CAH Annual and Quality of Care Report 2008 - South West Alliance ...

CAH Annual and Quality of Care Report 2008 - South West Alliance ...

Colac Area HealthAnnual and Quality of Care Report2008Respect Integrity Leadership Innovation Quality Partnership

VisionColac Area Health aims to be a recognisedleader in the development and provision ofresponsive, integrated health care.MissionTo promote the health and wellbeing of theColac and district community through theprovision of quality acute, aged, residentialand community services that are accessible,affordable, flexible and integrated.Corporate ValuesRespectIntegrityLeadershipInnovationQualityPartnership2 Colac Area Health

InsideContentsPageVision, Mission and Corporate Values 2Highlights 4High Achievers 4Calendar of Events 4Our Organisation 5Our Services 6Our Performance 7Our Community 8Auxiliaries 8Bequests and Donations 8Making a Donation 8Community Partnerships 8Volunteers/Certificates of Service 8Organisational Structure 9Chairman and CEO’s Report 10Strategic Direction 12Corporate Governance 16Executive Management Team 17Risk Management 17Board of Directors 18Clinical Services 21Acute Care Unit 22Corangamarah Residential Aged Carefacility 23Preadmission and Discharge PlanningClinic 24Operating Suite 25Day Surgery Unit 26Haemodialysis Unit 26Urgent Care Unit 27Infection Control 28Pharmacy 29PageEducation Centre 30Visiting Medical Staff 31Medical Services 32Health Information 33Primary Care Services 34Allied Health 34Community Nursing 37Family and Community Services 39Human Resources 40Occupational Health and Safety 40Service Awards 41Staffing Profile 42Support Services 43Waste Management 44Information and Communication 46Statutory Compliance 47Disclosure Index 49Financial Services 50Certification 51Auditor-General’s Report 52Financial Statements 54Sponsors 87Acknowledgements/Publications 87Consumer Liaison 872008 Annual and Quality of Care Report 3

HighlightsOfficial visit by Hon. Daniel Andrews,MP, Minister for Health, to recognise therefurbishment and naming of formernursing homes Otway Pioneers andPolwarth House Service Centre and OfficialAnnouncement of Galvin-McCarthyAdministration buildingCorangamarah Art Prize - con.ceit ‘07High AchieversColac Area Health (CAH) congratulates ChrisTowers on the successful completion of herMaster of Nursing with the publishing of herthesis titled “Secondary school nurses’ andtheir work providing school based sexual andreproductive health programs in Victorian publicschools”. Chris has now completed the clinicaland post graduate components required forendorsement as a Nurse Practitioner.Congratulations to Julie Hallifax and TamaraHolmes for obtaining scholarships to undertakefurther training in their respective areas ofAlcohol and Drugs and Children’s Counselling.Julie obtained a scholarship from FlindersUniversity South Australia to undertakeprofessional development in the area of comorbidity, and Tamara obtained a scholarshipfrom the Australian Rural Allied HealthProfessionals Network to study a GraduateDiploma in Mental Health Sciences: ChildAdolescent and Family Therapies.Relocation of Community Dental Clinic tomain campusSealing of carpark to facilitate safer,convenient parking for staff and visitorsCalendarEvents• Annual General Meeting - November2008• Blue Ribbon Foundation AnnualRodeo• Corangamarah Art Prize - con.ceit ‘09Colac Otway Business Awards- Employee of the Month Finalist4 Colac Area Health

Our OrganisationColac Area Health (CAH) provides services to ColacOtway, Corangamite and Surf Coast shires with acatchment population of about 30,000. Colac AreaHealth is a unique, integrated health service modelwhich provides Acute, Residential Aged Care andPrimary Care services. Colac Area Health currentlyoperates an acute public health service (50 beds),Corangamarah Residential Aged Care facility (75 beds),Birregurra Community Health Centre, Community DentalClinic, Community Nursing incorporating Home andCommunity Care, Hospital in the Home, Post Acute Care,Palliative Care and an extensive range of Primary Careservices.Our HistoryColac Community Health Services was establishedon July 1, 1995, by the amalgamation of ColacDistrict Hospital, Colac Area Community HealthCentre Incorporated and Colac Housing and FinancialCounselling Service. A further amalgamation took placewith the Birregurra and District Community Hospitalon January 1, 1997. From July 1, 2002 the organisationofficially became known as Colac Area Health.Colac Area Health commissioned the services of DrDawn Peel to document our comprehensive history. Herbook “Quality Community Care — Colac District Hospital1882 to Colac Area Health 2003” was officially launchedin March, 2004.Colac Area Health commenced a major redevelopmentproject in December, 2001. Stage 1A comprised theconstruction of a two-storey building which providedtemporary accommodation for the Primary Carestaff until 2007 and permanent accommodation forpharmacy and pathology services. This building alsoincludes the Helen Macpherson Smith Trust ConferenceCentre; an excellent venue for staff education.Stage 1B, the Acute Medical Services building, wascompleted in February, 2003. This was the first majorredevelopment of acute patient services since 1971. Thisbuilding comprises 15 single rooms, nine twin-sharerooms, two four-bed rooms, two birthing suites, sevenday surgery beds, Emergency Department, OperatingSuite and Central Sterilising Supply Department.In August 2006, CAH completed Corangamarah, a $14million state-of-the-art Residential Aged Care facilitywhich provides High Level Residential and Respite Careand comprises 75 beds; 14 twin-share and 47 singlerooms and includes a dementia-specific unit.Corangamarah has numerous private courtyards, aswell as having landscaped gardens for residents andrelatives to enjoy. While the facility incorporates largecommunal gathering areas, there are also private areasfor residents to take time out for personal relaxation.In 2008, the final stages of the redevelopment werecompleted with the refurbishment of Polwarth Houseand Otway Pioneers and the establishment of aCommunity Dental Clinic on the main campus.About ColacThe Colac Otway Shire is one of the most picturesquemunicipalities in Victoria, covering a diverse area fromvolcanic lakes, craters and plains in the north, throughto the hinterland forests of the Otway Ranges to theGreat Ocean Road coastline. The area provides diverseemployment through a range of primary industries,tourism and commercial and community services.Colac is the key industrial, commercial and servicecentre for the Colac Otway and surrounding region witha population of 12,000.Anglesea2008 Annual and Quality of Care Report 5

Our ServicesAcute Care• Acute Care• Day Chemotherapy• General Medicine• Haemodialysis• Midwifery Services• Obstetrics and Gynaecology• Paediatrics• Pharmacy• Rehabilitation• Surgery - Dental, General, Gynaecology,Ophthalmology, Orthopaedic, Urology• Urgent CareAged Care• High Level Residential and Respite CareAllied Health• Adult Day Activity Centre• Community Dental Clinic• Community Rehabilitation Centre• Health Promotion• Nutrition• Occupational Therapy• Physiotherapy• Podiatry• Speech PathologyCommunity Nursing• Barwon Post Acute Care• Birregurra Community Health Centre• Chronic Disease Management• Community and Adolescent Health• Community Women’s Health• Continence Resource• Diabetes Education• Home Nursing• Hospital in the Home• Lymphoedema Clinic• Palliative Care Nursing/Volunteers• Wound Management ResourceCommunity Programs• Alcohol and Other Drugs• Colac Community Hub• Children’s Resource Program (Regional)• Drug Diversion Network (Regional)• Family Violence• Gambler’s Help• Supported Accommodation Assistance Program(Regional)• Women’s Health• Youth DevelopmentFamily Services• Child FIRST Intake• Family Support• Financial Counselling• Saver Plus Program• Transitional Housing• Women’s Counselling• Youth and Children’s CounsellingDiagnostic Services• Pathology• Radiology/Medical ImagingVisiting ServicesThere are Visiting Services such as Family Planning,Drink Driver Education Program, Legal Aid,Prosthetics and Orthotics and Geelong CentreAgainst Sexual Assault.Co-Located Services• Department of Human Services Child Protection• Diversitat• Neighbourhood Renewal• Pathways PDRSS• Time for Youth6 Colac Area Health

Our PerformanceFinancial2007/2008 2006/2007 2005/2006 2004/2005 2003/2004 2002/2003Total Revenue 30,293,886 29,421,802 34,497,391 27,362,187 25,165,947 27,835,998Total Expenditure 29,863,963 28,783,276 27,876,313 27,266,900 25,676,618 24,270,073Revaluation Increment 821,236 - 5,602,270 - - 2,243,556Fund Decrease Resulting fromChange in Accounting Policy - - - - - (35,215)Surplus/(Deficit) inc. CapitalIncome and Unfunded Depreciation 429,923 638,526 12,223,348 95,287 (510,671) 5,774,266Total Assets 44,355,128 42,905,863 41,823,383 28,938,566 29,007,894 28,617,037Total Liabilities 6,426,450 6,582,740 6,796,864 6,484,135 6,808,388 5,909,754Total Equity 37,928,678 36,323,123 35,026,519 22,454,431 22,199,506 22,707,283StaffFull Time Equivalent 283.41 285.29 285.90 285.60 282.55 283.80Bed DaysHospital 13,279 14,608 13,417 13,495 13,602 14,809Average Length of Stay 2.52 2.84 2.67 2.78 3.05 3.32Aged Care 26,478 26,901 25,418 24,385 25,965 27,713Births 216 187 179 194 190 168Operations 2,304 2,168 2,280 2,190 1,999 2,108Inpatient StatisticsSame Day 2,680 2,649 2,722 2,524 2,231 2,281Multi Day 2,527 2,484 2,308 2,342 2,231 2,293TOTAL SEPARATIONS 5,257 5,133 5,210 5,060 4,462 4,574Weighted Inlier Equivalent Separations(WIES)2,997 3,144 3,019 2,925 2,822 2,859Aged Care StatisticsResidents 111 126 127 140 155 112Urgent CareOutpatient Attendances 7,914 7,296 7,029 6,941 8,091 8,091Community ServicesTotal Contacts 57,097 57,286 56,951 51,092 52,707 52,531Total Clients 12,871 9,499 9,422 8,614 8,697 8,666Patient Fees Outstanding – Outstanding Debtors as at 30 June 2008Under 30Days30-60Days60-90DaysOver 90DaysTotal30/06/08Total30/06/07Total30/06/06Total30/06/05Total30/06/04Private 39,768 17,635 8,295 9,142 74,840 60,515 10,251 140,263 80,848TAC - - - - - - - - -VWA 7,346 - 5,560 - 12,906 8,999 6,006 7,350 8,6842008 Annual and Quality of Care Report 7

Our CommunityAuxiliariesColac Area Health (CAH) recognises the valuablecontribution of our Auxiliary members overmany years. The members have raised thousandsof dollars which has enabled CAH to purchaseequipment, furnishings and fittings to benefit thecommunity when using the Health Service. InAugust, 2007 CAH was presented with a cheque for$3,500 by the Colac Auxiliary.The Birregurra Community Health CentreAuxiliary continues to support the CommunityHealth Centre at Birregurra and provides ongoingfundraising which assists with the purchase ofequipment for the Centre.Bequests and DonationsAs a result of fundraising campaigns, localcommunity members, auxiliaries, volunteers,service clubs and groups, bequests, localbusinesses and CAH staff have raised in excess of$139,140.Colac Area Health has been successful inreceiving funds from the following philanthropictrusts, bequests and donations:• Tattersalls Foundation $40,000• Estate RJ Speirs (distribution) $11,500• Perpetual Trustee Co- RP Medical Fund $10,800• Palais Bingo $ 6,000Making a DonationColac Area Health is very fortunate to receivegenerous contributions from our communitythrough donations and bequests.We encourage you to consider Colac Area Healthwhen making your Will. If you wish to discuss thisfurther, please contact the Chief Executive Officeron (03) 5232 5123. All enquiries are treated withthe strictest confidence.Community PartnershipsBlue Ribbon FoundationA small but dedicated committee came together sixyears ago with a novel idea to host a rodeo in Colac. Thisevent became part of the New Year calendar for many,attracting enthusiastic crowds.However due to circumstances beyond our control, the2008 rodeo was cancelled. Plans are underway for 2009and this event will continue to raise awareness of thisimportant foundation while raising funds to purchasevital equipment for the Emergency Department at CAH.VolunteersColac Area Health currently has 209 registeredvolunteers, excluding palliative care volunteers.These volunteers continue to be recognised asa vital part of CAH and provide assistance in thefollowing areas:- Adult Day Activity Program- Childminding- Clerical Roles- Colac Area Health Auxiliaries- Community Hub- Community Programs- Flower Ladies- Pastoral Visiting- Residential Aged CareCertificates of ServiceCertificates of Service are awarded to volunteerson completion of ten years service. Recipients atthe Annual General Meeting held in November,2007, were as follows:- Mrs. Betty Cadby - Palliative Care- Mrs. Lorraine Evans - Palliative Care- Mr. Michael McGannon - Palliative Care- Mrs. Leona Pekin - Palliative Care8 Colac Area Health

Organisational StructureThe CommunityDirectorClinical ServicesManager PharmacyNurse Unit ManagerAcute Care UnitBusiness Nurse ManagerResidential Aged CareBoardofDirectorsClinicalCoordinators--------Nurse Unit ManagerOperating SuiteNurse Unit ManagerUrgent CareClinical EducatorInfection Control NurseCoordinatorNo LiftChiefExecutiveOfficer--------------------------------------------------------DirectorCorporate ServicesHuman ResourcesManagerCoordinator Preadmission& Discharge PlanningManagementAccountantFinancialAccountantManager Information &CommunicationManager HealthInformation ServicesManagerAdministration ServicesManagerSupport ServicesManagerPayroll ServicesManagerQuality & RiskManager SupplyHead ChefDirectorPrimary CareManagerAllied HeatlhManagerCommunity NursingManagerCommunity ProgramsManagerFamily Services2008 Annual and Quality of Care Report 9

