M ALDON HOSPITALCommitted to care since 1859

MALDON HOSPITAL Annual Report

2014

Chapel Street Maldon Victoria 3463 Telephone 03 5475 2000 Facsimile 03 5475 2029 Email admin@maldhosp.vic.gov.au

ANNUAL REPORT 2014

Contents

MISSION STATEMENTBuilding community health and wellbeing.

VISIONOur vision is to be a thriving health service contributing to a happy and healthy community.

BOARD OF MANAGEMENTMr Gordon Carter, President - appointed 01.07.2009

Dr Helen McBurney, Vice President - appointed 01.11.2008

Mr John Fitton, Treasurer - appointed 01.11.2004

Mrs Barbara Ford, Board member - appointed 01.11.2003

Ms Megan Purcell, Board member - appointed 01.07.2011

Mr Colin Thornton, Board member - appointed 01.07.2011

Ms Cheryl Axell, Board member - appointed 01.07.2008 (resigned)

COMMITTEE REPRESENTATION

Audit committee

Mr Michael Grimes (Independent Chair)

Mr Gordon Carter (Board)

Mr John Fitton (Board)

Mr Colin Thornton (Board)

Mr Geoff McLean (community representative)

Mr Gary Johnstone (community representative)

Clinical governance committee

Dr Helen McBurney (Chair)

Barbara Ford

Ms Megan Purcell

Continuous Improvement and Risk Management Committee

Dr Helen McBurney (Chair)

Barbara Ford

Ms Megan Purcell

Community Consultation Committee

Mr Gordon Carter (Board)

Mr John Fitton (Board)

Maldon Hospital is a public hospital incorporated under the Health Services Act 1988 and has a variety of programs and services funded by:

Department of Health (Federal)

Minister for Health - The Hon Peter Dutton MP

Minister for Social Services - The Hon Kevin Andrews MP

Minister for Indigenous Affairs Senator - the Hon Nigel Scullion

The Department of Health (Victoria)

Minister for Health and Ageing - The Hon David Davis MP

Minister for Mental Health - The Hon Mary Wooldridge MP

The Department of Human Services (Victoria)

Minister for Community Services, Minister for Disability Services & Reform - The Hon Mary Wooldridge MP

The Department of Education and Early Childhood Development (Victoria)

Minister for Education - The Hon Martin Dixon MP

Board of management 1

Report to the community 2

Key achievements/Our services 3

Mandatory Reporting 5

Statement of availability of other information 7

Strategic priorities 9

Acknowledgements 9

Disclosure Index Inside back cover

The annual report of Maldon Hospital 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 PG ReferenceMinisterial DirectionsReport of OperationsCharter and purposeFRD 22E Manner of establishment and the relevant Ministers IFFRD 22E Objectives, functions, powers and duties IFFRD 22E Summary of activities 2FRD 22E Nature and range of services provided 3Management and structureFRD 22E Administrative and organisational structure 4

Strategic Plan 9Financial and other informationFRD 10 Disclosure index 10FRD 11A Disclosure of ex-gratia expenses 6FRD 12A Disclosure of major contracts 6FRD 21B Responsible person and executive officer disclosures 6FRD 22E Application and operation of Carers Recognition Act 2012 6FRD 22E Application and operation of Freedom of Information Act 1982 7FRD 22E Compliance with building and maintenance provisions of Building Act 1993 6FRD 22E Details of consultancies over $10,000 6FRD 22E Details of consultancies under $10,000 6FRD 22E Employment and conduct principles 6FRD 22E Major changes or factors affecting performance AFSFRD 22E Occupational health and safety 7FRD 22E Operational and budgetary objectives and performance against objectives AFSFRD 22E Significant changes in financial position during the year AFSFRD 22E Statement of availability of other information AFSFRD 22E Statement on National Competition Policy 6FRD 22E Subsequent events AFSFRD 22E Summary of the financial results for the year AFSFRD 25B Victorian Industry Participation Policy disclosures 6FRD 29 Workforce Data disclosures 6SD 4.2(g) Specific information requirements 6SD 4.2(j) Sign off requirements 6SD 3.4.13 Attestation on data integrity 6SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 6SD 4.5.5 Risk management compliance attestation 6Financial StatementsFinancial statements required under Part 7 of the Financial Management Act

