Brhs Ann Rep Web 2010

Bairnsdale Regional Health Service

Annual Reportincorporating Quality of Care Report

2009-2010

Bairnsdale Regional Health ServicePO Box 474 Bairnsdale VIC 3875Telephone (03) 5150 3333 Facsimile (03) 5152 6784 Email [email protected]

www.brhs.com.au ...focusing on you

MissionLeading, shaping and delivering quality health care services to East Gippsland

VisionTo be a key provider of healthcare services in East Gippsland through:• Innovationinthedeliveryofhealthcareservices• Recognitionbyitsclientsasbeingcommittedtoqualitycare• Workinginpartnershipwithotherhealthcareproviders• Responsivenesstocommunityneeds• Recognitionbyitsstaffasanemployerwhovaluestheircontributions;and• Deliveryofcosteffectiveservices

Values• CustomerService• Respect• Teamwork• Efficiency

Our motto ...focusing on you

The Bairnsdale Regional Health Service is established under the Health Services Act 1988. TheresponsibleMinisterduringthereportingperiodistheHonDanielAndrewsMP. The Bairnsdale Regional Health Service Annual Report 2009/10 has been preparedinaccordancewiththeHealthServicesAct1988,FinancialManagementAct1994,StandingDirectionsoftheMinisterforFinance(Section4FinancialManagementReporting)andFinancialReportingDirections(SpecificallyFRD22).

ConstructionofnewOncology&DialysisUnit-June2010

Contact DetailsBairnsdale Regional Health ServicePO Box 474, Bairnsdale VIC 3875Ph: (03) 5150 3333 Fax: (03) 5152 6784 Email:[email protected]:www.brhs.com.au

Hospital122DayStreet,BairnsdaleVIC3875

Community Health CentresRoss Street, Bairnsdale VIC 3875Shop 19, The Esplanade, Paynesville VIC 3880

Residential Aged CareMaddocks Gardens, McKean Street, Bairnsdale VIC 3875Sutherland Lodge, McKean Street, Bairnsdale VIC 3875

Planned Activity GroupsRoss Street, Bairnsdale VIC 3875Ph: (03) 5152 0222

AcknowledgementsDesign & PrintingEgee PrintersP: (03) 5152 5055 F: (03) 5152 1387 E:[email protected]:www.egee.com.au

PhotographyJetsPhotographyP: 0419 169 859 E: [email protected]

External AuditorsAuditor-General, Victoria

Internal AuditorGrant Thornton

Bairnsdale Regional Health Service 2010 Annual Report 1

CONTENTS

Profi le 2

Services 3

President and CEO Report 4

Summary of Strategic Goals 6

Summary of Key Result Areas 7

Financial Results 9

Activity Data 10

Workforce Data 12

Corporate Governance 13

Organisational Structure 16

Organisational Chart 17

Management Committees 18

Specialists and Visiting Specialists 19

Financial Donations 20

Life Governors 22

Community Engagement 23

Quality of Care 24

Report of Operations 30

Glossary of Terms 32

Donations / Bequests 34

Index 35

Disclosure Index 36

2 Bairnsdale Regional Health Service 2010 Annual Report

PROFILE

Bairnsdale Regional Health Service (BRHS) provides healthcare services to more than 40,000 people across the East Gippsland Shire covering an area of 21,000 square kilometres. Towns to benefi t from the services of BRHS include Bairnsdale, Benambra, Bruthen, Buchan, Ensay, Lakes Entrance, Mallacoota, Metung, Omeo, Orbost, Paynesville, Swan Reach and Swifts Creek. • Hospital services operate from the main campus in Day Street, Bairnsdale and include acute and post acute services, specialist consulting rooms, dialysis and oncology outpatient services, allied health outpatient services, radiology, pathology and residential aged care facilities. • Community health services are located in both Bairnsdale and Paynesville providing outpatient allied health services, Planned Activity Group, and dental services in Bairnsdale. Outreach Planned Activity Groups are also located in Metung, Buchan, Bruthen, Lindenow and Paynesville. • Outreach healthcare and education services are also provided throughout the region including allied health services at the Lake Tyers Aboriginal Trust and the Gippsland and East Gippsland Aboriginal Co-operative (GEGAC); outreach midwifery and maternal health, district nursing and in-home palliative care.

BRHS HISTORY 1887 Opening of the Bairnsdale District Hospital 1930 Opening of the Orbost Hospital 1940 Relocation of the Bairnsdale District Hospital to Day Street (current site) 1963 Training facilities for nursing built on site 1967 Extension of hospital to facilitate outpatient facilities 1975 Name changed to East Gippsland Hospital 1981 Opening of children’s ward 1986 Completion of building works incorporating radiology, pathology, pharmacy and medical records 1992 Opening of new operating theatre 1992 Bairnsdale Regional Health Service established as an entity under the Health Services Act 1988 following amalgamation of the East Gippsland Geriatric Centre and East Gippsland Hospital

1993 Amalgamation of Community Health Services into the Bairnsdale Regional Health Service 1996 Establishment of Sutherland Lodge, dementia specifi c aged care facility 2004 Establishment of Maddocks Gardens residential aged care facility 2007 Construction of the new Emergency Department and associated works 2008 Extension of the Monash Rural Clinical School 2009 Master Planning commenced for construction of Oncology & Dialysis unit, and extension to pharmacy 2010 Pharmacy extension completed, construction underway on Oncology & Dialysis unit.


SERVICES

Services offered by Bairnsdale Regional Health Service include: Acute & Sub Acute HealthDialysisEmergency Services Geriatric Evaluation and ManagementMedicalMedical ImagingObstetrics OncologyPaediatricsPalliative CarePathologyPharmacy RehabilitationStomal TherapySurgical Care Theatre

Aged CareRehabilitationRehabilitation Physician Residential Dementia Residential High CareResidential Low CareRespite Care

Allied HealthDieteticsEquipment Service - Aids and Equipment ProgramInpatient RehabilitationKoori Hospital LiaisonOccupational TherapyOutpatient ServicePhysiotherapyPodiatrySocial WorkSpeech Pathology

Ancillary AudiologyMedical LibraryMental HealthOrthotics

Community HealthAdolescent HealthBreast CareCardiac Rehabilitation Community Dental Health ProgramContinence Advisory ServiceDiabetes EducationHome Based Nursing Service (District Nursing)Hospital Admission Risk Program (HARP)Hospital in the Home (HiTH)Needle Exchange ProgramPalliative CarePlanned Activity Group (PAG)Post Acute Care (PAC)Pulmonary RehabilitationQUIT program – smoking cessationWomen’s Health

Visiting Specialists AudiologyCardiologyCognitive Dementia and Memory ServiceGastroenterologyGeneral PhysicianGeneral SurgeonGynaecologyHead, Throat, Neck & NoseCounselling ServicesLow Fertility ClinicLow-Vision ClinicNeuropsychology OncologyOphthalmologyOrthopaedic Outreach Polio Clinic (bi-annual) Paediatric SurgeonPaediatricianRehabilitation CardiologistRenal PhysicianRheumatologistUrology Vascular Surgeon


PRESIDENT AND CEO REPORT

On behalf of the Board of Management, management and staff, we are pleased to present the Annual Report of Bairnsdale Regional Health Service (BRHS) for 2009-10.

During 2009-10 BRHS adopted a new strategic plan for the years 2009-2013. The plan builds on BRHS’s mission of; leading, shaping and delivering quality health care services to East Gippsland and a summary of the goals and strategies can be found following this report. The plan sets out the pathway for BRHS to build on its services as the opportunities arise over the next four years and to achieve these objectives whilst maintaining core clinical services and operating effectively within the resources we have.

The healthcare landscape we operate in is both dynamic and challenging and the Board and management of BRHS are pleased to report that we have successfully met and navigated through these challenges for the benefi t of all sections of the community. With the ever increasing demands for service provision and costs of healthcare, it is our priority to ensure that BRHS is able to meet as many as possible of the needs of our community. Satisfying these competing demands is a constant and complex challenge for management.

Without question the issue of the consulting suites and whether visiting consultants should pay for the use of the rooms and BRHS staff to conduct private clinics was locally controversial. A successful outcome for the visiting consultants and BRHS, in line with

accepted industry wide practice, was achieved through the goodwill and co-operation of all parties concerned. In late 2009 BRHS committed $196,000 towards renovating the consulting suites and staff accommodation. This project will be completed in August 2010 resulting in improved reception and waiting areas, air-conditioning, painting, carpeting, blinds and disabled access and toilets etc.

In November 2009 BRHS signed a contract with local builder Brooker Builders, for the construction of the much awaited Oncology and Dialysis Unit. Construction has commenced and it is anticipated that the building will be operational in early 2011. This will bring to fruition a project that will have a total budget of 3.5 million dollars which in the main is self funded by BRHS and community fundraising. We would like to acknowledge the wonderful work of the many individuals and companies who have contributed to this project either directly or through the Toonalook Waters Project. Special mention needs to be made of the tireless fundraising efforts and contributions of the Pelicans, the Practical Men of the Village, particularly Mick Campbell & Vin Martin, and Mina Armstrong who donated the land for the Toonalook Waters Project, whose contribution made this project such an outstanding success.

In delivering our mission of “quality health services” BRHS continues to seek independent affi rmation of our progress in this area and it is pleasing to report on some signifi cant outcomes. BRHS Radiology Department successfully undertook accreditation through the Royal Australian and New Zealand College of Radiologists/ National Association of Testing Authority. The BRHS Radiology Department at the time was the only Victorian radiology department to successfully achieve accreditation and is one of only three accredited services in Victoria. BRHS’s midwifery service was also reaccredited under the “Baby Friendly” accreditation scheme. “Baby Friendly” is an internationally recognised accreditation process and provides reassurance to our community that the services provided are both best practice and benchmarked. Maddocks Gardens, our Aged Care service, was likewise reaccredited by the Federal Government Aged Care Standards & Accreditation Agency. BRHS also commenced year one of a three year program to improve the focus on customer service throughout the organisation. In excess of 200 front line staff undertook customer service training during 2009 and we are confi dent of building on the gains made to date. The achievements outlined are representative of multiple activities that are undertaken by BRHS staff on a continuous basis. We commend our staff on their achievements to date and encourage their future pursuits in this area.