Chairman and CEO’s ReportIn accordance with the Financial ManagementAct 1994, we are pleased to present the Report ofOperations of Colac Area Health (CAH) for the yearending 30 June, 2008.2007/08 financial year witnessed the conclusionof a decade of facilities redevelopment at CAHwith the refurbishment of the former CommunityNursing building to be the home of the DentalClinic. The Clinic commenced operations in its newhome in May, 2008.Over the year, the following works werecompleted as part of the main campusredevelopment project:• Finalisation and occupancy of Polwarth HouseService Centre opened by Hon. Daniel AndrewsMP, Minister for Health, on 8 February 2008.• Expansion of rehabilitation capacity withthe establishment of a bigger more spaciousgymnasium enjoyed by many of our communitymembers.• Construction of a sealed car park for visitors andstaff, with higher level of safety for pedestrianswith marked crossing and signage.The Board was delighted to host the Ministerfor Health on 8 February, 2008, to announcethe naming of the Galvin-McCarthy Building inhonour of Drs. Frances Galvin and Jim McCarthy.The occasion was made even more special byhaving the company of both Frances and Jim whoresponded to the Minister and outlined manychanges and advances they had seen during theirprofessional years.At Board level, 2007/08 was the first year ofoperation of the Risk Committee established underthe governance reforms undertaken during the2006/07 financial year. One pleasing aspect ofthe Committee functions is the increased level ofunderstanding and knowledge of CAH’s operationsnoted by Directors during the year.To support the Risk Committee, a suite of KeyPerformance Indicators have been developed thatcontribute to the Committee’s primary functions;to be assured the Health Service is well managed.The introduction of a new budget managementsystem called Power Budget occurred duringthe latter half of the year, which will facilitate thedevolution of operating budget managementacross the organisation. 2008/09 financial year willbegin to see the benefits of providing the righttools for Directors and Managers to better managethe Service.A new payroll system was introduced duringthe year which will reduce the number of payrollqueries from staff and improve morale. The “golive” date for the new system is July, 2008.Education and professional developmentopportunities are vital for staff of a vibrantprogressive organisation. The year saw theestablishment of a more sustainable EducationCentre within the Clinical Services Program. TheUnit will have a wider organisational educationactivities focus than has been customary. We havebeen able to attract excellent highly qualified staffto the Unit and look forward to the expanding ofrelationships with Deakin University over the nextdecade or so.Colac Area Health enjoys a robust and proactiverelationship with Visiting Medical Staff and PracticeManagers. In partnership with both Practices,work has begun on development of a combinedroster system for on-call arrangements; ambitionis for a roster arrangement that is able to bemanaged with live access for updating capabilitiesby the Practices. This would greatly assist patients,nursing and medical staff.During 2007/08 the Board provided leadershipon the public oral health initiative by supportingand advocating for the introduction of fluorideto the public water supply. Government is tobe congratulated for its Fluoride Policy whichwill have a marked positive impact on futuregeneration’s health.In March, the Board signed an agreement for theassumption of responsibility of both communitydental and former school dental services whichhave been integrated into one system. BarwonHealth Dental Services manage the service, underan agreement; the guidance and managementexpertise of Dr. Michael Smith and his staff isacknowledged. During 2008/09 CAH will seek toexpand dental services capacity.2007/08 was a very busy year for the Service.Inpatient activities at CAH were one of the busiestwith 5257 inpatients being treated, the highest10 Colac Area Health

Strategic DirectionOver 2007/08 financial year, the following matterswere identified as priorities and actions taken toaddress:Management InformationSystemsA continuing challenge is the use of timely servicedata that effectively assists with managing ofphysical and human resources.While improvements and developments havebeen achieved there still remains a challenge tohave a fully integrated system that provides keymanagement information about the organisation.Currently there is no single integrated system thatprovides Executive Directors and Managers withsuch an overview.One notable development that emerged outof consumer feedback highlighting the need forbetter monitoring of food services has been the“Temperature Monitoring System” that providesa rigorous regime of recording that is comparedwith accepted industry standards. Regularreporting, with 14 and five day comparisonreports, are provided to Executive and Managersto ensure standards are met and for the purposeof demonstrating to regulatory bodies acceptedindustry practices are in place.An established system of measuring activity isin place that provides month on month reviewsof performance against funding bodies expectedtargets.The Board, through the Risk Committee, monitorsthe activities regularly and seeks guidance andassurance from the Executive on any notedvariances in performance from expectedachievements. A suite of Key PerformanceIndicators provide the Risk Committee with anoverview not only of activity but also regulatoryand quality compliance levels within theorganisation.Team DevelopmentWhile 2007/08 year witnessed the loss of twoExecutive Directors recruitment success in thesecond half of the year has brought about stabilityat Executive level.Work had continued on from 2006/07 financialyear in promoting the Corporate Values of ColacArea Health (CAH) being:Quality, Respect, Innovation, Leadership, Integrity,Partnership.Reform to the Management Team continued toengender a contemporary management cultureacross the organisation. Focus has been on culturedevelopment that is one of pride and pursuit ofexcellence as a health service; an organisation thatpeople want to join is CAH’s ambition.Corporate ProgramBudgets and Power BudgetOver 2007/08 the Executive expanded on theinitial work in the previous financial year whichhas established the base for program budgetsintroduction in 2008/09 at Director and Managerlevels. The work will provide a much more robustinternal budgeting process and facilitate internalreviews as part of an organisation sustainabilitystrategy. Budget development work hasnecessarily involved:- Budgeting education for program managers andteam leaders- Budget development workshops to refineprograms and units budgets- Training in and operation of Power Budgetsystem.Corporate SystemsDevelopmentOne challenge that has been faced by theExecutive has been the lack of integratedcorporate systems. As indicated in the 2006/07Annual Report as an objective; 2007/08 saw aninvestment of resources towards developing anintegrated corporate suite of systems that assistswith the provision of an entity integrated report forthe Management Team.Fundamental building blocks to such anintegrated system included:• Implementation of ChrisPay21, that providescurrent data and contemporary managementreports and feeds into budgeting system12 Colac Area Health

• Introduction of Power Budget; a strongerfinancial management reporting system• Integrated activities management system whichhas commenced with TrakHealth-Clinicals andTrakHealth-Community to replace PJB and othersoftware used in the Primary Care Program• Robust corporate suite that includes:- Addressing legislative compliance throughBACeS,- Contracts and Agreements Managementsystem- Credentialed Health Professional Register- Policies and Protocols management throughPROMPT.FacilitiesOver 2007/08 the Board and the community canbe justly proud of the facilities developmentachievement across the organisation. In briefthese developments included:• Conclusion of the major redevelopment acrossColac Area Health (CAH)• Finalisation of Polwarth House Service Centre• Expansion of gymnasium capacity to supportthe concept of a stronger rehabilitation and subacute services in conjunction with Barwon Health– McKellar Centre• Relocation of the Community Dental Clinic ontothe main campus site• Establishing the “Blue Shed” as a communitymeeting facility with kitchen capacity• Establishment of a sealed carpark thatprovides convenient and safe parking with soundpedestrian access• Building of a more sustainable EducationCentre in the former Family Services offices• Finalised the plans and submission to theCommonwealth for twelve bed studentaccommodation facility for Colac• Establishment of the Speirs Meeting Room toprovide an executive meeting room for the Boardand VIPs with built in technology to assist withpresentations.Operations and ServicesThe provision of monthly documentation and theconduct of the Risk Committee have met Boardexpectations on the level of information anddetail about CAH’s operations to give the Boardconfidence in its governance role.Detail provided included:Residential Aged Care- Resident Classification Scale (RCS) mixmanagement- Comparative revenue analysis- Occupancy management.Acute Care- Weighted Inlier Equivalent Separations (WIES)targets achievement- Admissions monitoring, both public and privatepatients- Estimate operating theatre throughput requiredto reach WIES target for 2007/08 and monitoringof throughput- Measuring acute services revenue generated andthe variance from target.Primary CareAchievement of activity compared with targets for:Major Funded Programs under Primary Carewhich account for more than 12000 under Homeand Community Care and Community Health.Professional services provided include:• Dietetics• Occupational Therapy• Physiotherapy• Podiatry• Social Work• Speech Pathology.Family Services and Community ProgramsWhile measurement of such a diverse rangeof activities has been challenging at executivemanagement level during 2007/08 financial year,better monitoring of activity occurred for the2008 Annual and Quality of Care Report 13

Board, showing overall achievement level againsttarget for the following activities:• Alcohol and Other Drugs Counselling Services• Child FIRST – Family Services• Family Support• Financial Counselling• Gamblers Help• Housing Services - Transitional Housing Support• Saver Plus – Partnership• Victims of Family Violence Support• Women’s Health Support.Governance DevelopmentsAs a follow-up to work reported in the 2006/07Annual Report, 2007/08 has been the first yearof Risk Committee functioning which has beenmodestly successful. A comprehensive suite of KeyPerformance Indicators (KPI’s) has been establishedreflecting organisation wide operationalmanagement of Programs and Units. Duringthe year some modifications were made as theRisk Committee became more experienced andcomfortable with its role and operations. CurrentlyColac Area Health (CAH) has 99 KPI’s beingreported against on a financial year cycle.A review of the Risk Committee’s operationshas been foreshadowed for consideration during2008/09 financial year.Over the last financial year the financial andactivity reporting framework to the Board has beenmodified.In 2008/09, CAH will be moving away fromaccreditation by the Australian Council onHealthcare Standards (ACHS) to ISO system; theAged Care Standards and Accreditation AgencyLtd. will continue for residential aged care.CommunicationStaffWell informed staff is vital to an organisation thatfunctions 24 hours per day 7 days per week andprovides such a diverse range of services as CAHdoes. The concept of the “Weekly News” has beencontinued to provide a conduit for keeping staffinformed of developments within CAH.The Executive has endeavoured to maintaina high level of engagement through theManagement Team meetings, structured Unitmeetings, and operational discussions such asbudget development, activity monitoring, policiesand protocols.There is always room to improve; communicationis generally at the top of the list of criticism ofExecutive staff in any staff climate survey. Over2008/09 continued effort will be put into providinginformation to all staff, particularly managementinformation on CAH’s performance, stronger accessto operational policies via PROMPT and practiceadvice. A range of work has been identified tobring human resource policies, processes andprocedures up to date which will begin in 2008/09.BoardAs with 2006/07, during 2007/08 a concertedprogram has been to ensure that Board Directorshave been provided with information and detail topromote discussion and exploration about CAH’sperformance in respect of the following:- Financial performance- Legislative Compliance- Service activities achievements against targets- Quality Assurance.Key Stakeholder EngagementsVictorian Healthcare Association (VHA)Over 2007/08, Colac Area Health increased itslevel of communication and engagement withthe Executive of VHA as the peak body for healthservices in Victoria.Over 2008/09 this pattern of engagement willcontinue.Visiting Medical Staff (VMS)Overall the level of engagement and discussionwith the VMS as a group and individuallyhas increased and the relationship with bothCorangamite Clinic and Otway Medical Clinic is apositive one.14 Colac Area Health

Over 2007/08 a number of activities has occurredto engage and to inform VMS including:- Chief Executive Officer and Director ClinicalServices attendance at VMS monthly meetings- Exploration of different models including theengagement of career medical officers- Use of KPI’s to inform of trends and performanceincluding:• Category 2 Triage attendance measures toUrgent Care• Medical Records completion rate• Discussions on the development of combinedon-call roster between both Medical Practices• Obstetrics Model development discussions.MediaColac Area Health (CAH) has a good relationshipwith local media in particular The Colac Heraldand Corangamite Extra. The Chief Executive Officerhas a regular appointment with The Colac Heraldjournalists that aids understanding and keepingthe community informed of events, developmentsand achievements during the year.The Health Service has enjoyed a high level ofmedia exposure and good publishing rate ofarticles and press releases.Over 2008/09 there will be an endeavour tomaintain a similar level of engagement.Department of Human Services(DHS)Colac Area Health has a very effective andmature relationship with the DHS built on open,transparent and honest dialogue. The efforts of theBoard and Executive in managing the challengesfaced have been topics of positive comment byRegional Office staff.Strategic ObjectivesColac Area Health Board2007-2010 Strategic Goals1. Excellence in Service Provision – by providingthe right service, at the right time, with bestpractice.2. Vibrant well managed Health Service – that iswell respected, meets activity targetsunderpinned by financial sustainability,operational efficiency, sound management andeffective governance.3. Sustainable and Progressive Workforce – bypromoting a values based environment thatpromotes staff skills and being an importantsite for medical, nursing and allied healthstudent experiences and ongoing education.4. Robust organisational environment – thatpromotes a highly responsive service based oninformation and knowledge management.5. Contemporary facilities and equipment – tosupport the provision of relevant, timely serviceframework.The focus for 2008/09 will be:Strengthening service profile with an emphasison:- Achieving a sustainable obstetrics and midwiferyservices model.- Establishment of a Health and Wellbeing Clinic- Strengthening sub acute and rehabilitationservices.Efficacy and efficiency gains- Through reform of internal process andefficiency gains in:• Patient and client management processesand systems.• Clinical Services operations and functions.• Establishment of a Midwifery Unit.• Reorganisation of Program responsibilities toclarify decision making.- By the conduct of a program of internal reviewsand structural reform.- By embedding improved processes.- To support the Visiting Medical Staff modelof operations by recruitment of Career MedicalOfficers with a priority for staff with Obstetricsand Emergency training- Building on existing relationships with BarwonHealth to provide a sustainable range of services.2008 Annual and Quality of Care Report 15

Corporate GovernanceColac Area Health (CAH) is a Victorian public sectororganisation incorporated under the Health ServicesAct 1988 and operates under the provisions of thisAct.The Minister responsible for the administration ofthe Health Services Act is the Minister for Health,Hon. Daniel Andrews MLA. Colac Area Health isaccountable through the Board of Directors (BOD) tothe Minister for Health.Colac Area Health is governed by a eight personBOD appointed by the Minister. Board members areappointed for periods up to three years and serve in avoluntary capacity.Governance refers to arrangements in place toadminister, manage and monitor services provided.In past years the focus of the Board’s governanceobligations was in management and financial areas.Today, public health service providers are requiredto be more transparent and accountable to thecommunity in their governance obligations, such asclinical governance and risk management.The functions of the Board of Directors are:• To conduct the Service in a manner that is consistentwith the Mission Statement and the Health ServicesAct 1988• To establish reporting mechanisms to monitor theperformance, reports and audit processes of theService and to ensure that they comply with theFinancial Management Act 1994• The general governance of the Service• To maintain proper accountability to governmentby close observation of all legislative requirements,ensuring that the Service meets or exceeds targetsas agreed in the Health Services Agreement andcomplies with all standards governing the Service• To ensure compliance with legislative requirementsgoverning Health Services and promote a safe,effective, appropriate and consumer orientatedservice within this legislative framework• To annually review the past twelve months’ activitiesand set future direction• To reflect the needs of the community and tocommunicate policy and strategic direction byconsultations, publications and promoting the profileof the Service• To ensure that the Service provides a range ofappropriate services, promotes excellence andsupports educated, competent staff• To promote good working relationships withGovernment Departments.Colac Area Health is addressing the governanceissues associated with Health Service delivery to:• Meet community expectations by achieving qualityhealth service delivery• Ensure there are corporate and clinical standards foraccountability and leadership within the Service• Address the management and identification ofrisks and hazards by implementing a comprehensiveclinical and non-clinical risk management system.• Ensure staff and facilities are assessed, reviewed andcredentialled.Board Orientation andEducationOrientation and Board Education has beenundertaken by attendance at sub-regional forumsconducted by the Department of Human Services(DHS).This education is directed at clarifying the rolesand accountability of Board members in providingeffective governance of their agencies.Colac Area Health has continued to be a leader indeveloping an integrated Health Service deliverymodel.Underpinning the philosophy of this model isproviding access to a range of appropriateservices for rural communities.Project Control GroupEffective Board Governance required members ofthe Board and the Executive Management Team(EMT) to participate in the Project Control Group(PCG) which oversaw the Redevelopment Project.Representatives from DHS Regional Office, CapitalManagement Branch, Architects, Project Managersand the Quantity Surveyor received reports onconstruction progress.It is timely and appropriate at the conclusionof the redevelopment project to recognise thecontribution and professional support affordedColac Area Health (CAH) by Kevin Hughes, CapitalManagement Branch, Department of HumanServices (DHS), over many years.16 Colac Area Health