Letter of comfort AFSSD 4.2(a) Statement of changes in equity AFSSD 4.2(b) Comprehensive Operating Statement AFSSD 4.2(b) Balance Sheet AFSSD 4.2(b) Cash Flow Statement AFSOther requirements under Standing Directions 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements AFSSD 4.2(c) Accountable officer’s declaration AFSSD 4.2(c) Compliance with Ministerial Directions AFSSD 4.2(d) Rounding of amounts AFSLegislationFreedom of Information Act 1982 7Carers Recognition Act 2012 6Victorian Industry Participation Policy Act 2003 6Building Act 1993 6Financial Management Act 1994 2/AFS

Disclosure Index

Financial statement attached. If the statement is not attached please contact Maldon Hospital on (03)5475 2000.

AFS - Attached Financial Statement; IF - Inside Front

Maldon Hospital acknowledges the support of the Victorian Government

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Report to the Community

It is again a pleasure to present the 2013/2014 Maldon Hospital Annual Report to the community. 2013/2014 has been a successful year for Maldon Hospital in terms of maintaining our accreditation standards across all services; occupancy of the aged residential beds was high and we achieved a balanced budget.

This success can be attributed to many factors but the wonderful work of all our managers, staff, volunteers and the support of Doctor Fowler were key. It also reflects that Maldon Hospital retains the image of a respected, homely and caring community hospital that serves its community well through access to a significant range of health services.

Some of the highlights of the year were:

• ACommunityHealthNeedsAnalysiswascompleted.

• CastlemaineandDistrictCommunityHealthServicewascontracted to deliver and increase access to health promotion activities to the community of Maldon.

• Governmentcapitalgrantsof$163,000wereawardedtoupgrade aged residential care facilities and implement WiFi throughout the building.

• VisitfromtheMinisterDavidDavistoabreakfastmeetingwith the Board and senior management.

• CommunityConsultationCommitteeestablished.

• Organisationsurpluswasachieved.

Maldon Hospital has always sought to engage its community inwhatandhowservicesaredelivered.GovernmentsandNationalStandardsacrossallservicesrequireustohavegreater consumer participation, not only in directing their personal care, but also to be engaged in processes where significant decisions are made that may impact on them as consumers.

TheestablishmentofaMaldonHospitalCommunityConsultationCommitteewillbethecornerstonetoprogressively integrating consumer participation across the organisation.

There is increasing responsibility for Board members to attend additional internal and external forums and participate in continuing education and development training. We acknowledge the spirit in which our Board members take on the role and willingly go beyond meeting their obligations. ThankyoutoVicePresidentDrHelenMcBurney,TreasurerJohnFittonandBoardmembersBarbaraFord,MeganPurcellandColinThorntonforvolunteeringtheirtimeandexpertise.

WealsothankDirectorofNursingJanetHutchinson,whofinished on the 30 June after many years of service. We acknowledge her contribution to the success of Maldon Hospital and in particular the passion she displayed in caring for our residents.

We are looking forward with excitement to next financial year. In September 2014 Maldon Hospital will be surveyed by the AustralianCouncilonHealthcareStandardsforbothacuteandhome care services and in March 2015 the Australian Aged CareQualityAgencywillsurveyouragedresidentialservices.A new strategic plan is being developed and will establish our future directions. We will continue to increase consumer participation and along with the great team of staff at Maldon Hospitaldeliversafe,highqualityandneededlocalhealthservices to our community.

In accordance with the Financial Management Act 1994 I am pleasedtopresenttheReportofOperationsforMaldonHospital for the year ending 30 June 2014.

MrGordonCarter MrIanFisher

BoardPresident CEO

Performance PrioritiesACTIVITY TARGET 2013-14

ACTUALSWIES public 35.38

WIES private 23.64

TOTAL WIES (public and private) 59.02

WIES DVA 14.18

WIES TAC 0

WIES TOTAL 73.19

Quality and safetyHealth service accreditation Full compliance Full compliance

Residential aged care accreditation Full compliance Full compliance

Cleaning standards (overall) Full compliance Full compliance

Cleaning standards (AQL-A) 90 NA

Cleaning standards (AQL-B) 85 96

Cleaning standards (AQL-C) 85 98.5

Health care worker immunisation - influenza 75 71

Submission of data to VICNISS Full compliance Full compliance

Hospital associated infection surveillance No outliers Achieved

Hand hygiene rate 70% 90.5

SAB rate per occupied bed days <2/10,000 0

Victorian Patient Satisfaction Monitor (OCI) July – December 2013) 73 NA

Consumer Participation Indicator (July – December 2013) 75 NA

Victorian Hospital Experience Measurement Instrument (Jan – June 2014)

Not yet commenced

People Matter Survey Full compliance Full compliance

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ANNUAL REPORT 2014

Key achievements/Our services

Acute

TheGeorgeRayWingprovidesfour-bedacuteinpatientservices to the Maldon community. The hospital has the capacity to offer care to patients with low acuity medical conditions, palliative care and convalescence.

