintenance and associated risks due to the ageing infrastructure.
Our ambulatory services provide services in both specialist streams to patients in their home or residential
facility, in addition to a range of programs through Day Centres and Outpatient Clinics.
The Neurological Ambulatory Service provides specialist consultation and support for clients and their
families, which focuses on those with advanced progressive neurological disease and more complex
needs. This is complemented by outpatient clinics and neurological day centre which both operate 3
days per week.
The Community palliative care service provides specialist consultation and support for clients and
their families with a terminal illness. This service provides specialist consultation, education and
support, in addition to an after hours service. The service is complemented by the palliative day centre
which operates 2 days a week.
Both day centres promote well-being, social interaction and independence, in addition to providing respite
for carers.
The integration of our hospital based and ambulatory services ensures that patients are supported
according to their needs through a coordinated model of care and can be transitioned from one level of
care to another in a seamless way. The interdisciplinary team works in collaboration with the patient’s
general practitioner, medical specialists and other health professionals or services to ensure optimal care
delivery.
By developing partnerships with peak bodies, health professionals and community services we can
achieve our goal of a fully integrated network of services, and develop our capacity in relation to
education, training and research which are essential as a statewide provider.
System improvements identified for 2010-2011 are:
Complete the restructure and redesign of ambulatory services.
Completion and evaluation of care planning project.
Ongoing implementation of research and education framework.
Implementation of Information Technology plan which includes e-health medical record.
Community engagement strategy.
Implementation national LCMHC OH&S project.
CHCB service priority is to work closely with the Department of Health in exploring options available to
address current infrastructure issues, and to develop a sustainable specialist model of care and become a
recognised Centre of Excellence.
8

Calvary Health Care Bethlehem
Strategic planning
CHCB health service strategic plan can be read at http://www.bethlehem.org.au/aboutus/docs/CHCBServicePlan.pdf
Strategic priorities for 2010-11
Strategic priorities
Workforce
1
2 Model of Care
3 Excellence in Care
4 Service and capital planning
5 Community engagement
6 Corporate governance
Deliverables/outcomes
Workforce strategy: OH&S, reduction in Lost Time Injuries,
development suite of HR KPI’s for benchmarking, reduction in
sick leave.
Culture: Values in action programme incorporating customer
service training; Moderate Achievement in Mission Audit;
improvement in staff satisfaction.
Research and Education framework: Leadership program for
emerging leaders developed and implemented; complete
Palliative Model of Care Research project; restructure of Centre
for Education and Development completed.
Complete review of ambulatory and neurological inpatient
services: Finalise redesign of neurological ambulatory services
and develop a strategy with Department of Health for minimising
fragmentation of funding streams for neurological ambulatory
services in order to support optimal model of care.
Transmit VINAH data to the department
Expand statewide consult model for palliative and neurological
care: Develop sustainable palliative care consult model for
Gippsland region; increase neurological satellite clinics;
Nurse practitioner role incorporated into community palliative
care service.
Care planning project implemented in all service areas.
Implement e-prescribing and health record.
Benchmarking of clinical outcomes (Palliative Care Outcomes
Collaboration) commenced.
CHCB will continue to work with the Department of Health in
exploring the options available to address current infrastructure
issues; the options being redevelopment of the Kooyong Rd site
and the planned relocation to Kingston. Contribute to
Department of Health development / preparation of Business
Case by November 2010.
Work with the Department of Health on alternative options if
required, following incoming government commitments and
budget outcomes.
Cultural diversity/health promotion strategy: One new health
promotion activity with local school.
Community benefit: One new palliative care program scoped
and implemented.
Refurbish mortuary viewing area in collaboration with community
involvement.
Implement Resourcesmart strategy and develop KPI’s.
Complete review of capital expenditure process and procedures
by Dec 10.
Implement new telephony system.
9

Calvary Health Care Bethlehem
Part B: Performance priorities
Financial performance
Operating result
2010-11 target
Annual operating result ($m) 0
Cash management/liquidity
Creditors
Debtors
2010-11 target
< 60 days
< 60 days
Service performance
Quality and safety
Health service accreditation
Cleaning standards
2010-11 benchmark
full compliance
Full compliance
Hand Hygiene Program compliance (%) 65
Victorian Patient Satisfaction Monitor (VPSM) 73
SAB rate (OBDs) Less than 2/10,000
10

Part C: Activity and Funding
Calvary Health Care
Bethlehem
2010/11
2010/11
Activity and Funding Type Activity Budget ($'000)
Sub Acute Inpatient
GEM (non DVA) 10,417 $7,348
Palliative Care - Inpatient 13,666 $7,488
Palliative Care - Unassigned 115 $63
Palliative Care - DVA 444 $293
Ambulatory
Non VACS Outpatients $10
Hospital Admission Risk Program (HARP) $107
SACS - Non DVA 2,500 $1,427
Post Acute Care $41
Palliative Care - Other $508
Palliative Care - Community 33,826 $2,759
Aged Care
Other Aged Care $1,367
Other
Specified Grants $372
Total Funding $21,784
Funding for Service Agreement Management System (SAMS) as rolled over on 1 July 2010
Due to the machinery of government changes only Dept of Health funding is included for 2010-11
11