Executive Management Team L-RJillian Dunbar, Director Clinical Services,Garry Ellis, Director Corporate Services,Donna Hay, Manager, Human Resourcesand Geoff Iles, Chief Executive Officer.Committee StructureThe Board has established a committee structurewhich complies with the Health Services Act 1988and fulfils the requirements of the Board and theMission Statement to ensure that policies set inplace are community and client-focused.The following are sub-committees of the Board:Risk CommiteeThis committee receives reports from theExecutive Directors which reflects compliance withaccounting standards and mandatory reportingrequirements along with service activities andquality initiatives. Monthly monitoring of thefinancial performance of the Service is undertakenby the committee as are all aspects of both theinternal and external programs.Medical Appointments AdvisoryCommitteeThis committee makes recommendations to theBoard on medical appointments.Medical Staff CommitteeThis committee provides monthly reports onparticular matters of clinical nature.Clinical Services AdvisoryCommitteeThis committee provides advice on clinical servicesdevelopment.Executive ManagementTeamThe Board of Directors has delegated theoperational activities of Colac Area Health tothe Chief Executive Officer (CEO), the ExecutiveManagement Team (EMT) and staff in accordancewith the Instrument of Delegation and the HealthServices Act 1988 (Division 4 Section 33).Risk ManagementI, Geoff Iles, certify that Colac Area Healthhas progressed risk management processesduring 2007/08 financial year consistent withthe Australian/New Zealand Risk ManagementStandard and has an internal control system inplace that enables the executives to understand,manage and satisfactorily control risk exposures.The Risk Committee verifies this assurance andthat the risk profile of Colac Area Health has beencritically reviewed in the last 12 months.Geoff IlesChief Executive22 September, 2008Colac2008 Annual and Quality of Care Report 17

Board DirectorsMr Richard Riordan,ChairmanB.Bus. (Management)Richard is a local businessman,having returned to Colac aftercompleting a degree in BusinessManagement at Monash University.Richard has been active in the localcommunity, having been involvedon the committees of managementfor the local Business and RetailersAssociation, Adult Education Board,Lake Foreshore Committee and localsports club. Richard is an enthusiasticsupporter of improving anddeveloping community services inColac and has been the driving forcebehind the establishment of con.ceitCorangamarah Art Prize.Cr Anthony Graham,Senior Vice-PresidentAdv Dip. Disability Work, Dip. FMI,Dip. Tas, Adv. Cert. R.A.C.S, Cert. IVWorkplace and TrainingTony has been a member of the CAHBoard for several years, includingthree years as Chairman. Tony hasrepresented our service over the pastseven years as an elected Councillorwith the Rural and Regional HealthDivision of the Victoria HealthcareAssociation (VHA) and wasappointed as a Director of the Boardof Management of VHA in 2004.Currently he works as a training anddevelopment consultant with RoyalMelbourne Institute of Technology(RMIT). Tony has been elected asChairman, Regional and Rural CouncilVHA. In 2008 Tony was appointed as aCouncillor Colac Otway Shire.Mr Wayne O’Brien,TreasurerB.Com, C.A., C.P.A.Wayne is a Chartered Accountantand has been a principal of a localaccounting firm for 17 years. Beforereturning to Colac, Wayne workedwith a large accounting firm inMelbourne with secondmentsinterstate and overseas. Wayne isan active squash and tennis playerand has a wide involvement incommunity affairs. Wayne has servedon the board for nine years whichhas included terms as Chairman andTreasurer. During this period Waynehas overseen all stages of the majorredevelopment projects whichcommenced in 2001 and concludedin May 2008.Term of appointment:1 March, 2007 to 30 June, 2008Board and Committee attendance:Board 12 of 13Risk Committee 7 of 10Term of appointment:1 November, 2004 to 30 June, 2008Board and Committee attendance:Board 10 of 13Risk Committee 0 of 10Term of appointment:1 November, 2004 to 30 June, 2008Board and Committee attendance:Board 12 of 13Risk Committee 9 of 1018 Colac Area Health

Mrs Alison McDonald,Junior Vice-PresidentB.A. (Hons) Food and AccommodationManagement, Cert. III Small Bus.Management, Master of Teaching(Primary)Alison resides at Birregurra and is apartner in a family farming business.As a former member of the BirregurraAdvisory Committee she contributedto the development of the BirregurraCommunity Health Centre. She isactively involved in the communityas a member of the Birregurra HealthAuxiliary, together with past andongoing participation at committeelevel with the local pre-school andprimary school. She is currentlyteaching full time at Birregurra PS.Alison did not seek reappointmentwhen her term of appointmentexpired in November, 2007.Mr Anthony BaldwinTony is a self-employed businessmanand dairy farmer. He has an interestin quality assurance procedures,financial management and strategicplanning. Tony is actively involved inthe community as a member of theRotary Club of Colac and ElliminytPrimary School and Trinity CollegeParent Committees.Ms Kathryn McBrideDip. Fine Arts (ceramics), Grad Dip.Education, Dip. of ManagementKathryn is employed by City ofGreater Geelong as Coordinator CareServices. She is currently a committeemember of Villamanta DisabilityLegal Service and Swan Marsh Hall.Kathryn has previously held positionson Arts Colac and Colac CommunityDevelopment Association andDisability Managers Association.Term of appointment:1 November, 2004 to 31 October, 2007Board and Committee attendance:Board 3 of 4Risk Committee 1 of 4Term of appointment:1 March, 2007 to 30 June, 2009Board and Committee attendance:Board 8 of 13Risk Committee 7 of 10Term of appointment:1 March, 2007 to 30 June, 2009Board and Committee attendance:Board 12 of 13Risk Committee 7 of 102008 Annual and Quality of Care Report 19

Board DirectorsMr James RyanB.A., L.L.B.Jim is a partner of a local law firm anda Life Member of the Law Institute ofVictoria. He was a Councillor of the Cityof Colac for nine years and Colac OtwayShire for eight years, during which timehe held the position of Mayor for threeterms. Jim is president of the Colacand District Cricket Association andColac Turf Club, a committee memberof Colac Do Care Inc., and is activelyinvolved in community affairs.Mr Robert DaltonDiploma of Education, Bachelor ofArts, Bachelor of CommunicationBob is employed as Chief ExecutiveOfficer of Skills Connection and hasextensive corporate managementbackground and experience. WhilstBob has only been a resident of Colacfor the past three years, he has madea significant contribution to thecommunity as a Member of OtwayBusiness Inc., Colac CommunityEnterprise and Otway FM CommunityRadio Special Development Group.Mr Max ArnottAdvanced Diploma of FinancialServices, CFP Certified FinancialPlannerMax is a Certified Financial Planner whoestablished the business Adviser GroupFP by bringing together advisers andstaff from Colac, Geelong, Hamiltonand Albury into a diversified business.This Group is now one of the top tenpractices for the Licensee of MLC/Garvan Financial Planning Vic/TasStates. Max is an active member of thecommunity having been awarded a LifeMembership of the Apex Club of Colac,and is currently a member of the RotaryClub of Colac West, State Delegateof MLC/Garvan Advisory Board, andTreasurer of Otway Business Inc.Term of appointment:1 November, 2005 to 31 October, 2008Board and Committee attendance:Board 12 of 13Risk Committee 7 of 10Term of appointment:26 February, 2008 to 30 June, 2010Board and Committee attendance:Board 5 of 6Risk Committee 2 of 4Term of appointment:26 February, 2008 to 30 June, 2010Board and Committee attendance:Board 5 of 6Risk Committee 3 of 420 Colac Area Health

Jillian DunbarDirector Clinical ServicesClinical ServicesIt is with great pleasure I present my first annualquality report as Director Clinical Services. Whilsthaving occupied this position for a period ofonly five months at the end of this reportingcycle, I reflect on the challenges, achievementsand highlights in clinical services over theentire previous twelve months and in doingso acknowledge the efforts of my predecessorSimon Walter who resigned from the position inDecember, 2007.The focus and goal has been to develop a teamorientated learning environment within a cultureof respect, integrity, innovation, leadership,quality and partnerships. The outcome will bean organisation of choice for the recruitment andretention of highly qualified and motivated staff.This year has been a year of capacity building;providing staff with the opportunities,qualifications and equipment to facilitate theprovision of safe, contemporary quality care tothe community. This will continue to be a work inprogress.Critically reflecting on the way we do things andlooking for opportunities for improvement hasinstigated reviews of varying degrees in manyareas of Clinical Services. An external review ofthe culture in Clinical Services was undertaken inFebruary by RTK Resolutions. This review identifiedareas of concern in relation to behaviours amongsome staff that did not comply with the Valuesof the organisation. Several recommendationswere put forward by the consultants, includingresponsibilities of the Executive. Staff involved inthe review have also been involved in planningthe ‘way forward’ in a collaborative effort toachieve our goal. Whilst this review was somewhatconfronting for all concerned, it has provided anexcellent platform to move forward and I sincerelythank all staff who participated and contributed inthis challenging quality initiative. I believe we havecome a long way as a result of this review.The introduction of the PROMPT system has beena quality initiative project that, while still in itsinfancy stage and requiring further development,has far reaching benefits not only for the ClinicalServices staff including medical staff, but stafforganisationally wide. PROMPT facilitates arobust policy and protocol system that providescontemporaneous gold standard practice. This isan invaluable resource for rural health services andcan only serve to promote best quality practice inrural areas.This year Colac Area Health (CAH) has nominateda sponsor for the ‘Focus on Variation’ Projectfacilitated by the Victorian Health ServiceManagement Innovation Council. This provides uswith an opportunity to benchmark performanceagainst like size health services in an anonymousformat. We look forward to progressing thisProject in 2008/2009The development of a ‘learning’ environment isessential for CAH with the prospect of medicalstudents from Deakin University placed at theorganisation in 2010. This will be an excitingtime for all staff to be closely aligned to DeakinUniversity, bringing with it valuable opportunitiesfor professional development. Added to this,discussions are taking place for the placement ofmidwifery students and peri-operative students atCAH.I would like to take this opportunity toacknowledge the following senior staff who haveresigned their positions at CAH this year and thankthem sincerely for the contributions they havemade to the organisation: Simon Walter, PamelaMatheson, Donna Field, Tasha Parker and LyndaInglis. We welcome to the organisation WendyPenney and Deborah Payton.My sincere appreciation goes to all staff in ClinicalServices. I thank you all for the support you haveprovided to me since my appointment. I amimpressed with the dedication to the provision ofquality care and look forward to an exciting yearahead.Department Managers and Associate Managershave provided informative reports on each of theirdepartments and I commend these reports to youfor an insight into the contribution these areasmake in the delivery of quality care.Jillian M DunbarDirector Clinical Services2008 Annual and Quality of Care Report 21

Acute Care UnitThis busy Unit provides care to patients admittedwith acute medical and surgical conditions as wellas maternity, paediatric and palliative care. A largeteam of dedicated nurses work collaboratively withmedical and allied health staff to provide patientcentred, holistic care.This graph identifies the trend of increased acutecare patient throughput from 2004 to 2008.The number of patients treated in this Unitcontinues to increase on a yearly basis, staff aretherefore always looking for ways of ‘workingsmarter’ whilst improving the delivery of our care.The variety of conditions of patients admitted tothis Unit places additional demands on nursingstaff to have a broad knowledge and experience.Education and Professional developmentopportunities are therefore very well acceptedby our staff and advantage is taken of the variousinternal and external education sessions. NineDivision 1 nurses completed the Certificatein Advanced Life Support and four Division 2nurses completed the Medication EndorsementCertificate. All staff on the Unit are competent inBasic Life Support and ‘No Lift’ techniques and anumber of staff have undertaken the IntravenousCannulation Competency.The nursing staff in this Unit are very involved insupporting the Graduate Nurses in their transitionfrom a Graduate Nurse to a competent andconfident nurse. Two of our Graduate Nurses haveremained on staff this year.Our midwives have been extremely busy this yearwith a record number of births for six years (asshown in the graph opposite). On one occasionfive babies were born in seven hours. This was ahectic night for our midwives but went withouta hitch thanks to our very competent and calmstaff. Numerous study days and courses havebeen attended by the midwives with severalundertaking the Advanced Life Support inObstetrics (ALSO) course. This is a two daycourse for all maternity care providers includingphysicians and provides the knowledge andskills required to effectively manage potentialemergencies during the perinatal period.Midwives are looking forward to the developmentof a collaborative model of care between Medicaland Midwifery staff to ensure maternity servicesare sustainable in Colac.Our Acute Care Unit has received numerouspieces of equipment over the past year including:• Portable Oxygen Saturation and Vital SignsMonitoring Machines.• Maternal and Foetal Monitors, Foetal Dopplerswith Probes, Thermometers and Digital Scales.• Shower Chairs.A continuous quality improvement culture inthe Acute Care Unit, means we are reviewingour practices and service with improvement inmind on a daily basis. Many initiatives have beenintroduced this year in the provision of patientcare. Review of Discharge Planning, Care Plans,Clinical Pathways, Policies and Procedures haveresulted in improved practices.Sue Spowart,Acting Nursing Unit ManagerAcute Care Unit22 Colac Area Health