Residential Aged Care

Maldon Hospital provides residential aged care through 12 lowcare(hostel)placesinJessieBoweHouseand16highcare (nursing home) places in Mountview Home. The residents are well supported by family, friends and volunteers who work with the hospital staff to ensure the residents can maintain contact with the general community and continue to participate in activities they had enjoyed prior to coming to live at Maldon Hospital.

Whilst living in Jessie Bowe House and Mountview Home, residents continue to access allied health professionals, such as physiotherapist, podiatrist, speech pathologist, dietician, visiting geriatrician and adult mental health services. The two residential facilities are well supported by visiting Allied Health ProfessionalsfromCastlemaineHealthandstaffaresupported through specialist departments and the ProfessionalDevelopmentdepartmenttoensureresidentsreceive appropriate clinical care.

Residential Aged Care OccupancyDuring the year 2013-14 the average occupancy rate for Jessie Bowe House was 97.7% and Mountview Home 95.96%.

Non InpatientsTheUrgentCareDepartmentatthehospitalprovidescaretopatients presenting with a range of conditions. The majority of presentationsreceiveimmediatetreatmentfromNursingstaffand/ortheVisitingMedicalOfficer.Patientswithmorecomplex needs are referred to Bendigo Health and are monitored and supported until they are transported by ambulance.

The total number of presentations for outpatients in 2013-14 was76,with181hoursand30minutesofnursingtime.Thetotal presentations for urgent care in 2013-14 was 70, with 50 hoursand28minutesofnursingtime.

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun0

10

20

30

40

50

60

2012 - 2013 2013 - 2014

Acute Occupancy %

Residential Aged Care Occupancy %

82

86

84

88

90

92

94

96

98

100

July Aug Sep Oct Nov Dec Jan Feb Mar Apr May JunJesse Bowe House %Mountview Home %

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4

Our Services continued

CEO(Castlemaine Health)

DON / Manager

VMO

District Nursing

NUM Acute & Residential

Community / Social Support Program

Coordinator

Contracted Services (Castlemaine Health)

Hotel Services & Engineering

Contracted Services(Castlemaine Health)

Other

Social Support Staff & Volunteers

Associate Nurse Unit Managers

Registered NursesEnrolled NursesPersonal care

Workers

Activities Coordinator

Reception / Ward Clerk

Board of Management

Home and Community Care Activities (HACC) HACCPlannedActivityGroups(PAGs),andvolunteerassisted Social Support activities are for frail, aged and younger people with a disability. Most programs are of short duration, with an emphasis on physical activity and social connection and wellness.

District Nursing

TheMaldonHospitalDistrictNursingServicecontinueddelivering home based nursing support, health education and promotion seven days a week throughout the year. The hospitalnursestravelfromWelshman’sReeftoLaanecoorie,Baringhup to Walmer and everywhere in between.

Regulatory Compliance

At Maldon Hospital we have full accreditation with Australian CouncilonHealthcareStandards(ACHS)until30thNovember2016.BothresidentialfacilitiesreceivedafurtherthreeyearsaccreditationwithAgedCareStandardsAgency-MountviewHometo13thJune2016andJessieBoweHouseuntilJune2015.

TheHospitalisalsoauditedonFoodSafety,CleaningStandards and WorkSafe inspectors. The results of the Maldon Hospital audits were as follows:

Food Safety Audit ExternalFoodSafetyAuditconductedby‘SimranFoodSafetyServices”, 3rd June 2014, resulted in 100% compliance audited with no recommendations for improvement made. This is a reflection of the high standard of work produced by theHotelServiceStaffcontractedfromCastlemaineHealth.

