2013 - 2014 - Mildura Base Hospital

Transcription

Mildura Base Hospital
Annual Report > 2013-2014
Working with the community to achieve the best health outcomes.
Annual Report 2013/2014
1
What’s inside
2 CEO’s Report
4 The Year in Summary
6Mildura Base Hospital – At a
Glance
Mildura Base
Hospital:
working with
the community to
achieve the best
health outcomes.
7 Our Management Team
8 Our Organisational Structure
9 Committee Structure
10 Community Advisory Board
13 Statement of Priorities
19 Reportable Information
22Attestation
23 Financial Report
Mission Statement
Our People
Improving the health and wellbeing of our community by
providing quality health services, with care, compassion and skill.
• W
e will be an employer of choice and actively encourage
co-operation, accountability, teamwork and respect
Our Vision
Your Hospital – we care.
– Continuously improve communication throughout the
organisation
– Attract and maintain appropriately skilled staff
– Ensure a culture of respect, individual responsibility,
tolerance and teamwork.
Our Values
Mildura Base Hospital embraces the following values in its
day-to-day operations.
Our Community
• We will pursue improved community engagement
Our Patients
• W
e will provide responsive, easily accessible, integrated,
quality health care services
– Enhance communication with the general community and
promote the work of the hospital
– Undertake effective health promotion and enhance
linkages with other health services.
– C
ontinuously improve the quality and safety of care, to
enhance the patient experience
– Encourage patient and carer ownership for health
– Meet the requirements of the National Health Reform
– A
ddress specific cultural diversity needs of patients and
carers and respond effectively
– P
roactively develop services and linkages which will benefit
patient care.
Our Business
• W
e will operate our business in a manner that ensures our
viability, and sustainability
– Ensure adequate data collection, integrity and analysis to
maximize financial and clinical outcomes
– Manage appropriate infrastructure development to meet
evolving needs
– Provide an efficient governance framework that ensures
compliance with all requirements
– Evaluate and implement improved business processes.
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CEO’s Report
2013-2014
We constantly strive to improve the level of service and health care facilities we provide to the
community of Mildura and surrounds and 2013-14 has been one of the most progressive and
exciting periods for the Hospital.
Our long-awaited $16 million building and refurbishment program moved into delivery stage in this
financial year. Progress has been rapid, with work proceeding on budget and on time for all the major works
so far.
In total, there have been five major projects completed or commenced in this financial year – a huge
undertaking by any estimate. It is a credit to the development teams both here at the Hospital and with our
contracting partners, that all of these projects have progressed rapidly. We have continued to provide all
services with absolutely minimal interruption and at the high level that the community and we expect.
The initial project involved the upgrading of the Oncology Unit and represented an important advance for
cancer treatment services in Mildura. The upgrade doubled the capacity of the unit to eight chairs, ensuring
many more people can have treatment close to home and within reach of their support networks. With the
completion of this project we implemented an Oncology Telemedicine Service in November – a first for our
region.
As the oncology upgrade was completed, the most significant phase of the Hospital redevelopment
program was beginning – the expansion of the Emergency Department, Maternity Ward and Mental Health
Services areas. These projects represent the biggest expansion and upgrade of the Hospital’s infrastructure
since it opened in 2000. Work began on November 21 and will be completed on schedule at the end of the
2014 calendar year.
It was pleasing also to make a start to the accommodation development in Thirteenth Street, near the
old Mildura Base Hospital. This will provide an appropriate and appealing housing option for students and
clinicians and will be of ongoing assistance in recruiting and retaining quality health professionals to our
region.
The recruitment and retention of medical staff continues to be a major challenge for all rural and remote
hospitals. However, we have had a successful year in this area, with surgical appointments to Oncology, Ear,
Nose and Throat, Obstetrics and Gynaecology, Paediatrics, Orthopaedics and Nephrology. In addition, we
have successfully recruited an additional anaesthetist, and extra rotational doctors and general surgeons.