Corangamarah ResidentialAged Care FacilityOur facility will be two years old in August2008. We continue to make improvements forour residents and this year we have focused oncreating a more ‘home-like’ environment. We haveencouraged residents, family and friends to bringin special personal belongings for the residents’rooms. A garden especially designed for ourdementia sufferers has been requisitioned; shadesails have been erected in the garden areas; airconditioners have been installed in the passageways and refurbishment to the front entrance hasbeen planned.We value suggestions on how to improvethe environment and the care provided inCorangamarah. To facilitate this, an Aged CareForum has been organised; the first of regularforums. This will allow relatives of existingand past residents, an opportunity to providevaluable feedback, to ensure we are meeting theneeds of our residents, families and friends. Webelieve involvement of families and friends in ourresidents’ care is paramount for their health andpsychosocial welfare.Added to this, we have reviewed the ‘Complaints,Compliments and Comments’ process atCorangamarah to ensure access to this process byeveryone involved in the care and welfare of ourresidents. All staff in Corangamarah have attendededucation sessions on the process.The review of this process will ensure a timelyresponse to any complaints or suggestions, andfollow up with the resident or complainant toensure the problem has been addressed to theirsatisfaction where possible.The conversion to a new food production systemcreated enormous challenges for us this year.Many complaints were received from staff andresidents in relation to the quality of the mealsand we received a visit from representativesof the Aged and Community Care Branch,Department of Health and Ageing as a resultof registered complaints. We welcomed theopportunity to undertake a complete review ofthe menu, production and plating of the mealsprovided in Corangamarah. A Working Partywas established and a monitoring and feedbacksystem implemented to continually monitor andimprove the quality of the meals provided. Anew menu was developed and implemented andmodifications were made to the food productionequipment. Whilst residents express high levelsof satisfaction of the meals now served, mealswill continue to be monitored on a daily basis,evaluation of the menu satisfaction is ongoing andthe Working Party will continue to meet to discusshow we can continue to improve the meals for ourresidents. I would like to express my appreciationto our Head Chef and all catering staff involvedin making such significant improvements to themeals we now serve to our residents. I have beenimpressed with the dedication of all staff to rectifythis problem and improve the care to our residents.I also extend my appreciation to the residents andtheir families and thank you for your contributionand patience during this challenging time.Another challenge for staff this year was thetransition to a new Aged Care Funding Model(ACFI). Staff must be complimented on thesmooth transition from the old to the new whichinvolved considerable education, assessments anddocumentation. I would like to acknowledge ourAdministration Manager, Financial Accountant,Business Manager, and Clinical Nurse Manager,Residential Aged Care, for making this possible.Compliance to required documentation andassessment is essential for CAH to receive fundingfor the care and services we provide.Recreational and social activities for our residentsrate as a high priority, and staff in Corangamarah,led by the Diversional Therapist and Activity Co-Ordinators take pleasure in providing a variety ofactivities and outings throughout the year. Oneof the highlights was the Corangamarah Ballwhich gave staff, residents, family and membersof the community the opportunity to enjoy theatmosphere of an old time Ball. Our dementiasufferers enjoy the activities and companionshipprovided through the introduction of the‘Sundowners Program’ in West Wing. This is a sevenday a week program, provided at a time whenresidents tend to become restless. A DiversionalTherapist provides activities to assist residents torelax and this has proven to be a most successfuland valuable program in the care of theseresidents.2008 Annual and Quality of Care Report 23

A significant achievement for this year wasthe development of a Philosophy of Care forCorangamarah. All staff had the opportunity tohave input into this statement. Several versionswere drafted. This Philosophy of Care underpins inevery aspect, the way we care for our residents andwill be framed and proudly displayed in our facilityand referred to regularly to ensure we abide by our‘philosophy’.Philosophyof CareWe offer residents and their familiesa respectful and compassionatehome-like environment.We promote an holisticapproach to care and foster highstandards of accountability,honesty and integrity.Our professional care is offeredto all without discrimination.We strive for an environment whereall staff are supported andvalued for their contributionto the team.Staff in Corangamarah are fortunate to haveaccess to ongoing education through installationof the ‘Aged Care Channel’. Aged care education isprovided through this medium three times a dayon a fortnightly basis. Internal ongoing educationthrough CAH’s Education Centre will be plannedfor the year ahead to enhance opportunity forprofessional development of staff. Many of ourDivision Two Registered Nurses have completedthe Medication Endorsement Certificate. Wecongratulate them on this wonderful achievementand look forward to many more of our staffcompleting this certificate next year.Lynda Inglis resigned from her position asBusiness Manager in June to take up a moresenior role in Geelong. We wish Lynda success inher new position and extend our appreciation toher for her commitment to the care of residentsduring her time at Colac. Esteelia Marcucci hasbeen appointed to this position until a permanentappointment is made.Again this year we have grieved the passingof some of our residents. Our condolences areextended to respective families and friends.We have also welcomed new residents and feelhonoured to have the opportunity to make theirtime with us at Corangamarah a happy and homelyone.Jillian DunbarDirector Clinical ServicesPreadmission andDischarge Planning ClinicThe Preadmission and Discharge Planning Clinic(PADPC) is integral in the seamless transitionfrom admission to discharge for our patients.Surgical patients are preadmitted to the hospitalby attending the Clinic in person or by telephoneinterview. A Discharge Plan is initiated and patientsare provided with the relevant information abouttheir procedure. At this interview, referrals to otherhealth professionals such as, Physiotherapists andOccupational Therapists are arranged, as required.Attendance to the Clinic provides patients withthe opportunity to meet staff and familiarisethemselves with the Day Surgery and Acute CareUnits and raise any questions or concerns theymay have in relation to their hospital stay. ThePreadmission Co-Ordinators make every effort toallay patients’ anxiety in an endeavour to maketheir hospital visit as pleasant and comfortable aspossible.This past year 1197 patients were preadmittedof which 327 attended in person and 870 wereinterviewed by telephone.Preadmission Co-Ordinators are also involvedin Working Parties and Committees and thedevelopment and implementation of policies,clinical pathways and audits, relevant to admissionand discharge tools and processes.Audits based on the Effective Discharge StrategyGuidelines, conducted twice yearly, identifywhat we do well and where we can improve inour Discharge Planning. The Victorian PatientSatisfaction Monitor (VPSM) also provides valuablefeedback, from a patient perspective, on ourperformance of admission and discharge.24 Colac Area Health

The VPSM graph (right) dentifies the level ofoverall patient satisfaction.Colac Area Health (CAH) patient satisfactionlevels are higher than overall state hospitals andcomparable sized hospitals.The year ahead will see a review of our currentDischarge Planning process to ensure we aremeeting patient and family needs and legislativecompliance to provide quality outcomes for ourpatients.Both Co-Ordinators completed the AdvancedCare Planning training with one taking on the roleof Advanced Care Planning Resource Nurse forCAH.This past year we have oriented four nursingstaff members to the role of Preadmission andDischarge Co-Ordinator to provide leave supportfor the Clinic.Julie Trigg RN Div1/Jenny Lang RN Div1Preadmission/Discharge Planning Co-OrdinatorsOperating SuiteColac Area Health provides an extensive rangeof surgical procedures to the local communityand surrounding districts, including General,Obstetric, Endoscopic, Orthopaedic, Urological,Gynaecological, Ophthalmic and DentalProcedures. This is made possible by our twocommitted Colac based General Surgeons,GP Anaesthetists and eight Visiting SpecialistSurgeons.Advances in Laparoscopic surgery performed atCAH result in patients being discharged earlier andhave the ability to return to work sooner than withconventional surgery.Surgical Procedures 2003-2008The graph depicts increase in Surgical Proceduresperformed at CAH from 2003-2008.Staff are always appreciative of new equipmentto assist in the provision of quality care in theOperating Suite and acknowledge the supportof the Executive and Department of HumanServices for the purchase of the following items ofequipment:• Electric Operating Table• Gas assisted Lithotomy Stirrups• Autoclavable Laparoscopic Camera• 30 Degree Telescope• Fluid Warming Unit• Portable Patient Monitor• Two Anaesthetic Machines with Entropy• Machine Update for Attest Biological IndicatorTest• Mattresses for Patient Transfer Trolleys.We are committed to continuously reviewingthe way we provide our service and how we canimprove. As a result we have implemented severalquality initiatives throughout the year, for example:• ‘Wash checks’ for instrument washer monitoring• ‘Heli-checks’ for hollow load challenge testing forpre-vacuum steam sterilisers• Reusable convective warming blankets for prewarmingpatients in the Day Surgery Unit• Vital Patient Management System• Rapid Infusion Kits• Trial of Disposable Patient Control AnalgesiaPumps• Post Acute Care Unit Discharge Criteria• Day Surgery Unit Intravenous DisposalThe commitment of Operating Suite staff toeducation must be commended. This yearhas been no exception. As well as mandatoryorganisational education, staff have undertakeneducation in Anaesthetic Emergencies;Operating Room and Post Acute Care Unit2008 Annual and Quality of Care Report 25

Nursing staff celebrateInternational Nurses Daywith morning/afternoon teain the staff Cafeteria.Nursing; Anaesthetic Crisis Management at theCrisis Resource Management Centre, MonashUniversity; Endoscopic Cleaning and MaintenanceSterilisation; and attended various workshops onorientation to new equipment.The Central Sterilising Department is integralto the smooth functioning of the OperatingSuite. Surgeons, Anaesthetists and PerioperativeNurses depend on staff in this Unit for cleaning,maintenance and sterilisation of surgical,anaesthetic and monitoring equipment and for theavailability of this equipment in a timely manner.Added to the Operating Suite responsibilities, thisDepartment also provides a sterilisation servicefor the organisation and to medical clinics andother community services. Staff maintain stringentinfection control and sterilisation standards, andundergo an annual audit of AS4187 standards.Evidence of the sterilisation of all articles is auditedand is available to ensure quality sterilisingservices.Amanda Tout RN Div1Nursing Unit ManagerOperating SuiteDay Surgery UnitThis Unit is often the ‘face’ of Surgical Services atColac Area Health (CAH). The Day Surgery Unitprepares patients for operations and surgical andmedical procedures and receives patients postoperatively for day surgery. Patients are admittedto this Unit prior to undergoing their procedure.Staff in this Unit work in concert withPreadmission/Discharge Planning Co-Ordinators,Operating Suite and Acute Care Unit staff tofacilitate a seamless episode of care for patientsand pride themselves on the welcomingenvironment they create for the patients. TheVictorian Patient Satisfaction Monitor reportsexcellent satisfaction levels by patients who havebeen cared for by the staff in this Unit.Quality activities have included: Review ofDay Surgery Clinical Pathway, update of PatientInformation Sheets, Location Audit – finding ColacArea Health and the Day Surgery Unit, Disposalof Infectious Waste Audit, Bowel Return Audit forColonoscopy patients.Staff continue to update their skills andprofessional development opportunities byattending internal and external educationsessions. In the past year all staff have commencedIntravenous Cannulation Competencies andattended an update in Anaesthetic Emergencies,Pharmacology and Trauma Management forOperating Room and Post Acute Care Unit Nurses.Two new staff members were also orientated tothe Unit.Jenny Lang RN Div1/ Pauline Kerr RN Div1Associate Unit ManagersDay Surgery Unit26 Colac Area Health

Urgent Care Presentations 2007/08Discharged from Urgent Care 5603Transfers for higher level of care 184Referred to General Practitioner 573Admitted to Hospital 1418Haemodialysis UnitThe Haemodialysis Unit provides a vital service topatients suffering renal disease in the communityand surrounding districts. The unit comprisesthree machines and operates three days per weekdialysing up to six clients each week. Currently fiveof these patients are dialysed three days per week.The service is a satellite service from BarwonHealth and we are extremely appreciative of thevaluable support they provide to us through staffeducation, equipment and machine maintenance.This year they supplied a ‘backup’ dialysis machineto minimise the risk of service interruption toour clients in the event that one of our existingmachines requires repair. This enhances theservice delivery to our clients preventing thenecessity of travelling to Geelong in the event ofunavailability of a machine due to malfunction.Added to this, Barwon Health has providedthe Unit with a laser printer and BOSS softwarewhich enables staff to access clients blood resultsand implement essential treatment interventionswithout delay.Infection control compliance is paramount inthe care of our clients and we have introducedthe use of a ‘hand rub’ disinfectant for the use ofstaff, patients and visitors to minimise the risk oftransmission of infection.The purchase of a new hydraulic lifting trolley hasassisted us in manual handling.Three new staff members have been orientated tothe Unit for unexpected leave replacement whichensures staffing sustainability of the service andstaff attend education sessions on a regular basisat Barwon Health to ensure currency of skills andcontemporary practice.All our clients complete ‘satisfaction’ surveys.These provide us with extremely importantfeedback and we look forward to receiving anysuggestions on how we can improve our service.We were delighted to receive the donationof a lovely print from a past client’s family, inrecognition of the care provided by the staff inthe Unit. This hangs proudly on the wall for thepleasure of our staff and clients.Kerrie Anderson RN Div 1/Helen Morrissy RN Div 1Associate Nursing Unit ManagersHaemodialysis UnitUrgent Care UnitPatient attendances for Urgent Care continuesto increase on a yearly basis. This year 7778presentations were recorded as requiringassessment, treatment and referral as appropriate.Triaging of all patients presenting to the Unit is anessential function that underpins the delivery ofcare. It is a decision making and communicationtool that ensures patients are treated according tothe clinical urgency of the presenting condition.The Australasian Triage Scale (ATS) is a nationallyaccepted scale used to categorise patients. Allstaff in Urgent Care attended education sessionsconducted by the Department of Human Servicesthis year on Emergency Triage.The Needle and Syringe Exchange Programservice provided by the Urgent Care Unitcontinues to provide a vital and well utilisedservice. This Program assists in minimising therisk of transmission of blood-borne viruses suchas HIV and Hepatitis B and C to the community.To enhance this service we have installed anexternal disposal bin to facilitate the safe disposalof needles. This initiative will promote a safeenvironment and is also available for use by thegeneral community.Needle Exchange Program2008 Annual and Quality of Care Report 27