Cleaning Audit AnExternalCleaningauditwasconductedinAugust2013by‘RelianceHospitalityConsulting’.TheoverallscoreforHighRiskareaswas96%andModerateRisk98.5%withacomment from the auditor “the results of the audit indicate that the cleanliness of Maldon Hospital is to be a very high standard”.

ANNUAL REPORT 2014

Corporate ServicesFinance, Supply, Information Technology, Laundry, Food & Catering, Environmental and Security

CorporateServicesatMaldonareadministeredundercontractbyCastlemaineHealth.Thecontractcoversthefinancial management of the hospital, as well as procurement andsupplyofmaterials(includingnewequipment),information technology services, linen and laundry services, food preparation and catering, vehicle management, and cleaning, waste disposal and security services.

Supply Services

The ordering and supply of materials is administered from CastlemaineHealth;MaldonstaffraisepurchaserequisitionsforproductsandmaterialsonlinetoCastlemainewhereorders are processed and delivery arranged, as well as receiving prompt advice and resolution of purchasing and supply issues.

During the past year Maldon Hospital’s budget benefited from savings made in being increasingly compliant with the State Government’srequirementstoprocuregoodswhereverpossibleviaHealthPurchasingVictoria(HPV).

Information Technology

The IT Department has made further improvements to the performance and reliability of services over the past year. All PCshavenowbeenupgradedtoruntheWindows7OperatingSystem.Newsoftwarehasalsobeeninstalledthatallows the IT Department to remotely monitor network devices for performance and to assist with the location of any faults. A large project is also currently under way that will see some major improvements to the way network services are provided in the future. This will include new cabling and faster data communications systems throughout the hospital. A new offsite data backup system has also been installed to provide a more robust disaster recovery solution.

Hotel Services

A small team of seven staff provide the Hotel Services to patients and residents at Maldon.

Food Services

Thirty two meals are provided for each meal service daily by CastlemaineHealthFoodServicesstaff.Ourcustomersatisfaction surveys continued to demonstrate excellent resultsintermsofthequalityofresidents’meals,andexternalaudits again scored our service highly in terms of the strict cleaning standards demanded of public hospitals.

Linen Services

CastlemaineHealthprovidesLinenServicestoMaldonHospital and includes bedroom and bathroom linen, continence products and resident personal items.

Cleaning Services

CastlemaineHealthprovidesasevendaycleaningservicetopatients and residents.

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Mandatory Reporting

Attestation on Compliance with Australian/New Zealand Risk Management Standards: I, Ian Fisher, certify that Maldon Hospital has risk management processes in place consistentwiththeAustralian/NewZealandRiskManagementStandard and an internal control system is in place that enables the executives to understand, manage and satisfactorily control risk exposures. The audit committee verifies this assurance and that the risk profile of Maldon Hospital has been critically reviewed within the last 12 months.

Attestation on Data Accuracy: I, Ian Fisher, certify that Maldon Hospital has put in place appropriate internal controls and processes to ensure that the Department of Health is provided with data that reflects actual performance. Maldon Hospital has critically reviewed these controls and process during the year.

Attestation for Compliance with the Ministerial Standing Direction 4.5.5.1: I, Ian Fisher, certify that Maldon Hospital has complied with Ministerial Direction 4.5.5.1 – Insurance.

IANFISHER ChiefExecutiveOfficer 12 July 2014

Ex-Gratia Expenses: Maldon Hospital had one ex-gratia expenses for the year ending 30 June 2014.

Compliance with Building and Maintenance Provisions of Buildings Act 1993: All building works have been designed in accordance with the Department of Health’s GuidelinesandcomplywiththeBuildingAct1993andtheBuildingCodeofAustralia1996.

Specific Information Requirements (SD 4.2 (g)): This report provides users with general information about the entity and its activities, operational highlights for the reporting period, future initiatives and other relevant information not included in the financial statements.

Disclosure of Major contracts (FRD 12A): There were no contractsgreaterthan$10millionenteredintoduringtheyearended June 2014.

Statement on National Competition Policy (FRD 22E): MaldonHospitalcompliedwithallGovernmentpoliciesregardingneutralityrequirementswithregardstoalltenderapplications.

Employment and Conduct Principles (FRD 22E): Maldon Hospitaliscommittedtoapplyingmeritandequityprincipleswhen appointing staff. The selection processes ensure that applicantsareassessedandevaluatedfairlyandequitablyonthe basis of the key selection criteria and other accountabilitieswithoutdiscrimination.Employeeshavebeencorrectly classified in workforce data collections.

