Colac Area Health Annual and Quality of Care Report 2009

Colac Area Health
Annual and Quality of Care Report
2009
* Photo courtesy of The Colac Herald
Respect I Integrity I Leadership I Innovation I Quality I Partnership

Vision
Colac Area Health aims to be a recognised
leader in the development and provision of
responsive, integrated health care.
Mission
To promote the health and wellbeing of the
Colac and district community through the
provision of quality acute, aged, residential
and community services that are accessible,
affordable, flexible and integrated.
Corporate Values
Respect
Integrity
Leadership
Innovation
Quality
Partnership
2 Colac Area Health

Inside
Contents
Page
Vision, Mission and Corporate Values 2
Highlights 4
Our Organisation 5
Our Services 6
Our Performance 7
Our Community 8
Auxiliaries 8
Bequests and Donations 8
Making a Donation 8
Community Partnerships 8
Volunteers/Certificates of Service 8
Organisational Structure 9
Chairman and CEO’s Report 10
Strategic Direction 13
Corporate Governance 16
Executive Team 17
Risk Management 17
Board Directors 18
Clinical Services 21
Acute Care Unit 22
Corangamarah Residential
Aged Care Facility 23
Preadmission and Discharge
Planning Clinic 24
Perioperative Service 25
Day Surgery Unit 26
Haemodialysis Unit 26
Emergency Department 27
Community Nursing 27
Infection Control 28
Page
Education Centre 29
Birregurra Community Health Centre 30
Quality and Staff
Development Services 31
Visiting Medical Staff 35
Medical Services 36
Health Information Services 37
Community Services 38
Allied Health 39
Family and Community Programs 42
Human Resources 44
Occupational Health and Safety 44
Service Awards 45
Staffing Profile 46
Support Services 47
Waste Management 48
Supply Department 49
Information and Communication
Technology 50
Statutory Compliance 51
Disclosure Index 53
Financial Services 54
Certification 55
Auditor-General’s Report 56
Financial Statements 58
Acknowledgements/Publications 85
Consumer Liaison 85
2009Annual and Quality of Care Report 3

Highlights
Way Finding project
completed in May 2009.
enabling clear access
throughout the CAH site.
Con.ceit ‘08 - Winner Mark Threadgold
“From Where We Were Standing We Knew
We Only Had Two Options”
Corangamarah garden upgrade
commenced in April 2009.
Designed by Karen Harvey.
The mobility
garden - a joint
project with
Rotary.
4 Colac Area Health

Our Organisation
Colac Area Health (CAH) provides services to Colac
Otway, Corangamite and Surf Coast shires with a
catchment population of about 30,000. Colac Area
Health is a unique, integrated health service model
which provides Acute, Residential Aged Care and
Community services. Colac Area Health currently
operates an acute public health service (50 beds),
Corangamarah Residential Aged Care facility (75 beds),
Birregurra Community Health Centre, Community Dental
Clinic, Community Nursing incorporating Home and
Community Care, Hospital in the Home, Post Acute Care,
Palliative Care and an extensive range of Community
services.
Our History
Colac Community Health Services was established
on July 1, 1995, by the amalgamation of Colac
District Hospital, Colac Area Community Health
Centre Incorporated and Colac Housing and Financial
Counselling Service. A further amalgamation took place
with the Birregurra and District Community Hospital
on January 1, 1997. From July 1, 2002 the organisation
officially became known as Colac Area Health.
Suite and Central Sterilising Department.
In August 2006, CAH completed Corangamarah, a $14
million state-of-the-art Residential Aged Care facility
which provides High Level Residential and Respite Care
and comprises 75 beds; 14 twin-share and 47 single
rooms and includes a dementia-specific unit.
Corangamarah has numerous private courtyards, as well
as having landscaped gardens for residents and relatives
to enjoy. While the facility incorporates large communal
gathering areas, there are also private areas for residents
to take time out for personal relaxation.
In 2008, the final stages of the redevelopment were
completed with the refurbishment of Otway Pioneers
and the Polwarth House Service Centre, which
now accommodates Community Services staff, the
construction of a sealed car park and the establishment
of a Community Dental Clinic on the main campus.
Colac Area Health commissioned the services of Dr
Dawn Peel to document our comprehensive history. Her
book “Quality Community Care — Colac District Hospital
1882 to Colac Area Health 2003” was officially launched
in March, 2004.
Colac Area Health commenced a major redevelopment
project in December, 2001. Stage 1A comprised the
construction of a two-storey building which provided
temporary accommodation for the Primary Care
(now known as Community Services) staff until 2007
and permanent accommodation for pharmacy and
pathology services. This building has since been named
the Galvin-McCarthy Building and includes the Helen
McPherson Smith Trust Conference Centre, Speirs
Meeting Room and accommodates the Executive Team
and Administration Staff.
Stage 1B, the Acute Medical Services building, was
completed in February, 2003. This was the first major
redevelopment of acute patient services since 1971. This
building comprises 15 single rooms, nine twin-share
rooms, two four-bed rooms, two birthing suites, seven
day surgery beds, Emergency Department, Operating
About Colac
The Colac Otway Shire is one of the most picturesque
municipalities in Victoria, covering a diverse area from
volcanic lakes, craters and plains in the north, through
to the hinterland forests of the Otway Ranges to the
Great Ocean Road coastline. The area provides diverse
employment through a range of primary industries,
tourism and commercial and community services.
Colac is the key industrial, commercial and service centre
for the Colac Otway and surrounding region with a
population of 21,000.
2009 Annual and Quality of Care Report 5

Our Services
Acute Care
• Acute Care
• Day Chemotherapy
• Emergency Department
• General Medicine
• Haemodialysis
• Midwifery Services
• Obstetrics and Gynaecology
• Pharmacy
• Rehabilitation
• Surgery - Dental, Endoscopic, General,
Gynaecology, Ophthalmology, Orthopaedic,
Urology
Aged Care
• High Level Residential and Respite Care
Allied Health
• Adult Day Activity Centre
• Community Dental Clinic
• Community Rehabilitation Centre
• Health Promotion
• Nutrition
• Occupational Therapy
• Physiotherapy
• Podiatry
• Social Work
• Speech Pathology
Community Nursing
• Barwon Post Acute Care
• Birregurra Community Health Centre
• Community and Adolescent Health
• Community Women’s Health
• Continence Support
• Diabetes Education
• Home Nursing
• Hospital in the Home
• Lymphoedema Clinic
• McGrath Breast Care Clinic
• Palliative Nursing Care and Support/Volunteers
• Wound Management Resource
Family and Community
Programs
• Alcohol and Other Drugs
• Colac Neighbourhood House
• Child FIRST Intake
• Children’s Resource Program
• Family Support
• Family Violence
• Financial Counselling
• Housing Support
• Regional Women’s Health
• Saver Plus Program
• Supported Accommodation Assistance Program
• Regional Networker
• Women’s Counselling
• Youth Development
• Youth and Children’s Counselling
Diagnostic Services
• Pathology
• Radiology/Medical Imaging
Visiting Services
• Barwon Community Legal Services
• Drink Driver Education Program
• Family Planning
• Geelong Centre Against Sexual Assault
• Geriatric Services
• Ophthalmology
• Pharmacotherapy Provider
• Prosthetics and Orthotics
• Victims of Crime
• Victorian Legal Aid
Co-Located Services
• Department of Human Services Child Protection
• Diversitat
• Glastonbury Family Services
• Neighbourhood Renewal
• Pathways
• Time for Youth
6 Colac Area Health

Our Performance
2008/2009 2007/2008 2006/2007 2005/2006 2004/2005 2003/2004
Financial
Total Revenue 31,602,538 30,293,886 29,421,802 34,497,391 27,362,187 25,165,947
Total Expenditure 31,806,210 29,863,963 28,783,276 27,876,313 27,266,900 25,676,618
Revaluation Increment 3,759,284 821,236 - 5,602,270 - -
Surplus/(Deficit) inc. Capital
Income and Unfunded Depreciation (203,672) 429,923 638,526 12,223,348 95,287 (510,671)
Total Assets 47,307,421 44,355,128 42,905,863 41,823,383 28,938,566 29,007,894
Total Liabilities 5,822,403 6,426,450 6,582,740 6,796,864 6,484,135 6,808,388
Total Equity 41,485,018 37,928,678 36,323,123 35,026,519 22,454,431 22,199,506
Staff
Full Time Equivalent 286.83 283.41 285.29 285.90 285.60 282.55
Bed Days
Hospital 12,849 13,279 14,608 13,417 13,495 13,602
Average Length of Stay 2.49 2.52 2.84 2.67 2.78 3.05
Aged Care 23,766 26,478 26,901 25,418 24,385 25,965
Births 217 216 187 179 194 190
Operations 2,414 2,304 2,168 2,280 2,190 1,999
Inpatient Statistics
Same Day 2,545 2,680 2,649 2,722 2,524 2,231
Multi Day 2,595 2,527 2,484 2,308 2,342 2,231
TOTAL SEPARATIONS 5,140 5,257 5,133 5,210 5,060 4,462
Weighted Inlier Equivalent Separations (WIES) 3,006 2,997 3,144 3,019 2,925 2,822
Aged Care Statistics
Residents 128 111 126 127 140 155
Emergency Department
Emergency Attendances 7,793 7,914 7,296 7,029 6,941 8,091
Community Services
Total Contacts 60,313 57,097 57,286 56,951 51,092 52,707
Total Clients 13,591 12,871 9,499 9,422 8,614 8,697
Patient Fees Outstanding – Outstanding Debtors as at 30 June 2009
Under 30
Days
30-60
Days
60-90
Days
Over 90
Days
Total
30/06/09
Total
30/06/08
Total
30/06/07
Total
30/06/06
Total
30/06/05
Private 82,241 8,810 636 968 92,655 74,840 60,515 10,251 140,263
TAC - - - - - - - - -
VWA 12,276 0 0 1,498 13,774 12,906 8,999 6,006 7,350
2009 Annual and Quality of Care Report 7

Our Community
Auxiliaries
Colac Area Health (CAH) recognises the valuable
contribution of our Auxiliary members over
many years. The members have raised thousands
of dollars which has enabled CAH to purchase
equipment, furnishings and fittings to benefit the
community when using the Health Service. In
August 2008, CAH was presented with a cheque for
$3,000 by the Colac Auxiliary.
The Birregurra Community Health Centre Auxiliary
continues to support the Community Health
Centre at Birregurra and provides ongoing
fundraising which assists with the purchase of
equipment for the Centre. The Auxiliary provided a
further donation of $1,400 in June 2009.
Bequests and Donations
As a result of fundraising campaigns, local
community members, auxiliaries, volunteers,
service clubs and groups, bequests, local
businesses and CAH staff have raised in excess of
$173,458.
Colac Area Health acknowledges the receipt of the
following funds:
• Estate RJ Speirs $128,710
• Palais Bingo $ 3,000
• Lions Club of Colac $ 1,247
Making a Donation
Colac Area Health is very fortunate to receive
generous contributions from our community
through donations and bequests.
We encourage you to consider Colac Area Health
when making your Will. If you wish to discuss this
further, please contact the Chief Executive Officer
on (03) 5232 5123. All enquiries are treated with
the strictest confidence.
Community Partnerships
Blue Ribbon Foundation
A small but dedicated committee came together
seven years ago with a novel idea to host a rodeo
in Colac. This event became part of the New Year
calendar for many, attracting enthusiastic crowds.
Due to circumstances beyond our control, the 2008
Rodeo was cancelled. In January 2009 the Rodeo
was again held at the Colac Showgrounds and
attended by a large crowd. This event will continue
to raise awareness of this important foundation
while raising funds to purchase vital equipment for
the Emergency Department at CAH.
Volunteers
Colac Area Health currently has 150 registered
volunteers, excluding palliative care volunteers.
These volunteers continue to be recognised as
a vital part of CAH and provide assistance in the
following areas:
- Adult Day Activity Program
- Colac Area Health Auxiliaries
- Neighbourhood House
- Flower Ladies
- Pastoral Visitors
- Residential Aged Care
Certificates of Service
Certificates of Service are awarded to volunteers
on completion of ten years service.
Recipients at the Annual General Meeting held in
November 2008, were as follows:
- Mr. Anthony Graham – Board Director
- Mr. Wayne O’Brien – Board Director
- Mr. Richard Riordan – Board Director
- Mrs. Helene Brown – CAH Auxiliary
- Mrs. Alma Oborne – CAH Auxiliary
8 Colac Area Health

Organisational Structure
The Community
Director
Clinical Services
Assistant Director Clinical
Services - Patient Services
Assistant Director Clinical
Services - Aged Care
Board
of
Directors
After Hours Clinical
Coordinators
Coordinator Quality & Staff
Development
Chief
Executive
Officer
Director
Community Services
Manager
Allied Heatlh
Manager
Family & Community
Programs
Director
Corporate Services
Finance Manager
Financial
Accountant
Manager Information &
Communication
Technology
Manager
Administration Services
Manager
Supply Services
Manager
Support Services
Director
Human Resources
Payroll Co-ordinator
Director
Medical Services
Manager Pharmacy
Manager Health
Information Services
2009 Annual and Quality of Care Report 9

Chairman and CEO’s Report
In accordance with the Financial Management
Act 1994, we are pleased to present the Report of
Operations of Colac Area Health (CAH) for the year
ending 30 June, 2009.
2008/09 financial year is the first of recent years
that was not benefitted by substantial capital
inflow for facilities development. The year was a
challenging one for the Board and staff at CAH.
Notwithstanding the challenges of financial
management it was a year of achievement which
included:
• Development of an External Environment
Improvement Strategy that saw:
o The commencement of the Corangamarah
Garden Redevelopment Project that, when
completed, will provide the residents and
families of Corangamarah a wonderful
garden precinct to enjoy; the Board and
staff of CAH are appreciative of the support
of the Speirs family who provided the funds
to bring this project to fruition – an
achievement the local community can be
proud to own.
o Establishment of native plantings across the
car park.
o An intention to continue to improve the
surrounds of CAH by revamping the
entrance to Polwarth House from Miller
Street and establishing a garden along
the After Hours Entrance to the Galvin-
McCarthy Building during the 2009/10
financial year.
• Improved signage across the organisation called
“Way Finding”. The project was part of the Long
Stay Older Persons Project funded by
government and has provided a significantly
better schema to direct pedestrian traffic
throughout the organisation. The Board is
grateful to the Department of Human Services
(DHS) for their initiative with this project.
• Improving the internal environment of
Corangamarah to make the facility much more
“home like” by providing improved window
coverings and furnishings. It has been gratifying
to receive the positive comments from residents
and their families on these improvements.
In keeping with Board strategy to enhance
rehabilitation services at CAH, the Mobility Garden
Project was completed during 2008/09. The
Mobility Garden has been developed to assist
with Occupational Therapist’s assessment on
rehabilitation patient’s mobility. The project could
not have been completed without the wonderful
support of the Rotary Club of Colac West and
BDH Constructions. The Board wishes to express
sincere appreciation to both Rotarians and
BDH Construction staff who contributed many
volunteer hours to bring the project to fruition.
During 2008/09 the Board reviewed the
operations of the Risk Committee with Dr. Heather
Wellington. A number of recommendations were
made that have been considered and will be
implemented in the 2009/10 financial year.
In the 2007/08 Report, comment was made on
the introduction of a new budget management
system. Further work was undertaken during
2008/09 financial year to establish stronger
budget management processes; the benefits
of this work should come to the fore during the
2009/10 year.
The introduction of a new payroll system has
provided positive effect across the organisation
with the significant reduction of payroll queries
from staff. Current rate of payroll queries has
reduced from 30-40 per pay to less than 5, making
for happier staff and improved morale.
Preparations are well underway to welcome
Deakin University medical students in 2010.
Concept and design work has commenced on
the establishment of an education facility in the
Otway Pioneers building as originally intended.
The facility will provide accommodation for
current Quality and Staff Development Unit staff,
Deakin University staff and students. The Board
looks forward to seeing all the planning come to
10 Colac Area Health