BRHS continues to pursue partnerships for the improved client outcomes and was pleased to have the BRHS and Gippsland Lakes Community Health joint draft work plan, as mentioned in last year’s report, adopted. This has resulted in a number of joint projects getting under way. BRHS is proud of its many working partnerships which include; the many auxiliaries that provide invaluable service to BRHS, partner organisations, our community advi-sory committee and the many volunteers throughout BRHS.


Recruitment and retention of skilled staff in the rural setting is an on-going challenge. BRHS has been fortunate to receive funding to facilitate two GP Obstetric registrars, Drs Daniel Otounye and Andrew Linton and we are appreciative of the opportunity to provide this experience and hope that we will be able to provide such programs in the future. In the addition to the Obstetric registrars BRHS was able to secure $125,000 in funding from the Department of Health to review and develop alternative models of care for maternity services. A multi-disciplinary working party consisting of GP Obstetricians and Midwives has been exploring ways we can improve our maternity model of care and the recruitment and retention of both GP Obstetricians and Midwives. We also acknowledge the retirement of Dr. Geoff Brown, who during more than 34 years at BRHS, held roles of Medical Superintendant and Chief Radiologist and we acknowledge his dedication and commitment to the Health Service.

BRHS notes the retirement of Mr Ian Roberts and Ms Lidia Thorpe from the Board of BRHS and thanks them for their contribution. Thanks is also extended to the Board who contribute many hours in a volunteer capacity to ensure that the mission, vision and values of BRHS remain at the fore front of our endeavors.

BRHS commends the commitment of Board members, staff, medical offi cers and volunteers for their efforts and looks forward to a continuing contribution and partnership in the provision of health services to the East Gippsland community.

Philippa deVoil Wayne SullivanPresident, Board of Management Chief Executive Offi cer


SUMMARY OF STRATEGIC GOALS

Innovation in the deliveryof healthcare services

Commitment to providing quality care

Working in partnership

Responding to community needs

Valuing and developing our workforce

Cost effective service delivery

Develop and promoteintegration andcontinuity of care

Provide excellence in customer service

Promote open communication with staff, health service partners and other stakeholders

Enhance the community’s engagement with BRHS services

Achieve a full workforce compliment skilled to meet service deliveryrequirements

Provide effi cient services and make best use of existingfacilities

Provide servicesthat are appropriate and accessible to Koori patients, clients and families

Progressively develop information systems that link seamlessly with local and regional health services

Improve community health through health promotion, illness prevention and service coordination

Develop aninformation technology strategy to support clinical and business improvements

Progressively implement environmentally friendly policies and reduce the BRHS environmental footprint

Advocacy for improved services for our community

Partner with regional health services to support service delivery and workforce requirements

Develop innovative and sustainable service models to meet community needs

Enhance quality practicethroughout BRHS

Work with other health serviceorganisations to develop cooperative strategic partnerships

Strengthencapacity in core clinical services

Promote an organisational culture that refl ectsorganisational values in all aspects of BRHS activities

Develop facilities to meet contemporary health carerequirements

Build recognition and support in the community

Support and strengthen subregionalhealth care partnership forums

Establish a high dependency unit (HDU) within fi ve years

Ensure staff feel informed, listened to and engaged

Develop shared service solutions with other Gippsland health providers

Develop sub acute services consistent with DoH subacute policy directions

Effectivelymanage discharge planning

Enhance cultural competence

Develop strong partnerships with teaching and training organisations

Provide residential aged care services that best meet community needs

Develop fl exible and adaptable professional roles to best utilise the workforce and skills available to BRHS

Prudently manage fi nancial, capital and staff resources within the annual health services agreement and funding availability

Support staff to gain and keep current qualifi cations and experience needed to sustain BRHS service requirements


SUMMARY OF KEY RESULT AREAS

Key Result Area Comment Compliance

Partial

90% of patients admitted through the ED should not be waiting longer than 12 hours for a bed.

Substantial

All category 1, 2 and 3 patients presenting themselves to the Emergency Department (ED) are seen within the time performance expectations established by the Department of Health.

Benchmark:Category 1 – 100% seen immediatelyCategory 2 – 80% seen within 10 minutesCategory 3 – 75% seen within 30 minutes

The waiting time for outpatient allied health services should not exceed the DH target number of working days.

Whilst there is only a partial compliance, there has been consistent improvement over the fi nancial year, with the end result being an 82% compliance.

Partial

Conservative dental interventions should not exceed the Victorian State target identifi ed by Dental Health Services Victoria.

BRHS Dental Services has maintained a consistently low waiting period with an average of 11.7 months, compared to the State target of 22 months.

Substantial

The number of acute care bed days occupied by patients awaiting residential care placement should not exceed 90 days during the month.

Substantial

The overall level of inpatient satisfaction should exceed the performance of BRHS’s peer group.

BRHS score for the individual questions in the patient satisfaction survey varied considerably with some areas being well above peer average, but others below. The overall care index was 77 for BRHS compared to 78 for peer health services.

Partial

The rate of medical readmissions within 28 days should not exceed 10%.

BRHS’ average rate of medical readmissions was less than 1%.

Substantial

The rate of pressure ulcers acquired at BRHS should not exceed 30% of reported cases.

BRHS’ performance in stage one pressure ulcers was BRHS 0.5, State-wide 0.48, peer group 0.7. In regards to stage two pressure ulcers, BRHS .25, State-wide .65 and peer group .78. Overall pressure ulcer rates per ‘000 bed days, BRHS .78, State-wide 1.1 and peer group 1.59.

Partial

No incident during the month should exceed a severity rating more than 6.

Partial

There are no clinical death reviews outstanding greater than 30 days.

Substantial

Staff agree their contribution to the organisation is valued as assessed via staff survey.

BRHS as a value driven organisation is pleased that an average of 77% responded positively in regards to their contribution being valued.

Substantial

BRHS achieved 100% compliance for this target.


Substantial

BRHS has less sick leave, as a percentage of productive hours, than 90% of other agencies participating in the Regional HR Benchmarking exercise.

Substantial

100% of staff have completed a current performance development plan.

The number of WorkCover claims remaining month end, with time off greater than 10 days and no return to work plan, is zero.

BRHS has maintained its compliance with ensuring all WorkCover claims have a specifi ed return to work program developed.

Substantial

There has been an in-house development / applications of IT solutions to improve the effi ciency of clinical staff time.

Applications include: vaccination booking system; chemotherapy cancer streams statistics reporting; ambulance transport management system; aged care packages management system etc.

Substantial

Overall elective surgical day of admission rates should exceed 95%.

Substantial

There should be no YTD variation for any of the top 20 DRG’s in comparison to the State average.

This key result area measures length of stay for specifi ed medical conditions. In an effort to reduce length of stay based on State guidelines, without compromising patient health, BRHS is consolidating clinical pathways for conditions including chronic obstructive pulmonary disease, chronic heart failure, cellulitis and chest pain.

Partial

The YTD average length of stay for GEM patients should not exceed the State average.

Substantial

The YTD average length of stay for rehabilitation patients should not exceed the State average.

Substantial

Hospital in the home bed days YTD should constitute 10% of multi day stay bed days. Note: excludes nursery and patient discharged with a postcode outside Bairnsdale/Lakes Entrance catchment.

Partial

The combined YTD public and private WIES actuals at least exceeds the DH target

Partial

GEM bed days at least exceed the DoH target. The GEM and rehabilitation bed day funding is interchangeable. Although GEM bed days were under target, the shortfall was recovered in rehabilitation bed days.

Partial

Nineteen agencies participate in the sick leave benchmarking across Victoria. BRHS has consistently remained in the top 10% of agencies within the survey.

Signifi cant gains have been made in regards to this Key Result Area, the target is being amended in line with State average.

Whilst the target was not met due to extended periods of absence by our resident general surgeon, the outcome was within the 2% variance as allowed by the Department of Health.

Rehabilitation bed days at least exceeds the DoH target.

Substantial

SubstantialThere is documented evidence that 90% of all multi day stay patients have been asked if they are receiving service from another community provider and that e-notifi cation message has been sent.

PartialEighty percent of all specialist discharges are completed.

SubstantialFinancial Outcome.

Strategies are in place to address this Key Result Area.

Compared to budget, fi nancial outcome was an improvement of 13%.


FINANCIAL RESULTS

The organisation produced an operational surplus of $1,036,000 (2008/09 $2,156,000) before transfers to and from reserves, capital grants and depreciation being applied. During the year BRHS received capital grants of $1,323,000 (2008/09 $1,343,000) and applied a total depreciation amount of $3,856,000 (2008/09 $2,051,000). This resulted in an overall Defi cit of $1,556,000 (2008/09 surplus $1,385,000).

Total RevenueTotal ExpensesOverall Surplus / (defi cit)Retained Surplus / (Accumulated Defi cit)Total AssetsTotal LiabilitiesNet AssetsTotal Equity

2010$000

2009$000

2008$000

2007$000

2006$000

54,81656,372(1,556)27,63365,52117,85447,66747,667

53,35651,971

1,38528,70866,90117,67949,22249,222

52,20049,555

2,64427,17148,54515,08733,45833,458

50,00546,218

3,78724,37843,28112,90130,38030,380

44,57343,160

1,41321,76239,96413,37026,59326,593

Changes in Prices, Fees, Charges, Rates and LeviesThe Service charges fees for services it provides to: Aged Care Residents, Allied Health Clients accessing services through HACC and CACPs and district nursing, as well as private patients in our main hospital. In all of these occasions the organisation charges according to schedules of fees published by the appropriate federal authority, and fees are only increased when advise is received from the appropriate Commonwealth Department.