Carers Recognition Act 2012 (FRD 22E): Maldon Hospital has taken all practical measures to comply with its obligations under the Act.

Staff Analysis as at 30 June 2014*

Percentage of total headcount*

FULLTIME PARTTIME CASUAL TOTAL

Medical 0% 0% 2% 2%Nursing 5% 41% 32% 78%

Clerical 0% 3.5% 2% 5.5%

PersonalCareWorkers/Recreational Workers

0% 4.5% 10% 14.5%

Total 5% 49% 46% 100%

WorkcoverPremiums

Insurance Year

Remuneration or Wages

Premium Paid (inc

GST)

% of Remuneration

2009/2010 $1,995,477 $60,005 3.01%

2010/2011 $1,726,127 $48,000 2.78%

2011/2012 $1,656,493 $50,135 3.03%

2012/2013 $1,845,282 $51,666 2.80%

2013/2014 $1,962,738 $51,964 2.65%

Year ending June FTE*

WorkCover

NoWorkCoverclaimswerelodgedforthisreportingperiod,with no days of compensation paid.

Consultancies

Therewerenoconsultanciesofmorethan$10,000forMaldonHospital in the year 2013/14.

In 2013-14, Maldon Hospital engaged six consultancies where the total fees payable to the consultants were a total of $21,521.02.

Labourcategory MonthendingJuneFTE* JuneYTFTE*

2013 2014 2013 2014Nursing 21.91 24.20 21.71 22.30

Administration andClerical 1.03 1.50 1.05 1.12

Hotel & Allied 1.93 1.62 1.74 1.72Medical support 0.08 0.23 0.44 0.20

Total 24.95 27.55 24.94 25.34

Victorian Industry Participation Policy Act 2003 (FRD 25B): During the year there were 0 contracts completed at Maldon HospitalwhichVIPPapplied.

Statement on National Competition Policy (FRD 22E): MaldonHospitalcompliedwithallGovernmentpoliciesregardingneutralityrequirementswithregardstoalltenderapplications.

Workforce Data Disclosure (FRD 29)

ANNUAL REPORT 2014

Statement of availability of other information

Freedom of Information applications

All applications were processed in accordance with the provisionoftheFreedomofInformationAct1982,whichprovides a legally enforceable right of access of information heldbyGovernmentagencies.CastlemaineHealthprovidesareportontheserequestsonbehalfofMaldonHospitaltotheDepartment of Justice.

FreedomofInformationrequestscanbesubmittedtotheChiefExecutiveOfficer,CastlemaineHealth,POBox50,Castlemaine3450.Applicationformsareavailableonthewebsite www.castlemainehealth.org.au, or by phoning 5471 1555.Applicationchargesandfeesapply($24.40).

Twenty-fiverequestswerereceivedunderFreedomofInformationin2013/14.Allrequestswereprocessedwithintherequiredtimeframes.

Fees Charged for Service

All fees and charges charged by Maldon Hospital are regulatedbytheCommonwealthDepartmentofHealth&AgeingandtheHospitals&Charities(Fees)Regulations1986,asamendedandasotherwisedeterminedbytheDepartmentofHumanServices,Victoria.Policiesandprocedures are in place for the effective collection of fees owing to the service.

Ethical Standards

The Board of Management promotes the continued maintenance of corporate governance practice and ethical conduct by the Board members and employees of Maldon Hospital. The Board has endorsed a code of conduct which applies to Board Members, officers and all employees.

Pecuniary Interests

Members of the Board of Management of Maldon Hospital are requiredtonotifythePresidentoftheBoardofanypecuniaryinterests which might give rise to conflict of interest in accordancewithMaldonHospitalBoard’sCodeofConduct.

Tax Deductible Gifts

Maldon Hospital Health is endorsed by the Australian Taxation OfficeasaDeductibleGiftRecipient.GiftstoMaldonHospitalasaPublicHealthServicequalifyforataxdeductionunderitem 1.1.1 of Section 3-BA of the Income Tax Assessment Act 1997.

Disability Act 2006

Maldon Hospital has been incorporated in the Access and InclusionPlandevelopedbyCastlemaineHealththatincorporatesrequirementsoftheDisabilityAct2006.