In addition to the progress outlined above, in the past year our successful efforts to secure additional
services and staff have also included:
• Successful funding application and recruitment of a full time Breast Cancer Nurse
• Installation of 128 Slice CT Scanner – enabling cardiac investigations
• Funding for expansion of special care nursery and development of resuscitation area
• Establishment of Pain Service
• Increased Clinics (including Obstetrics and Gynaecology, Ear Nose and Throat)
• Funding for E-Records and new patient management computer system
• Funding for new sterilisers, to be installed January 2015
• Successful submission for headspace unit for youth mental health
• Successful submission for Prevention And Recovery Care unit for adult mental health
•
Car Park expansion
• Successful funding application for development of Aboriginal Healing Centre
In terms of Indigenous health, we completed an “Improving Care for Aboriginal and Torres Strait
Islanders” Plan in November. We have since formalised and strengthened our relationships with the Mallee
District Aboriginal Services and Dareton Community Health. The Hospital’s Koori Health Unit staff continue
to provide support and advocacy to ensure our services are culturally appropriate to Indigenous community
members.
Mildura Base Hospital is working constantly to improve its effectiveness as the region’s acute care health
service provider. The Medical Advisory Committee under the chairmanship of Dr Alison Walker provides
essential support in clinical matters and policy development and I thank them for their commitment. We
continue to focus additional resources on identifying and addressing particular health needs within our
community and region. To this end, I am grateful for the support, insight and input from the Community
Advisory Board.This voluntary group, under the chairmanship of Vernon Knight, provides an important
conduit between the community and hospital.
Finally, I would like to express my sincere appreciation to our staff, medical staff and management team.
It has been an extraordinarily challenging year and this hardworking group of people has, again, risen to the
challenge. It is testimony to their commitment that, under the circumstances, the Hospital has continued to
provide a great service to our community
Dane Huxley
Chief Executive Officer
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2013-14 – A Year of Progress
This has been a year of unprecedented development and
expansion at Mildura Base Hospital.
Mildura Base Hospital is working constantly to improve its
effectiveness as the region’s acute care health service provider.
In the past year, our successes in securing additional services,
resources and staff have included:
July
•Aboriginal Healing Centre - Installation of artwork outside
Aboriginal Healing Centre adjacent to hospital. Artwork
designed by local artists.
•headspace - A Mildura consortium won the battle for a
specialised youth mental health service
•Oncology upgrade – work starts on a half-million dollar
expansion of Mildura Base Hospital’s cancer treatment
facilities
October
•A start is announced to the biggest expansion of the
Mildura Base Hospital since construction of the new
hospital in 2000. Melbourne-based firm Building
Engineering Pty Ltd is appointed as the manager for the
12-month $7 million construction project.
November
•A dedicated Jane McGrath Foundation breast care nurse,
Louise James, is appointed to Mildura, ensuring an
increased level of support and advocacy for women with
breast cancer
•MBH welcomes staff consultant Ear, Nose and Throat
specialist Dr Peter Van Vuuran
September
•
ork starts on the $7 million MBH redevelopment. The
W
projects are scheduled to take a year to complete, and
will focus on the three priority areas – Accident and
Emergency, Maternity and Mental Health
January
•Mildura Base Hospital’s upgraded and expanded cancer
treatment facility takes its first patients. The work triples
the size of the Oncology Department, and doubles the
number of chemotherapy chairs to eight, allowing more
patients to receive treatment in Mildura
•A new CT Scanner is installed at MBH. The previous
scanner performed six axial slices of the anatomy – its highresolution replacement version is 128 axial slices. It allows
heart-scanning procedures at MBH for the first time
February
•The MBH Emergency Department redevelopment begins
to take shape, with the removal of the Emergency
Department canopy at the front of the hospital
•A new $5000 scholarship is announced by Ramsay
Healthcare to support nursing students at La Trobe
University Mildura
June
•A new Prevention and Recovery Centre (PARC) in
Mildura is announced in the Victorian Budget to focus
on re-integrating mental health patients back into the
community. The $4.4million centre will be run by Mildura
Base Hospital and a community provider
Other initiatives and developments throughout
2013-14 have included:
March
•Resident Oncologist Dr Divy Dua arrives in Mildura
•MBH stroke unit receives the Annual MBH Quality Award
recognising the team’s work in reducing the average
length of stay for stroke patients by more than two days.