Completed Toonalook Waters home


Admitted Patient

Same Day Multi Day Total Separations

Acute Sub-Acute Mental Health

Other TotalAdmitted Patient

Separations

Total WIES

Total Bed Days

7,8864,465

12,351

0379379

000

01414

7,8864,858

12,744

5,904.26

26,535 6,148 200 32,883

Non Admitted Patient

Outpatient Services – occasions of services (VACS and Non VACS clinics)

Acute Sub-Acute Mental Health

Other TotalNon Admitted Patients

Emergency Department Presentations

Other Services – occasions of services

Total occasions of service

9,807 9,807

16,339 9,807 26,146

16,339 16,339

Private Patient InitiativeThe private patient initiative continued in 2009/10, providing net income of $955,305 an increase of 32.3% compared to the previous fi nancial year. This initiative is very important for the hospital as it provides additional revenue to the service which is used to supplement government funding.

% of Total Bed DaysTotal Bed Days

2010

13.69%32,795

2009 2008 2007 2006

13.99%32.970

14.13%34,640

12.47%32,380

9.15%30,220

Admitted Patient

ACTIVITY DATA


WIES

The Weighted Inlier Equivalent Separations (WIES) is the Casemix instrument that is used by the Victorian Government to fund hospitals. All health services have WIES targets and funding depends on the number of WIES the organisation attains. BRHS’ WIES target for the year was 6,050 and achieved 5,904 or 146 less than target.

The result was heavily infl uenced by the fact that we lost our resident surgeon through the year and had to source locum surgeons to continue to provide our services to the community. Although the result is under target it is within an acceptable range.

PublicPrivateRenalTACDVA

Target

4,387.001,012.00

217.0027.00

407.00

Actual Variance

4,350.95987.57213.27

27.34325.13

-36.05-24.43

-3.730.34

-81.87

TOTAL 6,050.00 5,904.26

Private Patient Net Income1,200,000

1,000,000

800,000

600,000

400,000

200,000

-

2010 2009 2008 2007 2006


NursingAdministration and ClericalMedical SupportHotel and Allied ServicesMedical Offi cersHospital Medical Offi cersSessional CliniciansAncillary Staff (Allied Health)Dental Offi cersOther Dental Clinicians / Specialists

Labour Category

WORKFORCE DATA

June Current Month FTE June YTD FTE

108.4279.6121.93

101.253.82

10.180

30.923.00

.49

176.4576.3327.05

106.342.678.82

032.44

2.11.52

The industrial relations environment at BRHS remains stable. BRHS has not experienced any lost time through industrial accidents or disputes.

The Human Resources Department at BRHS has worked very closely with the Information Technology Departmentto redevelop our Workforce Development Software. The new system allows us to better document our staff competencies, allowing us to track mandatory qualifi cations and competencies that staff must meet to provide excellent patient care.

Occupational Health and Safety (OH&S)The Health Service complies with all its obligations under the Occupational Health and Safety Act 2004. BRHS has in place an OH&S Policy and a Return to Work Policy, it collects information about all OH&S incidents and its OH&S Committee analysed them at every meeting to try to identify trends and to put in place corrective actions to protect the health and safety of all staff, patients and clients visiting our facilities.

Over the last twelve months BRHS has performed very well in all OH&S areas of the service.

In order to improve Occupational Health & Safety the organisation invested in a software program that allows us to centralise all chemical’s Material Safety Data Sheets (MSDS) that the organisation uses. Together with this program the process for purchasing chemicals has been centralised to our supply department, who will be responsible to source not only the chemical but the MSDS required for its safe use.

Whistleblowers Protection Act 2001 Under the provisions of the Whistleblowers Protection Act 2001 (the Act), Bairnsdale Regional Health Service does not tolerate improper conduct by its employees, offi cers or members nor the taking of reprisals against those who come forward to disclose such conduct. Bairnsdale Regional Health Service is committed to the principles and intent of the Act and to the protection of genuine whistleblowers against action taken in reprisal for the making of protected disclosures. In line with this, Bairnsdale Regional Health Service has in place a corporate policy and procedure, which complies with the Act. Disclosures made under this policy will be investigated swiftly, professionally and discretely. A copy of the Act is available for inspection from the Health Service’s library. The policy is also available to all staff on the BRHS intranet.


CORPORATE GOVERNANCE

There was only one change to the Board of Management throughout 2009/10, that being the resignation of Lidia Thorpe.

Vice PresidentAngela HutsonAppointed 2000BA (UM); Dip Ed; MBA; Masters in Organisational Leadership; Graduate Dip Business in Entrepreneurship and Innovation;Grad Cert Enterprise Management;Diploma of Frontline Management.

Extensive experience in executive management and governance in the public sector. Currently CEO of East Gippsland TAFE.

Peter CrickAppointed 1992Held various bank management positions in the Gippsland region and Tasmania over a 23 year period from 1979 – 2002. Vice President of the Pelicans community fundraising committee. Signifi cant association with

Freemasonry for over 40 years. Keen gardener and walker.

Anoop ChauhanAppointed 2009B. Comm., Ll.B., C.A. (Ind), Member CPA Australia; ACHSE; Dip. in System & Program Development / Management, Grad Cert - Human Resources & Industrial Relation

Extensive experience in executive management and governance in public and private health sector incl. acute, aged, sub-acute, primary health care etc. at senior executive and board level. Hands-on involvement in business, fi nancial and corporate strategic planning and policy development/implementation for over twenty years.

Board of Management

President Philippa deVoilAppointed 2001BA (Admin); Dip App Sc. (Nursing)Former Executive Director of Nursing, served on various government advisory committees. Extensive health service experience

including aged care services in public and private sectors at management and board levels. Rotarian and local volunteer.

TreasurerKen WhiteAppointed 2009BBus; CA; GradCert FP Chartered Accountant, Director of Whites Accounting and Taxation Solutions. Extensive experience in public practice

accounting, taxation and business management.

Dr David FormbyAppointed 2008MB BS.DCH; FRACP; FRCP; FRACMA; MHA.Former Medical Director Princess Margaret Hospital for Children, Perth, Wangaratta Regional Hospital and Latrobe Regional Hospital. Previous Treasurer

and Chairman of the Federal Assembly of the AMA. Former surveyor with the Australian Council of Health Care Standards. Formerly Consultant Paediatrician at Princess Margaret Hospital, Latrobe Regional Hospital and Bairnsdale Regional Hospital. Past President of the Bairnsdale Golf/Bowls Club.


Ian RobertsAppointed 2000Former Regional Manager VECCI, Gippsland. Experience in training and workplace assessment, staff management. Trade qualifi cations in carpentry, current Bail Justice/Justice of the Peace, past President East Gippsland

Legacy, past member of Bairnsdale Rotary, and past President Bruthen RSL.

Lidia ThorpeAppointed 2008 (resigned May 2010)Manager, Lake Tyers Aboriginal Training Centre and own business in Aboriginal Events Management. Past member of Government advisory committees, current fellow in Aboriginal leadership

in Victoria. Victorian representative to the National Indigenous Body Workshop.


Tony WardAppointed 2000B. Laws; B. JurisprudencePrincipal, Wards Barristers & Solicitors Pty Ltd. Married to Sharon, four children. Former Chairman, Nagle College School Council.

Board of Management Attendance 2009/10 P. de Voil 8 of 11A. Hutson 10 of 11K. White 10 of 11A. Chauhan 7 of 11P. Crick 9 of 11D. Formby 8 of 11I. Roberts 10 of 11L. Thorpe 5 of 11T. Ward 9 of 11 The Board recessed for January 2010

Completed Pharmacy renovation



Finance, Audit and Business Development Committee The Audit and Compliance Committee was renamed the Finance, Audit and Business Development Committee. It is a sub-committee of the Board of Management. The Committee assists the Board in fulfi lling its governance responsibilities relating to, and including, the accounting and fi nancial reportingprocesses, external and internal audit functions, the risk management system and legal and regulatory requirements. The Committee meets quarterly. Board Committee members during 2009/10 were: Ken White

Angela Hutson

Tony Ward

Anoop Chauhan

Quality Audit CommitteeThe Quality Audit Committee is a sub-committee of the Board of Management. The Committee oversees progress of the strategic quality plan and monitors each dimension of quality, safety, effectiveness and appropriateness to ensure an organisational wide quality program and culture exists.

Board Committee members during 2009/10 were:

Philippa deVoil

Ian Roberts

Lidia Thorpe

Medical Credentialing CommitteeThe Medical Credentialing Committee is a sub-committee of the Board of Management. The Committee is responsible for assessing the professional expertise, competence, reputation and authenticity of the qualifi cations of medical staff seeking appointment or re-appointment to the medical staff of BRHS. The Committee meets as required.


Peter Crick

Philippa deVoil

Tony Ward

Community Advisory CommitteeThe Community Advisory Committee is a sub-committee of the Board of Management. The Committee provides mechanism for local community involvement in the BRHS strategic planning process and local health service delivery. The Committee meets quarterly.


Peter Crick

David Formby

Lidia Thorpe


Wayne SullivanChief Executive Offi cerMaster of Business; Grad Dip Health Science (Administration); Grad Dip Nursing (Community Health); RN Div 1; Cert of Gerontology; Diploma AICD Company Director’s Course; FACHSM; CHE; GAICD.

Broad experience within the health sector having commenced as a nurse and in the ensuing 27 years held clinical and management roles in health. Prior to joining BRHS was CEO at Maryborough District Health Service.