Following the Safe Active and Independent LivingProject (SAIL), an initiative of the Department ofHuman Services, we have introduced a screeningprogram for older persons at risk of falls thatpresent to the Urgent Care Unit. All patients 50years and older admitted to hospital and patients65 years and older who are discharged home fromthe Urgent Care Unit are screened. The aim of theprogram is to reduce the frequency and severityof falls and related injuries. Two hundred patientspresented to the Urgent Care Unit over the pastyear with injuries resulting from a fall.The employment of additional nursing staff forthe Unit has enabled nursing staff to be based inthe Unit on a 24 hour basis. This has enabled theestablishment of a rotating roster for staff over thethree shifts, thereby providing opportunity for staffto attend education sessions for skill acquisitionand maintenance.Delia Melville RN Div1Nursing Unit ManagerUrgent Care UnitInfection ControlInfection Prevention and Control continues tohave a high priority at Colac Area Health (CAH). Allstaff across the organisation have an awarenessof the importance of infection prevention andcontrol by attending orientation and educationsessions and actively participating in the process.The Infection Control Consultant is also involvedwith the Regional Infection Control Practice Group(RICPRAC) and provides a consultancy serviceto health services in the Sub-Region of BarwonSouth-Western Region.Hand HygieneFor the past few years CAH has been involved,along with other public hospitals, in improvinghand hygiene compliance to prevent the spread ofinfection within health care facilities. As part of thisfocus we have been ensuring our staff have quickand easy access to hand hygiene products. Visitorsare also becoming more aware of how germs arespread on hands and can be seen using the alcoholbased hand rub when coming in and out of thehospital.In 2007, the Hon. Daniel Andrews MP, Ministerfor Health, launched the “Start Clean” – VictorianInfection Control Strategy. This is a four yearcomprehensive strategy in the prevention,detection and management of health careassociated infection. Part of this focus is onmaintaining the improvements made in handhygiene. Hand Hygiene Victoria was establishedfollowing on from the Victorian Quality CouncilProject and the coordinating centre is based atAustin Health. Recently introduced has been the“5 Moments” for Hand Hygiene which is currentlybeing promoted through the Acute Care Unit. Thecurrent compliance rate measure is 55% and atCAH we are achieving above this rate.Equipment SterilisationThe Central Sterilising Department, located in theOperating Suite, is a very important functionalarea within our Operating Suite as it processesthe instruments that are used for surgery. Auditsare conducted annually to measure compliancewith Australian standard AS/NZS 4187: 2003. Theaudit includes cleaning, disinfecting and sterilisingreusable medical and surgical instruments andequipment and maintenance of associatedenvironments in health care facilities. These arecompared through the Rural Infection ControlPractice Group (RICPRAC) with similar sizedhospitals.Comparative Compliance rate for sections 7 & 8:• 2007 – 98%• 2008 – 99%VaccinationWe offer a full vaccination program to our healthcare workers according to recommendations fromthe National Health and Medical Research Council.These include Hepatitis B immunization andannual Influenza immunization. Each year we havebeen working to improve the uptake of Influenzavaccination. All residents in Corangamarah areoffered an annual Influenza vaccination.28 Colac Area Health

Multi-Resistant Organisms (MRO)These organisms can be a problem in manyhospital settings as some “strains” of bacteriahave developed resistance to many antibiotics.We continue to screen patients coming frommetropolitan hospitals for Methicillin ResistantStaphylococcus Aureus (MRSA) to minimize thespread of antibiotic resistant bugs. If MRSA isdetected, necessary precautions are instituted andrelevant education and information provided forthe patient and family.Through good hygiene practices and preventionprograms we are continuing to maintain a safeenvironment for our staff, patients and visitors.Ann Gray RN RM Div1Infection Control ManagerPharmacy2007/08 sees Pharmacy services continuingto explore new avenues of service scope anddelivery through its commitment to professionaldevelopment and novel service platforms.Our Pharmacy Technicians have completedCertificate III Studies in Health Service Pharmacyand 2008/09 begin their Certificate IV studies,allowing Technicians to further assist Pharmaciststhrough the admission and medication allocationprocess to acute inpatients. This represents a wholenew opportunity in ‘smoothing’ the admissionprocess relational to medication management andfreeing the Pharmacist to concentrate specificallyon knowledge value adding to the patient, doctorand other healthcare professionals.Our Pharmacist continues to support andmaintain:- Inpatient care- Outpatient services (including pharmacotherapyservices)- Specialist services (including the HighlySpecialised Drugs Program)- Primary Health Care Programs (including WellWomen’s Clinic, Family Services and self referrals)- Shared Care services (with members of ourcommunity who require complex shared carewith a Teaching or specialist health service orhospital)- Clinical support to allied health, nursing andother professionalsThe Pharmacist is committed to continuingprofessional development which supports theseclinical services as well as the leadership andmanagement support he provides to the HealthService. To further this end the Pharmacist isworking with the allied health team to createa clinical review forum allowing allied healthprofessionals to reflect on cases and best practiceas well as discuss issues of common interest.The Patient Satisfaction Survey againdemonstrated a high degree of patient satisfactionwith the Pharmacy service. Further a survey ofmedication sheets ordering the anticoagulantWarfarin were shown to be within the complianceparameters of the NSW Therapeutic AssessmentGroup Indicator for this medication.The Pharmacist, in consultation with the Directorof Clinical Services, Clinical Educator and theManager, Information and CommunicationTechnology is piloting an online forum formatfor working up pharmaceutical advisory issues.This allows for input from a wide number ofstakeholders across the organisation beforeseeking medical input potentially reducing thetime from idea inception to action.David WaltersPharmacy Services ManagerEducation CentreThe Education Centre has benefited from ColacArea Health’s (CAH) commitment to develop aculture of learning throughout the organisation,with the aim of recruiting, retaining and traininghighly skilled staff to deliver quality contemporarycare to the community.The delivery of education and training is nowsupported by a computer laboratory, skills station,resource library and facilities for audio-visualpresentations. We are looking forward to thearrival of ‘Resus Annie-Cardiac Simulator’ manikinand accessories to enhance our skills stationto facilitate the maintenance of Advanced LifeSupport and Basic Life Support skills acquired bystaff throughout the year.2008 Annual and Quality of Care Report 29

Additional staffing resources enable the provisionof more frequent education sessions which areopen to all areas across the organisation. TheCentre also accommodates the Infection ControlNurse and we welcomed the relocation of theQuality, Risk and Special Projects Manager to ourCentre this year. Infection Control, Quality andRisk are entwined in organisational education andwill enhance the service we provide to staff.We are also extremely proud of the high level ofskills and qualifications of staff working within theCentre. Collaboratively, we are well equipped toprovide quality education.The Graduate Nurse Program provides graduatenurses with broad experience by rotations throughthe Acute Unit, Corangamarah, CommunityNursing, Urgent Care, Perioperative Servicesand Lorne Community Hospital. This Programcurrently supports seven graduate nurses and willbe reviewed and revised in the coming year tofurther improve the opportunities for graduatesto consolidate their knowledge and skills and todevelop into competent, confident nurses. Wesupport the aim of the organisation in strivingfor the reputation of best Rural Graduate NurseProgram, evidenced by the broad range of skillsand professionalism of nurses at the completion ofthe Program. Our Program will equip all graduateswith the skills and experience to pursue theircareer aspirations.Colac Area Health also supports eight traineeswho are undertaking their Division TwoRegistered Nurse Certificate IV in Health (Nursing).Traineeships provide an excellent opportunity forthe application of theory into clinical practice in asupportive environment.Many students from schools, TAFEs andUniversities have undertaken placements atCAH throughout the year. Allied Health andNursing staff have been integral in supportingthese students and have provided them with anunderstanding of our integrated health service andthe various health professionals that support it.Internal education sessions have been conductedon a regular basis for organisational widestaff. Many workshops such as ‘Searching andAppraising Evidence’; ‘Advanced Life Support’; and‘Development of Computer Skills’; have been wellreceived.Provision of education via technology isbecoming more prevalent. Videoconferencingenables current, evidence-based information to beprovided by experts in the field. Electronic learningis an advancement in the provision of educationthat will enable all staff at CAH access to educationin a more flexible manner.This year the Education Centre has developeda range of education packages that are nowavailable to Nursing staff. This self-directedlearning approach, in conjunction with educationsessions, has enhanced nursing knowledge andclinical skills throughout the organisation.We have had many achievements this past year,however two highlights should be promoted.Firstly, co-ordination of Advanced Life SupportTraining for Registered Nurse Division 1. TwentyoneNurses undertook the Advanced Life Support(ALS) with all being deemed competent. This is anexcellent result for all concerned.The second highlight of note is the successfulcompletion of the Medication EndorsementCertificate undertaken by many of our Division 2Registered Nurses. These staff are now qualifiedto administer medications within their scope ofpractice.In the coming year, the Education Centre willundergo further development as it aims tocontinue to create a learning environment andprovide more extensive education across theorganisation with the promotion of best practice,contemporary, quality care.Anna ReillyClinical EducatorEducation Centre30 Colac Area Health

Visiting Medical StaffDr. M.P. Alexander, M.B., B.S., F.R.A.C.G.P., M.B.A. (ResignedNovember 2007)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., D.R.A.N.Z.C.O.G.,M.R.A.N.Z.C.O.G. (Appointed July 2007)Dr. D. Borsos, M.B., B.S., D.R.A.N.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 MedicineDr. 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.(Appointed March 2008)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. T.R.C. Fitzpatrick, M.B., B.S., M.F.M., Dip. R.A.C.O.G. (ResignedMay 2008)Dr. I. Grant, M.B., B.S., F.R.A.C.G.P., F.A.Ch.P.M. (Appointed October2007)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.Dr. P.H. Hewson, M.D., F.R.A.C.P., M.B., B.S. (Resigned July 2007)Dr. B. Huang, M.B., B.S. (Appointed December 2007)Dr. D.M. Jones, M.B., B.S., D.A., D.R.C.O.G.Dr. T.W. Jones, M.B., B.S., U.C.H.M.S. (Resigned February 2008)Dr. D. Kerr, M.B., B.S., F.A.Ch.P.M. (Appointed October 2007)Dr. G. Kunjidapaadhum, M.B., B.S., D.T.C.D, G.R.A.C.G.P (AppointedApril 2008)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.A.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. (AppointedMarch 2008)Dr. A. Mander, M.B., B.S., F.R.A.C.P. (Resigned March 2008)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.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 1Mr. 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. W. Rouse, M.B., B.S., F.R.A.C.G.P, D.R.A.N.Z.C.O.G., Grad Dip. RuralG.P. (Resigned May 2008)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 (Appointed July 2007)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. (Appointed March 2008)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.Symbion HealthVisiting Radiologists:Dr. C.M. Blecher, M.B., B.S., F.R.A.N.Z.C.R., D.D.UDr. 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.Dr. A.D. Felber, M.B., B.S., D.D.R., F.R.A.N.Z.C.R.Dr. P.E. James, M.B., B.S., M.Med, F.R.A.N.Z.C.R (Resigned 2008)Dr. W.J. Rogers, M.B., B.S., F.R.A.C.G.P., F.R.A.N.Z.C.RDr. C.S. Woodward, M.B., B.S., F.R.A.C.R.St. John of God PathologyVisiting 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. D.W. De Leacy, M.B., B.S., B.Sc., F.R.C.A.P.A. (Resigned June 2008)Dr. H.J. Fairweather, M.B., B.S., F.R.C.P.A. (Appointed June 2008)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. (Appointed June 2008)Dr. C.M. Pilbeam, M.B., B.S., B.Med.Sc., Ph.D., F.R.C.P.A., M.I.A.C.(Resigned June 2008)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. D.R. Trethewie, M.B., B.S., F.R.C.P.A. (Resigned June 2008)Dr. S.L. Wallace, M.B., B.S., F.R.C.P.A.Visiting Dental StaffDr. 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 StaffRoyal Australian College of General Practitioners Registrar ProgramDr. H.H.S. Chew, M.B. B.S. (February 2007 – February 2008)Dr. K.H. Loo, M.B., B.S. (February 2008 – February 2009)Dr. F.D. Maxwell, M.B., B.S. (February 2007 – February 2008)Dr. J.M. Ngui, M.B., B.S. (February 2008 – February 2009)Dr. B. Nguyen, M.D. (February 2008 – February 2009)Dr. F. Okedara, M.B., B.S., D.R.A.N.Z.C.O.G. (February 2006 – January2008)Dr. R.G. Organas, M.B., B.S. (February 2005 – February 2008)Dr. F. Polani, M.B., B.S. (February 2008 – February 2009)Dr. M. Saka, M.B., Ch.B. (February 2007 – February 2008)Dr. M.M. Saka, M.B., Ch.B.(February 2007 – February 2008)Dr. M. Zhang, M.B., B.S., PhD. (February 2008 – February 2009)2008 Annual and Quality of Care Report 31

Medical ServicesDr. Danny Jones continued his excellent work asChairman of the Visiting Medical Staff until theOctober 2007 meeting of that body, when we werefortunate to have Dr. Justin Madden take over thatrole. Both these doctors have provided exemplaryservice to Colac Area Health and to the Executivesworking with them. My thanks to both.Congratulations are also extended to Dr. Joneswho received an “Outstanding Service to RuralCommunities Award” from the Rural WorkforceAgency of Victoria. This prestigious Awardacknowledges his contribution to medical services inColac during the past 21 years and is extremely welldeserved.I would also like to recognise the contribution of Dr.Max Alexander, Executive Director of Medical Servicesat Colac Area Health. Dr. Alexander commenced inFebruary 2005, and resigned from the position inNovember 2007.I made reference in last year’s report as to the dearthof new procedurally trained GPs joining the workforce generally, and in Colac in particular. While theDeakin Medical School’s curriculum and modusoperandi is geared towards correcting this issue,there is an inevitable delay of years before theirgraduates will be able to contribute towards solvingthis problem. Coincidentally, we look forward toreceiving the first Deakin medical studentsmid way through 2010.In a welcome move, there has been a fundamentalchange in the provision of after hours servicesthis year, with both practices joining forces tohelp provide ongoing obstetric care. This hasbeen a difficult task, much assisted by the doctors’willingness to look at alternative ways to theirprevious methods of the organisation of theirpractices.Just at the end of this reporting period, agreementwas reached with the Visiting Medical Staff, for thehospital to explore the possibility of employing GPRegistrars/Career Medical Officers. With the rightappointees there would be a contribution to theareas of particular medical shortage.We welcomed the following Visiting Medical Staffwho have provided services to CAH during the pastyear:Dr. M. BardsleyDr. J. BrownDr. I. GrantDr. B. HuangDr. D. KerrDr. G. KunjidapaadhumDr. V. MakkadaDr. R. SollyDr. M. UddinWe thank the following for their service, whom wefarewelled during 2007/08:Dr. M. AlexanderDr. T. FitzpatrickDr. P. HewsonDr. T. JonesDr. A. ManderDr. W. RouseDr. Ed DavisConsultant Director of Medical ServicesDr Ed Davis,Consultant DirectorMedical ServicesDr Justin MaddenChairmanVisiting Medical Staff32 Colac Area Health