Occupational Health and Safety/WorkCover

Maldon Hospital is uncompromising in its commitment to work towards having established, measurable objectives and targets to ensure a mindset of continuous improvement in health and safety and entrench behaviours that focus on eliminating workplace injury and illness.

Maldon Hospital ensures that in the pursuit of excellence in providing patient and resident care, we do not jeopardise the safety or health of our employees. We continue to comply withtherequirementsofrelevantlegislationandsupportingregulations and hold our managers accountable for providing a healthy and safe environment for our teams to work in.

Achievements

Injury Preventative Program

CastlemaineHealth’sOHSDepartmenthasimplementedavoluntary referral process for any staff member who has a work or non work related injury at the Maldon Hospital. Staff from Maldon Hospital have participated in this program and evennegotiatedappointmentswithCastlemaineHealth’sPhysiotherapistsonsiteatMaldon.Bygettinginvolvedassoon after injury has occurred as possible, injury information can be collected and used to set the employee on the right courseoftreatment.Overall,anearlyinterventionapproachenables Maldon Hospital to facilitate proactive injury management,qualitycare,andearlyreturn-to-work(RTW)outcomes.

Proactive Approach

Maldon Hospital remains proactive in its approach to the reportingofhazardsandanyrequiredfollowupmaintenancerequestswhichfacilitatesapositivecultureofhealthandsafety.

Coming up

Maldon Hospital is currently working on competency assessments and training for all staff on any new piece of equipmentbroughtintothehospital.ThiswillincludeOccupationalAssessmentsonanyequipmentpriortopurchaseorequipmentbroughtintothehospitalonatrialbasis.

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Clinical Risks related to the delivery clinical care of all patients, resident and clients.

Corporate Risk related to the sound and effective corporate governance.

Emergency Preparedness and Business Continuity

Risks associated with readiness to sustain minimum business functionality and an organised response to a crisis or unexpected event.

FinancialRisks associated with the financial management, reporting, accounting and administration of funds.

Governance and LegislationRisks associated with non compliance to legislation, regulations and maintaining standards.

Human ResourcesRisks associated with ensuring policies, procedures and processes are in place for the recruitment, retention, management of staff.

Infrastructure and Equipment

Risks related to ensuring infrastructure and equipment are maintained in an appropriate manner to be safely and effectively used.

Knowledge and SystemsRisks associated with IT systems, management and protection of information and corporate knowledge.

Public Relations/Reputation Risks associated with engaging customers and the community.

Safety Health and Environment

Risks associated with ensuring a secure and safe working environment for all staff, contractors, visitors & compliance with the Occupational Health & Safety Act 2004.

Risk Management

Maldon Hospital has a strong commitment to managing risk and has actively worked to increase sound risk management practice throughout the organisation. The review of the Risk Management Framework in 2013 aligns business opportunities and supports managers and staff in the identification and treatment of risks as they arise. Risk Management is overseen at operation level by the QualityImprovementCommitteeandataGovernancelevelbytheAuditandRiskManagementandtheClinicalGovernanceCommittees.

All identified risks are aligned with ten high level corporate risks:

Emergency ManagementEmergency Response and Recovery Planning Committee

TheEmergencyResponseandRecoveryPlanningCommitteemeetsonamonthlybasisfromOctobertoMarchtoplaneachyear and then on an as needs basis. The committee has joint membershipwithCastlemaineHealth.

Emergency Response & Recovery Plan

TheEmergencyResponse&RecoveryPlan(ERRP)hasbeenextensively revised to incorporate the changes in the State HealthEmergencyResponsePlan(SHERP)publishedinDecember2013.TheERRPdocumentsthearrangementsforthe prevention of, response to, and recovery from an incident, emergency or crisis that may impact upon Maldon Hospital, its staff, the community, stakeholders or physical assets. It is expected that knowledge of and adherence to these procedures will ensure that all clients, visitors and Staff are guaranteed the highest possible standards of health and safety whilst in Maldon Hospital.

ANNUAL REPORT 2014

Strategic Priorities

State and MH Priorities Action Deliverable Status

Developing a system that is responsive to people’s needs

• Implementformaladvancecareplanningstructures and processes that provide patients with opportunities to develop, review and have their expressed preferences for future treatment and care enacted.

• Inpartnershipwithotherlocalproviders,apply existing service capability frameworks to maximise the use of available resources across the catchment.