Vicki FarthingDirector of NursingRN; Stomal Therapist; BA Nursing; Grad Dip Health Informatics; Masters, Health Management; FRCNA; AACHSEThe Nursing Clinical Services Directorate at BRHS incorporates a wide range of nursing,

community and residential aged care services. It is able to provide 24 hour emergency care, general surgical services, obstetric service, district nursing service, provide patient assistance in the management of chronic disease, plan and assist patient discharge and follow-up, pharmacy services and aged care for high and low level residential care needs. The nursing division includes a dialysis unit for patients with chronic renal disease and treats patients requiring chemotherapy agents and manages infection prevention at BRHS.

Ka Chun TseDirector of Medical ServicesMB; BS; The Medical Services Directorate at BRHS supports the development and planning of the medical workforce of Bairnsdale Regional Health Service, as well as the quality of care and clinical

governance framework of the Health Service. Medical Services provides advice on the operational management of medical staff in the Health Service, and works collaboratively with East Gippsland Regional Clinical School to promote medical student placements in Bairnsdale.

Remberto RiveraDirector Corporate Services & Business DevelopmentBEcon; Grad.Dip Bus. (Accounting); Grad.Dip. Aged Care Management; MBA; ASA; AHSFMAThe Corporate Services & Business Development Directorate at BRHS oversees the fi nancial

management and compliance of BRHS; as well as Human Resources, Facilities Management, Hotel Services, and Health Information Management. In short the directorate provides most of the ancillary services BRHS needs to operate effectively.

Megan MorseDirector Allied & Community Health ServicesB.Pod (Hons); M.Ed. (Ed & Tr); MBA; Grad Cert H.EcThe Allied & Community Health Services Directorate at BRHS provides inpatient and outpatient allied health services at the Day

Street campus, in addition to providing outreach services to two Community Health sites. The Ross Street campus accommodates a Dental service, along with Community Health Nursing and the Bairnsdale Planned Activity Group (PAG), one of six PAG’s that BRHS manages for local communities. The Paynesville site hosts a similar range of services on a visiting basis, and serves as the base for the East Gippsland Post Acute Care program. The Directorate also includes the Aids & Equipment program, the Consulting Rooms and Medical library.

Lorraine Parsons(Former) Director Allied & Community Health ServicesResigned January 2010BA (Social Sciences); BSW; Grad Cert Management; MAASWLorraine joined BRHS in February 2008 after working in the public health sector for 16 years in Victoria and the Northern Territory.

ORGANISATIONAL STRUCTURE

Chief Executive Offi cer and Directors


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MANAGEMENT COMMITTEES

Bairnsdale Regional Health Service (BRHS) believes committees are an excellent means of communication and has an active committee meeting structure which provides a valuable means of formal communication.

BRHS Management Committees support our role through the exchange of ideas, decision-making, investigation of events, assessment and review of patient care and services, consideration of reports, ensuring legislative or funding requirements are met and overseeing the implementation of plans or policy.

All our committees have ‘Terms of Reference and Membership’, which set out the role and function of the Committee. Membership for each committee is appropriate for the role and function it performs.

The Board sub-committees as listed on page 15.

• Finance, Audit and Business Development Committee

• Quality Audit Committee

• Medical Credentialling Committee

• Community advisory Committee

Report directly to the Board.

All clinical and non clinical committees at BRHS report to the Board through our peak committee which is the Quality Management Committee. These committees are listed below.

• BRHS Quality Management Committee

• Theatre/Anaesthetics & Surgery Committee

• Obstetrics & Neonatal Committee

• Emergency Department & Medicine Committee

• Pharmaceutical/Transfusion/Infection Prevention Committee

• Maddocks Gardens Continuous Improvement Committee

• Ambulatory Care Committee

• Information Management Committee

• Corporate Services Committee

• Occupational Health & Safety Committee

• Human Resources Committee

During the year each committee has reviewed its Terms of Reference and Membership.

The Occupational Health & Safety Committee continues to function within the scope of the Occupational Health & Safety Act.

All committee meetings are minuted and available to staff through the intranet.

BRHS Board Quality Audit Committee

Quality Management Committee

Ambulatory CareCommittee

Maddocks Gardens Continuous Improvement

Committee

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Emergency Department & Medicine Committee

Obstetrics & Neonatal Committee

Theatre / Anaesthetics & Surgery Committee

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Corporate Services Committee

Occupational Health & Safety Committee

Human ResourcesCommittee

Clinical Committees Corporate Committees


AudiologistsSue ClutterbuckNeil Clutterbuck (ceased June)Sue Luscombe

CardiologistsDr David BertovicDr Justin MarianiDr Meroula RichardsonDr James ShawDr Andrew Taylor Head, Neck, Nose & ThroatProf Andrew Sizeland GastroenterologistsDr David IserDr Jeremy Ryan General SurgeonsMr Adrian AitkenMr Bob IrunguMr Anamitra Sarkar Mr Clem Smith GynaecologistsDr Robert McKimmDr Michael SedgleyDr Mac TalbotDr Gareth Weston NephrologistsDr. David HookeProf David Power OncologistsDr John Scarlett OpthalmologistDr Pradeep Madhok

Orthopaedic / LegalDr Stan O’Loughlin Orthopaedic SurgeonsMr Andries DeVilliers (commenced April)Mr Peter Rehfi schMr Peter SmithMr Warwick Wright

PaediatriciansDr Peter GossDr Jo McCubbin Paediatric SurgeonsMr Chris KimberMr Neil McMullen PhysicianDr Krishna Mandaleson

Rehabilitation PhysicianDr David McConachy

Renal PhysicianDr. David Hooke RheumatologistsDr Anthony Boers (ceased May)Assoc Prof Peter Ryan UrologistsProf Mark FrydenbergDr Jeremy Grummet

Vascular SurgeonMr Peter Milne Visiting Medical Offi cersAdrian AitkenAndrew RutherfordAndrew SizelandAndrew TaylorAnimitra SarkarAsh Arunachalam (RMO)Bob IrunguClem SmithDaniel Otuonye (RMO)Andrew Linton (RMO)Daryl SmithDavid BertovicDavid HookeDavid IserDavid McConachyDavid McConvilleElizabeth BoydEmma Wong (RMO)Gareth WestonGraham BromwichJames Shaw

SPECIALISTS AND VISITING SPECIALISTS AT BRHS

Jeremy GrummettJeremy RyanJo McCubbinJohn ScarlettJohn UrieJustin MarianiKrishna MandalesonPoh NgMargaret NiemannMark FrydenbergMeroula RichardsonMichael SedgleyMyles ChapmanNaveen JoshiPeter GossPeter LindstedtPeter MilnePeter Rehfi schPeter WorboysPhillip SewellPradeep MadhokRobert McKimmRoss de SteigerScott DellerSema YilmazSue GeorgeTomasz GrabinskiWanda Wysocka-GrabinskaWarwick WrightY “Echo” Jiang (RMO) Gippsland Lakes Community Health District Medical Offi cers serving the Hospital in the Home Program Cunninghame Arm Medical Centre District Medical Offi cers serving the Hospital in the Home Program


FINANCIAL DONATIONS TO BRHS 2009/2010

Bequests and EstatesErica Cromwell Trust $5,523.59Estate of Letitia Maynard $319.93Ian & Jeannie Cooper-Brown $93,341.13

BRHS AuxiliariesBower Birds EGH Fund Raising Group $10,050.00Paynesville Pelicans $2,142.00Pelicans Interest $28,083.51Toonalook Waters proceeds $313,990.70

Business SectorAllan Corrie Painting $100.00Bairnsdale Golf Club $2,101.00Bairnsdale RSL Sub Branch $1,150.00Bairnsdale Windscreens $200.00Brooker Builders Pty Ltd $250.00Bunnings Warehouse $5,000.00Collins Booksellers $250.00D A Johnson $250.00Dahlsens $100.00Dulux Group $405.00GSI $2,000.00House & Gift $736.90James Yeates & Sons Pty Ltd $893.30King & Heath $50.00Reg Biggs $200.00Safetech $100.00Slap Architects $250.00Tyco Healthcare $585.41Whiters Street Glass & Glazing $200.00

Woolworths Bairnsdale Social Club $428.05

Community GroupsBairnsdale Day Centre $700.00BRHS Flower Auxiliary $3,000.00Community Nursing $6.50CWA $500.00CWA High Country Branch $100.00Kilmany Remote Family Services $110.00

Lindenow Lioness Club $700.00Lions Club of Lakes Entrance $500.00Paynesville Bowling Club $350.00Paynesville Hospital Auxiliary $1,000.00Paynesville RSL $100.00Paynesville Uniting Church Friendship Shed $2,000.00Riviera Quilters Inc $1,000.00St Johns Anglican Op Shop $550.00Urban Funk Dance $1,502.00

IndividualsRebecca Ah Chow $10.00KN & J Alexander $100.00R & S Alexander $100.00Anonymous $2,511.80Wilhelmina Armstrong $1,000.00E MacArthur $50.00Glenn Baberton $4.00GH Barnett $200.00Mrs MJ Bell $15.00Carol Beveridge $8,000.00R & F Bills $50.00Mr Brennan $20.00John Brookes $100.00Mr & Mrs Bryant $50.00Kylie Peter & Jayne Bud $165.00Mr & Mrs Burrowes $50.00Jean Butcher $20.00L & V Calvert $20.00MD Campbell $1,000.00John & Maureen Campbell $200.00Kath Cassidy $20.00Ron Claridge $45.00Joyce Clemm $1,000.00Alan & Christine Clyne $50.00Stan M Collins $1,000.00Maureen Connolly $20.00Gweneth Cooper $2,250.00Janine Cooper $30.00Allan Cracknell $50.00Deirdre Crick $110.00R & W Cunningham $50.00