Health InformationHealth Information Services is responsible forreporting a number of Key Performance Indicators(KPIs), Daily Inpatient Statistics, unplannedreadmission rate, medical records – coded casesrate, completed discharge summary ratio andnumbers of medical records audited. The KPI targetof completing coding of all discharges within 11days of the end of the month has in the main beenachieved each month except two over the lastfinancial year.The department has participated in two externalaudits of coded records within the last year, anda Department of Human Services (DHS) audit ofsome 63 records. The final results of the DHS auditare still pending.Two staff attended the ICD-10 –AM sixth Edition,held by the National Coding Centre in preparationfor the changes to coding guidelines and books asfrom 1 July, 2008.Freedom of InformationFreedom of Information (FOI) applications arehandled though this department and totalled 35for the year.Of those 35 applications up until 30 June, 2008,29 were granted, two were refused being due tono records being held for that particular applicant,three are pending approval and one applicationwas withdrawn. Thirty three applications were forpersonal information and two applications werefor non-personal information. A total of $716 wascollected in application and photocopying fees.Health Information Services has processed nineSubpoenas to present medical records to variouscourts and nine Coroners cases throughout theyear.The introduction of the Clinical Review Sub-Committee has initiated a number of ongoingreviews of unplanned readmissions, deaths,transfers to major hospitals and patientsremaining in over 35 days. New procedureshave been introduced to ensure completedocumentation is maintained for recordsprocessed through the Coroners Office.Future DirectionsA major review of patient / client record systemswithin Colac Area Health will be undertaken by thisdepartment with a view to consolidating recordsystems into an integrated system within existingboundaries.Roslyn EdsallHealth Information Manager2008 Annual and Quality of Care Report 33

Primary Care ServicesAn overall goal of the Program within Colac AreaHealth (CAH) is to support a wide range of individualsand families though the diverse services providedacross four teams:• Allied Health• Community Nursing• Family Services• Community ProgramsThe untiring efforts of a committed staff areacknowledged during what has been a challengingtwelve months.Another Move !Polwarth House – An opportunity for strongeralignment and integration:As part of CAH’s program of consolidating serviceson the main campus site in Colac, the refurbishmentof Polwarth House provides the new home for FamilyServices, Community Nursing, Palliative Care andRegional Networkers. The shift occurred in October,2007.Joining the team in Polwarth House has been our colocatedcolleagues in Child Protection – DepartmentHuman Services, and Pathways Psychiatric DisabilityRehabilitation Services. The refurbishment representsa milestone in achieving a more integrated servicesystem and improved alignment between services.Allied HealthThe Allied Health Team provides services in Nutrition,Rehabilitation, Physiotherapy, Podiatry, OccupationalTherapy, Speech Pathology, Adult Day Activities in acommunity setting and organisational wide HealthPromotion. The clinical services are available in AcuteCare, Residential Aged Care and Primary Care. Severalservices are contracted out to other agencies andassist to maintain a clinical presence in surroundingdistricts, as well as Colac and the Colac Otway Shire.Expansion of CommunityRehabilitation CentreSignificant changes took place in the CommunityRehabilitation Centre during 2007/08, not the leastbeing the relocation of client services to four majornew spaces, effectively increasing the area availableby 400%.During 2007/08, $125,000 was provided byDepartment Human Services (DHS) for equipmentidentified as being necessary to assist in the provisionof an excellent service.New clinical areas include two gymnasiums,enabling groups to be conducted in one whileindividual clients simultaneously receive therapy inanother.A separate group room is used for discussion groupsand programs that do not require use of the gym oroccupational therapy areas.An extremely well appointed occupational therapytraining room for activities of daily living has beencreated with space for all activities of daily living andmost personal activities.Planning work has commenced on a rehabilitationand mobility garden which Occupational Therapistswill use for therapy activity for clients.We are fortunate to have three separate treatmentrooms, a workroom/splint room, a functionalbathroom/laundry and a nurse/doctor interviewroom to complete the rehabilitation complex.The main gymnasium is available for staff use duringclient free periods.Rehabilitation Programs• Cardiac rehabilitation is an eight week openprogram run continuously throughout the year.During 2007/08, 64 people were able to benefit fromthese lifestyle focused sessions.• Pulmonary rehabilitation program is a nine weekopen program run continuously through the year.• A weekly balance group.• A weekly maintenance group.• A large and expanding orthopaedic group.Physiotherapy ServiceThe redevelopment of Polwarth House has providedideal private treatment areas for the Physiotherapiststo cater for people with a wide variety ofmusculoskeletal, respiratory and neurologicaldisorders.Physiotherapists were involved in treating over 1000different clients with approximately 3500 treatmentsessions across acute care, aged care and communityservices.34 Colac Area Health

Community members welcomed theopportunity to view the refurbishment ofthe former nursing home during an OpenDay of Polwarth House Service CentrePhysiotherapy groups• Hand Clinic• Water based exercise group• Respiratory ClinicOccupational Therapy ServiceA focus for occupational therapy is to keeppeople safe and in their own home environment.Occupational Therapists are involved in FallsPrevention strategies and programs, as well asindividualised home safety checks. OccupationalTherapists completed over 2300 consultations with553 clients during 2007/08 and continue to beinvolved in an extensive range of services to the ColacOtway community, including rehabilitation.Nutrition ServiceDuring 2007/08 dietetics services was expanded toaccommodate bi-monthly routine nutrition reviewsfor all dialysis clients. Community InformationHandouts for weight advice and meal plans thatinclude accurate analysis were developed.Cookbooks developed and produced by Colac AreaHealth (CAH) have been reprinted due to communityand staff demand. The Healthy Lifestyles Programfunded a copy for each disability accommodationfacility in Colac district. Positive feedback wasreceived, including a dialysis client who said theywere fantastic because there are low salt recipes andthe sodium content is listed, making it easy to chooseappropriate foods.Other activities included:• Healthy Women, Healthy Weight -The first programhas been completed with evaluation proceeding.• Fluid Balance - a small project, in partnership withAcute Care Unit, that aims to improve nursingstaff and patient understanding of fluids to moreaccurately record fluid balance for patients while inthe Acute Care Unit.• Healthy Eating articles in Colac Herald – regulararticles as part of the ‘Kids in the Kitchen’- greatpublicity!!• Monthly Supermarket Tours for clients, as wellas specific groups such as Cardiac Rehabilitationparticipants.Our two dietitians were responsible for over 2700consultations with 780 clients.Speech Pathology TeamSpeech Pathology Department works closelywith local services in both preschool and schoolsettings to improve the outcomes for children withcommunication difficulties. The Team are membersof the local Preschool-School Transition Network thathosted a series of workshops on the topic of CuedArticulation for Teachers. The workshops were verywell attended; teachers showed great enthusiasmand reported they would be interested in similarprofessional development activities.Speech Pathologists provided consultations to 310clients with nearly 1600 contacts, excluding directwork in school settings during 2007/08.Other Allied Health NewsDuring 2007/08 peer education meetings were heldevery three weeks. Hosted by Allied Health staff theyprovided a forum for health professionals to meetand debate various health topics, recent research andmedical literature.At the first meeting, the annual Roberta Hay Award,in recognition of her contribution to Allied Health inColac, was introduced. Roberta, who had previouslyworked with the District Nursing team at ColacDistrict Hospital in the 1950’s/60’s, pioneered the roleof a full-time Social Worker as a Welfare Sister. Sheoccupied this position from 1973 until her retirementin 1993. Her colocation with other Allied Healthstaff, and broad role within Colac District Hospital,endeared her to all her work colleagues.2008 Annual and Quality of Care Report 35

Adult Day Activity Centre“Garden Expo”The Adult Day Activity Centre held a “Garden Expo” inDecember 2007 to showcase the talents of its clientswhen their beautiful garden and festive seasoncreations were put on display.Officially opened by Colac Area Health (CAH) ChiefExecutive Officer, the exhibition included crystal suncatchers, plants, mobiles, paintings, table decorations,knitted items and various other handmade gifts.A lavish afternoon tea was provided, with a varietyof entertainment, including a flower arrangementdemonstration. Numerous raffles and lucky doorprizes ensured that many people went home winnersand the day was thoroughly enjoyed by the manyfamily members and friends in attendance.All Adult Day Activity programs promote selfesteem, confidence and a sense of belongingand this well planned function was a wonderfulexample of providing an outlet for keen and talentedparticipants.PodiatryThe Podiatry service extends across all care areas ofColac Area Health (CAH). The service to BirregurraCommunity Health Centre increased from one tothree afternoons each month in response to growingneeds in the district. Demand for podiatry serviceshas increased with the opening up of more aged carebeds in Colac. During the financial year 692 clientsreceived over 2000 service contacts.Health PromotionColac Area Health’s aim is to promote and furtherdevelop an integrated approach to health promotionacross the organisation’s operations.Over the 2007/08 financial year a key task hasbeen the continued implementation of the threeyear integrated health promotion plan. The plancommenced in 2006 and will conclude in June 2009.The three key priority areas are:o Reducing Tobacco Related Harmo Healthy Eating and Physical Activityo Mental WellbeingImportant services such as the Smoking CessationClinic have been conducted as part of a plannedapproach to developing sustainable programsaddressing our key priority areas. Other healthpromotion groups have included:• No Falls Exercise Program• Men’s Vintage Achievers• Huff ‘n’ Puff• Strength Training• Better Health Self Management.During 2008/09, the last year of the current healthpromotion plan, CAH will be working with partnerorganisations within Colac and across the BarwonSub-Region to determine agreed priority areas forthe next three year integrated health promotion plan,which will commence in July 2009.Australian Early Development IndexThe Australian Early Development Index (AEDI):Building Better Communities for Children is apopulation measure of young children’s developmentfrom a teacher-completed checklist and measuresfive developmental domains:o Language and cognitive skillso Emotional maturityo Physical health and wellbeingo Social competenceo Communication skills and general knowledgeUnder the project, two hundred and seventy ninechildren in their first year of full-time schooling withinthe Colac Otway Shire were assessed during 2007/08.36 Colac Area Health

AEDI is a population-based measure with a focus ona population rather than the individual. A populationbased approach means that important factorsthat impact on a child’s health and development,such as community factors and the broader socialenvironment, are taken into account. For ColacOtway Shire the results showed 65% of the childrenwere performing well in one or more domain.However, 28% of the children were vulnerable inone or more domains. The AEDI results presented atan Early Childhood Conference in Colac on 17 April2008 stimulated an exploration of new ways in whichschools, early childhood services and local agenciescan work together to ensure children are providedwith the best possible start in life.Colac Community Dental ClinicThe Colac Community Dental Clinic has achieved amilestone this year in May with the much anticipatedmove from the Hart Street Clinic to a newlydeveloped four chair clinic, onsite in Miller Street. Thecurrent model of integrated community dental healthand the successful ongoing collaborative partnershipbetween Colac Area Health (CAH) and BarwonHealth has enabled the Colac community to accessa public service of enviable quality. The service hasmet 2007/08 productivity expectations and fundingtargets.Key Performance Indicators01/07/07 – 30/06/08 Ave/monthNumber of clients 4981 415Number of visits 6231 519Number of treatments 16880 1406Oral HealthColac Area Health received funding from DentalHealth Services Victoria to coordinate the Smiles 4Miles Program with Otway Health and CommunityServices and the Corangamite Shire. Each serviceformulated an oral health promotion plan andworked with their preschool communities to alignoral health promotion messages with those of goodnutrition, healthy lifestyles and active play.Pauline MaunsellAllied Health ManagerCommunity NursingIn December 2007, Community Nursing moved fromMiller Street to the redeveloped Polwarth HouseService Centre, which was a positive development forstaff and clients alike.ServicesCommunity Nursing has twenty-nine dedicated andprofessional staff working across two campuses;Colac and Birregurra, delivering twelve communityservice activities as detailed on Page 6.PartnershipsDuring the financial year the Community HealthNursing team working in partnership with otherPrograms, Colac Otway Shire and colocated servicessuch as Diversitat, provided in excess of 19000contacts to more than 1500 clients and families.The Community Nursing teams have workedcollaboratively with other healthcare providers andcommunity groups including:• Colac Police• Education Department• Department of Human Services - Disability provide innovative activities and programs, suchas the Kinder Capers Program; a health promotionactivity aimed at introducing children attendingthe local kindergartens to the Health Service andembrace the opportunity to promote health andwellbeing.The team has continued to provide successfulPrograms to community groups including:• Puberty Clues• Mum’s on the Move• Bubs at the Hub• Strength Training Group• Beechey Trail Trek.Equipment SupportColac Area Health was successful in a submission tothe Department Human Services - Disability MinorWorks and Equipment Grant, to purchase specialisedequipment which will improve women’s healthcare2008 Annual and Quality of Care Report 37

services provided by the Community Health Nursesand Visiting Medical Officers. The generous support ofthe Department is acknowledged.Sustainable Farm FamiliesSustainable Farm Families is an initiative of WesternDistrict Health Service and delivered in partnershipwith the Department of Primary Industry. Colac AreaHealth has provided ongoing support to this initiativesince inception with participation from ExecutiveDirectors on the original steering committee. Twosenior staff undertook the original facilitator training;both have continued to support Western DistrictHealth Service in the delivery of the Program acrossthe State and into Northern Queensland.During 2007/08 financial year Colac Area Health(CAH) was successful in an application for initialfunding to provide the Program to our localcommunity. A third staff member undertook thefacilitator training, and in February 2008 the teamdelivered the Program to 23 local dairy farmingfamilies. The Program was well attended and wellreceived by the participants, and CAH has receivedconfirmation of a successful second round of fundingto offer the Program again in February 2009.Palliative CareCommunity Nursing said farewell to GeraldineGartland in February 2008, a long term employeeof the Health Service. Geraldine was our PalliativeCare Clinical Nurse Specialist for the past eightyears; we thank Geraldine for her commitment andcontribution and wish her well in her retirement.We extend our gratitude and sincere thanks to thePalliative Care Volunteers who continue to work withour team to support families and individuals facedwith grief and loss. This component of the serviceis integral to the care of clients and families dealingwith end of life.The Department of Human Services provided fundsduring the 2007/08 financial year for “After-HoursCommunity Palliative Services” to improve access to‘After-Hours’ care for clients cared for in their homeor in the community. Equipment has been purchasedunder the program to respect clients choice to becared for at home with safety and integrity.Birregurra Community Health CentreThe community of Birregurra is utilising the purposebuilt gymnasium at the Birregurra Community HealthCentre very well. The gymnasium was built with thegenerous bequest from the Estate of the late JackWhittaker. The success of the gym at Birregurra isthe result of the dedication and commitment of theBirregurra Advisory Committee to meet the needs ofthe community.Health Independence SupportProgram2007/08 marks the expansion of the management ofChronic Disease Programs offered within the HealthService. The innovation of the “Health IndependenceSupport Program”, a developing Program thatemerged from the collaborative work of staffmembers across Primary Care. The new initiativeoffers an exciting opportunity to the community toimprove access to services and offers an increasedlevel of case management for consumers who utilisemultiple services within the Health Service.Professional DevelopmentCommunity Nursing, supported by the ExecutiveManagement Team and external agencies continuesto value the ongoing education of staff members andthe pursuit of best practice.During 2007/08 financial year we had presentationsby five staff members at three national conferencesincluding National Breast Care Conference, NationalWound Care Conference and the National ContinenceConference. The attendance of staff at a nationalforum has been a pivotal part of our strategicdirection to address succession planning in specialtyareas and the continuation of provision of theseessential services.Anita WhytcrossCommunity Nursing Manager38 Colac Area Health