fruition. Thanks to Professor Brendan Crotty and
his team at Deakin University for their ongoing
support.
The Board is delighted to report that the relocation
of the Dental Clinic onto the main campus site has
produced positive results. The increase of chairs
from a previous three to five has seen a reduction
of waiting time by six months, from three years to
two and a half years. While acknowledging the
difficulties of having to wait for such a period, the
reduction over the last six months is a credit to Dr.
Michael Smith, Director, Dental Health Services,
Barwon Health, and his staff who are contracted to
provide the service.
Colac Area Health enjoys a positive relationship
with Visiting Medical Staff and Practice Managers.
2008/09 has been a challenging year with the
departure of Dr. Danny Jones who, for family
reasons, moved away from Colac. The departure
of Dr. Jones lead to a negotiated arrangement for a
joint roster between Colac’s General Practitioners
to provide after hours cover for obstetric services.
The Board expresses its appreciation to Dr.
Justin Madden, Chair Visiting Medical Staff, and
his colleagues for the positive way in which
negotiations were addressed and resolved.
2008/09 was a busy year for the Service. Inpatient
activity at CAH was 5,140, very similar to the
previous year, emergency presentations were
slightly less with 7,793 presentations, 217
babies were born during the year, with one
notable occasion of nine births within 24 hours.
Community Services remained a busy service with
13,591 clients and 60,313 contacts. Even though
the Bed Days in Aged Care were lower than last
year, more residents were accommodated during
the year.
Two key projects will be addressed by the Board
during 2009/10 financial year:
• Establishment of suitable student
accommodation for the many students who
undertake clinical placement and work
experience at Colac Area Health.
• Commencing discussions with Department of
Human Services to replace the kitchen facility
which has equipment that is 15-17 years old.
During the year the Board engaged Aspex
Consulting, with the support of Department
of Human Services, to review the financial
performance of Colac Area Health and to develop
a service model for the next five to seven years.
Considerable work had been undertaken by
year end and will be concluded during 2009/10
financial year.
The service model developed will provide a basis
on which organisation strategy will be built.
CAH has formed an access and equity working
party that will be working on the Disability Action
Plan and the Cultural Plan. The working party has
staff from across the organisation to give input and
ensure a representative plan is developed.
In December 2008, the Board sadly learned of
the untimely passing of Peter Bunter, Manager,
Health and Aged Care, Barwon South Western
Region, Department of Human Services. Peter had
developed a good working relationship with staff
at Colac Area Health and Board.
Jan Snell, Regional Director, DHS, was farewelled
in September 2008 after seven years in her role.
The Board welcomed Jim Higgins to the region
as Regional Director who commenced on 1
September 2008.
In April 2009 we farewelled Pauline Maunsell,
former Manager, Allied Health Services, who
retired. Pauline had been with Colac Area Health
for 29 years and was instrumental in many
initiatives and changes during her time. The Board
wishes Pauline well in her retirement.
Colac Area Health welcomed Marie Shea, Director
Community Services and Strategy, in July 2008.
We farewelled Garry Ellis, Director Corporate
Services , in March 2009, after which Marie Shea
was Acting Director Corporate Services and
Margaret White was Acting Director Community
Services. Dr Ed Davis was appointed Director
Medical Services in November 2008.
As a recipient of a Colac Area Health “Employee of
the Month” award, Adam Lamanna, Information
and Communications Technology Support,
represented Colac Area Health in the “Employee
of the Year” category at the 2008 Powercor Colac
Otway Business Awards.
Once again, Richard Riordan, Chairman, Board of
Directors, provided leadership to the Board during
a year full of challenges; financially and service
wise.
During the year Richard farewelled Kathryn
McBride who resigned to better meet work
commitments, and welcomed Tim McCue on to
the Board.
As Chair, Richard guided the Board through a
successful year.
2009 Annual and Quality of Care Report 11

The Corangamarah Art Prize – con.ceit ’08 was a
highlight in a busy year; for the second year the
winner was announced at a function held at Otway
Estate Winery and Brewery in August 2008.
The winning artist was Mark Threadgold of
Abbotsford, with his entry “From Where We Were
Standing We Knew We Only Had Two Options”.
For an organisation like Colac Area Health to be a
success many people are involved. The Chairman,
Board of Directors, and Chief Executive Officer,
take this opportunity to recognise and thank all
who contributed to the service during 2008/09
and, in particular, wish to record an appreciation
for the work of:
• Directors of the Board
• Executive and staff
• Program Managers, Team Leaders and staff
• Visiting Medical Staff
• Birregurra Community Health Auxiliary and
Colac Area Health Auxiliary
• Volunteers
• Birregurra Community Health Advisory
Committee
• Colac Neighbourhood House Advisory
Committee
• Regional Director and staff, Barwon South
Western Region, and Central Office staff,
Department of Human Services
• Business community of Colac
• Service Clubs, in particular Rotary Club of Colac
West
• Colac Otway community.
Richard Riordan
Chairman
11 September, 2009
Geoff Iles
Chief Executive Officer
11 September, 2009
12 Colac Area Health

Strategic Direction
During the 2008/09 financial year, particular
emphasis was placed on the following matters by
the Board:
Service System
Development
One of the most pressing challenges facing
medium sized health services in a rural location is
the sustainability of medical services. Colac Area
Health is no different in this respect.
Medical workforce challenges involve the difficulty
private medical practices have recruiting and
retaining medical staff, the ageing of the medical
workforce and the different aspirations and
expectations of the younger generation of doctors.
A consequence of the combined impact of these
drivers of change begs the question of whether the
current model of visiting fee-for-service medical
staff is sustainable and able to provide for future
demand. The Board is of the view that the fee-forservice
model is not sustainable and strategies to
support the current medical workforce have to be
put in place.
In response to this the Board has:
• Developed a “Grow Our Own” workforce
strategy which seeks to ensure Colac Area Health
is proactive in promoting both employment and
education opportunities for staff.
• Been proactive in its partnership with Deakin
University by developing an effective clinical
placement regime for medical students.
• Encouraged the engagement of other medical
schools to look to Colac for orientation into rural
practice and career opportunities.
• Determined to recruit a Career Medical Officer to
provide support to general practitioners within
the health service.
To support the “Grow Our Own” strategy,
Colac Area Health applied for and was granted
provisional accreditation as a “Teaching Post”
by the Australian College of Rural and Remote
Medicine (ACRRM) in 2008. An accreditation visit
was undertaken by the College on 27 March, 2009;
the health service is awaiting the outcome of the
visit.
Coupled with the workforce challenges is the ever
present vulnerability of obstetric services due to
a limited number of GP obstetricians. The Board
is very keen to see obstetric services on a sound
footing and for public services to be strengthened.
An objective of the Board is for Colac Area Health
to be more engaged and a partner in the provision
of both services and support during pregnancy,
including ante and post natal care, in collaboration
with GP obstetricians. During 2008/09 this model
has been debated and developed; it is anticipated
that during 2009/10 financial year, robust
arrangements can be put in place.
Management Information
& Business Systems
Over 2008/09 financial year improvements were
made to the internal management information
and business systems.
One of the barriers faced by Executive and
management has been the lack of an integrated
system that is able to provide timely management
information across all services and activities.
Trendcare, an existing system, has been revitalised
to provide better management information.
Further revitalisation of the system will occur
during the first six months of the 2009/10 financial
year.
During 2008/09 the budget management system,
Power Budget, was introduced. Directors and
managers have become more conversant with the
system over 2008/09 in line with the principle of
devolving responsibility to cost centre managers.
2009/10 will see continued improvements in the
area of resources management organisation wide.
2009 Annual and Quality of Care Report 13

Corporate Systems
Development and
Enhancements
Over 2008/09 additional reporting arrangements
have continued, with improvements to Human
Resources and Payroll systems. Work was
undertaken during the year to prepare for
Employee Self Service (ESS) system introduction
which should occur during the first six months
of the 2009/10 financial year. The ESS system
will provide ease of access for staff to their leave
records and entitlements, reducing the level of
enquiry on Human Resource staff.
Staff have been preparing for the introduction of
the Oracle financial system under Healthsmart
which will occur during 2009/10 financial year.
Work will continue to be undertaken to improve all
administration processes and systems during the
next financial year.
Facilities
Colac Area Health is indeed fortunate to have
an array of modern facilities. The redefining of
the Board’s Masterplan in 2006 has had many
advantages, most significantly the retention of
serviceable and versatile buildings that have
become integral and essential locales for service
delivery and accommodation. During 2008/09
financial year additional clinic rooms were
refurbished in Polwarth to support future service
development, particularly obstetric services.
Planning work has been undertaken to relocate
the Quality and Staff Development Unit to
Otway Pioneers building in preparation for
accommodating medical student placements and
Deakin University staff during 2010.
The Board has a priority to ensure pedestrian
access to the service is as safe as possible; during
2008/09 there has been considerable discussion
around safer pedestrian access to Corangamarah
that will complement the Corangamarah Garden
Redevelopment. With the assistance of Colac
Otway Shire, the Board will endeavour to improve
the pedestrian crossing in Corangamite Street and
to promote the construction of two pedestrian
crossings to the medical practices in Connor and
Miller Streets.
In line with the “Grow Our Own” strategy, the Board
is very keen to ensure that all students placed at
Colac Area Health have a fulfilling and safe clinical
placement. To this end the Board will continue to
advocate for the establishment of contemporary
student accommodation on Colac Area Health
property.
Operations and Services
To meet governance expectations and fulfill its
role, the Board, through the Risk Committee,
receives regular reports on Colac Area Health
operations. Detailed reports are provided on the
following range of activities and performance:
Residential Aged Care
o Occupancy management and trends
o Resident dependency and need mix based on
Resident Classification Scale (RCS) and Aged
Care Funding Instrument (ACFI). (It is worthy
to note that the RCS model of funding is being
phased out).
o Comparative daily revenue analysis.
Acute Care
o Public and private patients admissions patterns
compared with targets
o Weighted Inlier Equivalent Separations (WIES)
generated compared with targets
o Predicted Perioperative Admissions and WIES
throughput compared with targets.
o Estimated revenue generation compared with
target.
o Comparative trends with past year.
o Private patients throughput compared with
predicted throughput.
Community Services
o
Major Funded Activities monitoring activity
compared with target which includes the
following services:
• Allied Health
• Home and Community Care
• Home Nursing
• Rehabilitation Services
o Family and Children Services monitoring of
activities compared with target for a range of
activities including:
• Alcohol and Other Drugs Service
• Child FIRST
• Family Support
• Housing Services
• Saver Plus
• Family Violence
• Financial Counselling
14 Colac Area Health

Governance
As foreshadowed in the 2007/08 Annual Report,
the Board sought to have the operations of the
Risk Committee reviewed, this occurred in the first
half of the financial year.
The review found the Risk Committee functioned
very well and was fulfilling its governance
requirements. The review provided a range of
matters for the Board to consider early in the
2009/10 financial year.
A key component of the Risk Committee’s
operations is the review of a suite of Key
Performance Indicators (KPI’s) developed for Colac
Area Health covering Legislative compliance
requirements; quality indicators, financial
performance and funding targets; business
operational requirements.
During 2009/10 financial year the KPI suite will
be reviewed and improved drawing upon the
experiences of the past twelve months.
Over the last three years there has been
considerable conversation by the Board on the
development of a “Foundation” to assist with
fundraising to support Colac Area Health. During
the latter half of the financial year a range of advice
was provided to the Board for consideration about
the relative merits and obligations of establishing
a Foundation. The Board will determine a position
early in 2009/10 financial year.
Media
Colac Area Health enjoys a very good relationship
with both printed media and electronic media.
There has been positive media coverage of the
events at Colac Area Health; the Chief Executive
Officer meets regularly with The Colac Herald
and the Colac Extra journalists to promote
understandings of challenges facing the
organisation and to keep the community informed
of events, developments and achievements during
the year.
The Board particularly wishes to acknowledge the
support of both The Colac Herald and the Colac
Extra for their positive engagement of the Chief
Executive Officer and Executive staff throughout
the year.
Department of Human
Services
Colac Area Health is indeed appreciative of the
support, guidance and assistance offered by the
Department of Human Services.
2008/09 financial year has been a particularly
challenging one, both from a financial and services
development perspective. Notwithstanding these
challenges, there has been an effective and mature
relationship with Regional Office and Central Office
staff and the Board is most grateful for this.
Key Stakeholder
Engagements
• Victorian Healthcare Association (VHA).
During 2008/09 financial year Colac Area Health
continued to engage with VHA, as the peak
body for health services in Victoria, in a range of
discussions on policy matters.
The Board has been kept informed of emerging
trends and policy debate at state and
national levels through VHA membership.
• Barwon Health
Over 2008/09 Colac Area Health has, again,
received extensive support from Barwon Health
Executive on many matters including clinical
services support when required. The Board
records its appreciation of the continued support
from Sue De Gilio, Chief Executive Officer, and
her Executive over the financial year.
2009 Annual and Quality of Care Report 15

Geoff Iles
Chief Executive Officer
Commenced:
July 2006
Jill Dunbar
Director Clinical
Services
Commenced:
January 2008
Dr Ed Davis
Director Medical
Services
Commenced:
November 2008
Corporate Governance
Colac Area Health (CAH) is a Victorian publicly funded
organisation incorporated under the Health Services
Act 1988 and operates under the provisions of this
Act.
The Minister responsible for the administration of
the Health Services Act is the Minister for Health,
Hon. Daniel Andrews MLA. Colac Area Health is
accountable through the Board of Directors (BOD) to
the Minister for Health.
Colac Area Health is governed by a nine person
BOD appointed by the Minister. Board Directors are
appointed for periods up to three years and serve in a
voluntary capacity.
Governance refers to arrangements in place to
administer, manage and monitor services provided.
In past years the focus of the Board’s governance
obligations was in management and financial areas.
Today, public health service providers are required
to be more transparent and accountable to the
community in their governance obligations, such as
clinical governance and risk management.
The functions of the Board of Directors are:
• To conduct the Service in a manner that is
consistent with the Mission Statement and the
Health Services Act 1988
• To establish reporting mechanisms to monitor
the performance, reports and audit processes of
the Service and to ensure that they comply with the
Financial Management Act 1994
• The general governance of the Service
• To maintain proper accountability to government
by close observation of all legislative requirements,
ensuring that the Service diligently works towards
achieving or exceeding targets as agreed in the
Health Services Agreement and complies with all
standards governing the Service
• To ensure compliance with legislative requirements
governing Health Services and promote a safe,
effective, appropriate and consumer orientated
service within this legislative framework
16 Colac Area Health
• To annually review the past twelve months’
activities and set future direction
• To reflect the needs of the community and to
communicate policy and strategic direction by
consultations, publications and promoting the
profile of the Service
• To ensure that the Service provides a range of
appropriate services, promotes excellence and
supports educated, competent staff
• To promote good working relationships with
Government Departments.
Colac Area Health is addressing the governance
issues associated with Health Service delivery to:
• Meet community expectations by achieving quality
health service delivery
• Ensure there are corporate and clinical standards
for accountability and leadership within the Service
• Address the management and identification of
risks and hazards by implementing a
comprehensive clinical and non-clinical risk
management system
• Ensure staff and facilities are assessed, reviewed
and credentialled.
Board Orientation and
Education
Board Directors are kept abreast of governance
expectations and changes through advice provided
by Victorian Healthcare Association, Department
of Human Services and attendance at sub-regional
forums conducted by Department of Human
Services from time to time which the Chair attends
on the Board’s behalf.
Legislative changes are made known through law
updates and briefings by the Chief Executive Officer.
The range of advice provided aims to clarify the role,
expectations and accountability placed on Board
Directors in providing effective governance.

Donna Hay
Director Human
Resources
Commenced:
March 2008
Garry Ellis
Director Corporate
Services
Commenced:
December 2006
Resigned:
March 2009
Marie Shea
Director Community
Services & Strategy
Commenced:
July 2008
Acting Director
Corporate Services
from March 2009
Margaret White
Manager Family &
Community Programs
Commenced:
February 1999
Acting Director
Community Services
from March 2009
Under Board direction CAH strives to meet its
mission to promote the health and well-being of the
Colac and District community.
Committee Structure
The Board has established a committee structure
which complies with the Health Services Act 1988
and fulfils the requirements of the Board and the
Mission Statement to ensure that policies set in
place are community and client-focused.
The following are sub-committees of the Board:
Risk Commitee
This committee receives reports from the
Executive Directors which reflects compliance with
accounting standards and mandatory reporting
requirements along with service activities and
quality initiatives. Monthly monitoring of the
financial performance of the Service is undertaken
by the committee as are all aspects of both the
internal and external programs.
Clinical Appointments Advisory
Committee
This committee makes recommendations to the
Board on medical appointments.
Medical Staff Committee
This committee provides monthly reports on
particular matters of clinical nature.
Clinical Services Advisory
Committee
This committee provides advice on clinical services
development.
Executive Team
The Board of Directors has delegated the
operational activities of Colac Area Health to
the Chief Executive Officer, the Executive Team
and staff in accordance with the Instrument of
Delegation and the Health Services Act 1988
(Division 4 Section 33).
Risk Management
Attestation on Compliance with Australian/New
Zealand Risk Management Standard
I, Geoff Iles, certify that Colac Area Health 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 executives to understand, manage
and satisfactorily control risk exposures. The Risk
Committee verifies this assurance and that the
risk profile of Colac Area Health has been critically
reviewed in the last 12 months.
Attestation on Data Accuracy
I, Geoff Iles, certify that Colac Area Health has
put in place appropriate internal control and
processors to ensure that the Department of
Human Services is provided with data that reflects
actual performance. Colac Area Health has critically
reviewed these controls and processes during the
year.
Geoff Iles
Chief Executive Officer
Colac Area Health
20 August, 2009
2009 Annual and Quality of Care Report 17