Marie Curtis $100.00Tanya & Simon Dalley $30.00Ellen Davies $75.00Deller Donations $5,879.35Philippa de Voil $100.00Ruth Engel $50.00Nicola Fanning $50.00Jim Ferguson $65.00Jan & Mike Finn $30.00Ken Firth $50.00KS Ford $400.00Dr David Formby $100.00Robert Franck $1,000.00T & M Goode $100.00MF Greenwood $10.00Mr & Mrs Griffi ths $50.00JB Guerin $40.00Mrs A M Guy $20.00Elise Hall $20.00Ken Hall $7.00K & M Hanley $135.00AC & LE Harrington $40.00Maureen Hartigan $10.00Dael & Leo Heirman $200.00Mark Hocking $100.00WD Holden $548.27Mrs I Hutton $20.00Lorraine Jennings $20.00Shirley Keamy $20.00TP Keyte $100.00Bertha Khote $100.00Ros Kleinitz $50.00Elizabeth Lade $50.00Elizabeth Leadoux & Family $100.00SM & PM Logan $30.00June Mackie $20.00Arthur Thomas Martin $4,000.00Ron & Roma Martin $100.00Marijke Mascas $100.00Michelle McNairn $20.00Merle McRae $1,500.00Barry Mills $50.00Wayne Morgan $20.00

RA Murphy $100.00Karen Nattrass $50.00B & R Nicholes $50.00Betty Noris $50.00A Norman & Family $40.00Carl Poeschel $100.00Millicent Reggardo $20.00WA & GM Roberts $100.00Dr Jeremy Ryan $500.00M E Sanders $50.00Noel Scott $50.00Ken Simpson $100.00Sizeland Donations $5,558.55Joyce Smiley $50.00Gus & Jennifer Sperti $500.00Lois Stewart & Friends $420.00Denis & Rosalie Stringer $50.00Ian & Gwen Strobridge $50.00Wayne Sullivan $100.00Gail Swankie $20.00Leigh & Marc Tricard $220.00Spiros Tsetsos $1,000.00John & Mendy Urie $1,000.00Anthony Veale $100.00Mary Waites $100.00Tess Walker $50.00Norma Ward $100.00Mary Wassink $50.00Sara Wayman $500.00Matthew White $300.00Laurel Wilesmith $10.00Jennelle Wilkes/Paul Start $100.00Elaine Winterbottom & Family $50.00The Young Family $500.00Friends of Joyce Young $950.00

Philanthropic Collier Charitable Foundation $50,000.00


LIFE GOVERNORS

Bairnsdale District Hospital opened in 1887. In 1940, the hospital moved to its current site in Day Street. In 1975, the hospital changed its name to East Gippsland Hospital and then again in 1992 to its current name Bairnsdale Regional Health Service. The East Gippsland Geriatric Centre and East Gippsland Hospital were amalgamated from this date.

1890 William Bird1890 John Kennedy SmithPre1917 HT ArthurPre1917 Richard G BrownlowPre1917 Mrs Richard BrownlowPre1917 GH ColePre1917 John ConnellyPre1917 F EastwoodPre1917 HB GibbsPre1917 WB GilesPre1917 Sharp HalmshawPre1917 Mrs WL HarrisPre1917 Mrs HawkesPre1917 John HolfordPre1917 Frank V HollowayPre1917 HF HollowayPre1917 J HutchisonPre1917 John KingPre1917 JH LawlerPre1917 J LaurentPre1917 Mrs MudiePre1917 A MurrayPre1917 Mrs John MillsPre1917 AJ McKenziePre1917 PJ O’ConnorPre1917 J O’KeefePre1917 GB OsbornePre1917 Hon William PearsonPre1917 GW PeartPre1917 Mrs George RossPre1917 E SaundersPre1917 Angus ShawPre1917 Mrs James StewartPre1917 Mrs E TwentymanPre1917 Mrs W Winkelmann1919 W Garlick1919 TW Murphy1921 John Reid

1921 AT Bieri1922 Alex McPherson1922 EJ Williams1923 Mrs H Bankin1923 WP Craig1923 EJ Roder1923 C Healey1925 Miss Irene Leonard1926 Mrs H Wood1927 Mrs L Dawe1927 Mrs A Goodman1928 Robert Gilder1928 Harry Hopkins1928 Mrs C Neal1928 THC Johnson1928 Mrs Mary Liddell1928 Ernest Lindeman1930 Mrs J Bull1930 AJ Gilsenan1930 EP Burke1930 F Healey1930 Mrs T Mathieson1930 Mrs RJ Loveridge1930 JW Marriott1930 A McPherson1931 JG Stanway1931 MT Walsh1932 Mrs L Jemmeson1932 Mrs E Ross1933 LR Skipworth1933 W Garlick1934 Roy Rieper1934 F Rogerson1934 Mrs W Vickers1934 Mrs A Leask1935 Mrs Grace Douglas1935 Miss Elizabeth Bull1936 AW Collins1936 Mrs S Stein1937 Mrs AE Bell1937 Lord Nuffi eld1938 Dr Charles J Alsop1938 Mrs R Alsop1938 Arthur Dyer1938 Mrs V Glen1939 W Buchanan1939 Mrs W Buchanan1939 Mrs Clancy1939 Mrs HJ Arthur1940 Mrs R Meek

1940 VV Vincent1940 Mrs VV Vincent1941 Mrs T Varney1941 N Dunn1941 JG Clapperton1941 H Clues1941 B Chadwick1941 Mrs G Baker1941 WD Gibbs1941 Mrs AJ Gilsenan1941 Miss BJ Hollingsworth1941 PC Murray1941 Miss Julia O’Shea1941 Mrs EM McCann1941 Mrs M McNeill1941 Mrs PE McPherson 1943 Mrs J Dean1943 Miss Grace Buse1943 Mrs J Appleton1943 Mrs Patten1943 Mrs T Willhelme 1943 C Moon1943 Mrs N Norris1943 Mrs TW Murphy1943 Mrs R Calder1943 Mrs ME Martin1943 Mrs C Meddings1943 Mrs TK Lloyd1943 TK Lloyd1944 Mrs AE Bieri1944 CW Pittman1944 Mrs WJ McCormack1944 P McFarlane1944 HR Growcott1944 Mrs E Kidd1944 Joseph Lay1945 J Doyle1945 Kay Donoghue1945 HC Reynolds1945 LJ Taylor1945 Miss E Stokes1945 Mrs AC Yandle1946 Mrs BE Thewlis1946 J O’C Davies1946 Rev A McMillan1946 Miss Margaret Johnston1946 Mr AT Gunn1946 Dr A Robertson1946 CE Goodman1946 W O’Doherty


1993 Peter Engel1993 Robert Mansell1993 Milton Murphy1993 GJ Foard1993 Ewan Logan1993 Helen M Schutt (Trust)1993 Mrs GF Barter1993 LG Tipper1993 J Siggins1993 Miss JH Scott1993 FH Ray1993 J Parker1993 Rev DM Muller1993 Mrs DM Mitchell1993 W Meade1993 J Leatham1993 Mrs E Ingle1993 EGR Horsfi eld1993 Miss JH Holford1993 JW Hawksley1993 Mrs Patricia Evans MBE1993 WH Elridge1993 Mrs J Court1993 HN Cox1993 KL Cook1993 M Campbell1993 Mrs MA Cameron1993 AE Boucher1993 W Bills1994 Derek Dahlsen1994 Ray Holloway1994 Mrs P Lane1994 T Grass1994 Mrs A Grass 1995 Ms T Gillies1995 Dr F Malatt1996 Mrs K HeathPre2006 Mr E DahlsenPre2006 Mr T EagerPre2006 Mr WH EldridgePre2006 Mr R GregoryPre2006 Miss JH HolfordPre2006 Mr P LayPre2006 Mrs R MarshPre2006 Mrs M McRaePre2006 Mrs M Winnette2008 Dr James Evans2008 Mr Michael Padula

1946 A O’Leary1947 FH Redman1947 Mrs V King1947 Mrs Jean Lafsky1947 Mrs E McLaren1948 Glynn D Timmins1950 FL Johnston1950 W Thatcher1951 Mrs Judy Beatty1951 John Spirason1953 Mrs Betsy Cathcart1953 Mrs Jean Loud1954 S Telfer1954 Ian Thatcher1954 Leonard Rule1955 CR Holman1955 Ben Ogden1955 Mrs Anne F Ikin1955 Arthur Winter1955 Mrs Flora Brumby1957 Mrs B Watson1959 Mrs Margaret Latimer1959 Mrs Phyllis Rodgers-Wilson1961 Rev Canon GFD Smith1963 Mrs Isabel (Doris) Savige1965 Thomas Hansen1965 PJ Thompson1968 Victor Cole1968 Dr Thomas O’Beatty1968 Mrs Mary Nicholls1969 Mrs M (Peg) Bailey1969 Joe Alvin1970 Rex Foard1970 Kenneth Beynon1972 Miss Eileen O‘Leary1972 William Rodgers-Wilson1973 Gordon Arthur Henry Smith1974 Clement John Sharp1975 Miss Margaret McIntyre1976 Mrs Margaret Sheehan1979 William McCallum1979 Robert Bosworth1987 DM Yeates1992 Alan Glass1992 Mrs Thelma Glass1992 Ron Nation1992 Albert Rodd1992 Mrs May Winnett1993 Ian Campbell1993 Brian Hopkins

Community Engagement

In 2009/10 Bairnsdale Regional Health Service delivered two newsletters to the general community, providing an overview of news and events at our organisation and they presented an excellent opportunity to disseminate information relating to acute, sub-acute and community health services at BRHS.

The 2009-2013 Strategic Plan was also fi nalised during the year, with copies available to the public from the hospital or on the BRHS website.

The Health Service also updated the community through media releases in the local papers on issues such as the progress of the Toonalook Waters project, the building of the new Oncology & Dialysis Unit, the pharmacy extension, donations to the Health Service, accreditation achievements, fundraising events, community health services and more.


QUALITY OF CARE

Infection prevention Infection prevention is very important to hospital staff and the community. BRHS has an Infection Prevention Coordinator with expert knowledge to assist staff, patients and visitors to minimise infection risks.