Family and CommunityProgramsChoosing just a small number of activities tohighlight from Community Programs is difficultgiven the achievements that the workers accomplishon a day-to-day basis. The quality and diversity ofthe programs and services enhance the health andwellbeing of the community with a strong and coordinatedapproach to service delivery and planning.A list of services are outlined on Page 6.Youth TeamOne of the best examples of an integrated approachto service provision at Colac Area Health (CAH) isthe Youth Team. This team has been a strong anddynamic team for a number of years, planning,developing and providing a number of exciting andinnovative programs to the local community.The team brings together workers from threeprogram areas in Primary Care with a diverse range ofskills and experiences relating to youth services. Theteam consists of Adolescent Health Nurses, Children’sCounsellor, Alcohol and Other Drugs Worker, anddelivers programs for young people aged 12 – 18years.Health promotion is a strong focus; the teamhas been very creative in developing programsthat explore many challenges confronting youngpeople and their families. The programs include“safe partying”, “standard drinks”, “sexual health andreproduction” and “risk and resiliency”, and are verypopular with the local secondary schools, enablinga partnership approach between CAH and theeducation sector. The team has a strong presencein schools across the Shire, including Apollo Bay andLavers Hill, with active support provided at the ApolloBay Music Festival during the year. Team membersworked over two evenings providing clinical supportin a “Chill Out” tent. The support was greatly valuedby the local community and the Colac Otway ShireEvents Co-ordinator wrote “The professional supportprovided by the staff from Colac Area Health wasgreatly appreciated and quite obviously required.Assistance and guidance provided to the youngpeople……undoubtedly ensured their safety.”Family Violence Prevention ProgramFamily Violence Prevention Program was funded byVicHealth in 2007 under the Respect & Responsibility:Ending Violence against Women to raise awarenessaround Family Violence, particularly in relation to theimpact of Family Violence on the workplace.The Project commenced in October, 2007 andactivities included the White Ribbon Campaign inNovember 2007, development of a Family ViolencePolicy for CAH, education and training opportunitiesand activities for staff, creation and dissemination ofan attitudes survey together with the distribution ofposters and brochures.The Project ends in October, 2008, by which time – itis anticipated – the policy, awareness raising and stafftraining will be embedded in organisational culture.Rotary Club of Colac West, FamilySupport Partners ProjectThe Family Support Program has been a veryappreciative beneficiary of a “Partners Project” bythe Rotary Club of Colac West. The project this yearfocused on literacy improvement. The Rotary Clubof Colac West approached Colac Area Health to be itspartner in this project and generously donated fundsto the Family Support Program to purchase children’sbooks. The Family Support Program provides supportto vulnerable families and children, including thosewho are particularly disadvantaged.The books serve as an engagement tool for workerswhen developing a relationship with the parents andchildren. Using the books in a variety of ways, butparticularly to model and encourage parents to readto their children. The Partners Project will be a greatenhancement to the Program and will provide accessto books for a number of young children who mayotherwise not have had the opportunity.Marg WhiteFamily and Community Programs Manager2008 Annual and Quality of Care Report 39

Human ResourcesDonna HayHuman Resources ManagerThe Human Resources Department exists to provideservices, advice and support to Colac Area Health(CAH) managers and staff in relation to all humanresource functions. This includes payroll and salarypackaging activities, as well as workforce planningcomprising recruitment and selection, staff trainingand development and performance management.The Department is also responsible to ensure theorganisation and its employees meet the legislativerequirements outlined in Employee and IndustrialRelations Regulations including Occupational Healthand Safety (OHS) and Equal Employment Opportunity(EEO).The Department consists of 4.7 Full Time Equivalent(FTE) including the Manager, Human Resources,Payroll Coordinator, Payroll Officer, Human ResourcesCoordinator and Human Resources Administrator.The team is extremely dedicated to serving the bestinterests of the organisation and delivering outcomesthat are in accordance with the organisation’s Visionof being recognised as a leader in the developmentand provision of responsive, integrated health care.Our Corporate ValuesThe CAH Corporate Values of respect, integrity,leadership, innovation, quality and partnerships areextremely important in the way the human resourcesteam operates and they proactively promote thevalues throughout the organisation.Upon commencement at CAH the team ensuresthat new members of staff are aware that theseorganisational behaviours exist and are expected ofall our employees by including them as part of theorientation package. These Values are also apparentthrough the delivery of our service and included inthe advice and support that we offer to managersand employees.Payroll and Salary PackagingThe CAH payroll service is currently responsiblefor the fortnightly payroll for approximately 471employees at CAH and one other local agency. Theservice was extended to include an additional agencyas well, however, this arrangement ceased during theyear.In addition to the payroll service, the Unit is alsoresponsible for delivering the salary packagingprogram to CAH employees. This program offersconsiderable benefits to employees enabling staffto access taxation benefits which can increasetheir take-home pay. At 30 June, 2008, 308 CAHemployees, which comprises approximately 74%of the total workforce, chose to utilise the salarypackaging service.The decision was made during the year to purchasea new payroll system given the arrangement with thecurrent system provider was due to cease on 30 June2008. Considerable work has been completed overthe past year setting up the new system, “Chris 21”, toensure we are ready to “go live” on the first pay periodof the new financial year. The team will continueto work on the system in the new financial year tofurther develop its effectiveness. It is also intended toimplement an “Employee Self Service” in the comingmonths enabling employees to access their ownpayroll information on-line.Occupational Health andSafetyOccupational Health and Safety (OHS) continues tobe a high priority of CAH as significant work has beencompleted to ensure we meet our obligations underthe Occupational Health and Safety Act 2004.The OHS Committee has convened on a monthlybasis with health and safety representatives and,managers have been required to complete quarterlyaudits of their areas. Colac Area Health has facilitatedvisits from WorkSafe over the year and staff haveattended locally conducted WorkSafe informationsessions. The OHS systems, policies and procedureswill continue to be reviewed and updated throughoutthe next year to ensure they remain current withlegislative requirements and that CAH meetsemployer obligations.40 Colac Area Health

Adam Lamanna accepting the Certificateof Recognition from Geoff Iles, CEO, whenannounced the inaugural Employee of theMonth recipient in April.Staff Recruitment andOrientationStaff recruitment continues to be an ongoingchallenge to ensure the organisation recruits thehighest calibre of staff through a fair, open andtransparent process. The human resource team takespride in its recruitment principles that demonstratefairness, credibility, equal employment opportunityand merit.It is extremely important to ensure newly recruitedemployees are orientated to the organisationappropriately. The Human Resources departmenthas orientated 110 new and current staff over thepast year to ensure they are familiar with Colac AreaHealth (CAH) processes, policies and procedures. Theone day program comprises speakers from differentareas of the organisation and contains informationregarding human resources activities, infectioncontrol, safety and quality systems, informationtechnology, privacy and confidentiality, emergencyresponse and CPR, No-Lift and Family Violence. Theprogram will continually be reviewed and updated toensure the most current information is conveyed tostaff.Promoting SkillsDevelopmentColac Area Health continues to focus on skillsenhancement and emphasises the advantagesof developing current staff to ensure successionplanning for the future. Over the last year graduateprograms, traineeships and apprenticeships wereoffered in nursing, food services, administration anddental services.Reward and RecognitionEmployee of the Month ProgramIn April 2008, an Employee of the Month Programwas implemented to recognise our star performers.The award is given to an individual each month whohas demonstrated exceptional performance withintheir position at CAH. This includes promoting andcarrying out our Corporate Values – partnerships,innovation, leadership, integrity, quality and respect– as well as showing superior customer service,initiative or expertise within their position. Thefollowing employees were recipients of this award in2007/08:• April - Adam Lamanna (Information andCommunications Technology Support Officer)• May - Lillian Duggan (Midwife) and Jan Hall (Foodand Domestic Services Assistant)• June - Michelle Carmody (Associate Nurse UnitManager Acute Care Unit)The award will continue throughout the nextfinancial year and the organisation looks forwardto publishing the winners for 2008/09 in the nextAnnual Report.Service AwardsCertificates of Service are awarded to staff andVisiting Medical Staff on completion of 15 yearsservice.Recipients at the Annual General Meeting held inNovember, 2007 were as follows:Mrs. Donna Chandler - Corporate DivisionMs. Faye Fox - Corporate DivisionMrs. Debbie Park - Clinical DivisionDr. George Gray - Visiting Medical StaffIndustrial RelationsThroughout the year the Nurses (Victorian PublicHealth Sector) Multiple Business Agreementexpired and discussions took place between theVictorian Hospitals Industrial Association (VHIA) andthe Australian Nurses Federation (ANF) for a newagreement. Negotiations were finalised in Marchand the terms and conditions of the new agreementcame into effect. Representatives from CAH workedwell with the representatives from the ANF to ensurechanges were implemented and will continue to workon this throughout the next financial year.The Health Services Union of Australia – HealthProfessionals and the Health Services Union ofAustralia – Medical Scientists, Pharmacists andPsychologists certified agreements also expiredduring the year and discussions took place betweenthe VHIA and relevant Union bodies to negotiatenew agreements as well. Negotiations for bothagreements were not finalised before 30 June, 2008.2008 Annual and Quality of Care Report 41

Service ImprovementAdministration Casual PoolIn order to assist managers cover expected andunexpected staff absences in the administrationareas, an Administration Casual Pool was developedfor managers to access ensuring services aremaintained in periods of staff absence. The pool iscoordinated by the Manager, Administration Serviceswho provides administration relief when staff are onleave. To date the casual pool has been successful inassisting managers cover periods of leave to ensureservices are upheld at all times.Whistleblowers’ ProtectionColac Area Health is committed to the aims of theWhistleblowers’ Protection Act 2001. In accordancewith the requirements of the Act, CAH has in place apolicy to facilitate the making of disclosures underthe Act. For the year 2007/08 no disclosures weremade.Donna HayHuman Resource ManagerEqual EmploymentOpportunity (EEO)StatementColac Area Health (CAH) considers EEO principles asimperative to ensure compliance with the guidelinesset out under the State Services Authority. The “Codeof Conduct for Victorian Public Sector Employees”,which outlines public sector values and the reasonsfor the code, was distributed to each staff memberduring the year. Colac Area Health has demonstratedcommitment to these standards by ensuring EEOprinciples are included as standard practice forrecruitment, training, transfer and promotionopportunities. All vacant positions within CAH areadvertised internally (as a minimum) on our websiteas well as on our noticeboards.Colac Area Health aims to promote a discriminationfreework environment which fosters employeerespect and working relationships with manybehavioural policies in existence, as well as grievanceprocedures as an avenue for re-dress if required.Staffing ProfileAs at 30 June, 2008, our staffing profile was made upof the following components:LABOURCATEGORYJUNE 08CURRENTMONTH FTEJUNE 08YTD FTEJUNE 08CURRENT MONTHHEAD COUNTNursing 152.44 147.70 233Administration and Clerical 33.17 32.60 43Medical Support 26.32 25.94 35Hotel and Allied Services 54.02 54.12 73Ancillary Staff (Allied Health) 22.27 23.05 34TOTAL 288.22 283.41 41842 Colac Area Health

Support ServicesSupport Services oversees the following areas, andalso has the responsibility for fleet management,contract management, security and signage.Food Services• Acute patients• Residential Aged Care residents• Staff• Visitors• Meetings• Meals on Wheels• Emergency Service meals• Prisoner meals.Environmental Services• Cleaning to Wards, Operating Suite andEmergency Departments• Cleaning to Corangamarah Residential Aged Carefacility• Cleaning to Community Dental Clinic• Cleaning to Pathology and Medical Imaging[contract]• Porter/courier service• Assist where required with furniture andequipment relocation• Linen distribution• Personal linen to Corangamarah ResidentialAged 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 andequipment relocations.Supply Department• Management of the procurement process for allconsumables and equipment items required tosupport the operations of Colac Area Health(CAH).AchievementsAudit of Cleaning ServicesIn accordance with requirements, an externalaudit was conducted at CAH on 1 April, 2008.Results are shown in the table below.Congratulations to the environmental staff forachieving excellent results with the external auditof acute facilities at CAH.With the opening of Polwarth House ServiceCentre for Primary Care staff and the relocationof the Community Dental Clinic, staff againdemonstrated the willingness to accept changeand continue to provide excellent service.AreaAreasAudited2006 2007 2008AreasAreasScore Audited Score AuditedScoreGroup A -Very High RiskOperating Suite, ICU 8 96% 11 100% 8 95%Group B–High and Moderate RiskCSSD, Sterile Supply areas,Emergency Dept, Pharmacy cleararea, Wards etcGroup C – Low RiskLaboratories, Mortuary, MedicalImaging, Waiting Rooms,Administration17 97% 23 100% 18 97%1 96% 3 100%Totals 26 96.4% 37 100% 26 96.5%ALL areas meet the Cleaning Standards Acceptable Quality Level (AQL)2008 Annual and Quality of Care Report 43