Board Directors
Mr Richard Riordan,
Chairman
BBus (Management)
Richard is a local businessman,
and takes a keen interest in the
development and well being of the
Colac Otway community. Married
with 4 children, he is actively involved
in many aspects of Colac and district.
Richard is an enthusiastic supporter
of improving and developing
community services in Colac and
has been the driving force behind
the establishment of con.ceit
Corangamarah Art Prize.
Mr Anthony Graham,
Senior Vice-President
Adv Dip. Disability Work, Dip FMI,
Dip Tas, Adv Cert. R.A.C.S, Cert. IV
Workplace and Training
Tony has been a member of the CAH
Board since 1998, including three years
as Chairman. Tony has represented
our service over the past seven years
as an elected Councillor with the Rural
and Regional Health Division of the
Victorian Healthcare Association (VHA)
and was appointed as a Director of the
Board of Management of VHA in 2004.
In 2008 Tony was appointed Chairman
of the Board of Directors of VHA.
He is also a Board member of the
Community Services and Health
Industry Training Board representing
health organisations in Victoria.
Currently he works as Manager of
Community Services with Royal
Melbourne Institute of Technology
(RMIT).
Mr Wayne O’Brien,
Treasurer
BCom ACA, CPA
Wayne is a Chartered Accountant
and is a principal of WHK, a local
accounting firm within a national
group. He joined WHK in 2001 and
before that he was a partner in a
local accounting firm since 1991.
Prior to returning to Colac in 1987,
Wayne worked for Touche Ross, an
international accounting firm in
Melbourne and during this time he
was seconded for several interstate
and overseas engagements. Wayne
is an active tennis player and avid
walker and has a wide involvement
in community committees. Wayne
has served on the Board since
1998 which has included terms as
Chairman and Treasurer. During this
period he has overseen all stages of
the major redevelopment projects
on the current Colac Area Health site
as chairman of the Project Control
Committee.
First appointed: 01/11/1998
Term of current appointment:
1 November 2008 to 30 June 2011
Board and Committee attendance:
Board 12 of 13
Risk Committee 9 of 10
First appointed: 01/11/1998
Term of current appointment:
1 July 2008 to 30 June 2011
Board and Committee attendance:
Board 11 of 13
Risk Committee 0 of 10
First appointed: 01/11/1998
Term of current appointment:
1 November 2008 to 30 June 2011
Board and Committee attendance:
Board 13 of 13
Risk Committee 10 of 10
18 Colac Area Health

Mr Anthony Baldwin
Tony is a self-employed businessman.
He has an interest in quality assurance
procedures, financial management
and strategic planning. Tony is
actively involved in the community as
a member of the Rotary Club of Colac.
Ms Kathryn McBride
Dip. Fine Arts (ceramics), Grad Dip.
Education, Dip. of Management
Kathryn is employed by City of
Greater Geelong as Coordinator Care
Services. She is currently a committee
member of Villamanta Disability
Legal Service and Swan Marsh Hall.
Kathryn has previously held positions
on Arts Colac and Colac Community
Development Association and
Disability Managers Association.
Kathryn resigned from the CAH Board
in November 2008.
Mr James Ryan
BA, LLB
Jim is a partner of a local law firm and
a Life Member of the Law Institute of
Victoria. He was a Councillor of the City
of Colac for nine years and Colac Otway
Shire for eight years, during which time
he held the position of Mayor for five
terms. Jim is president of the Colac
and District Cricket Association, Colac
Turf Club and Southwest Do Care Inc.
Jim holds the position of Chairman
of COPACC Trustees, and is actively
involved in community affairs.
First appointed: 01/11/2003
Term of current appointment:
1 March 2007 to 30 June 2009
Board and Committee attendance:
Board 12 of 13
Risk Committee 10 of 10
First appointed: 01/11/2004
Term of current appointment:
1 March 2007 to 20 November 2008
Board and Committee attendance:
Board 4 of 4
Risk Committee 2 of 3
First appointed: 01/11/2005
Term of current appointment:
1 November 2008 to June 2011
Board and Committee attendance:
Board 11 of 13
Risk Committee 5 of 10
2009 Annual and Quality of Care Report 19

Board Directors
Mr Robert Dalton
Diploma of Education, Bachelor of
Arts, Bachelor of Communication
Bob is employed as Chief Executive
Officer of Skills Connection and has
extensive corporate management
background and experience gained in
the mining HR and pastoral industries.
Whilst Bob has only been a resident of
Colac for the past three and a half years,
he has made a significant contribution
to the community as a Member of
Otway Business Inc, Colac Community
Enterprise and Otway FM Community
Radio Special Development Group.
Mr Max Arnott
Advanced Diploma of Financial
Services, CFP Certified Financial Planner
Max is a Certified Financial Planner who
established the business Adviser Group
FP by bringing together advisers and
staff from Colac, Geelong, Hamilton
and Albury into a diversified business.
This Group is now one of the top ten
practices for the Licensee of MLC/
Garvan Financial Planning Vic/Tas
States. Max is an active member of the
community having been awarded a Life
Membership of the Apex Club of Colac,
and is currently a member of the Rotary
Club of Colac West, State Delegate
of MLC/Garvan Advisory Board, and
Treasurer of Otway Business Inc.
Mr Tim McCue
Bachelor of Laws, Bachelor of
Engineering, Bachelor of Commerce,
Grad Cert Performance Based Building
Codes, Grad Diploma of Fire and Risk
Engineering
Tim is a Director of Johnstaff Projects
a national Consultant Project
Management company specializing
in the delivery of major capital
developments for Government and
the Private Sector. He brings to the
Board a broad depth of experience in
health and commercial operational
contexts through his experience in
the delivery of several health facility
redevelopments across the State. Tim
is also an active member of the local
area through his young family and
farming interests.
First appointed: 26/02/2008
Term of current appointment:
26 February 2008 to 30 June 2010
Board and Committee attendance:
Board 8 of 13
Risk Committee 2 of 10
First appointed: 26/02/2008
Term of current appointment:
26 February 2008 to 30 June 2010
Board and Committee attendance:
Board 12 of 13
Risk Committee 6 of 10
First appointed: 01/07/2008
Term of current appointment:
1 November 2008 to 30 June 2010
Board and Committee attendance:
Board 6 of 13
Risk Committee 2 of 10
20 Colac Area Health

Jillian Dunbar
Director Clinical Services
As I reflect back on the challenges and changes that
have taken place this year, particularly in the clinical
services area, it is hard to believe that we have
achieved so much in a short time frame. It is with
significant pride that I acknowledge the Quality
Improvements that have taken place over the last
twelve months and present the reports prepared by
the Clinical Services management team. While we
said goodbye to Ann Gray who contributed many
years of service in the area of Infection Control and
Marg Trigg, Nurse Unit Manager of the Acute Care
Unit, we welcomed several new staff who have
significantly strengthened the management team
and I take this opportunity to introduce them.
Libby Fifis joined us in the position of Assistant
Director Clinical Services-Patient Services. Libby
replaces Mark Roberts who is on study leave
and brings a wealth of management and quality
experience with her from Cabrini Hospital in
Melbourne. Angela Erwin was appointed Assistant
Director Clinical Services –Aged Care in January
2009, bringing much needed knowledge and
leadership to our residential home - Corangamarah.
Angela was soon joined by Maurice Oates who
took up the position of Care Coordinator, Maurie
is well known for his experience in aged care
through his work in the community. We were also
very fortunate to attract Christine Holland to the
position of Risk and Infection Control Manager.
Chris comes to us from St Vincent’s Hospital in
Melbourne bringing extensive experience in Risk
Management. During this time of restructure
Angela Holland successfully applied for the position
of Nurse Unit Manager of the Acute Care Unit,
Angela has significant clinical experience and is
well known due to her previous role as one of
the After Hours Clinical Coordinators. Myles Geue
joined the After Hours Clinical Coordination team
bringing further clinical expertise to CAH.
The appointment of these experienced managers
has enhanced the restructure of the clinical
services area and it is anticipated that combining
quality, risk, infection control and education
will support continuous quality improvement
at CAH by maximizing resources to focus on risk
prevention/minimization and staff development.
The appointment of an Assistant Director Clinical
Clinical Services
Services - Aged Care recognises the critical need to
manage our aged care services at CAH.
In my previous report I suggested that our goal was
to develop a team orientated learning environment
within a culture of respect, quality, partnership,
integrity, innovation and leadership with an
outcome that results in an organisation of choice
for recruitment and retention of highly qualified
and motivated staff. I commented that this would
be a work in progress and I am confident to report
that we have achieved the first goal in recruiting
highly qualified staff to provide quality care to the
community and we have developed a structure that
will facilitate successful implementation of ISO 9001
Quality Management Certification in 2010.
Our challenge for 2009/10 will be to retain our
valued staff and this will require us to continue to
critically reflect on the way we do things, continually
keeping in mind our core values particularly
respect and integrity. We need to continue to forge
partnerships with the community and remain
innovative in the way we provide our services. In
this time of financial restraint we need to hold on to
the vision that our primary goal is to provide a safe
quality service to our consumers (residents, patients
and clients).
I would like to take this opportunity to sincerely
thank my managers and all staff involved in
the delivery of clinical services, a service which
encompasses acute, emergency, community, perioperative
and aged care. Without individual and
collective dedication and support my role this year
would not have been possible. While the coming
year will not be without further challenges the
clinical services team has developed a firm base
from which to deliver quality care.
Jillian M Dunbar
Director Clinical Services
2009 Annual and Quality of Care Report 21

Acute Care Unit
It is with great pleasure that I provide my first
annual report as Nurse Unit Manager of the
Acute Care Unit (ACU). Whilst I have been the unit
manager for four months this report will reflect
the achievements of the entire reporting cycle. It
is important to acknowledge the work of Susan
Spowart who acted as the Nurse Unit Manager
prior to my appointment.
The ACU provides high quality care to postoperative,
medical, palliative care and midwifery
patients. The unit’s staff are actively encouraged
to practice core values of partnership, innovation,
leadership, quality, respect and integrity.
The ACU team recognises that our success is
dependent upon developing and utilising our
most important asset; people. This is achieved
in an environment which focuses on providing
career opportunity and continuing education. I
wish to acknowledge the support and work of
the Associate Nurse Unit Managers (ANUM’s),
who consistently model the core values, are open
and responsive to change and provide strong
clinical leadership within our department. I wish
to congratulate the appointment of two new
ANUM’s; Sara Carmody and Olivia Zaia. As well as
overseeing the day to day running of the unit, the
ANUM’s have embraced portfolio responsibilities.
Sue Spowart, the Palliative Care and Equipment
portfolio holder is currently developing a new pain
assessment tool and a palliative care pathway. Sara
Carmody has taken up the Education portfolio
and is responsible for promoting education
sessions and is in regular contact with the staff
development team informing them of staff needs.
Jane Leadbetter, the Quality portfolio holder,
continues to consider quality initiatives to
improve the care provided to our patients. This
year Jane has undertaken work to refine the way
we document patient’s fluid balance as well as
reviewing current patient handover practices.
Health and Safety portfolio and also shares the
Infection Control portfolio with Michelle Carmody.
Both ANUM’s have been involved in auditing
and promotion of the infection control hand
hygiene program this year. Michelle Carmody also
continues to manage the rosters within her Roster
portfolio.
Finally, the Midwifery portfolio is shared by Mandy
De Leeuw, Pauline Cowan and Jan Phillips who
have reviewed a number of midwifery policies and
guidelines, ensuring our care is consistent with
best practice.
The unit continues to have a strong focus on
professional development with nursing staff
attending a number of internal and external
conferences and study days. This year, like the
last, the nursing staff within the unit have been
involved in supporting the graduate nurse
program and the Division Two nurse program. For
the first time we have been pleased to welcome
medical students and to support nursing staff
undertaking the Advanced Clinical Skills Program.
A number of equipment purchases throughout
the year have assisted us in improving the quality
of patient care, including the purchase of a baby
resuscitator for warming our vulnerable newborns,
as well as the purchase of twenty new and
improved patient chairs.
Other quality initiatives taken on by the unit
include the review and development of patient
assessment tools and clinical management
plan. Olivia Zaia has taken on the Occupational
22 Colac Area Health

Corangamarah
Front Entrance
I would like to take the opportunity to thank the
wonderful staff in Acute Services for supporting
me in my new role.
Angela Holland
Nurse Unit Manager
Acute Care Unit
Corangamarah Residential
Aged Care Facility
The past twelve months has seen some significant
and exciting changes for Corangamarah. A
restructure of the management positions led to
the appointment of myself as the Assistant Director
Clinical Services – Aged Care, commencing
in January. I was Director of Nursing at Mercy
Health and Aged Care Colac for three years prior
to coming to join the team at Colac Area Health
(CAH) and have worked in the Aged Care Industry
for the past eighteen years. The appointment of
Maurie Oates to the position of Care Coordinator
in March completed the management team for
Corangamarah. Maurie returns to CAH after an
absence of twelve years. Prior to his return he was
Director of Nursing at South West Health Care -
Camperdown and Cobden District Health Service.
This newly formed team has set a number of goals
for the next twelve months and we look forward to
an exciting year ahead.
One of the most exciting improvements
for Corangamarah in 2009 has been the
commencement of the garden redevelopment.
This included the relocation of individual
community, Lions Club and Rotary Club of Colac
West pavers to a more prominent position at the
front of Corangamarah. Two new garden and
entertainment areas were created for the North
and South wings. The North garden benefited from
a new deck protected by a shade sail, drought
resistant plants, a new irrigation system, and
extensive garden furniture and sculptures. The East
garden was redesigned to improve the access due
to the steep incline at the front of Corangamarah.
This included the installation of bench seats,
drought resistant plants, a new irrigation system,
and a seating area under a shade sail complete
with a new water feature. Stage three of the
redevelopment was the front of Corangamarah
which once again utilised drought resistant plants,
bench seats, an easy access pathway from the
front of Corangamarah to the pedestrian crossing,
and the extension of the parking bay. A new
sculpture called “The Guardian of the Mount” was
commissioned for the front of Corangamarah
symbolising Mount Corangamarah.
Although Corangamarah is only three years old
this August some significant improvements and
renovations have occurred internally in order
to create a more home like environment for our
residents, family and friends. This includes new
window furnishing for all residents’ rooms and
planned painting of feature walls in resident
rooms, lounge areas and corridors later this year.
Average occupancy for the past year has sat at
88.6% but the end of this financial year has seen
an increase in resident admissions ending the
year with occupancy of 92% in June. Enquiries for
admission to Corangamarah remain strong and a
waiting list has recommenced.
Due to the generosity of our community, we are
grateful for the opportunity to be able to enhance
the resident’s lifestyle by purchasing additional
furniture and equipment. We continue to value the
support from our many volunteers as well as the
family and friends of residents in Corangamarah.
Staff working in Corangamarah continue to
support and mentor four trainees completing their
Division Two Registered Nurse Certificate IV in
Health (Nursing), which they will complete by the
end of 2009. These trainees will be the first group
to graduate as Medication Endorsed Division 2
Registered Nurses. Four staff graduated from their
traineeships as Division 2 Registered Nurses at
the end of 2008. Many staff have also taken up
the opportunity to attend education offered by
the CAH Quality and Staff Development Unit. Two
Division 1 Registered Nurses are due to graduate
with an Advanced Diploma of Management in
October 2009.
2009 Annual and Quality of Care Report 23