The Infection Prevention Coordinator helps by:

• Developing policies and procedures to help staff know what to do about infection prevention• Minimising the risks to patients, staff and visitors from infection transmission • Reducing the risk that a patient’s existing infections may spread• Observing and examining high risk procedures to reduce risks• Ensuring that infection prevention standards are met• Education of staff, patients and visitors about infections and prevention strategies• Managing outbreaks of infections such as gastroenteritis and infl uenza when they occur so they do not spread to others.

Along with other hospitals in Victoria, BRHS continues to review/audit areas of infection risk with the Victorian Nosocomial Infection Surveillance System (VICNISS). VICNISS monitors infections patients get while in hospitals. Included in this auditing are areas such as:

• Hand Hygiene (washing your hands)• Infections you may get in your blood stream• Infections you may get in your wound after surgery• Infections that are resistant to treatment (multi-resistant organisms)• Staff injuries from exposure to blood or body fl uids• Staff compliance with vaccination requirements.

Hand washing compliance has had a strong focus within BRHS throughout this year. This national initiative through the Australian Commission on Safety and Quality in Healthcare has a target of 65% compliance across Victoria for the 2010-2011 year.

During the audit period every person who steps into the patient area is monitored. BRHS has performed well in the audits conducted for the 2009-2010 year with results equal to and above the Victorian expected compliance rate for the period.

The ‘5 Moments’ of hand washing are observed in the audit to make sure they occur and at the required standard. The 5 moments are:

• Moment 1 – Before touching a patient• Moment 2 – Before a procedure• Moment 3 – After a procedure or body fl uid exposure• Moment 4 – After touching a patient• Moment 5 – After touching a patient’s surrounding (bed, medical equipment).

Bloodstream infections continue to be monitored with a priority focus on Staphylococcus aureas bacteraemias. Rates remain extremely low and well within the accepted rate for health services of equivalent size.

Surgical site infections continue to be monitored with the main focus being on caesarean sections. There have been two infections reported for the year.

Results from all infection prevention activities are reviewed by doctors, nurses, and other relevant staff to work out the best way to reduce the risks identifi ed. All staff work with the infection prevention coordinator and reduce the risk of infection by making appropriate changes to practice.

Education for the staff has continued to be a focus especially in the health of our staff and minimising exposures.

Hand washing is the single most important activity that minimises risk of infection for staff, patients and visitors in hospitals and in the community.

You can and should ask staff members caring for you “Have you washed your hands?”


How Clean is Your Hospital?Cleaning standard audits are undertaken regularly and completed in accordance with the Department of Health Cleaning Standards for Victorian Health Facilities 2009.

The audit results indicate that cleaning processes in place are suitable, as the cleaning outcomes (Scores) are well above the Acceptable Quality Levels (AQL) required for each risk category.

Patient Satisfaction at BRHS - Results of 2009-2010 SurveyBRHS takes part in an annual patient satisfaction survey. The survey is undertaken to inform us, from the patients’ view, what we do well and how we can improve. A company contracted by the Department of Health called UltraFeedback collects the information through questionnaires it sends to patients that have been discharged from BRHS.

If you do receive a questionnaire from UltraFeedback, we encourage you to complete it and return it to them in the envelope provided. Your opinion is important to us.

Risk Categories

Very High Risk Areas

Location and Frequency of Audit

Acceptable Quality Level (AQL)

High Risk Areas

Moderate Risk Areas

Monthly – Operating Theatres, Central Sterilising Supply Unit

90

Monthly - Emergency Department, acute wards, pharmacy, oncology, dialysis

85

85Quarterly – Dental Services, Rehabilitation areas, residential accommodation, day activity centres, medical imaging (X-Ray), waiting rooms, public areas including toilets.

All areas/issues that are identifi ed are noted during the audit are actioned by cleaning staff immediately or within 24hours.

The last patient satisfaction survey let us know that our cleaning standards meet patient’s approval.

We welcome any feedback from you about the cleanliness of the hospital and if you visit, please let a staff member know about your concerns.

Thirty nine percent (39%) of BRHS patients who were sent the survey completed and returned it to UltraFeedback. Group B hospitals, of which BRHS is one, had 37% of patients return surveys.

Patients were very satisfi ed with most aspects of their stay at BRHS. We are performing in line with the Category B hospital average. The majority of patients reported that they were helped a great deal by their stay at BRHS and felt that the length of time spent in hospital was about right.

Consumer Participation78 79 80

Discharge and Follow-up76 76 77

Physical Environment74 75 76

Complaints Management78 80 80

Treatment and Related Information77 78 79

General Patient81 82 82

Access and Admission78 76 77

Average of Overall Care77 78 78

All Hospitals

HospitalC

ategory B

BRHS

Key: All Hospitals = All Public Hospitals in Victoria Group B Hospitals = Rural Hospitals similar in size and patient mix to BRHS


High performing scores were obtained for the following items:► The courtesy of the nurses ► The courtesy of the doctors ► The cleanliness of the room where patients spent most of their time► Being treated with respect

Areas where we could most improve include: facilities for storing belongings - availability, security and ease of use; privacy in the room where patients spent most of their time; and waiting room comfort.

These fi ndings are supported by comments made by patients, with 8.4% mentioning facilities for the question “what could the hospital do to improve the care and service it provides to better meet the needs of the patients?”

We are working out ways to improve in each of the areas and will monitor how we have met your needs when the next survey is done in 2011.

Continuous Improvement and Accreditation BRHS is committed to continuous improvement and in the last year has undergone external reviews by a number of external agencies. These reviews have confi rmed that improvement is ongoing, and we have successfully met all requirements against the following standards:

In June 2009 we were reviewed against the Evaluation and Quality Improvement Program where we underwent self assessment of our clinical care in the acute services of BRHS. Feedback from the Australian Council on Healthcare Standards was very positive and comments have been used to make improvements in the 2010 Organisation Wide review.

November 2009 saw us assessed against the Post Graduate Medical Council standards. These standards review us as a teaching hospital for junior doctors. The results were positive and suggestions for improvement have been actioned.

The Aged Care services were reviewed by the Aged Care Standards and Accreditation Agency. Aspects of care reviewed included, management systems staffi ng and organisational development, health and personal care, resident lifestyle and physical environment and safe systems. The feedback has been positive and full three years accreditation granted.

Falls PreventionSlips, trips and falls can happen to anyone but they are more common and more signifi cant as we get older.

It is easy to dismiss falls as part of “getting older” or “just not concentrating,” but they are often warning signs that something is “just not right.” It is important to discuss all falls with your doctor. Falls are a common problem and are often the reason why people come to hospital.

The Good News• Many falls are preventable• Injury from falls can be minimised• Aging does not have to mean loss of independence

The reasons or causes of falls are known as RISK FACTORS. Some people are more likely to fall than others because they have more risk factors. Risk factors for falls include:

• Poor eyesight• Reduced balance, weak muscles, stiff joints• Less feeling in your legs• Slower reaction times• Some health problems such as stroke, Parkinsons disease, arthritis, postural hypertension (low blood pressure when you stand up), dizziness, diabetes, dementia, problems with your “waterworks” or bowels (incontinence), poor nutrition (not eating enough, not eating a balanced diet or drinking enough water)• Even short term sicknesses (the “fl u” and other infections) or surgery can increase your risk of falling• Medicines – some types of medicines can increase your risk of falling, including those you may take for sleeping, anxiety or depression

Falls prevention is a priority at BRHS.

Total BRHS Falls 2009-2010

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

60555045403530


In the last year there has been an eighteen percent (18%) reduction in falls. Serious injury from falls remains stable.

There are a number of approaches we have to help recognise if you have a high risk of falls. These approaches will reduce the risk, and they are:

• Risk assessments (asking you questions about the risk factors above)• Accommodating those at risk in adjustable height beds • Use of alert devices that let staff know when you are getting up, so they can come and help you• The Pharmacist will review the tablets you are taking • If appropriate, refer you to the “No Falls” preventative exercise program• Talk with you/your family/carer about ways that you can reduce your risk of falls, particularly when you return home• Review the suitability of your walking aids – on occasions your needs may change• If you have had a fall at home that requires you to come to hospital we will arrange a visit to check the safety of your home and work with you to improve your safety if required

Co-ordination of the Ambulance Victoria / Department of Health / BRHS Falls referral program has enabled clients across East Gippsland who fall, but are not transported to hospital, to receive follow up in the community eg initial phone contact by Integrated Care Coordinator and offered referral to physiotherapists. Liaison with GPs and Community Care Case Managers who may not be aware their client has had a fall is also considered.

Reducing Medication ErrorsPrescribing (what the doctor does), dispensing (what the pharmacist does) and administering of medication to the patient (what the nurse does) is the most common activity undertaken in hospitals. Managingmedications is a very complex task and requires hospital staff, patients and carers to work closely to make it safe. What Can You do to make Taking Medications Safer?It is very important that you know and tell staff about any previous side effects or bad reactions to any medications or if you have any allergies. It is also a good idea to tell them about any “over the counter” medications or tablets you are taking or consideringtaking as they may react with tablets the doctor prescribes.

You will be able to manage your health and medications a little easier if you know the following about the medications you are taking:

• Is this a new medication that I haven’t taken before?• What is my medication for?• How much medication do I take?• When and how do I take my medication?• How long do I take my medication for?• Can you take it with food or other medications?• How should I store my medication?• What do I do if I miss a dose?• What are the common side effects and what should I do if I think I have side effects?

Nursing and medical staff are required to explain what your medication is for and answer any questions you may have about your medications.

Medication safety is very important to the staff at BRHS and there are many strategies in place to reduce the risk of medication incidents occurring, including:

• All nurses have an annual test for medication safety.• All staff are required to ask you “what is your name”, and check your armband, name and check that the tablet prescribed matches the name and tablet recorded on the prescription as well as the tablet bottle.• BRHS uses the same prescription document as the rest of Australia. This standardisation means that doctors, nurses and pharmacists Australia wide use the same form, which reduces the risk of errors occurring.• An expectation about medication safety is given to all new staff when they begin employment.