Audit of Food Safety ProgramLegislation requires that an external audit of theFood Safety Program be conducted. The auditof Colac Area Health (CAH) was completed on 24January, 2008.There were seven non-notifiable areas requiringcorrective action. These were attended to andcertificates were issued on 21 February, 2008.Food ServicesAs noted above, food service is provided to variousareas in and around CAH, as well as externalcontract provision. The following is a summary ofthe number of meals provided during 2007/2008.Meal Summary 2007/2008Meals %Acute 35205 19.23Corangamarah 107508 58.72Operating Suite 2500 1.37Cafeteria 7735 4.22Adult Day Activity Centre 2725 1.49Functions 5127 2.80Day Surgery Unit 2221 1.21Meals on Wheels 18007 9.83Other 2068 1.13Total 183096 100.00Waste ManagementColac Area Health is a member of the BarwonWaste Wise Healthcare Network and is certified asWaste Wise with assistance from Barwon RegionalWaste Management Group. Colac Area Healthwas the first healthcare facility in Victoria toreceive Waste Wise Certification in 1999. A wastemanagement action plan has been developedbased on the principles of reduce; reuse andrecycle. Annual waste audits are conducted forgeneral, clinical and related waste streams.Colac Area Health is very proud to be certified asWaste Wise. In our industry there are certain itemswhich are single-use in order to meet infectioncontrol standards. We continue to strive toachieve improvements and to build on our earlierinitiatives.There are no toner cartridges, saline bottles,paper or cardboard included in Colac Area Health’sgeneral waste - these materials are all recycled. Inaddition, confidential documents are shreddedand recycled, garden waste is composted andlaundry chemical packaging has been reducedthrough bulk purchasing.Colac Area Health staff support the effort toremain Waste Wise through their work to correctlysegregate waste at the point of generation.Contamination of bins has almost been eliminated;an essential component of effective recycling.Supply DepartmentIn accordance with the Vision and MissionStatement of Colac Area Health, the SupplyDepartment offers a wide range of services to“promote the health and wellbeing of the Colacand District community”.Over recent years the department has expandedfrom providing basic services to meeting therequirements of a complex health facility whichincludes acute, residential aged care and primarycare services.44 Colac Area Health

In response to the needs of the wider community,the department offers supplies and services to anumber of external organisations, including:• Lorne Community Health Service, Hesse RuralHealth, Cobden Health Service and ColandaCentre• Transport Accident Commission (TAC) clients• A number of Department of Human Servicesfacilities in and around Colac.The supply of goods and services to individualclients of Colac Area Health is another area ofmajor value and importance to clients and thecommunity. This support to the continuum of careincludes the provision of dietary supplements,continence aids, wound care products and the hireand loan of rehabilitation equipment.It is recognised that to continue to respondto the needs of the community and the healthservice, the Supply Department must integratethe many time saving advantages made availableby new technology. To this end it is intended tointroduce on-line requisitioning and orderingprocedures that will further increase thedepartment’s efficiency and ability to grow withthe organisation.Trevor NelsonSupport Services Manager2008 Annual and Quality of Care Report 45

Information and CommunicationThe Colac Area Health (CAH) Information andCommunication Technology (ICT) staff (Managerand ICT Officer) manage all the ICT functions atCAH.2008 is a year of consolidation, following therollout of a number of large projects in 2007.The Personal Computer (PC) and laptop fleet sizehas increased slightly to 210 PCs and laptops, with460 staff having access to email applications.For some time now, CAH has been participatingin a project which has seen the introduction ofan experimental Bedside Entertainment SystemTechnology (BEST), which replaces traditionaltelevisions with a touchscreen monitor mountedon an adjustable “arm”. The major benefits of thissystem, over that of a traditional system, include:• Austar – 15 channels of Pay-TV• A selection of movies which can be streamed toany monitor – similar to the system employed inmany hotels• A large selection of music video clips• Internet access.As mentioned, the system is not as yet fullyfunctional and will most likely change in the futureas new uses are determined and abilities explored.Some current ideas being looked at are:• Custom CAH content, e.g. patient information,maps, health promotion material, etc.• The ability for staff and/or patients to plan theirmenu choices at the bedside• The possibility of doctors using the system torecord progress notes.Currently the system is in place for all 43 AcuteCare Unit beds as well as the 7 Day Surgery Unitbeds.Late 2007 saw the streamlining of CAH’s hardcopydevice fleet to almost 100% photocopier / laserprinter based.The fleet is now maintained under a facilitiesmanagement agreement which has provided thefollowing benefits to CAH:• Greatly reduced number of hardcopy devices -from around 80, down to 30• Devices are multifunction, which providesphotocopying, faxing, scanning, emailing• The speed, capabilities and efficiency of the fleetfar surpasses older laser/inkjet printing technology• Savings of approximately 20% over the olderlaser/inkjet printing technology• The ability to more actively monitor and manageusage levels amongst various departments.Future ICT directions at CAH includes somestrategic and innovative changes:• Migration to a completely integrated ActiveDirectory Services model – the technologywhich drives security and access to the network.Colac Area Health is currently participating insuch a model managed by SWARH (South WestAlliance of Rural Health), and is a primary driverfor maintaining and updating the model so otherregional health agencies can join. The eventualgoal of this model is to go statewide – one healthnetwork and services model to supply the entireState of Victoria.• Colac Area Health will be participating in a new ITServices Strategy for the region, which will includethe provision of IT Services to all health services inour geographic region. This is an initiative beingmandated by the Department of Human Services.Randall HoseInformation and Communication TechnologyManager46 Colac Area Health

Legislative ComplianceBased on legislative information received,Colac Area Health (CAH) has complied with allActs and Regulations. Legal advice providedon behalf of Victorian Healthcare Associationindicates that there is no longer a requirement forpublic hospitals to include a full list of Acts andRegulations in the Annual Report.National Competition PolicyColac Area Health complied with all governmentpolicies regarding competitive neutrality.Compliance with Building ActColac Area Health complies with the BuildingAct 1994 under guidelines for publicly ownedbuildings issued by the Minister for Finance 1994 inall redevelopment and maintenance issues.• Building Inspections Standards AssessmentColac Area Health facilities have been the subjectof a fire audit by a Fire Services Engineer. Thescope of that audit considerably exceeded thescope of an inspection by a Building Surveyor inline with the Minister for Finance’s Guidelines.• Arrangements Regarding Registered BuildingPractitionersThe Board of Directors requires all buildingprofessionals engaged on building projects to beregistered with the Building Practitioners Board orbe Registered Architects.• New BuildingsIt is required that a building permit be issuedat the completion of each building project. Thataction ensures that new buildings and work inexisting buildings conform to building standardsand that the ten year liability cap is invoked.During the year, the following works wereundertaken to ensure comformity with therelevant standards.Building WorksNumberOccupancy Permits Issued 1Works in construction and thesubject of mandatory inspection NilMaintenanceNumberNotices issued for rectificationof substituted buildings requiringurgent attentionNilStatutory ComplianceConsultanciesThere was one consultancy totalling $28,178undertaken at Colac Area Health during the2007/08 financial year.Fees and ChargesColac Area Health charges fees in accordance withrelevant Department of Human Services directives.Financial ManagementCompliance Framework (FMCF)The Financial Management ComplianceFramework (FMCF) was introduced from July 1,2003 and applies to all Victorian Public Sector (VPS)entities. The Framework has been establishedto ensure that all VPS entities have implementedappropriate systems to ensure that publicresources are used in an efficient, effective andresponsible manner.Colac Area Health is working to ensure that fullcompliance is achieved. Colac Area Health willcontinue to review its performance, policies andprocedures to ensure that the Service is operatingin an effective and responsible manner.Pecuniary InterestMembers of the Board of Directors are required tonotify the President of the Board of any pecuniaryinterest which may give rise to a conflict of interestas defined in accordance with the Directions of theMinister for Finance. All declarations of pecuniaryinterest have been completed and are availableon request to the relevant Minister, Member ofParliament and the public.Services Contracted OutThe range of Services contracted out has remainedunchanged during the 2007/08 financial year.2008 Annual and Quality of Care Report 47

Statutory ComplianceAdditional InformationStatementThe following information, where it relates toColac Area Health and is relevant to the financialyear 2007/08 is available upon request by relevantMinisters, Members of Parliament and the public:(a) A Statement of pecuniary interest has beencompleted.(b) Details of shares held by senior officers asnominee or held beneficially.(c) Details of publications produced by thedepartment about the activities of the entity andwhere they can be obtained.(d) Details of changes in prices, fees, charges, ratesand levies charged by the entity.(e) Details of any major external reviews carriedout on the entity.(f) Details of major research and developmentactivities undertaken by the entity that arenot otherwise covered either in the Report ofOperations or in the document that contains thefinancial report and the Report of Operations.(g) Details of overseas visits undertaken includinga summary of the objectives and outcomes of eachvisit.(h) Details of major promotion, public relationsand marketing activities undertaken by the entityto develop community awareness of the entity andits services.(i) Details of assessments and measuresundertaken to improve the occupational healthand safety of employees.(j) General statement on industrial relationswithin the entity and details of time lost throughindustrial accidents and disputes, which is nototherwise detailed in the Report of Operations.(k) A list of major committees sponsored by theentity, the purposes of each committee and theextent to which the purposes have been achieved.48 Colac Area Health

Disclosure IndexThe Annual Report of Colac Area Health is prepared in accordance with all relevant Victoria legislation. Thisindex has been prepared to facilitate identification of the Department’s compliance with statutory disclosurerequirements.Legislation RequirementPage ReferenceMinisterial DirectionsReport of Operations - FRD GuidanceCharter and purposeFRD 22B Manner of establishment and the relevant Ministers......................................................16FRD 22B Objectives, functions, powers and duties............................................................................16FRD 22B Nature and range of services provided................................................................................ 6Management and StructureFRD 22B Organisational Structure............................................................................................................... 9Financial and Other InformationSD 4.2(j) Accountable Officer, signed off Report of Operations....................................................10SD 4.5.5 Risk Management Compliance................................................................................................17FRD 22B Operational and budgetary objectives and performance against objectives.......12FRD 22B Statement of merit and equity................................................................................................ 42FRD 22B Workforce Data Disclosures......................................................................................................42FRD 22B Occupational Health and Safety............................................................................................. 40FRD 22B Summary of the Financial Results for the year.................................................................. 7FRD 22B Significant changes in financial position during the year............................................. 57FRD 22B Major changes or factors affecting performance............................................................. 12FRD 22B Subsequent Events...................................................................................................................... 86FRD 22B Application and operation of Freedom of Information Act 1982...............................33FRD 22B Compliance with building and maintenance provisions of Building Act 1993..... 47FRD 25Victorian Industry Participation Policy disclosures........................................................N/AFRD 22B Statement on National Competition Policy........................................................................47FRD 22B Application and operation of the Whistleblowers Protection Act 2001...................42FRD 22B Details of consultancies over $100,000................................................................................47FRD 22B Details of consultancies under $100,000.............................................................................47FRD 22B Statement of availability of other information..................................................................48FRD 10Disclosure Index............................................................................................................................49FRD 11Disclosure of ex-gratia payments...........................................................................................67FRD 21A Responsible person and executive officer disclosures................................................... 83Financial Statements - FRD GuidanceFinancial Statements required under Part 7 of the FMASD 4.2(b) Operating Statement...................................................................................................................54SD 4.2(b) Balance Sheet.................................................................................................................................55SD 4.2(b) Statement of Changes in Equity..............................................................................................56SD 4.2(b) Cash Flow Statement...................................................................................................................57SD 4.2(c) Accountable officer’s declaration............................................................................................51SD 4.2(c) Compliance with Australian accounting standards and other authoritativepronouncements..........................................................................................................................58SD 4.2(c) Compliance with Ministerial Directs......................................................................................58SD 4.2(d) Rounding of amounts.................................................................................................................58LegislationFreedom of Information Act 1982.............................................................................................................................33Whistleblowers Protection Act 2001........................................................................................................................42Victorian Industry Protection Act 2003..................................................................................................................N/ABuilding Act 1993............................................................................................................................................................47Financial Management Act 1994...............................................................................................................................58Audit Act 1994..................................................................................................................................................................522008 Annual and Quality of Care Report 49

Financial ServicesGarry EllisDirector Corporate ServicesThe entity financial result for 2007/2008 was asurplus of $0.430m. Excluding capital income anddepreciation, the operating result was a surplusof $0.248m. This compares to an entity result in2006/2007 of $0.638m and an operating result of$0.130m.The financial year 2007/2008 has been one ofconsolidating our financial systems to providea platform for producing timely and accuratefinancial statements.We have continued the development of ourbudgeting system, which will enable monitoringof the financial position at department level,with managers heavily involved in analysis andreporting. There has also been a significant effortapplied to reviewing and updating financialpolicies and procedures.Features of 2007/2008With the support of Department of HumanServices funding, the following capital projectshave been completed:• Finalisation of the refurbishment of OtwayPioneers and Polwarth House Service Centre.• The building previously occupied by HomeNursing has been completely redeveloped toenable the Community Dental Clinic to move tothe main campus. This was achieved in May 2008,completing the objective of having all majorservices consolidated on the one site.• The previously unsealed main car park hasbeen sealed, marked and landscaped, with a totalcapacity of 75 car parks, including disabled andshort term parking bays.The Future• In March 2008 a new funding system (theAged Care Funding Instrument) was introducedfor Residential Aged Care facilities. The fundingmechanism used by this system is quite differentto that previously used, so adapting to andmonitoring the changes will be required to assessthe impact on Colac Area Health’s finances.• Further development of devolved budgets andinvolvement of managers in assessing financialperformance. To assist in the understanding of therelationship between the organisation’s operationsand financial position, a more wide ranging suiteof Key Performance Indicators and other measureswill be provided to managers.• An increased focus will be placed on reviewingand updating financial policies to ensurecompliance with legislation and standards.Although reporting a surplus for 2007/2008,the result included a significant amount of grantincome received during the year, for whichexpenditure will be incurred in 2008/2009. TheBoard of Directors, Executive and Staff will focustheir work to ensure that the current levels ofservices are maintained and improved into thefuture.Significant progress has been made to ensurethe structures within the organisation will supportthe development of services to meet communityexpectations.We would like to acknowledge the support of theDepartment of Human Services during the pastyear, and also pass on our thanks to the staff ofColac Area Health for their commitment in whathas again been a challenging year.Garry EllisDirector Corporate Services50 Colac Area Health

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