Our Lifestyle Coordinators continue to provide an
innovative, stimulating, multi-sensory activities
program to enhance the physical, psychological
and emotional well being of the residents. After
a short absence, our residents were delighted
to see the return of their bus allowing the
recommencement of bus tours and outings. The
‘Sundowners program’ continues in the dementia
wing providing a most successful activity program
at a time when residents become restless and
unsettled.
Philosophy
of Care
We offer residents and their families
a respectful and compassionate
home-like environment.
We promote an holistic
approach to care and foster high
standards of accountability,
honesty and integrity.
Our professional care is offered
to all without discrimination.
We strive for an environment where
all staff are supported and
valued for their contribution
to the team.
Again this year we have grieved the passing
of some of our residents. Our condolences are
extended to respective family and friends. We
have also welcomed many new residents to
Corangamarah this year and feel honoured that
they have put their trust and faith in us to ensure
they receive the highest care possible.
Angela Erwin
Assistant Director Clinical Services – Aged Care
Preadmission and
Discharge Planning Clinic
The Preadmission Clinic operates Monday to Friday
and is staffed by two registered nurses Julie Trigg
(Preadmission Discharge Planning Coordinator)
and Irene Galbraith RN Div 2. The resignation of
Jenny Lang from the Preadmission Clinic in 2008
was received with regret. I wish to thank Jenny
for her professionalism, guidance and work ethic
during her time in this position. Registered nurses
from the Day Surgery Unit cover periods of leave in
the clinic.
Preadmission of patients occurs either by phone
or attending the clinic and allows for the patients
relevant medical/nursing information to be
collected and a discharge plan commenced
with the patient being given information and
education about their procedure or operation.
The commencement of a discharge plan with the
patient and their care givers assists in identifying
any potential problems and for the appropriate
referrals to be made to Physiotherapy, Home
Nursing, and Occupational Therapy. Attendance at
the clinic allows patients to familiarise themselves
with the hospital environment and ask any
questions they may have thus allaying fears or
concerns.
For the 2008/09 financial year, 438 patients
attended the preadmission clinic and 946 were
pre-admitted by phone as well as 783 phone calls
by the Day Surgery Unit staff.
The Coordinator’s role includes:
• Working with Acute Care Unit staff and Allied
Health on discharge planning
• Policy development - Advanced Care Planning,
Limitation of treatment guidelines
• Auditing twice yearly on the guidelines from
Effective Discharge Strategy to monitor and
improve the discharge process
• Supporting the work experience program
• Supporting the Graduate Nurse program
• Project Officer for Longer Stay Older Patient
Project. Council of Australia Governments
initiative to
24 Colac Area Health

prevent functional decline in hospitalised older
patients
• Project Officer for Advanced Care Planning -
Respecting Patient Choices model
• Participating in the review of Admission
Assessments, Nursing Care Plans and
commencement of three month trial of new
assessments and care management plans
• Participating in Enhancing Practice Program with
eleven other CAH staff with a further program to
be commenced in October 2009.
Julie Trigg
Pre-Admission Discharge Planning Coordinator
Perioperative Service
Perioperative Services at Colac Area Health is
comprised of two operating rooms, a seven bed
Day Surgery Unit, Central Sterilizing Department
(CSD) and Pre-Admission and Discharge Planning
services. Perioperative Services continue to
boast a vast range of surgical services. Highly
skilled specialist surgeons continue to make their
regular trip to Colac to ensure an extensive range
of surgical services are accessible by the local
community and surrounding areas.
All staff in Perioperative Services undertake to
provide the highest standards of care through
continuous education and safe practice of
these standards. The welfare of the patient is
the paramount consideration which must take
precedence over all other objectives. This year our
staff attended the Anaesthetic Simulator Session
at Monash Medical Centre. The course provides
increased knowledge and skills in dealing with
anaesthetic emergencies as well as fostering
positive relationships between GP Anaesthetists
and nursing staff.
Colac Area Health has ten visiting surgeons who
together with our two local General Surgeon’s
combine to offer the following surgical specialties:
• General Surgery
• Endoscopic Surgery
• Ophthalmic (eye) Surgery
• Orthopaedic Surgery
• Urological Surgery
• Gynaecological Surgery, and
• Dental Surgery.
Advances in laparoscopic surgery continue to
occur at Colac Area Health with the most recent
new surgical procedure conducted being a
Laparoscopic Assisted Bowel Surgery. Reduced
hospital stay and reduced post-operative pain are
just two of the benefits of this advancement in
laparoscopic surgery. Patients are able to go home
earlier and can generally return to normal work
much sooner than in conventional surgery.
CSD continues to provide an integral range of
services to not only the operating suite, but many
other departments of Colac Area Health as well as
community services and the medical clinics. The
CSD unit is currently undergoing an annual audit
process of AS 4187 Standards, whereby evidence
of the sterilisation of all items is audited and is
available to ensure accurate provision of sterilising
services by Colac Area Health.
Quality activities to date have focused on
improving patient and staff safety and have
included:
• Development of a foot roll for ACL
reconstructions and total knee replacements to
ensure stability of foot during surgery.
• Introduction of the formal “Time Out” process
for ensuring correct side and site of surgery
as initiated by the Royal Australian College of
Surgeons.
• Redesign of tourniquet cuff storage to ensure
ease of use, accessibility and maintenance
requirements.
• The introduction of disposable patient gowns, in
an effort to reduce our associated linen costs.
This year, Perioperative Services acknowledges
the support of the Executive and Department of
Human Services for the purchase of the following
equipment items:
• Anaesthetic Monitor
• Datex Ohmeda Light Monitor
• 2 Electrosurgical Units
• Un Interrupted Power Supply devices
• Stryker Endoscopy tower consisting of monitor,
processor, light source and video image capturer
• 2 Laptops for the entry of patient management
information data
• Arm supports for Denyers Operating table
Amanda Tout
Manager
Perioperative Services
2009 Annual and Quality of Care Report 25

Day Surgery Unit
At Colac Area Health, a high proportion of patients
are admitted via the Day Surgery Unit (DSU) and
are either transferred to the Acute Care Unit postoperatively
or discharged home from DSU.
Day Surgery staff work collaboratively with the
Preadmission Discharge Planning Coordinators,
Operating Suite and the Acute Care Unit to provide
continuity of care.
Staff are committed to continually improve
the service. This year, quality activities within
the unit have focused on a review of patient
discharge sheets, patient satisfaction with patient
information on wound management and updating
of surgeons’ pre operative preparation.
Staff continually update their skills and
professional development by attending internal
and external education sessions. This year, all
DSU staff attended a Preceptor Workshop. This
has assisted us in providing support to nursing,
medical and work experience students. All staff in
DSU embraced this opportunity.
In June 2009 Associate Nurse Managers
successfully completed reassessment for Advanced
Life Support. Examples of other education
attended include:
• Intravenous cannulation competency
• Enhancing Practice Program.
Julie Allen (Associate Nurse Manager) is currently
undertaking Advanced Diploma of Management.
Jenny Lang RN Div 1/Julie Allen RN Div 1
Associate Nurse Managers
Day Surgery Unit
Haemodialysis Unit
The Haemodialysis Unit at Colac Area Health has
been operational since November 2007. From
the establishment of the unit, it has grown from
treating one patient per week, to accommodating
up to six patients per week. There are currently
four regular patients from Colac and surrounding
districts utilising the facility, requiring treatment
three days per week. Some of these patients travel
up to 45 minutes to attend the unit at Colac.
This financial year has seen many enquiries for
holiday placements for patients requiring dialysis
whilst on vacation. Some of these requests
have come from as far as New Zealand. As well
as undertaking dialysis for renal patients, the
Haemodialysis Unit treats patients requiring day
stay infusions from other departments within the
hospital.
Staff have continued to demonstrate their
commitment to ongoing education by attending
study days at Barwon Health and attending renal
conferences.
In the next financial year, the day to day
management of the Haemodialysis Unit, will shift
from Perioperative Services to Acute Services. We
look forward to working more closely with the
Acute Care team.
Finally, in recognition to the care provided by the
Haemodialysis staff, a DVD player was donated
this year by a patient’s family. This kind gift allows
patients to bring in their own DVDs to watch. All
patients are very appreciative of this thoughtful
donation.
Helen Morrissy
Registered Nurse
Haemodialysis Unit
26 Colac Area Health

Emergency Department Presentations 2008/09
Emergency Department Presentations Discharge Status by
Percentage for the 2007/08 and 2008/09 Financial Years
80%
70%
72%
70%
60%
50%
40%
30%
20%
18%
20%
10%
8%
8%
2%
2%
0%
Discharged from
Emergency Department
Admitted to Hospital
Referred to General
Practitioner
Transfers for higher level
of care
Emergency Department
The Emergency Department continues to provide
a vital service to the Colac and District community.
Our focus is emergency care with non emergency
patients referred to the general practices after
nursing assessment.
Adult Retrieval Victoria (ARV) is available to
provide advice, support, stabilization and retrieval
of critical and time critical patients. This service
has been utilized a number of times to stabilize
patients before transfer and accompany the
patient to the receiving hospital.
The recruitment of new staff has enhanced our
pool of registered nurses with experience in
emergency and trauma nursing. The rotation
of Graduate Nurses through the department
has been expanded from 2 weeks to 9 weeks,
providing them with a comprehensive overview
of the role of emergency nursing. Each of the
graduates is provided with a preceptor who
delivers ongoing feedback and supervision
throughout their placement. The emergency
environment allows the participant the
opportunity to develop their patient assessment
and other clinical skills. Overall response from the
graduates thus far has been positive.
The Advanced Clinical Skills Program for Nurses
was introduced at the beginning of 2009. The
program has been developed for experienced
nurses wishing to enhance their skills in a
supported environment. The Emergency
Department provides a 12 week rotation for the
participants, providing them with experience in
the emergency care of acutely unwell adults and
children. Participants are also given an overview
of the triage system according to the Australasian
Triage Scale and its impact on the timely delivery
of patient care.
This experience may encourage participants to
choose emergency nursing as a career path and
continue to broaden their skills in emergency
nursing in the future.
Staff development has continued on a regular
basis with several staff undertaking courses in rural
nursing, trauma nursing, paediatric assessment
and business management.
Quality activities have focused on improving
consistency in patient documentation through
the development of new forms and assessment
guidelines.
Needle Exchange Program
2007/08 and 2008/09 Financial Years
Delia Melville
Nurse Unit Manager
Emergency Department
Community Nursing
As part of a successful Barwon South Western Rural
Integrated Cancer Services (BSWRICS) submission
to the McGrath Breast Care Foundation, Colac
Area Health has appointed a McGrath Breast Care
Nurse. The appointment is one day per week and
will provide support to breast care clients and their
families in the community. The position has been
well received by the community and is working in
partnership with the Breast Cancer Support Group.
The position was recently successful in applying
for a seed funding grant through the Polo Ralph
Lauren Pink Pony Campaign for the development
of a Community Breast Cancer resource centre.
The resource centre will be established at the
Neighbourhood House and will be well resourced
with all forms of literature to support women
and men with breast cancer and their families.
2009 Annual and Quality of Care Report 27

Sustainable Farm Families
Shopping Tour
This position is also working collaboratively with
the BSWRICS Cancer Link Nurse to establish
appropriate access to clinical services across the
continuum of care.
Community Nursing has again been successful
in two further applications for seed funding to
run the Sustainable Farm Families (SFF) Program
for the local farming communities. SFF is an
initiative of the Western District Health Service and
delivered in partnership with the Department of
Primary Industry. The team is now concurrently
running three by three year programs; the first
program hosted at Colac Turf Club completed the
second year of its program in February this year,
with a 90% return attendance to the program.
Again the program was well received with many of
the participants having made significant changes
to their health and well being. The major outcome
reported by the participants was the commitment
to access labour resources on the family farm, to
ensure they had adequate time away from the
farm to spend time with their children; some
families had been on family holidays for the
first time in years. Several of the participants
also reported having undertaken family home
renovations and one family even built a new home.
To ensure the 24 hour work home environment
of farming families included improvements to
the home not just the farming infrastructure. The
program has been well supported by the Executive
Team, with the CEO and the Director Clinical
Services attending lunch with the participants.
The Swan Marsh group commenced its first year
program in April in conjunction with the Swan
Marsh Hall Committee; with 24 participants the
program again was a great success. The team is
currently in the planning stages of organising
the first year of the program for the Birregurra
community in partnership with the Birregurra
Football Netball Club, scheduled for August.
The Community Nursing Team has continued to
provide a broad and diverse range of services to
the community including; Home Nursing, Post
Acute Care, Hospital in the Home, Palliative Care
Services, Continence Services, Lymphoedema,
Diabetes Education, Community Health Nursing
and services provided at the Birregurra Community
Health Centre.
The Home Nursing Team is largely funded by
the Department of Human Services under the
Home and Community Care (HACC) guidelines to
provide nursing services in the home environment.
In September 2008, the Home Nursing team
successfully participated in an external audit
with Australian Health Association (AHA). The
opportunity to be assessed by an external agency
was welcomed by the staff, the results provided
positive reinforcement for the quality of service
provided by the team and offered constructive
feedback for continuous improvement.
The strategic plan for Community Programs
in 2007/08 identified the need to increase the
utilisation of the Hospital in the Home program
to assist with the demand for acute inpatient
services. In the last financial year, the Home
Nursing activity in the delivery of the Hospital in
the Home Program increased from 7.5% to 12% of
overall Home Nursing clinical activity. The team
has also been working collaboratively with the
Family and Community Programs Team to increase
the accessibility to the Home Based withdrawal
program with positive outcomes for clients and
their families.
Anita Whytcross
Manager
Community Nursing
Infection Control
Infection prevention continues to be a high
priority at Colac Area Health. All staff across the
organisation have an awareness of the importance
of infection prevention and control by attending
orientation and education sessions and actively
participating in the audit processes.
Hand Hygiene
Regular extensive education is undertaken for
health care workers regarding hand hygiene
28 Colac Area Health

practices. Compliance with hand hygiene practices
is regularly audited.
Staff hand hygiene compliance has improved and
is currently sitting at 90%.
Vaccination
Colac Area Health offers a full vaccination program
to all staff based on recommendations from the
National Health and Medical Research Council.
Each year we work to improve the uptake of
Influenza vaccination by staff in order to reduce
risks to consumers particularly people who have
co morbidities, the young and elderly. All residents
in Corangamarah are offered an annual Influenza
vaccination.
Rates of Hospital Infections
The Infection Control Consultant submits data
from Colac Area Health to Victorian Hospital
Acquired Infection Surveillance System (VICNISS),
giving us the ability to compare our performance
with state infection levels. Infection rates that are
tracked against a state average include data on
surgical infections and on Methicillan
Resistant Staphylococcus Aureus (MRSA). Colac
Area Health results are favourable when compared
to established benchmarks.
Cleaning Audits
Cleaning standards aim to improve quality
health service provision by ensuring that all risks
involving cleaning are identified and managed in
an appropriate manner.
External audits are an important part of
benchmarking. The purpose of external audits
is to provide an independent evaluation of the
cleanliness of the health service. Colac Area
Health has consistently achieved a high level of
cleanliness as indicated in the graph at the top of
the page.
Christine Holland
Manager
Risk and Infection Control
Education Centre
Our staff have been involved in coordinating and
delivering a number of programs some of which
are ongoing. Of note are;
• Division 2 Traineeships – Four trainees based
in residential aged care, are now in their second
year of their Certificate IV in Nursing with the
University of Ballarat.
• Graduate Nurse Program –Six nurses completed
the graduate nurse program and this year
saw the commencement of a Rural Health
Graduate Nurses Program which has provided
six new graduates with the opportunity to rotate
through Residential Aged Care, the Acute Care
Unit, Perioperative Services and the Emergency
Department.
• Advanced Clinical Skills Program – the first year
of the advanced clinical skills
program which provides four nurses with the
opportunity to become highly skilled working
in home nursing, perioperative services, the
emergency department and the acute care unit.
• Post Graduate Perioperative Program – Two
registered nurses commenced their Post
Graduate perioperative studies at CAH in
conjunction with Deakin University, Burwood
Campus.
• Work Experience Students – Fourteen year
10 work experience students from a number of
schools in the region have undertaken a one
week placement at CAH in areas including:
allied health & nursing, information technology,
administration and food services.
• Nursing Students – Forty one nursing students
have been placed at CAH in the past twelve
months.
The number of nursing students is increasing.
• Medical Students –Seventeen medical students
from Monash University and Deakin University
have undertaken placement at CAH to gain
insight into a rural health care facility.
2009 Annual and Quality of Care Report 29

Movember charity event supporting
men’s health
• Allied Health Students –Six allied health students
in areas such as Speech Pathology, Occupational
Therapy and Phyisotherapy completed clinical
placements of Colac Area Health.
• Family and Community Programs - hosted
Psychology, Social Work and Welfare students.
The number of students is continuing to grow as
relationships develop between CAH and Higher
Education Providers throughout Australia.
The Quality and Staff Development Service
coordinated the provision of 405 hours of
education throughout the past financial year.
Education sessions are conducted on a regular
basis for all staff. At times these sessions were
conducted by staff within CAH who are highly
skilled in their chosen field and were able to
share their knowledge with other members of the
organisation.
Internal courses conducted:
• Division 2 Medication Endorsement Course
• Certificate IV in Training & Assessment
• Advanced Diploma of Management
• Certificate IV in Health Administration
• Gender & Diversity Training
• Student Preceptorship Workshops
• Shock Study Days
• Wound Care
• Mandatory Training
Anna Reilly
Clinical Educator
Birregurra Community
Health Centre
The Birregurra Community Health Centre provides
a full range of health and well-being programs
including allied health and alternative health
sessions. In April this year the health centre
celebrated its ten year anniversary. A significant
achievement due to the successful partnership
between the community advisory committee
who meet with the nurses and the Manager of
Community Nursing monthly; and an auxiliary
committee who raise money for the health centre
through various fund-raisers and Op Shop sales.
Current programs focus on promoting wellness:
• Healthy Heart Exercises- Men’s Group
• Gentle Exercise -Women’s Group
• Walking Group
• Weigh In Group
• Yoga
• Friday Exercise Group
• Community Gym
Programs that help people socialise include:
• Craft Sessions x 2
• Quilt Making for Fiji Club
• The Men’s Lunch
• Book Club
• Greet, Eat and Meet Club
Other Services
• A diabetes educator, dietitian, and podiatrist
sessions as required
• Diabetes support group monthly
• A Well Women’s Clinic occurs twice a month and
a bus is organized every 6 weeks to take women
to Geelong for Breast screens
• A community bus runs to Colac weekly on
Thursdays, providing much needed public
transport for community members to do their
business and shopping
• The Centre has a Child Care / After School Care
Service opened five days a week and is operated
by the Corangamite Shire
The Health Centre has offered the following to the
community over the past twelve months.
• First Aid classes
• Tai Chi
• Health screenings and information sessions such
as hearing tests, Stroke safe
• Cancer awareness days - Daffodil Day, Australia’s
Biggest Morning Tea
• Participation in Movember- charity event
supporting men’s health
• Suffragette vote display
• Funeral industry information session
Susan Langridge
Cheryl Lang
Community Health Nurses
30 Colac Area Health