BRHS Medication Incidents 2009 -2010


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25

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• Medication incidents are discussed with staff involved and corrective actions are taken. • Education about medication safety is ongoing and includes a newsletter from pharmacy with topics from the Department of Health or learning’s from incidents that have occurred.• Interruptions to medication rounds are kept to a minimum. Distractions / loss of concentration while giving medications is known to be the biggest contributing factor to medication incidents. Nurses are currently trialling an apron with “Medication Round - Do not Disturb” on it in order to reduce interruptions.

The number of incidents relating to medication prescribing, dispensing and administration has remained stable when compared to the previous year.

There have been no serious patient complications arising from medication incidents.

These diagrams show you where pressure ulcers occur in various positions or postures.

When sitting:○ tail bone (coccyx)○ buttocks (ischium)○ backs of heels○ elbows○ shoulder blades

When lying on your back:○ the back of your head○ shoulder blades○ tail bone (coccyx)○ elbows○ heels○ toes

When lying on your side:○ ear○ side of your shoulder○ pelvis○ hip○ knee○ ankle bones (malleolus)

If you would like written information about your medication, the pharmacist will be happy to give it to you, and the nurses and doctors will be happy to answerer any questions. Please ask them.

Preventing Pressure UlcersA pressure ulcer (also known as a pressure sore or bed sore) is an area of skin that has been damaged due to unrelieved pressure. A pressure ulcer may look minor, such as redness on the skin, but they can hide more damage under the skin.

Where are they found on the body?Pressure ulcers usually occur over bony areas, especially heels, buttocks and toes.

Who gets pressure ulcers?Anyone confi ned to a bed or chair, who is unable to move, has loss of sensation, loss of bladder or bowel control, poor nutrition or is unwell is at risk of getting a pressure ulcer.

The signs to look for (especially on skin over bony areas) are:Red / purple / blue skin, blisters, swelling, dryness or dry patches, shiny areas, cracks, calluses, or wrinkles


BRHS Total Pressure Ulcers - July 2009 - June 2010


30

25

20

15

10

5

0

The signs to feel for are:Hard areas, warm areas, or swollen skin over bony points

What can we do?The best thing you can do is relieve the pressure by keeping active, and changing your position frequently, whether you are lying in bed or sitting in a chair. If you are unable to move yourself, the staff will help to change your position regularly.

Special equipment such as air mattresses, cushions and booties are available and may be used to reduce the pressure in particular places.

Looking after your skinKeep your skin and bedding dry. Let staff know if your clothes or bedding are damp. Let staff know if you have any tenderness or soreness over a bony area or if you notice any reddened, blistered or broken skin. Avoid massaging your skin over bony parts of the body. Use a mild soap and moisturise dry skin.

Pressure ulcer prevention and monitoring is an ongoing process at BRHS, and is an important part of care for all our staff.

The number of pressure ulcers has reduced by 17% in the past year.

We contribute information to the Department of Health about our pressure areas and our rate of patients who get pressure areas when in hospital is half that of similar sized hospitals.

Meeting the Standards for Safe Food Handling/HygieneFood hygiene is a broad term used to describe the preservation and preparation of foods in a manner

that ensures the food is safe for human consumption. This process of kitchen safety includes proper storage of food items prior to use, maintaining a clean environment when preparing the food, and making sure that all equipment is thoroughly clean and free of bacteria that could lead to some form of contamination.

Preventing cross contamination is also an important aspect of food hygiene. Cross contamination can occur when cooking and preparation utensils are used with more than one type of food at a time. For example, if the knife used to debone a raw chicken breast is also used to chop lettuce for a salad, there is a risk that contamination will occur and possibly lead to food poisoning.

Staff that work in the kitchen play a vital role in providing patients, staff and visitors with nutritious meals that are safe to consume. BRHS serves approximately 21,000 meals to patients each year and also have a staff and visitor cafeteria which is well patronised.

As a health Service we undergo Food Safety Audits by the East Gippsland Shire. The Food Safety Audit is an in-depth analysis of the following processes: Receiving food/ingredients, storage, preparation, cooking, hold-ing, transportation to area for consumption, staff training, food recall and record keeping.

There is a focus on how food is handled, hygiene of those handling food, cleaning and sanitising of equipment used in food preparation, and the temperature control of food, contributes to the safety of our food.

The design and construction of the premises, fl oors, walls ceiling fi xtures, fi ttings and equipment are also assessed to make sure we meet required standards for food safety.

The East Gippsland Shire Audit indicated that compliance was reached in all areas.

In addition to the Shire Audit, kitchen staff monitor food safety standards on a meal by meal and monthly basis and this assures us that our food is safe and at the required standard.

Our patient satisfaction survey conducted this year told us that patients were very satisfi ed with the temperature of hot meals, the quality of the food and the amount of food provided.


Responsible bodies declaration In accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for Bairnsdale Regional Health Service for the year ending 30 June 2010.

Philippa deVoilPresident, Board of Management Bairnsdale16th August 2010

Summary of factors affecting operations The reporting period was affected by the fact that the service lost its general surgeon for around 30% of the year, this meant that the organisation had to rely on locum surgeons at a much higher cost. This issue also affected our ability to completely meeting our WIES targets consequently reducing the income level of the service.

Revenue Indicators

REPORT OF OPERATIONS

Events subsequent to balance date At the date of this report, Management is not aware of any events that have occurred subsequent to balance date that may have a material impact on the results of the next reporting period.

Attestation on Compliance with Australian/New Zealand Risk Management Standard I, Wayne Sullivan, certify that the Bairnsdale Regional Health Service has risk management processes in place consistent with the Australian/New Zealand Risk Management Standard and an internal control system is in place that enables the executives to understand, manage and satisfactorily control risk exposures. The Finance, Audit & Business Development committee verifi es this assurance and that the risk profi le of the Bairnsdale Regional Health Service has been critically reviewed within the last 12 months.

Wayne SullivanAccountable Offi cer Bairnsdale16th August 2010

PrivateTACVWAOther CompensableResidential Aged Care

Under 30 days

31 - 60days

61 - 90days

Over 90days

Total30/6/2010

Total30/6/2009

PrivateTACVWAOther CompensableResidential Aged Care

Average Collection Days

09-10 08-09

498378

747

4486413248

965,234 499,715

467,8342,677

00

134,824

134,8700

1,483247

14,301

307,89620,47613,506

3,797154,040

44,807270

00

3,373

140,1731,2202,205

42116,528

787,6844,1683,687

668169,027

Debtors outstanding as at 30 June 2010


Building Act 1993 Bairnsdale Regional Health Service complies with the building and maintenance provisions of the Building Act 1993.

Consultancies There were 21 consultancies in this fi nancial year (18 in 08/09), these consultancies included: Strategic Planning, Board training, Executive training on emergency procedures and development of training modules for dealing with clients exhibiting challenging behaviours. These consultancies cost $184,025 and no one consultancy cost more than $100,000

National Competition Policy In accordance with the national competition principals agreed by the Federal and State Governments in April 1995, Bairnsdale Regional Health Service has implemented policies and programs to ensure compliance with the National Competition Policy. These programs and policies include:• The benchmarking of signifi cant business activities against other agencies of a similar size and nature;• Examination of each business activity to establish the benefi ts or otherwise of applying market contestability; and• Tendering for the provision of services where appropriate.

Victorian Industry Participation Policy Act 2003BRHS did not commence or complete any contracts to which the VIPP Act 2003 would apply.

Freedom of Information Act 1982 The Freedom of Information Act 1982 (the FOI Act) gives people the right of access to information held by Bairnsdale Regional Health Service and applications for access to information and records are processed in accordance with the FOI Act by the Health Information Manager under delegation from the Director of Medical Services. Health Services charge a fee for Freedom of Information (FOI) requests in accordance with the guidelines set by the Department of Justice. Fees for Medico-Legal requests are also received. The revenue for this fi nancial year is $2,117.40. The Freedom of Information Application Fee is waived for those applicants holding a health care card.

Freedom of InformationMedico-Legal

Number ProcessedType of request

Total

11343

156

Attestation on Data Integrity I, Wayne Sullivan, certify that Bairnsdale Regional Health Service has put in place appropriate internalcontrols and processes to ensure that reported data reasonably refl ects actual performance. The Bairnsdale Regional Health Service has critically reviewed these controls and processes during the year.

Wayne SullivanAccountable Offi cer Bairnsdale16th August 2010

Consultancy Details

Total $ of Consultancies

18

$ 161,813

Number of Consultancies

Number of Consultancies > $100,000 0


GLOSSARY OF TERMS

AccreditationTo audit and give credentials to.

Acute CareCare that is generally provided for a short period of time to treat a certain illness or condition.

CardiacRelating to, situated near, or acting on the heart.

ChemotherapyA type of pharmacotherapy used in the treatment or control of disease, particularly cancer.

DementiaA usually progressive condition marked by the development of multiple cognitive defi cits.

DialysisThe process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein – also called hemodialysis.

DieteticsThe science of diet and nutrition.

DVADepartment of Veterans’ Affairs.

GastroenterologyA branch of medicine concerned with the structure, functions, diseases, and pathology of the stomach and intestines.

GeriatricA branch of medicine that deals with the problems and diseases of old age and aging people.

GovernanceThe way in which decisions important for the future of organisations are taken, communicated, monitored and assessed. It includes the processes an organisation has for holding managers accountable and measuring performance.

HACCHome and Community Care

HARPHospital Admission Risk Program that enhances and develops preventive models of care focused on people with chronic and complex conditions to prevent inappropriate emergency presentations or admissions.

HiTHHospital in the Home. The provision of hospital care in the comfort of the persons own home.

InternA physician gaining supervised practical experience in a hospital after graduating from medical school.

MidwiferyThe act of assisting at childbirth.