• Patientparticipationinadvancedcareplanning structures and processes implemented.

• Reviewcommunityservicesinpartnershipwith local providers.

Implemented in line with meeting the National Standards.

Contract entered into with Castlemaine and District Community Health Service to prepare a health needs analysis and provide a range of health promotion activities.

Improving every Victorian’s health status and experiences

• Improvethirty-dayunplanned readmission rates.

• CollaboratewithkeypartnerssuchasMedicare Locals, community health services and other providers to support local implementation of the Victorian Health and Wellbeing Plan 2011-2015.

• Developastrategyforreductioninthirtyday readmission rate.

• Participateandcontributetothedevelopment of the Mount Alexander Shire Public Health and Wellbeing Plan 2013 – 2018.

Nil readmissions occurred within 30 days.

Board of Management and senior management participated in a briefing for the strategy for the Shire’s Health and Wellbeing Plan 2013 – 2018.

Expanding service, workforce and system capacity

• WorkcollaborativelywiththeDepartmenton services and capital planning to develop service and system capacity.

• DevelopanewServicePlanaimedatestablishing sustainable health services.

Maldon Hospital part of Strengthening Health Services project.Agreed with Department to develop a strategic plan rather than a service plan.

Increasing the system’s financial sustainability and productivity

• Identifyopportunitiesforefficiencyandbetter value service delivery.

• Identifyandimplementopportunitiestoachieve efficiencies across the health services, including through regional initiatives with other Health Services.

• Developandimplementfinancialimprovement plan.

Contracted services are provided by Castlemaine Health. The contract will be reviewed prior to the end of the 2014 year.

Completed and will be revised in line with Strategic Plan and Staff Review.

Implementing continuous improvements and innovation

• Developandimplementimprovementstrategies that optimise access, patient flow, system coordination and the quality and safety of hospital services.

• Developandimplementstrategiestomaintain aged, acute and community services accreditation as per the accreditation cycle.

Additional resource engaged for quality. ACHS mock survey conducted on National Safety and Quality Standards status in May.

Increasing accountability and transparency

• PreparefortheNationalSafetyandQualityHealth services Standards, as applicable.

• Increasetransparencyandaccountabilityinreporting of accurate and relevant information about the organisation’s performance.

• Developreportingandmonitoringprocesses to support National Safety and Quality Standards.

• Reviewoffinancialandactivityreportingtothe Board against approved targets.

New reports developed for reporting to the Board and staff.

Completed. Will progressively be reviewed and improved.

Improving utilisation of e-health and Communication Technology

• MaximisetheuseofhealthICTinfrastructure to better connect a broad range of health care and other health-related workforces.

• Provisionoflogonandemailboxes to all staff.

• Staffperformancereviewprocesstoinclude individual ICT training needs analysis.

• StrategytoincreaseuseofMedicaretelehealth items developed.

• FinancialcontributionandCEOparticipation in Loddon Mallee Health Alliance to enhance regional capacity.

All staff allocated individual log-on and email addresses.In progress.

In progress.

CEO a Director of the LMHA.

9

AcknowledgementsWe wish to thank everyone who contributed to the writing and production of this year’s annual report. This includes staff, members of the community, volunteers and clients.

Printing and design

BendigoModernPress

Cover design

JanePrideauxgraphicdesign

Editor

LauraKeogh

Support data

Regional office, Department of Health

Banker

Bendigo Bank

Auditors

Auditor-general,Victoria

External auditors agents

Richmond Sinnott & Delahunty

Internal auditor

Accounting & Audit Solutions, Bendigo

ANNUAL REPORT 2014

Contents

MISSION STATEMENTBuilding community health and wellbeing.

VISIONOur vision is to be a thriving health service contributing to a happy and healthy community.