Quality and Staff
Development Services
Improving the quality of service we provide to our
consumers (residents, patients, clients) and the
community has been a motivating force behind
many of the changes that have occurred at CAH
over the last twelve months. One of the most
positive quality initiatives that has occurred is the
merging of education, quality, risk management
and infection control resources to form the Quality
and Staff Development Service, which aims to
provide a centralised set of resources to support all
departments in the organisation.
This combined service has been operating since
April 2009 and it is with great pleasure that I
present the inaugural report on behalf of the team
including highlights of achievements from all
areas. Christine Holland joined the staff at CAH in
February and has already improved our incident
management and risk reporting. Cathy Maxwell
(former Director Clinical Services PA) joined the
team to provide administrative support and her
sound IT skills have provided significant support
to data collection and policy management. Due
to the high number of undergraduate nursing
students visiting CAH (an expected 90 over the
next twelve months); Ronan O’Sullivan joined Anna
Reilly, Deborah Payton and Courtney McLennan to
provide resources to support these students, our
Graduates and advanced clinical students as well
as all other staff development, mandatory training
and education requirements. Having a transparent
comment and complaints process is an integral
part of the quality and staff development service.
This process also reports trends and key corrective
actions resulting from feedback received over the
last twelve months. An additional and exciting
role of our service is involvement in research and
special projects and this year saw the completion of
the Rural Nurse Practitioner project undertaken in
partnership with Barwon Health (BH). I welcomed
the opportunity to work with a long standing
colleague - Dr Jane Redden-Hoare and her team
on this collaborative project and present a brief
synopsis of our findings.
ISO 9001 Certification
As Coordinator of our Quality and Staff Development
Service much of my role to date has focused on
continuous improvement and facilitating the
transition from Australian Council on Healthcare
Standards (ACHS) accreditation to ISO 9001
certification. ISO (International Organization for
Standardization) is the world’s largest developer
and publisher of International Standards and will
require CAH to have a robust Quality Management
System which focuses on meeting consumer needs
and enhancing consumer satisfaction by focusing on
principles of continuous improvement, involvement
of people, leadership, factual decision making and
building meaningful relationships. The first step
in this international audit process, conducted by
benchmark (BSI) management systems commences
in September 2009.
Preparing for ISO 9001 certification is providing
us with the opportunity to reflect on and revise a
number of existing management processes and has
resulted in the decision to implement a new Quality
Management Information System (QMIS) Q-Pulse.
The key drivers behind the implementation of Q-
Pulse are:
• To aid in the control and approval of
documented processes-policies, procedures and
correspondence thus contributing to the
delivery of a high quality, consumer-centered
service in a safe, equitable and efficient way.
• To provide tools to manage auditing, corrective
and preventative action, equipment
maintenance, contractors, supply, purchasing,
and continuous quality Improvement projects.
• To satisfy national and state regulatory
requirements and best practice including
ISO, Aged Care Standards, various funding and
accreditation bodies, the Complaints
Commission, as well as professional bodies.
• To support corporate governance through the use
of a centralised information and communication
hub.
The senior leadership team has been involved in
several workshops in preparing for ISO certification
and further education sessions are planned for the
2009 Annual and Quality of Care Report 31

No. of items
20
16
12
8
4
0
coming months. We look forward to the future
with anticipation, as implementing a quality
management system supports improvements to
the quality of service provided at CAH.
Complaints
Colac Area Health aims to provide a service
that meets the needs of consumers and their
families and we strive for a high standard of care.
Our goal is to develop a safe and just culture of
openess and willingness to learn from incidents,
including complaints. We actively seek feedback
from consumers and their families, and CAH
staff about the care we provide. Complaints are
managed without judgement and are recorded
and monitored to achieve a satisfactory solution
and to continuously improve internal processes
and systems. Consumers, families and significant
others are provided with information relating to
internal and external complaints processes and
staff are educated on the comments/complaints
processes on a continuous basis through
orientation and mandatory training.
The following graph is for the reporting period 1
July 2008 – 30 June 2009.
There were 41 complaints lodged during the
reporting period and the issues raised fell into the
following categories: Access (3), Atmosphere/
Hotel (4), Communication (19), Cost (5), Rights (9)
and Treatment (10).
3
4
19
Access Atmosphere/Hotel Communication Cost Rights Treatment
We were able to maintain an average closure time
of 17 days well within the 35 day expectation.
5
9
10
While the closure of complaints in a timely manner
is important, communicating well with consumers
and developing corrective and preventative action
plans as a result, is our primary goal. The following
Quality initiatives were implemented as a result of
complaints:
• Formation of Food Services Continuous
Improvement Committee which provided
outcomes such as improved temperature
monitoring, review and introduction of 4 week
rotating menus and introduction of new
desserts for residents in Corangamarah
• Formation of Communication and Information
Technology Working Party. Examples of projects
undertaken to date include:
o A review of the call bell system in
Corangamarah including measurement and
monitoring of nurse response times
o Evaluation of the internal communication
system including capacity for improving
emergency communication.
• Review and development of policy, procedures
and implementation of staff education in the
areas of patient discharge, documentation and
management of critically ill persons.
Risk Management
All incidents/ hazards and near miss incidents
are reported by staff before being reviewed and
investigated by the Department Head and the Risk
Manager.
Several opportunities for improvement have
resulted following incident review including:
• Developing checking procedures for
medications supplied in Residential Aged
Care
• The purchase of floor level beds to reduce the
potential of injury as a result of falls from beds
• The development of several Clinical
Guidelines, policies, procedures to ensure
the management of patients is in line with
best practice
• Education and staff development initiatives
The Clinical Review Subcommittee forms part
of the Colac Area Health Risk Management
Strategy. The committee reviews reports from the
Coroner, DHS and Limited Adverse Occurrence
Screening (LAOS) to ensure lessons learnt from the
experiences of others are considered and
32 Colac Area Health

proactive management initiated to avoid similar
incidents occurring at Colac Area Health.
Medication
The graph below represents the number of
Medication incidents reported in the Acute Care
Unit as represented by the number of occupied bed
days. Reporting in this way ensures we are able
to benchmark against industry standards and our
results indicate we are well within an acceptable
range. However, more importantly these results
provide us with information to constantly measure
and reassess our practices as our aim is to continually
develop strategies to minimise the opportunity for
error.
Falls
In the community, around one in three people over
the age of 65 will fall each year. The risk of falling is
even greater for patients in hospital. Preventing falls
is a priority and represents a major challenge for all
health services. All patients are assessed for their
falls risk on admission and appropriate prevention
strategies are put in place to minimise the potential
risk of injury. Analysis of the data (see following
graph) provides valuable information to continually
improve fall management and minimise risk to
consumers.
Special Projects
Service Plan for the implementation of Nurse
Practitioner Role in Colac Area Health and
Barwon Health.
In April 2008 Barwon Health and Colac Area
Health were notified of their successful
submission to undertake a rural Nurse
Practitioner (NP) service-planning project
offered as part of the Victorian Nurse
Practitioner Project Phase 4 Round 4.1. The aim
of this project was to develop a comprehensive
service plan for the strategic and sustainable
deployment of Nurse Practitioners. Specifically,
the project provided the opportunity for the
two organisations to work collaboratively to
develop a service plan and policy framework
to support Nurse Practitioners in the Barwon
South West Region.
The project aimed to investigate the feasibility
of the NP role in both health organisations and
to collate and provide information about the
educational pathways and service requirements
for a NP workforce that is responsive to the
needs of the communities within the Barwon
Health catchment and Colac Area Health. Focus
group interviews and meetings were held with
key stakeholders in Colac Area Health and
Barwon Health. Interviews were conducted
using semi-structured questions to help guide
the project officers to gather and collate
similar data in both organisations. Extensive
consultations revealed that key stakeholders
and consumers supported the development of
further Nurse Practitioner Models to enhance
and extend existing health services.
2009 Annual and Quality of Care Report 33

The final report highlighted the priority areas
for future developments with a NP model of
care. The priority areas were Emergency, Renal,
Diabetic, Mental Health, Palliative Care, Aged
Care and specifically for Colac Area Health a
need for an Adolescent and Sexual Health Nurse
Practitioner. The stakeholders identified that a
Nurse Practitioner Model of care would provide
support to the regional approach to palliative
care. Prescribing pain medications and working
closely with the existing Clinical Nurse Specialist
(CNS) and the palliative care medical specialist for
the region was perceived as a solution to existing
pain management and continuity of care issues.
Furthermore it was identified that the
implementation of strategically placed Nurse
Practitioner roles in inpatient services would
clearly augment existing services through
improved access to health services and enhance
patient flow in both organisations. In addition to
the benefits to the inpatient/resident populations
Nurse Practitioners operating in outreach and
community programs such as mental health,
palliative care, and adolescent sexual health
would be responsive to immediate service gaps
revealed in the project. Overall, the evidence
suggests that Nurse Practitioners enhance service
delivery, provide easier access to care and increase
patient opportunities for timely care.
Closing Remarks
While writing this Annual Quality Report provides
the opportunity to pause for a moment and reflect
on past achievements it also highlights future
possibilities. This year we have laid the foundations
to continuously improve the quality of service we
provide to our community. We have consolidated
resources to manage the challenging economic
times ahead and identified the need to provide
equitable opportunities for education and staff
development across all areas of Colac Area Health.
Considerable progress has been made and I will
welcome the opportunity to provide further
feedback this time next year.
Dr Wendy Penney
Coordinator Quality & Staff Development
Consumer Forums
A significant initiative by the Director Clinical
Services Jill Dunbar was to hold a number of
community forums with the carers and families of
the Corangamarah residents.
Involving consumers, in this case families of past
and present residents in service planning and
delivery, improves quality and safety and ensures
planned changes meets need and are acceptable.
Several focus group meetings were held to gather
information, to identify specific issues and obtain
a range of views.
Several significant themes emerged from the first
forum and an action plan was developed and
returned to consumers for approval. Consumers
were kept informed of the progress via three
monthly meetings.
It is anticipated that these forums will be
expanded to include consultation with consumers
from across the health service to ensure ongoing
commitment to improve quality and safety.
34 Colac Area Health

Visiting Medical Staff
Dr. A.F. Appelbe, M.B., B.S., F.R.A.C.P.
Dr. M.D. Bardsley, M.B., B.S., F.R.A.C.G.P., F.R.A.N.Z.C.O.G.
Dr. D. Borsos, M.B., B.S., D.R.A.N.Z.C.O.G.
Dr. A. Brown, M.B., B.S., F.R.A.C.G.P., D.R.A.C.O.G., F.A.C.R.R.M., Dip.
Sports Medicine
Dr. J.M. Brown, M.B., B.S., D.R.A.N.Z.C.O.G, F.R.A.C.G.P., F.A.C.R.R.M.
Dr. M.D. Brownstein, M.B., B.S., F.R.A.C.G.P., D.R.A.N.Z.C.O.G.,
F.A.C.R.R.M.
Dr. D.M. Buckley, M.B., B.S., D.A., D.R.C.O.G.
Mr. K. Chao, M.B., B.S., Dip. R.A.C.O.G., F.R.A.C.S.
Dr. M.T. Connor, M.B., B.S., F.R.A.C.G.P., Dip. R.A.C.O.G., A.C.C.A.M.
Dr. C.P. Cooper, M.B., B.S., F.R.A.C.P.
Dr. C.B.E. Davis, R.F.D., M.B., B.S., M.B.A., A.F.C.H.S.E.
Dr. I. Grant, M.B., B.S., F.R.A.C.G.P., F.A.Ch.P.M.
Dr. G.L. Gray, M.B., Ch.B., D.R.C.O.G.
Dr. K.R. Griffiths, M.B., B.S., D.A., D.R.C.O.G., D.C.H.
Mr. R. Grills, M.B., B.S., F.R.A.C.S.
Dr. P. Hanson, M.B., B.S., F.F.A.R.A.C.S, F.A.N.Z.C.A.
Mr. D. Holdaway, M.B., B.S., F.R.A.C.S. (Vasc) F.R.A.C.S. (Gen)
Dr. B. Huang, M.B., B.S. (Resigned January 2009)
Dr. D.M. Jones, M.B., B.S., D.A., D.R.C.O.G. (Resigned January 2009)
Dr. D. Kerr, M.B., B.S., F.A.Ch.P.M.
Dr. G. Kunjidapaadhum, M.B., B.S., D.T.C.D, G.R.A.C.G.P (Resigned
March 2009)
Dr. V. Lee, M.B., B.S., M.Med, F.R.A.C.S., F.R.A.N.Z.C.O.
Dr. R. Llave, M.D.
Dr. T.J. Lowe, M.B., B.S., D.R.A.N.Z.C.O.G.C., F.A.C.R.R.M., B.A.
Mr. P.C. Lugg, M.B., B.S., F.R.A.C.S.
Dr. I. Mackay, M.B., B.S., D.A., Dip. R.A.C.O.G., F.R.A.C.G.P.
Dr. P.J. Madden, M.B., B.S., D.A., D.R.C.O.G.
Dr. V. Makkada, M.B., B.S., D.M., F.M.G.E.M.S., F.R.A.C.P.
Dr. P. Martin, M.B., B.Ch., B.A.O., M.Med., F.A.Ch. P.M.
Mr. T.W. Mason, M.B., B.S., F.R.C.O.G., F.R.A.C.O.G (Resigned
February 2009)
Dr. S.J. Menzies, M.B., B.S., M.Med, D.R.C.O.G., F.R.A.C.G.P.
Dr. L.G. Munro, M.B. B.S., M.A.C.P. Pt 1
Mr. D.L. Murphy, M.B., B.S., F.R.A.C.S.
Dr. R. McLennan, M.B., B.S., F.R.C.P., F.R.A.C.P.
Dr. P.J. Nice, M.B., B.S., D.A., D.R.C.O.G.
Dr. D.C. Robert, M.D., F.R.C.S. (Edin)
Dr. E.W. Ryan, M.B., B.S., F.R.A.C.P.
Dr. R.R. Sarkis, M.B., B.S.
Mr. J.W. Skelley, M.B., Ch B., F.R.A.C.S., F.A. Orth. A.
Dr. R.H. Solly, M.B., B.S., F.A.N.Z.C.A
Mr. C.S. Sutherland, M.B., B.S., F.R.C.S. (Edin), F.R.A.C.S.
Dr. M. Uddin, M.B., B.S. (Resigned January 2009)
Dr. A. Wong, M.B., B.S., F.R.A.C.G.P., D.R.A.C.O.G., F.A.C.R.R.M., Grad.
Dip. R.M.
Dr. A.D. Felber, M.B., B.S., D.D.R., F.R.A.N.Z.C.R.
Dr. W.J. Rogers, M.B., B.S., F.R.A.C.G.P., F.R.A.N.Z.C.R
Dr. C.S. Woodward, M.B., B.S., F.R.A.C.R.
St. John of God Pathology
Visiting Pathologists:
Dr. H.J.M. Armstrong, M.B., B.S., F.R.C.P.A.
Dr. G.P. Davey, M.B., B.S., F.R.C.P.A.
Dr. H.J. Fairweather, M.B., B.S., F.R.C.P.A.
Dr. O.C. Harris, M.B., B.S., F.R.C.P.A.
Dr. G.R. Kelsey, M.B. Ch.B., F.R.C.P.A.
Dr. C.M. Pilbeam, M.B., B.S., B.Med.Sc., Ph.D., F.R.C.P.A., M.I.A.C.
Dr. M.E. Robson, M.B., B.S., F.R.C.P.A.
Dr. R.L. Spokes, M.B., B.S., F.R.C.P.A.
Dr. G.W. Swinton, M.B., B.S., F.R.C.P.A.
Dr. S.L. Wallace, M.B., B.S., F.R.C.P.A
Visiting Dental Staff
Dr. P. Hou, B.D.Sc.
Dr. J. McEwan, B.D.Sc.
Dr. M. Trotter, B.D.Sc.
Dr. N.J. Trotter, B.D.Sc.
Dr. H. Voronina, B.D.Sc.
Barwon Health Dental Staff
Royal Australian College of General Practitioners Registrar Program
Dr. K.H. Loo, M.B., B.S.
Dr . J.M. Manohar, M.B., B.S. (Tamil Nadu Dr. M.G. R. India) 1997
Dr. A.M. McGuane, M.,B, B.S., B.Sc.
Dr. J.M. Ngui, M.B., B.S.
Dr. F. Pojani, M.B., B.S. (Tiranes -Albania) 1989
Dr. M.B. Theophilos, M.B., B.S. Ph.D., B.Sc. (Hons)
Dr. N. Zannatt, M.B., B.S. (Dhaka) 1999
Symbion Health
Visiting Radiologists:
Dr. C.M. Blecher, M.B., B.S., F.R.A.N.Z.C.R., D.D.U
Dr. J.N. Chamberlain, M.B., B.S., M.R.A.C.R., F.R.A.N.Z.C.R.,
D.R.A.C.O.G.
2009 Annual and Quality of Care Report 35