Nosocomial (as in VICNISS)Acquired or occurring in a hospital

ObstetricRelating to, or associated with, pregnancy and childbirth.

Occupational TherapyTreatment aimed at assisting people overcome limitations caused by injury or illness, enabling people to participate in the activities that have meaning to them.

OncologyA branch of medicine concerned with the investigation, diagnosis and management of people with cancer.

OphthalmologyA branch of medical science dealing with the structure, functions, and diseases of the eye.

OrthopaedicA branch of medicine concerned with the treatment of the musculoskeletal system.

PaediatricsA branch of medicine dealing with the development, care, and diseases of children.

PAGPlanned Activity Group


PalliativeA concept of care which provides coordinated medical, nursing and allied services for people who are terminally ill, delivered where possible in the environment of the person’s choice, and which provides physical, psychological, emotional and spiritual support for patients and for patients’ families and friends.

PathwayClinical pathways are standardised, evidence-based multidisciplinary management plans, which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for an homogenous group of patients.

PhysiotherapyThe treatment of disease by physical and mechanical means such as massage, regulated exercise, water, light, heat and electricity.

PodiatryThe medical care and treatment of the human foot.

Pressure Ulcer/AreaAn area of skin that has been damaged due to unrelieved pressure.

RadiologyA branch of medicine concerned with the use of radiant energy (as X-rays or ultrasound) in the diagnosis and treatment of disease.

RegistrarAn admitting offi cer at a hospital

RenalOf or relating to the kidneys or the surrounding area

Social WorkSocial work is committed to the pursuit of social Justice and addresses situations of personal distress and crisis. Social work is informed by an understanding of human development and behaviour and of complex social structures and processes.

Speech PathologyThe study and treatment of human communication disorders including disorders of speech, language and swallowing.

StomaAn artifi cial permanent opening especially in the abdominal wall made in surgical procedures.

Sub-acute careGoal-oriented interventions aimed at assessing and managing often complex conditions to maximise independence and quality of life for people with disabling conditions.

TACTransport Accident Commission

Toonalook WatersHouse constructed, and auctioned, to raise funds for the new Oncology & Dialysis unit.

VICNISSVictorian Nosocomial Infection Surveillance System

VWAVictorian Workcover Authority (now known as WorkSafe Victoria)

WIESWeighted Inlier Equivalent Separations – Unit of payment for acute admitted care.

WorkSafe VictoriaFormally Victorian Workcover Authority

Source: Merriam Webster Medical Dictionary (online); Pocket Macquarie Dictionary; Stedman’s Medical Dictionary.


DONATIONS / BEQUESTS

The generosity of the community by their fi nancial donations and volunteer support, to Bairnsdale Regional Health Service enables us to provide equipment, amenities and care that would normally be beyond our budgetary scope.

It is through these donations that we have purchased many pieces of equipment this year, such as thermometers, trolley’s, treatment chairs, oxygen equipment and more.

Thanks to everyone who contributed during 2009/2010.

To make a donation, call the BRHS Cashier on 5150 3413 and make a donation by credit card over the phone or join the BRHS Donor Program by completing the form below and sending it to BRHS Donor Program, PO Box 474, Bairnsdale VIC 3875.

First name Surname

Company name

Address Suburb P/code

Hm phone Other phone

Email

All donations over $2 are tax deductible.

I would like my donation to support the: Please accept my contribution of (circle):

Purchase of equipment $1000 $500 $250 Other Specifi c equipment as arranged with BRHS


INDEX

AAccreditation 4, 23 ,26Acute Care 3, 7Auxiliaries 4, 20, 34

BBrooker Builders 4, 20

CCleaning 25, 29Community Advisory Committee 4, 15Consulting Suites 4Continuous Improvement 18, 26

DDental 2, 7, 12, 25Department of Health 5, 25, 27, 28, 29Dialysis 2, 4, 23, 25District Nursing 2, 3, 9Donations 20, 23, 34

EEmergency Department 2, 7, 10, 18, 25

FFalls Prevention 26Financial Results 9Food Hygiene 29

GGEGAC 2Gippsland Lakes Community Health 4, 19Goals, Summary of 6Governance 13, 14, 15

HHand Hygiene 24

IInfection Prevention 18, 24

KKey Result Areas 7

LLife Governors 22

MMaddocks Gardens 2, 4, 18Medication Errors 27Midwifery 2, 4

OObstetric Registrars 5Occupational Health & Safety 12, 18Oncology 2, 4, 23, 25

PPalliative CarePathologyPatient Satisfaction 7, 25, 29Pressure Ulcer 7, 28, 29Private Patient Initiative 10

QQuality of Care 24

RRadiology 2, 4Rehabilitation 8, 19, 25

SStrategic Plan 4, 23

TToonalook Waters 4, 9, 23

WWIES 8, 10, 11, 30Workforce 6, 12Workcover 8

DISCLOSURE INDEX The Annual Report of the Bairnsdale Regional Health Service is prepared in accordance with all relevant Victorian legislation. This index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.

Legislation Requirement Page Reference MINISTERIAL DIRECTIONS REPORT OF OPERATIONS

Charter and purpose FRD 22B Manner of establishment and the relevant Ministers Front cover

FRD 22B Objectives, functions, powers and duties 2

FRD 22B Nature and range of services provided 3

Management and structure FRD 22B Organisational Structure 16

Financial and other information FRD 10 Disclosure index 36

FRD 11 Disclosure of ex-gratia payments n/a

FRD 21A Responsible person and executive officer disclosures 30

FRD 22B Application and operation of Freedom of Information Act 1982 31

FRD 22B Application and operation of Whistleblowers Protection Act 2001 12

FRD 22B Compliance with building and maintenance provisions of Building Act 1993 31

FRD 22B Details of consultancies over $100,000 n/a

FRD 22B Details of consultancies under $100,000 31

FRD 22B Major changes or factors affecting performance 30

FRD 22B Occupational health and safety 12

FRD 22B Operational and budgetary objectives and performance against objectives 9

FRD 22B Significant changes in financial position during the year 9, 30

FRD 22B Statement of availability of other information Back cover

FRD 22B Statement of merit and equity Front cover

FRD 22B Statement on National Competition Policy 31

FRD 22B Subsequent events 30

FRD 22B Summary of financial results for the year 9

FRD 22B Workforce Data Disclosures 12

FRD 25 Victorian Industry Participation Policy Disclosures n/a

SD 3.4.13 Attestation on Data Integrity 31

SD 4.2(j) Report of Operations, Responsible Body Declaration 30

SD 4.5.5 Attestation on Compliance with Australian / New Zealand Risk Management Standard 30

Legislation Requirement Page Reference FINANCIAL STATEMENTS

Financial statements required under Part 7 of the FMA SD 4.2(a) Compliance with Australian accounting standards and other

authoritative pronouncements Finance 8

SD 4.2(b) Comprehensive Operating Statement Finance 4

SD 4.2(b) Balance sheet Finance 5

SD 4.2(b) Statement of Changes in Equity Finance 6

SD 4.2(b) Cash Flow Statement Finance 7

SD 4.2(c) Accountable officer’s declaration Finance 1

SD 4.2(c) Compliance with Ministerial Directions Front cover

SD 4.2(d) Rounding of amounts Finance 9

Legislation Freedom of Information Act 1982 31

Whistleblowers Protection Act 2001 12

Victorian Industry Participation Policy Act 2003 31

Building Act 1993 31

Financial Management Act 1994 Finance 1

MissionLeading, shaping and delivering quality health care services to East Gippsland

VisionTo be a key provider of healthcare services in East Gippsland through:• Innovationinthedeliveryofhealthcareservices• Recognitionbyitsclientsasbeingcommittedtoqualitycare• Workinginpartnershipwithotherhealthcareproviders• Responsivenesstocommunityneeds• Recognitionbyitsstaffasanemployerwhovaluestheircontributions;and• Deliveryofcosteffectiveservices

Values• CustomerService• Respect• Teamwork• Efficiency

Our motto ...focusing on you

The Bairnsdale Regional Health Service is established under the Health Services Act 1988. TheresponsibleMinisterduringthereportingperiodistheHonDanielAndrewsMP. The Bairnsdale Regional Health Service Annual Report 2009/10 has been preparedinaccordancewiththeHealthServicesAct1988,FinancialManagementAct1994,StandingDirectionsoftheMinisterforFinance(Section4FinancialManagementReporting)andFinancialReportingDirections(SpecificallyFRD22).

ConstructionofnewOncology&DialysisUnit-June2010

Contact DetailsBairnsdale Regional Health ServicePO Box 474, Bairnsdale VIC 3875Ph: (03) 5150 3333 Fax: (03) 5152 6784 Email:[email protected]:www.brhs.com.au

Hospital122DayStreet,BairnsdaleVIC3875

Community Health CentresRoss Street, Bairnsdale VIC 3875Shop 19, The Esplanade, Paynesville VIC 3880

Residential Aged CareMaddocks Gardens, McKean Street, Bairnsdale VIC 3875Sutherland Lodge, McKean Street, Bairnsdale VIC 3875

Planned Activity GroupsRoss Street, Bairnsdale VIC 3875Ph: (03) 5152 0222

AcknowledgementsDesign & PrintingEgee PrintersP: (03) 5152 5055 F: (03) 5152 1387 E:[email protected]:www.egee.com.au

PhotographyJetsPhotographyP: 0419 169 859 E: [email protected]

External AuditorsAuditor-General, Victoria

Internal AuditorGrant Thornton

Bairnsdale Regional Health Service

Annual Reportincorporating Quality of Care Report

2009-2010

Bairnsdale Regional Health ServicePO Box 474 Bairnsdale VIC 3875Telephone (03) 5150 3333 Facsimile (03) 5152 6784 Email [email protected]

www.brhs.com.au ...focusing on you

Brhs Ann Rep Web 2010

Documents

Transcript of Brhs Ann Rep Web 2010