BOARD OF MANAGEMENTMr Gordon Carter, President - appointed 01.07.2009

Dr Helen McBurney, Vice President - appointed 01.11.2008

Mr John Fitton, Treasurer - appointed 01.11.2004

Mrs Barbara Ford, Board member - appointed 01.11.2003

Ms Megan Purcell, Board member - appointed 01.07.2011

Mr Colin Thornton, Board member - appointed 01.07.2011

Ms Cheryl Axell, Board member - appointed 01.07.2008 (resigned)

COMMITTEE REPRESENTATION

Audit committee

Mr Michael Grimes (Independent Chair)

Mr Gordon Carter (Board)

Mr John Fitton (Board)

Mr Colin Thornton (Board)

Mr Geoff McLean (community representative)

Mr Gary Johnstone (community representative)

Clinical governance committee

Dr Helen McBurney (Chair)

Barbara Ford

Ms Megan Purcell

Continuous Improvement and Risk Management Committee

Dr Helen McBurney (Chair)

Barbara Ford

Ms Megan Purcell

Community Consultation Committee

Mr Gordon Carter (Board)

Mr John Fitton (Board)

Maldon Hospital is a public hospital incorporated under the Health Services Act 1988 and has a variety of programs and services funded by:

Department of Health (Federal)

Minister for Health - The Hon Peter Dutton MP

Minister for Social Services - The Hon Kevin Andrews MP

Minister for Indigenous Affairs Senator - the Hon Nigel Scullion

The Department of Health (Victoria)

Minister for Health and Ageing - The Hon David Davis MP

Minister for Mental Health - The Hon Mary Wooldridge MP

The Department of Human Services (Victoria)

Minister for Community Services, Minister for Disability Services & Reform - The Hon Mary Wooldridge MP

The Department of Education and Early Childhood Development (Victoria)

Minister for Education - The Hon Martin Dixon MP

Board of management 1

Report to the community 2

Key achievements/Our services 3

Mandatory Reporting 5

Statement of availability of other information 7

Strategic priorities 9

Acknowledgements 9

Disclosure Index Inside back cover

The annual report of Maldon Hospital 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 PG ReferenceMinisterial DirectionsReport of OperationsCharter and purposeFRD 22E Manner of establishment and the relevant Ministers IFFRD 22E Objectives, functions, powers and duties IFFRD 22E Summary of activities 2FRD 22E Nature and range of services provided 3Management and structureFRD 22E Administrative and organisational structure 4

Strategic Plan 9Financial and other informationFRD 10 Disclosure index 10FRD 11A Disclosure of ex-gratia expenses 6FRD 12A Disclosure of major contracts 6FRD 21B Responsible person and executive officer disclosures 6FRD 22E Application and operation of Carers Recognition Act 2012 6FRD 22E Application and operation of Freedom of Information Act 1982 7FRD 22E Compliance with building and maintenance provisions of Building Act 1993 6FRD 22E Details of consultancies over $10,000 6FRD 22E Details of consultancies under $10,000 6FRD 22E Employment and conduct principles 6FRD 22E Major changes or factors affecting performance AFSFRD 22E Occupational health and safety 7FRD 22E Operational and budgetary objectives and performance against objectives AFSFRD 22E Significant changes in financial position during the year AFSFRD 22E Statement of availability of other information AFSFRD 22E Statement on National Competition Policy 6FRD 22E Subsequent events AFSFRD 22E Summary of the financial results for the year AFSFRD 25B Victorian Industry Participation Policy disclosures 6FRD 29 Workforce Data disclosures 6SD 4.2(g) Specific information requirements 6SD 4.2(j) Sign off requirements 6SD 3.4.13 Attestation on data integrity 6SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 6SD 4.5.5 Risk management compliance attestation 6Financial StatementsFinancial statements required under Part 7 of the Financial Management Act

Letter of comfort AFSSD 4.2(a) Statement of changes in equity AFSSD 4.2(b) Comprehensive Operating Statement AFSSD 4.2(b) Balance Sheet AFSSD 4.2(b) Cash Flow Statement AFSOther requirements under Standing Directions 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements AFSSD 4.2(c) Accountable officer’s declaration AFSSD 4.2(c) Compliance with Ministerial Directions AFSSD 4.2(d) Rounding of amounts AFSLegislationFreedom of Information Act 1982 7Carers Recognition Act 2012 6Victorian Industry Participation Policy Act 2003 6Building Act 1993 6Financial Management Act 1994 2/AFS

Disclosure Index

Financial statement attached. If the statement is not attached please contact Maldon Hospital on (03)5475 2000.

AFS - Attached Financial Statement; IF - Inside Front

Maldon Hospital acknowledges the support of the Victorian Government

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M ALDON HOSPITALCommitted to care since 1859

MALDON HOSPITAL Annual Report

2014

Chapel Street Maldon Victoria 3463 Telephone 03 5475 2000 Facsimile 03 5475 2029 Email admin@maldhosp.vic.gov.au