Medical Services
This past year has been stable as regards our medical
workforce, with only the two long serving doctors
leaving our service.
The first of these was Dr Danny Jones, who left us
to return to his native NSW in January 2009. His
departure was very keenly felt. The other was Dr Terry
Mason, a long term provider of gynaecological care
here who also will be missed.
Of those doctors joining us in Colac, there have been
two Pathologists, via St John of God Pathology, being
Drs G. Kelsey and H. Fairweather, as well as Mr D.
Holdaway, Vascular Surgeon. In addition 5 Infectious
Disease Physicians from Barwon Health have been
credentialed to CAH. We also welcome a number
of GP Registrars, as noted in the Visiting Medical
Staff list. The Registrars are an important part of the
medical workforce here, as elsewhere, and we trust
that they enjoy their stay in Colac, and perhaps settle
here permanently.
The major event during the year was the achievement
of a joint Obstetric roster, where the one rostered
doctor provides the Obstetric care after hours.
This has been in place since the 18th May 2009.
I would like to mention and thank Di Loubey,
Practice Manager of Otway Medical Clinic for the
extraordinary amount of work she has undertaken,
ensuring that the roster has been complete. This
move has been very important in maintaining
the Obstetric service here, in the face of declining
numbers of doctors practicing obstetrics. Dr Buckley
has left the Obstetric service after many years and his
contribution has been appreciated.
Dr Ed Davis
Director Medical Services
Finally I thank Dr Justin Madden, who has performed
exemplary work as the Chairman of the Visiting
Medical Staff.
Dr Ed Davis
Director Medical Services
Dr Justin Madden
Chairman
Visiting Medical Staff
36 Colac Area Health

Health Information
Services
Health Information Services is responsible for the
filing and storage of Acute medical records, Aged
Care medical records and Community Nursing
medical records.
The department is also responsible for reporting
the acute activity within Colac Area Health
especially the Victorian Admitted Episodes Dataset
(VAED) and Victorian Cancer registry. The other
aspects of responsibility include Freedom of
Information, and handling records for court.
Freedom of Information
This year Freedom of Information requests totalled
46. This was an increase of 11 applications from
last year. Of those 46 applications, 43 were
granted in full, 2 applications were unable to be
granted due to there being no documents held
for that particular applicant and 1 application
was withdrawn. All applications were for
personal information. A total of $1,106.00 was
collected in application and photocopying
fees and a total of $210.70 in fees were waived.
Education
Two members of staff attended a clinical update
workshop for ICD -10 – AM Sixth Edition, held by
the National Coding Centre. Another staff member
attended a 5 day Occupational Health and Safety
course for OH&S representatives.
Roslyn Edsall
Manager
Health Information Services
2009 Annual and Quality of Care Report 37

Community Services
The Primary Care Division at Colac Area Health has
been through a number of changes over the past
twelve months, including a change of name from
Primary Care to Community Services.
Along with the change of name came a restructure
which saw the Community Programs and Family
Services Teams come together to form the Family
and Community Programs Team. Community
Nursing moved from Community Services to Clinical
Services. Restructure has again raised the issue of
staff office location. The new Family & Community
Programs Team found itself situated between the
Polwarth and Otway buildings not the most desirable
situation, so another move to Polwarth for some staff
is imminent. Staff must be congratulated on their
co-operation and patience in this never easy process.
The outcome, however, should ensure a cohesive and
supportive team environment.
Marie Shea was appointed to the position of Director
Community Services & Strategy in July 2008. On the
resignation of the Director Corporate Services, Garry
Ellis, in March 2009, Marie assumed the role Acting
Director Corporate Services and Marg White moved
into the position of Acting Director Community
Services.
Another significant staffing change in Community
Services in 2009 came with the resignation of Pauline
Maunsell from her position as Allied Health Team
Manager, having been at Colac Area Health for 29
years. Pauline was a sole practicing Dietitian when
she began in 1980 and went on to experience many
changes and developments during her time at CAH,
including the amalgamation of the Colac District
Hospital with the Colac Community Health Centre in
1995 to form Colac Community Health Services which
later became Colac Area Health.
Pauline assumed the role of Allied Health Team
Manager in 2004, remaining passionate about her
field of nutrition and staying active in the sector,
regionally, statewide and nationally. Pauline was
highly respected throughout the organisation; a
highly skilled clinician and leader who was greatly
admired by her staff and colleagues. Thoughtful
and respectful, Pauline was both approachable and
consultative and her skills knowledge will be a great
loss to this organisation. In April 2009 at a farewell
function at Otway Estate Winery & Brewery, Colac
Area Health thanked Pauline for her very significant
contribution to the organisation and wished her well
in her retirement.
Jennifer Black was appointed to the Manager Allied
Health Team position in April and brings with
her a wealth of experience from her former roles
with Pathways and Barwon Health. Jennifer is an
Occupational Therapist by profession and has had
significant management experience. She has been
warmly welcomed by the Allied Health Team.
Picking up on the strategic planning process for
Community Services initiated by Marie Shea has
been interesting with active participation and input
from all staff in Community Service. The plan is in its
final stages after a stimulating and productive day
with consultant Roger Hastrich. Development of the
plan has provided staff with the opportunity to set
key directions, identifying four priority areas around
which to set goals, i.e. Leadership, Access and Equity,
Growth and Sustainability and Staff Health and
Wellbeing. The plan has a three year timeframe and
will be reviewed and updated on a regular basis.
The Allied Health Team underwent a significant
review process in August 2008 and has developed
an action plan for improvement and change. The
identified action streams include; service provision,
workload organisation, workforce development and
support and student activity. The action plan will
include areas such as data collection and reports,
co-ordinated intake, professional development and
student placement. Members of the team are to be
congratulated on their commitment to the process
and their work in developing the action plan and
implementing the changes.
The Neighbourhood House has been successful in
obtaining a “volunteer grant” from the Modernising
Neighbourhood House Grants. A total of $35,000
has been approved to create a reception area
and to update visual aids for the volunteers. The
Neighbourhood House is also part of the $88,000
grant to become an eco-living centre, with Lorne
38 Colac Area Health

Fig Tree taking the lead in this project. The funding
will be used to make each neighbourhood house
across the SurfCoast and Colac Otway Shires ecoliving
centres by modelling and demonstrating
environmentally sustainable day to day practices.
The wonderful achievements and diversity of services
and programs in Community Services makes it a very
vibrant and dynamic team to lead. It is very gratifying
to manage such a dedicated and committed group
of staff who are creative and innovative in their
approach; always with clients’ needs front and centre.
Marg White
Acting Director Community Services
Allied Health
The Allied Health Team provides a range of services
including Physiotherapy, Occupational Therapy,
Nutrition, Speech Pathology, Social Work, Podiatry
and a comprehensive Rehabilitation Service. The
Allied Health Team provides services internally in
Acute Care, Residential Aged Care and externally in
the community. In addition to this, Colac Area Health
Allied Health Team has contractual arrangements
with other smaller providers in the Colac Otway Shire,
to strengthen the ability of these services to provide
quality care.
Other Allied Health Services and projects include
the Adult Day Activity Centre, Health Promotion,
Knock out the Risks and a partnership with Barwon
Health to provide public dental services through the
Community Dental Clinic.
In May 2009 the Allied Health Team said farewell to
Pauline Maunsell who retired after being at the helm
of the team since 2004. Pauline was a well respected
leader of the Allied Health Team and a member of
CAH staff for 29 years.
Physiotherapy
Physiotherapy provides services to patients in Acute
as well as to residents of Corangamarah, and people
who attend Community Services for individual
treatment or community rehabilitation. Currently
there are six staff members with interest areas and
expertise in respiratory health, musculoskeletal/
orthopaedic and neurological conditions.
Special projects, such as the Make a Move project
(targeting people who are over 80 years and living
at home to remain fit and well) and the ongoing
delivery of a specialised Smoking Cessation Clinic
on and off site, continue to provide the community
and staff excellent opportunities to receive and
practice evidence based health interventions. The
Physiotherapy Team continues to monitor the
quality of the service it provides to the community
by encouraging and supporting staff development
and research opportunities, providing supervision to
a range of students in the health sector and regular
planning meetings to ensure service delivery is
optimum.
Smoking Cessation Program
CAH conducted a successful Smoking Cessation
Program on site at CRF, a local meat processing
plant. Three Allied Health Staff, including a Senior
Physiotherapist were involved in the development
and delivery of the program which included:
• Increasing workers’ awareness of smoking harm
and nicotine addiction
• Educating workers about smoking cessation clinics
• Providing a twice weekly smoking cessation clinic
at CRF in the CAH Health Promotion Caravan.
2009 Annual and Quality of Care Report 39

Community Hub Inc. provided funding for the
Smoking Cessation Program at CRF and a detailed
report was produced on completion of the program.
A presentation of the program results to stakeholders
was held in June 2009 at CAH. The innovative
program generated much interest across the region
with representatives from DHS Geelong and the G21
Regional Alliance attending the presentation. The
expertise of the Allied Health staff involved in the
Smoking Cessation Program is increasingly sought
by regional health service providers and nationally
recognised training providers in the field of lung
health.
Occupational Therapy
The establishment of the Occupational Therapy
Treatment Room as part of the relocation to the
Polwarth building has been a welcome addition to
the comprehensive treatment provided by the staff.
An Equipment Grant enabled the purchase of a range
of treatment and assessment resources. One highlight
has been the completion of the Mobility Garden
area which is being utilized by clients for functional
re-education and recovery of independence, in an
environment that is meaningful and stimulating and
mirrors the day to day environments of many of the
clients.
We are very proud to acknowledge our Rehabilitation
Occupational Therapist, Michelle Bao, who was
awarded Colac Otway Workforce Employee of the
Month for June 2009 for her work in the development
of the Mobility Garden. Michelle sourced special
funding and coordinated the development of the
garden, assisted by a band of keen Rotary and BDH
Volunteers whose hard work and goodwill must
also be acknowledged. Michelle is an outstanding
example of commitment to best practice with a
strong client focus.
Nutrition
Some highlights of the year for the Nutrition
Department included; involvement in Fluid Week
with the Acute Care Unit, delivering education
sessions on fluid balance, a review of the Milville
Childcare Centre menu, food satisfaction surveys for
the Acute Care Unit, hosting the Regional Nutrition
Network Meeting in December 2008 and February
2009 and involvement in student placements from
Monash University.
The Nutrition Department undertook a number of
education sessions and reviews including:
• Kinder Capers to kinder groups
• New parents’ groups
• Delivery of PEG training to disability support
services staff (Cass House and Langdon House,
Colanda) and CAH Acute nursing staff
• Supermarket tours for Acute nursing staff,
Diabetes Groups, Cardiac Rehabilitation, as well as
Terang and Colac
• Food service review for Cobden District Health
Service.
• Healthy Women, Healthy Weight
• Nutrition Risk Assessment form developed
and implemented at Lorne, Cobden, Terang and
Corangamarah Residential Aged Care Facility.
Speech Pathology
The Speech Pathology service, in conjunction with
the Nutrition team, developed a proposal for the
introduction of ready-thickened fluids. The proposal
was approved by the CAH Executive in December
2008 and now the final planning for implementation
of the products and the adoption of Australian
Standardised Terminology for texture modified foods
and thickened fluids is underway.
In April and May 2009 the Speech Pathology
Service completed a preschool screening program
in the three and four year old groups in all local
kindergartens. The service received 127 referrals (out
of 381 children) and 56% of children screened were
identified as needing some further speech pathology
intervention; either a follow-up assessment and
intervention at CAH or a home based program.
Social Work
The CAH Social Worker provides a service to Acute
Services, Residential Aged Care and Community
Services, including Palliative Care and Rehabilitation.
The Social Work Service moved from Family and
Community Services to the Allied Health Team at
the beginning of 2009. The Social Worker is strongly
committed to supporting the student placements
at CAH and is a member of the Student Placement
Working Party which ensures a streamlined approach
to placements across the organisation, at the same
time enabling a range of experiences that a rural
setting can provide. In 2008 the Social Worker
became a Respecting Patient Choices Consultant
through the advanced care planning training.
40 Colac Area Health

Podiatry
The Podiatry service extends across all areas of Colac
Area Health, including the Birregurra Community
Health Centre. In addition to this, the service has
arrangements with Mercy Health Aged Care and
Barongarook Gardens to provide an in-house service
at those locations. During the 2008/09 financial year
694 clients received 2,138 contacts.
Rehabilitation Services
Highlights within the Community Rehabilitation
Centre include:
• A nine week Pulmonary Rehabilitation Program
running from the Centre, with plans to establish
a combined Pulmonary and Heart Failure Group in
2009/10 which would combine exercise sessions
with education
• A 15 week “No Falls” falls prevention program;
40 out of 45 people completed the program, with
positive results
• The Rehabilitation Coordinator ran two sessions
at the annual five-day training program for Cardiac
Disease Rehabilitation and Secondary Prevention.
This was held at Royal Melbourne Hospital and
conducted by the Heart Research Centre
• Our eight-week Cardiac Rehabilitation Program
continues to be well attended and the demand
ensures that it is run all year at the Centre.
Adult Day Activity Centre (ADAC)
The Adult Day Activity Program has continued to
be well attended over the last twelve months with a
number of positive initiatives being achieved.
• ADAC has started to prepare for accreditation
to meet the requirements of the Disability Quality
Framework which will be the focus over the next
two years
• A number of quality improvement activities have
been undertaken including a complete review
of the operating policies of the program , the
inclusion of a multicultural notice board, creation
of a newsletter for Colanda clients and unit
staff, development of a men’s bus group, a review
of person centred plans, and completion of the
community garden
• A grant submission to Department Human Services
was successful and enabled the replacement of the
outdoor furniture
• Successful fundraising to enable the purchase of a
plasma television for clients
• Involvement in student placements for Certificate
III in Aged Care.
Health Promotion
The Health Promotion Program addresses issues
of inequity in health outcomes for the catchment
population. 2008/09 activities continued to focus on
the 2006-09 priority issues
• Reducing Tobacco Related Harm
• Healthy Eating and Physical Activity
• Mental Wellbeing
Activities included Dental Health Victoria’s Smiles
4 Miles Children’s Oral Health Promotion Program.
Smiles 4 Miles was delivered by the Health Promotion
Coordinator to all Colac and district Preschools.
During 2009/10 further capacity building work
with other Colac agencies and networks will be
undertaken to extend the reach of key oral health
promotion messages and activities to children and
their families.
The Community Gardens project at Colac
Neighbourhood House and the Adult Day Activity
Centre were completed in early 2009. Both gardens
were the setting for a very successful Sustainable
Garden Expo held in February. Jane Edmanson
from ABC TV’s Gardening Australia program was the
Guest Presenter at the Expo which attracted more
than a hundred local people. Ongoing community
engagement for both the community gardens is
continuing.
Consultations with CAH staff and partner
organisations are being undertaken to determine
the key Health Promotion Priority Issues for 2009-12.
Three Priority Issues will be selected to form the basis
of the Integrated Health Promotion Plan. A common
framework that promotes a ‘whole of community’
approach will be applied to each Priority Issue.
2009 Annual and Quality of Care Report 41

Refocusing our resources to these tasks is reflective
of a Victoria-wide shift towards population focused
integrated health promotion. The 2009-12 Integrated
Health Promotion Plan will have a clear emphasis
on investing organisation resources in problem
definition, solution generation and capacity building
that address the social and economic determinants of
mental and physical health which are:
• Physical Activity
• Social Connection
• Freedom from Violence
• Freedom from Discrimination
• Access to Economic Resources
Knock Out the Risks
In 2008, Colac Area Health received funding through
the Healthy Active Australia Grants (Department of
Health and Ageing) to conduct a project exploring
services for those in the Colac region with a chronic
illness. The project aims to work with key community
stakeholders to engage people at risk of, or with,
a chronic condition and people with disabilities to
participate in physical activity, healthy lifestyle and
healthy eating community based programs. It is
expected that one of the major outcomes of the
project will be the development of a universal
referral system to streamline the assessment, referral
and feedback processes of these programs across all
agencies to reduce the impact of chronic illness in
the Colac community. The project is funded until mid
2010.
Community Dental Clinic
The strength of the collaborative partnership
between Colac Area Health and Barwon Health to
provide an integrated community dental health
service has been evidenced in increased productivity
for 2008/09.
The relocation from Hart Street to the new clinic on
the main CAH campus has been successful. Having a
five-chair clinic has enabled more efficient scheduling
of patients (compared to the Dental van with two
paediatric chairs that were unsuitable for adults).
This has also enabled the clinic to accommodate
University of Melbourne final year dental students
on their clinical electives. Several students have
accompanied the Barwon Health dentists on their
rural rotation to Colac Area Health.
Practice Board of Victoria, which enables staff to be
credited with Continual Professional Development
(CPD) hours (2-year CPD cycle for registration).
Activity for 2008 - 2009
Key Performance Indicators
01/07/08 - 30/06/09 Total Ave/Month
Number of clients 6,040 503
Number of visits 7,343 612
Number of treatments 18,957 1,579
The Number of new patients receiving general care
Age
Group
Jul-
Sept
2008
Oct-Dec
2008
Jan-Mar
2009
Apr-Jun
2009
YTD
0-17 yrs 113 99 86 120 418
(56.2%)
18-24 yrs 3 10 4 5 22
(2.9%)
25-64 yrs 33 43 50 34 160
(21.5%)
65+ yrs 49 35 40 20 144
(19.4%)
Total 198 187 180 179 744
(100%)
Jennifer Black
Manager
Allied Health
Family and Community
Programs
The Family and Community Programs Team
successfully delivered a diverse and creative range of
programs and services to the community in the past
year. The innovation and integrity demonstrated by
the staff is of a high standard and their ability to ‘get
the job done’ is second to none.
The highlights of the year have been many and the
partnership approach to providing services has been
a key component of the success of the programs.
For the purposes of this report, I will focus on a small
number of highlights but the list could go on!
A trainee Dental Assistant has successfully completed
the Certificate III in Dental Assisting and another
local trainee has been employed. CAH staff attend
Barwon Health Oral Health Service (BHOHS) “In-
Services” enabling them to participate in continuing
professional development. BHOHS is an accredited
Educational Approved Provider with the Dental
42 Colac Area Health

Bubs in the Hub Program
Child FIRST (Family, Information,
Referral and Support Team)
Child FIRST primarily aims to strengthen services to
vulnerable children, young people and families. The
service, which has been through a period of growth,
provides coordinated intake aimed at promoting,
maintaining and strengthening the independence
and wellbeing of children and their families.
Child FIRST has been an active participant in the
development of the Partnership Agreement between
Family Violence Services, Child Protection and Family
Services, including Child FIRST. This agreement
describes a set of core elements which will govern
the collaborative relationship between these three
sectors. Overarching aims include safety, protection
and well being of children, safety and empowerment
for victims of family violence, and responsibility and
accountability of perpetrators of family violence.
Child FIRST and Family Support Services continue to
meet hours of service targets and the breadth of work
undertaken can range from assessment and referral
to counselling in the home environment, transport
and liasion with holiday programs to mediation
between parents and adolescents. This is only a small
list of the services provided by the Family Services
Team to ensure the development and wellbeing of
children.
‘Bubs in the Hub’ Program
The ‘Bubs in the Hub’ program is a joint initiative
between Family Support Staff and the Adolescent
Community Health Nurse program and is targeted
towards young women 25 years and under living
in the Colac-Otway district who are pregnant or
parenting. Referrals are received from midwives,
GP’s, Maternal & Child Health Nurses and a range
of services. There is a network of word of mouth
referrals and self referrals from young women in the
community. The group environment (held at the
Neighbourhood House) encourages the formation of
new friendships, education and sharing experiences
about parenting and pregnancy. The program
continues to grow and develop; currently there are
15-20 young mothers participating in the program
on a regular basis. The program has been supported
by a funding grant from the Barwon-South Western
Regional Women’s Health and the assistance from
that group is acknowledged.
Student Placement Program
The Family and Community Programs Team
(in conjunction with the CAH Quality and Staff
Development Unit) has developed ongoing
relationships with two universities for student
placements. The Ballarat University Psychology
Program began placing Psychology Masters Program
students at CAH for their final clinical placement.
The placements build capacity and provide quality
interventions within the counselling program. CAH
Psychologists provide high quality supervision and
support to the students who in turn provide valuable
clinical counselling to the broader community
through the provision of clinical counselling services.
Deakin University Social Work Program has had
an ongoing relationship with CAH and have
implemented a rolling placement arrangement for
first and final year students. Students are exposed to a
wide range of opportunities, including hospital social
work, family services and group work programs. The
willingness of supervising staff and team members
to commit to the development of a learning
environment enables growth for staff and students.
Exit interviews with students completing their
placements at Colac Area Health, together with
feedback from Ballarat and Deakin Universities,
overwhelmingly praised the placement program as a
professional, high quality service.
Alcohol and Other Drugs Service
The Alcohol and Other Drug team has undertaken
a comprehensive review and service improvement
program over the last twelve months. This has
included an audit of operations, improved data
capture and provided staff with dual diagnosis
training to assist clients with substance and
mental health concerns. Advocacy for further
service provision, particularly in the area of opiate
replacement therapies, participation in the Regional
Drug Action Plan, community partnerships with
Glastonbury and delivery of region-wide training in
conjunction with the Department of Human Services
have also been key components of the past twelve
months. The Alcohol and Other Drugs Service at CAH
consists of a robust and professional team of multiskilled
clinicians.
Tamara Holmes
Acting Manager
Family and Community Programs
2009 Annual and Quality of Care Report 43

Human Resources
Donna Hay
Director Human Resources
The Human Resources (HR) Department exists to
provide advice, services and support to Colac Area
Health (CAH) management and staff in relation to
all human resource functions. This includes payroll
and salary packaging, recruitment and selection,
occupational health and safety, reward and
recognition, performance management as well as
human resources policy and procedure development.
The department is also responsible to ensure the
organisation and its employees meet the legislative
requirements outlined in employee and industrial
relations regulations.
The department consists of 4.7 FTE including the
Director Human Resources, Payroll Coordinator,
Payroll Officer, Human Resources Coordinator and
Human Resources/Occupational Health and Safety
Officer. The team is extremely dedicated to serving
the best interests of the organisation and its staff, and
delivering outcomes that are in accordance with the
organisation’s vision of being recognised as a leader
in the development and provision of responsive,
integrated health care.
Our Corporate Values
The CAH corporate values of respect, integrity,
leadership, innovation, quality and partnership are
extremely important in the way the human resources
team operates and we proactively promote these
values throughout the organisation. During the
year the Workplace Code of Conduct (incorporating
the corporate values) was reviewed, updated and
communicated to all staff. Upon commencement
at CAH, the HR team ensures that new starters are
aware that these organisational behaviours exist by
including them as part of the orientation package.
These values are also apparent through the delivery
of our service and included in the advice and support
that we offer to managers and employees.
Payroll and Salary Packaging
The CAH Payroll Service is currently responsible
for the fortnightly payroll for approximately 460
employees at CAH and one other local agency.
In addition to the payroll service, the unit is also
responsible for delivering the salary packaging
program to CAH employees. The salary packaging
program offers considerable benefits to employees
allowing staff to access taxation benefits which can
increase their take-home pay. At 30 June 2009, 291
CAH employees chose to utilise the salary packaging
service which comprises approximately 63% of the
total workforce.
The decision was made in the previous year to
purchase a new payroll system given the arrangement
with the existing system provider was to cease on 30
June 2008. Considerable work was completed to set
up the new system, Chris 21, to enable us to “go live”
on the first pay period of this financial year.
It is pleasing to report that our first year on Chris 21
has been an enormous success. The implementation
of Chris 21 has provided the payroll staff with a more
efficient and user friendly system, with report writing
capabilities that allows the team to provide better
information to staff and the management team.
Chris 21 can also be used as a HR information system,
ensuring employee information can be stored on the
one central database.
The new system also has an “Employee Self Service”
capability which enables staff to access their own
payroll information on-line. To date this has been
trialled in some areas of the organisation with positive
feedback received. This will be implemented across
the organisation in the coming months.
Occupational Health and
Safety
Occupational Health and Safety (OH&S) continues to
be a high priority of CAH as significant work has been
completed to ensure we meet our obligations under
the Occupational Health and Safety Act 2004.
The OH&S committee was reviewed with an updated
terms of reference and committee structure being
introduced during the year. OH&S committee
meetings are convened on a bi-monthly basis with
health and safety representatives present, and
44 Colac Area Health

Chris Kendall, Employee of the Month
recipient for June 2009, accepting
the Certificate of Recognition from
Geoff Iles, CEO.
managers continue to complete safety audits in their
areas on a quarterly basis. We have facilitated visits
from WorkSafe over the year and have attended
WorkSafe information sessions that have been
conducted locally. The OH&S systems, policies and
procedures will continue to be reviewed and updated
throughout the next year to ensure they remain
current with legislative requirements and we meet
our employer obligations.
Staff Recruitment and
Orientation
Staff recruitment continues to be an ongoing
challenge to ensure the organisation recruits the
highest calibre of staff through a fair, open and
transparent process. The HR team takes pride in our
recruitment principles that demonstrates fairness,
credibility, equal employment opportunity and merit.
It is extremely important to ensure our newly
recruited employees are orientated to the
organisation appropriately. The Human Resources
Department has orientated 62 new staff over the past
year to ensure they are familiar with CAH processes,
policies and procedures. The one day program
was also reviewed and revamped during the year
and comprises speakers from different areas of the
organisation, who deliver information regarding:
• Executive Functions
• Human resources activities
• Organisational tour
• Infection control
• Safety and quality systems
• Information technology
• Privacy and confidentiality
• Principles of manual handling
• Emergency response
• Basic life support
• No lift
• Family Violence and Child Safety and Abuse
The program will continually be reviewed and
updated to ensure the most current organisational
information is conveyed to staff.
Reward and Recognition
Employee of the Month Program
The employee of the month program continued
throughout the year. The purpose of this award
is to recognise our star performers who have
demonstrated exceptional performance within
their position at CAH. This includes promoting
and carrying out our core values – partnership,
innovation, leadership, integrity, quality and respect
– as well as showing superior customer service,
initiative or expertise within their position. The
following employee’s were recipients of this award in
2008/09:
2008
July
August
September
October
November
December
2009
January
February
March
April
May
June
Michelle Bao
Marlene Caldwell
Vic Robinson
Tamara Holmes
Rebecca Simunitsch
Sara Carmody
Jannetje Newman
Julie Barrow
Wal Kantelberg
Anita Whytcross
Anna Reilly
Chris Kendall
The award will continue on throughout the next
financial year and the organisation looks forward to
disclosing the winners of 2009/10 in the next annual
report.
Industrial Relations
In the previous financial year the two certified
agreements expired, Health Services Union of
Australia – Health Professionals and the Health
Services Union of Australia – Medical Scientists,
Pharmacists and Psychologists. As a result discussions
between the Victorian Hospitals Industrial Association
(VHIA) and the relevant Unions began to take place
for a new agreement. Negotiations were finalised
for the Health Services Union of Australia – Medical
Scientists, Pharmacists and Psychologists certified
agreement and the terms and conditions of the
new agreement came into effect. Representatives
2009 Annual and Quality of Care Report 45

from CAH worked well with the representatives
from the Union to ensure the relevant changes
were implemented. Unfortunately, the negotiations
for the Health Services Union of Australia – Health
Professionals are still yet to be finalised and we
anticipate that this will be completed early in the new
financial year.
Service Improvement
Administration Casual Pool
In order to assist managers cover expected and
unexpected staff absences in the administration
areas, an Administration Casual Pool was developed
for managers to access ensuring services are
maintained in periods of staff absence. The pool is
coordinated by the Manager, Administration Services
who provides administration relief when staff are on
leave. To date the casual pool has been successful in
assisting managers cover periods of leave to ensure
services are upheld at all times.
Equal Employment
Opportunity (EEO)
Statement
CAH considers EEO principles as imperative to
ensuring we comply with the guidelines set out
by the State Services Authority and the Equal
Employment Opportunity legislation. The CAH
Workplace Code of Conduct was updated and
distributed to each staff member during the
year, which outlines the CAH corporate values
and the reasons that they exist. CAH has further
demonstrated our commitment to these standards
by maintaining an EEO policy, and by ensuring these
principles are included in our standard practice
for recruitment, training, transfer and promotion
opportunities. All vacant positions within CAH are
advertised internally (as a minimum) on our intranet
site, website and our noticeboards.
`
CAH also aims to promote a bullying and harassment,
discrimination-free work environment which fosters
employee respect and positive working relationships.
A policy review was completed during the year to
ensure our behavioural policies and procedures
have been updated and communicated to staff. This
includes providing avenues for re-dress if required.
Whistleblowers’ Protection
CAH is committed to the aims of the Whistleblowers’
Protection Act 2001. In accordance with the
requirements of the Act, CAH has in place a policy to
facilitate the making of disclosures under the Act. For
the year 2008/09 no disclosures were made.
Donna Hay
Director Human Resources
LABOUR
CATEGORY
JUNE 09
CURRENT
MONTH FTE
JUNE 09
YTD FTE
JUNE 09
CURRENT MONTH
HEAD COUNT
Nursing 149.67 149.40 257 (includes casual
nurse bank)
Administration and Clerical 34.66 33.73 46
Medical Support 15.57 16.72 21
Hotel and Allied Services 51.16 52.01 71
Ancillary Staff (Family & Community
37.89 34.97 65
Programs)
TOTAL 288.95 286.83 460
46 Colac Area Health

Corporate Services
Support Services
Support Services include the following
areas, Environmental Services, Food Services,
Engineering, Fleet Management, Security and
Signage.
Environmental Services
• Cleaning to Acute Care Unit, Operating Suite and
Emergency Departments
• Cleaning to Corangamarah Residential Aged Care
facility
• Cleaning to Community Dental Clinic
• Cleaning to Pathology and Medical Imaging
[contract]
• Porter/courier service
• Assist where required with furniture and
equipment relocation
• Linen distribution
• Personal linen to Corangamarah Residential
Aged Care facility
• Waste Management.
Engineering Services
• Preventative and breakdown maintenance
• Plant and equipment service
• On-Call service 24 hours per day 7 days per week
• Garden and surrounds
• Bus driving
• Assist where required with furniture and
equipment relocations.
Achievements
Environmental Services
The overall presentation of the facilities at CAH is a
credit to Environmental Services Staff and is due to
their ongoing willingness to strive to achieve the
highest possible cleaning standards.
Audit of Food Safety Program
Legislation requires that an external audit of the
Food Safety Program be conducted. The audit of
Colac Area Health was completed on 21 January
2009.
There were eight non notifiable areas requiring
corrective action, this action was attended to and
the certificate was issued on 4 February 2009.
Area
Areas
Audited
2007 2008 2009
Areas
Areas
Score Audited Score Audited
Score
Group A -Very High Risk
Operating Suite, ICU 11 100% 8 95% 7 97%
Group B–High and Moderate Risk
CSSD, Sterile Supply areas,
Emergency Dept, Pharmacy clear
area, Wards etc
Group C – Low Risk
Laboratories, Mortuary, Medical
Imaging, Waiting Rooms,
Administration
23 100% 18 97% 14 95%
3 100% 3 97%
Totals 37 100% 26 96.5% 24 96%
ALL areas meet the Cleaning Standards Acceptable Quality Level (AQL)
2009 Annual and Quality of Care Report 47

Food Services
The food service department continued to
cater for special events such as the Colac Rodeo
(Colac Showgrounds), Annual General Meeting
and Birregurra Community Health Centre 10th
Anniversary Celebrations, as well as providing
meals across the organisation daily.
Meal Summary 2008/09
Meals %
Acute 33,687 20.26
Corangamarah 96,337 57.95
Operating Suite 1,985 1.18
Cafeteria 6,254 3.76
Adult Day Activity Centre 2,353 1.42
Functions 5,313 3.20
Day Surgery Unit 3,356 2.02
Meals on Wheels 15,437 9.29
Other 1,528 0.92
Total 166,250 100.00
Waste Management
Colac Area Health, a member of the Barwon Waste
Wise Healthcare Network, is certified as Waste
Wise with assistance from Barwon Regional Waste
Management Group. A waste management action
plan has been developed based on the principles
of reduce; reuse and recycle.
The Annual Audit of Clinical and Related Waste
provided very positive results. Clinical and Related
Waste is managed in accordance with relevant
guidelines.
The amount of Non-Infectious Waste/Total Waste
Ratio has steadily decreased from 18.0% in 2000,
10.20% in 2003 to 3.97% in 2009. This is a clear
indication that staff are segregating waste at point
of generation.
The Annual Audit of General Waste was completed
in early June and the results confirm that CAH is
managing its Waste well.
CAH has a robust recycling program;
• Cardboard
• Paper
• Tin, Aluminium Cans, Plastic Bottles
• Scrap Metal
• Toner Cartridges
• Confidential Documents are recycled after
shredding
• Plastic Packaging, Wrapping, Bubble Wrap
was introduced this year by our local
Cardboard and Paper Recycler which had a
very positive impact by diverting the amount of
plastic going to landfill.
Colac Area Health is very proud to be certified as a
Waste Wise Organisation. This certification shall be
reviewed in July 2009.
Our efforts are supported by all staff who correctly
segregate waste at the point of generation so that
contamination of bins is reduced; which is essential
for effective recycling.
Way Finding
With the relocation of the Dental Clinic to the
main site, the need for updating the directional
information was highlighted. Identicorp were
contracted to develop a Way Finding strategy for
CAH. The outcome of this has been a user friendly
Way Finding System throughout the site.
Trevor Nelson
Manager
Support Services
48 Colac Area Health

Supply Department
In accordance with the Vision and Mission
Statements of Colac Area Health, the Supply
Department offers a wide range of services to
“promote the health and wellbeing of the Colac
and District Community.”
Over recent years, this department has expanded,
and provides services to meet the requirements
of a complex health facility, as well as responding
to the needs of the wider community. We offer
supplies and services to a number of external
organizations, including:
• Lorne Community Health Service, Hesse Rural
Health, Cobden Health Service and the Colanda
Centre
• Transport Accident Commission (TAC) clients
• A number of Department of Human Service
Facilities (houses) in and around the Colac
District.
Way Finding
The supply of goods and services to individual
clients of CAH is another area of major value
and importance, not only to the client, but as an
available service to the community as a whole.
This support to the continuum of care includes
the provision of accessible and most importantly
affordable items, such as dietary supplements,
continence aides, wound care products, and
the hire and loan of rehabilitation equipment.
These services again, support CAH’s vision of an
“integrated” and “affordable” health service.
To continue to respond to the needs of the
community and health service, Supply must
integrate the many time saving advantages of
available technology to ensure an efficient and
accessible service.
Tim O’Sullivan
Manager
Supply Services
2009 Annual and Quality of Care Report 49

Information and Communication
Technology
2008/09 has been a year of progress with several
new Information Technology (IT) projects being
introduced and implemented at Colac Area Health
(CAH).
One of the more visible changes is the ongoing
redevelopment to CAH’s Internet site, accessible
at www.colacareahealth.com.au. The site sports a
fresh new look with a redesigned user interface,
including drop-down menus and CAH-matching
colour scheme. New categories currently being
developed include “Babies”, where we will show
off new arrivals born at CAH. We would welcome
feedback on the new site design so we can
continue to improve our communication with the
wider community.
Wireless technology continues to have expanded
use at CAH. The percentage of wireless devices
has increased substantially over the past twelve
months as wireless becomes more popular and
opportunities to improve existing business
processes become apparent. Included are
innovations such as small wireless laptops, which
allow certain staff members in the field access into
the CAH network using Telstra’s NextG wireless.
Not only does this add to productivity, but allows
staff access to up-to-date client information
prevents potential errors.
The IT equipment list continues to grow, with
around 240 computers/laptops employed at the
Service. The number of staff access to email has
remained relatively stable at 460, meaning that
CAH is progressing towards its goal of a 60% staffcomputer
ratio.
Last year reported that CAH has been participating
in an innovative project to supply bedside
entertainment to the client. The BEST system
(Bedside Entertainment System Technology)
has now matured to the point where it is in “go
live” form and offers, for a small fee, access to the
following features:
• Television (Free to air, Austar)
• Large selection of streaming movies
• Large selection of streaming video music clips
• The Internet
• Games
• Audio books
The system is installed into the 43 Acute Care Unit
beds and the 7 Day Surgery Unit beds.
Later in 2009 we will see the completion of a
number of exciting new projects, including -
Q-Pulse Quality Information Management System
– this system will have a number of benefits to CAH
including:
• Document Management System – to replace
CAH’s ageing folder/file structure
• Correspondence tracking – any correspondence
will be managed, tracked and actioned much
more effectively
• Effective complaints process
• Integrated asset tracking process and contracts
management
• Streamlined preventative maintenance system
CAH will also be reactivating an Acute Wardbased
system called Trendcare, which will
streamline a number of existing processes into
one system, including rostering and enhanced
bed management. Eventually it is envisaged that
Trendcare will replace and augment other systems.
Randall Hose
Manager
Information and Communication Technology
50 Colac Area Health

Statutory Compliance
Legislative Compliance
Based on legislative information received,
Colac Area Health (CAH) has complied with all
Acts and Regulations. Legal advice provided
on behalf of Victorian Healthcare Association
indicates that there is no longer a requirement for
public hospitals to include a full list of Acts and
Regulations in the Annual Report.
National Competition Policy
Colac Area Health complied with all government
policies regarding competitive neutrality.
Compliance with Building Act
Colac Area Health complies with the Building
Act 1994 under guidelines for publicly owned
buildings issued by the Minister for Finance 1994 in
all redevelopment and maintenance issues.
• Building Inspections Standards Assessment
Colac Area Health facilities have been the subject
of a fire audit by a Fire Services Engineer. The
scope of that audit considerably exceeded the
scope of an inspection by a Building Surveyor in
line with the Minister for Finance’s Guidelines.
• Arrangements Regarding Registered Building
Practitioners
The Board of Directors requires all building
professionals engaged on building projects to be
registered with the Building Practitioners Board or
be Registered Architects.
• New Buildings
It is required that a building permit be issued
at the completion of each building project. That
action ensures that new buildings and work in
existing buildings conform to building standards
and that the ten year liability cap is invoked.
No new works were completed during the year.
Building Works
Occupancy Permits Issued
Works in construction and the
subject of mandatory inspection
Number
Nil
Nil
Consultancies
There were nine consultancies totalling $163,914
undertaken at Colac Area Health during the
2008/09 financial year; there were no consultancies
in excess of $100,000.
Fees and Charges
Colac Area Health charges fees in accordance with
relevant Department of Human Services directives.
Financial Management Compliance
Framework (FMCF)
The Financial Management Compliance
Framework (FMCF) was introduced from July 1,
2003 and applies to all Victorian Public Sector (VPS)
entities. The Framework has been established
to ensure that all VPS entities have implemented
appropriate systems to ensure that public
resources are used in an efficient, effective and
responsible manner.
Colac Area Health is working to ensure that full
compliance is achieved. Colac Area Health will
continue to review its performance, policies and
procedures to ensure that the Service is operating
in an effective and responsible manner.
Pecuniary Interest
Members of the Board of Directors are required to
notify the Chairman of the Board of any pecuniary
interest which may give rise to a conflict of interest
as defined in accordance with the Directions of the
Minister for Finance. All declarations of pecuniary
interest have been completed and are available
on request to the relevant Minister, Member of
Parliament and the public.
Services Contracted Out
The range of Services contracted out has remained
unchanged during the 2008/09 financial year.
Maintenance
Number
Notices issued for rectification
of substituted buildings requiring
urgent attention
Nil
2009 Annual and Quality of Care Report 51

Statutory Compliance
Additional Information
Statement
The following information, where it relates to
Colac Area Health and is relevant to the financial
year 2008/09 is available upon request by relevant
Ministers, Members of Parliament and the public:
(a) A Statement of pecuniary interest has been
completed.
(b) Details of shares held by senior officers as
nominee or held beneficially.
(c) Details of publications produced by the
department about the activities of the entity and
where they can be obtained.
(d) Details of changes in prices, fees, charges, rates
and levies charged by the entity.
(e) Details of any major external reviews carried
out on the entity.
(f) Details of major research and development
activities undertaken by the entity that are
not otherwise covered either in the Report of
Operations or in the document that contains the
financial report and the Report of Operations.
(g) Details of overseas visits undertaken including
a summary of the objectives and outcomes of each
visit.
(h) Details of major promotion, public relations
and marketing activities undertaken by the entity
to develop community awareness of the entity and
its services.
(i) Details of assessments and measures
undertaken to improve the occupational health
and safety of employees.
(j) General statement on industrial relations
within the entity and details of time lost through
industrial accidents and disputes, which is not
otherwise detailed in the Report of Operations.
(k) A list of major committees sponsored by the
entity, the purposes of each committee and the
extent to which the purposes have been achieved.
52 Colac Area Health

Disclosure Index
The Annual Report of Colac Area Health is prepared in accordance with all relevant Victoria legislation. This
index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure
requirements.
Legislation Requirement
Page Reference
Ministerial Directions
Report of Operations - FRD Guidance
Charter and purpose
FRD 22B Manner of establishment and the relevant Ministers ...................................................... 16
FRD 22B Objectives, functions, powers and duties ............................................................................. 16
FRD 22B Nature and range of services provided ....................................................................................6
Management and Structure
FRD 22B Organisational Structure ........................................................................................................................... 9
Financial and Other Information
SD 4.2(j) Accountable Officer, signed off Report of Operations ..................................................... 10
SD 4.5.5 Risk Management Compliance ................................................................................................. 17
FRD 22B Operational and budgetary objectives and performance against objectives ........ 13
FRD 22B Statement of merit and equity ................................................................................................. 46
FRD 22B Workforce Data Disclosures ....................................................................................................... 46
FRD 22B Occupational Health and Safety .............................................................................................. 44
FRD 22B Summary of the Financial Results for the year ......................................................................7
FRD 22B Significant changes in financial position during the year .............................................. 60
FRD 22B Major changes or factors affecting performance ................................................................ 7
FRD 22B Subsequent Events ....................................................................................................................... 83
FRD 22B Application and operation of Freedom of Information Act 1982 ................................ 37
FRD 22B Compliance with building and maintenance provisions of Building Act 1993 ...... 51
FRD 25 Victorian Industry Participation Policy disclosures ........................................................ N/A
FRD 22B Statement on National Competition Policy ......................................................................... 51
FRD 22B Application and operation of the Whistleblowers Protection Act 2001 .................... 46
FRD 22B Details of consultancies over $100,000 .................................................................................51
FRD 22B Details of consultancies under $100,000 .............................................................................. 51
FRD 22B Statement of availability of other information ................................................................... 52
FRD 10 Disclosure Index ............................................................................................................................. 53
FRD 11 Disclosure of ex-gratia payments ............................................................................................ 82
FRD 21A Responsible person and executive officer disclosures .................................................... 82
Financial Statements - FRD Guidance
Financial Statements required under Part 7 of the FMA
SD 4.2(a)
Compliance with Australian accounting standards and other authoritative
pronouncements ........................................................................................................................... 62
SD 4.2(b) Operating Statement ................................................................................................................... 58
SD 4.2(b) Balance Sheet .................................................................................................................................. 59
SD 4.2(b) Statement of Changes in Equity .............................................................................................. 60
SD 4.2(b) Cash Flow Statement ................................................................................................................... 61
SD 4.2(c) Accountable officer’s declaration ............................................................................................ 55
SD 4.2(c) Compliance with Ministerial Directions ................................................................................ 62
SD 4.2(d) Rounding of amounts .................................................................................................................. 58
Legislation
Freedom of Information Act 1982 ............................................................................................................................. 37
Whistleblowers Protection Act 2001 ........................................................................................................................ 46
Victorian Industry Participation Act 2003............................................................................................................ N/A
Building Act 1993 ............................................................................................................................................................ 51
Financial Management Act 1994 ............................................................................................................................... 62
Audit Act 1994 .................................................................................................................................................................. 56
2009 Annual and Quality of Care Report 53

Financial Services
The entity financial result for 2008/09 was a deficit
of ($0.204m). Excluding capital income and
depreciation the operating result was a surplus
of $0.519m. This compares to an entity result in
2007/08 of $0.430m, and an operating result of
$0.248m.
The financial year 2008/09 has been a challenging
one of consolidating our financial systems to
provide a platform for producing timely and
accurate financial statements.
We have continued the development of our
budgeting system, which will enable monitoring
of the financial position at department level,
with managers heavily involved in analysis and
reporting. There has also been a significant effort
applied to reviewing and updating financial
policies and procedures.
The 2008/09 financial year has been a very
challenging year that involved extensive review of
organisation in partnership with Department of
Human Services. Aspex Consulting has provided
extensive initial advice which will be acted on
during 2009/10 financial year as a priority of both
the Board and the Executive.
During 2008/09, on the basis of advice and
considerable support from Department of Human
Services, the budget for Colac Area Health has
been rebuilt on more contemporary practices
which has been a development phase for the
organisation.
Better and more timely reporting of activity
resource management is a high priority to ensure
Colac Area Health lives within budget.
The future will involve:
• Maximising revenue and growth opportunities
as an organisation across all activities
• Continue to refine and improve resource
management and develop and grow the
expertise of managers, particularly in proactive
and prospective analysis that promotes early
management interventions
• Increase efficiencies across all service areas of
Colac Area Health
• Meeting outcome standards for all accreditation
requirements during 2009/10 of which for Colac
Area Health there are many. Such a diverse
range of accreditation arrangements is a heavy
impost on the organisation and staff.
While the entity financial result, before capital
income and depreciation, was a surplus for
2008/09, the result included a significant level
of additional grant income received during the
year in support of Colac Area Health from the
Department of Human Services. An objective
for Colac Area Health’s Board and Executive is to
reach financial sustainability that does not rely on
continued support.
We take this opportunity to acknowledge the
support of the Department of Human Services
during the year and to thank all staff of Colac Area
Health for their commitment in what has been a
challenging year for all.
Geoff Iles
Chief Executive Officer
and Acting Director Corporate Services
54 Colac Area Health

Certification
2009 Annual and Quality of Care Report 55

56 Colac Area Health
Auditor-General’s Report

2009 Annual and Quality of Care Report 57

Financial Statements
Operating Statement for the year ended 30 June 2009
58 Colac Area Health

Financial Statements
Balance Sheet as at 30 June 2009
2009 Annual and Quality of Care Report 59

Statement of Changes in Equity for the year ended
30 June 2009
Financial Statements
60 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 June 2008
Financial Statements
Cash Flow Statement for the year ended 30 June 2009
S
S
S
S
S
S
S
D
D
D
2009 Annual and Quality of Care Report 61

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 1: STATEMENT OF SIGNIFICANT ACCOUNTING POLICIES
62 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
2009 Annual and Quality of Care Report 63

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
64 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
(r) Residential Aged Care Service
Corangamarah Residential Aged Care operations are an integral part of Colac Area Health and share its
resources. An apportionment of land and buildings has been based on fl oor space. The results of the two
operations have been segregated based on actual revenue earned and expenditure incurred by each operation in note 2a and 2b(i)
to the fi nancial statement.
2009 Annual and Quality of Care Report 65

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
66 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
2009 Annual and Quality of Care Report 67

NOTE 2: REVENUE
Colac Area Health
Notes to the Financial Statements 30 June 2009
68 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 June 2009
NOTE 2a: ANALYSIS OF REVENUE BY SOURCE
2009 Annual and Quality of Care Report 69

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 2b: EXPENSES
70 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
NOTE 2b(i): ANALYSIS OF EXPENSES BY SOURCE
2009 Annual and Quality of Care Report 71

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 2c: PATIENT AND RESIDENT FEES
NOTE 2d: NET GAIN/(LOSS) ON DISPOSAL OF FINANCIAL ASSETS
NOTE 3: DEPRECIATION
NOTE 4: CASH AND CASH EQUIVALENTS
72 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
NOTE 5: RECEIVABLES
NOTE 6: INVENTORIES
2009 Annual and Quality of Care Report 73

Colac Area Health
Notes to the Financial Statements 30 June 2008 2009
NOTE 7: INVESTMENTS ACCOUNTED FOR USING THE EQUITY
METHOD
74 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 June 2007 2009
NOTE 8: PROPERTY, PLANT AND EQUIPMENT
2009 Annual and Quality of Care Report 75

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 9: PAYABLES
NOTE 10: EMPLOYEE BENEFITS AND RELATED ON-COST PROVISIONS
NOTE 11: OTHER LIABILITIES
76 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
NOTE 12: EQUITY
NOTE 13: RECONCILIATION OF NET RESULT FOR THE YEAR TO NET CASH
INFLOW/(OUTFLOW) FROM OPERATING ACTIVITIES
2009 Annual and Quality of Care Report 77

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 14: FINANCIAL INSTRUMENTS
78 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
NOTE 14: FINANCIAL INSTRUMENTS (cont)
2009 Annual and Quality of Care Report 79

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 14: FINANCIAL INSTRUMENTS (cont)
80 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
NOTE 15: COMMITMENTS FOR EXPENDITURE
NOTE 16: CONTINGENT ASSETS AND CONTINGENT LIABILITIES
NOTE 17: SUPERANNUATION
2009 Annual and Quality of Care Report 81

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 18a: RESPONSIBLE RELATED DISCLOSURES
NOTE 18b: EXECUTIVE OFFICER DISCLOSURES
NOTE 19: REMUNERATION OF AUDITORS
82 Colac Area Health

Colac Area Health
Notes to the Financial Statements 30 30 June 2007 2009
NOTE 20: SEGMENT REPORTING
2009 Annual and Quality of Care Report 83

Colac Area Health
Notes to the Financial Statements 30 30 June 2008 2009
NOTE 21: EVENTS OCCURING AFTER THE BALANCE SHEET DATE
NOTE 22: ECONOMIC DEPENDENCY
84 Colac Area Health

Acknowledgements
Publications
Annual and Quality of Care Report 2008
Community News
Consumer Liaison
Colac Area Health (CAH) continually strives to
improve all aspects of service and therefore
recognises the complaints and compliments process,
as a vital link to help monitor, improve, implement
and develop appropriate services in the provision of
care, for all consumers.
Patients, residents, clients and their carers, together
with the general public are actively encouraged to
communicate any concerns they may wish to report
regarding our service.
All reported incidents are investigated with
outcomes advised to the complainant, as soon as
possible.
The number of compliment letters and cards
received by CAH, confirms the quality of care
remains at a high standard. All staff should be
congratulated for their continued excellence in
service provision.
Suggestions and comments are welcome and
should be directed to the Chief Executive Officer,
Colac Area Health, 2-28 Connor Street, Colac. 3250.
Editor:
Photography:
Design:
Production:
Wendy Bath, Colac Area Health
Colac Area Health, Colac Herald,
Wendy Bath, Julie Rippon, Colac Area Health
Printworks, Colac
This Annual Report is a public document. It aims to present the
performance, services and developments of Colac Area Health
during the last financial year in an open and user friendly manner
to government and the community. This Report is produced in
accordance with Legislative Requirements set by the Minister for
Finance.
2009 Annual and Quality of Care Report 85

Colac Area Health
2-28 Connor Street
Colac Vic 3250
T: (03) 5232 5100
F: (02) 5232 5199
E: cah@swarh.vic.gov.au
W: www.colacareahealth.com.au