The initiatives have also reduced the number of patients
experiencing complications from stroke to only nine
percent
•A new 37 unit accommodation complex for students and
clinicians is announced for 13th street
April
•A new community Stroke Support Group begins to operate
independently, after its formation was fostered by MBH
• Full time orthopaedic staff specialist surgeon Dr Willard
Bepete begins work
May
•Mildura Base Hospital announced as the lead agency to
develop a headspace facility in Mildura
• Establishment of Pain Service
•Increased Clinics (including Obstetrics and Gynaecology,
Ear Nose and Throat)
•Funding for E-Records and new patient management
computer system
• New sterilisers
•Securing funding for expansion of special care nursery and
development of resuscitation area
• Additional rotational doctors and RMOs
• Car Park expansion
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Mildura Base Hospital – At a Glance
Mildura Base Hospital is a 146 bed fully integrated regional
public hospital serving the Sunraysia area. The hospital
services an area population of approximately 80,000 and is the
major public referral centre for the Northern Mallee region
of Victoria, the far west region of New South Wales and the
Riverland area of South Australia and is a referral centre
for smaller regional hospitals such as Ouyen, Wentworth,
Robinvale, Balranald and Manangatang.
MBH provides a range of Acute Services, including
Emergency, Maternity, Intensive Care, General Medicine and
Surgery, Dialysis, Mental Health (Inpatient and community
services) and a range of ambulatory services:
• Ambulatory Care
– Physiotherapy
– Occupational Therapy
– Speech Therapy
– Dietary
– Audiology
– Social work
– Fracture clinic
– Wound Care clinic
– Rehabilitation
•Chemotherapy (eight beds)
•Operating Suite
– Day Surgery ( 12 beds and 6 recovery);Theatre
(3);Endoscopy Suite (1)
•Medical Imaging (Contracted)
•Dialysis (9 Chairs -satellite unit of Royal Melbourne
Hospital)
•Emergency Department (12 beds and 2 Resuscitation)
•Hospital Admission Risk Program
•Hospital In The Home
•Integrated Cancer Service (contractual)
•Infection Control
•Intensive Care Unit (5 beds)
•Maternity - (12 beds); Birth Suite (3); Special Care Nursery
(6)
•Medical (32 beds)
•Mental Health (10 plus 2 allocated for Aged persons)
•Paediatric
•Palliative Care (18 beds)
•Post-Acute Care
•Rehabilitation
•Surgical (32 beds)
•Transitional Care Program (TCP)
Our Management Team
Dane Huxley – Chief Executive Officer
Simone Heald – Director of Nursing
Dane was educated at Monash University where he obtained
a Bachelor of Arts and a Masters in Business Administration.
Dane has been actively involved in a number of organisations
in Mildura including the former positions of Chairman of
the Mildura Wentworth Arts Festival, Chairman of the
Northern Mallee Primary Care Partnership, Deputy Chairman
of the Sunraysia Mallee Economic Development Board and
Chairman of the Mildura Rural City Council Audit Committee
and Chair of the Mildura Development Corporation. Dane is
currently Chairman of the Sunraysia Modernisation Project.
Simone Heald joined Mildura Base in 1999 as a Registered
Nurse and Midwife. Simone has also complete studies in the
area of Childbirth Education, Adolescent Health and Welfare. She recently completed her Diploma of Management and is
now completing an MBA. Since commencing with Mildura
Base Hospital, Simone has held the Associate Director of
Nursing Role before taking on the Directors role in March
2010. Simone’s professional interests include developing a
collegial and supportive nursing department in which staff
are valued and respected.
Julia Morgan
– Director of Corporate Services
Julia Morgan commenced with Mildura Base Hospital in 2005
as an Accountant. After entering into a two year succession
plan in 2008, Julia was appointed Director of Corporate
Services following Brad Mottram’s retirement in January
2010. With qualifications in Accounting and Management
Julia previously held Senior Management positions in the
Higher Education sector in Adelaide before moving to
Mildura and commencing her career within the health
industry.
Dr Alison Walker – Director of
Anaesthetics & ICU, A/Director of Medical
Services
Dr Walker started at Mildura Base Hospital as a Staff
Consultant Anaesthetist in August 2010. Less than 12
months later she was appointed to the role of Director
of Anaesthetics and ICU – overseeing the provision of
anaesthetic services and the running of the hospital’s 5 bed
Intensive Care Unit. Dr Walker was promoted into the role of
Acting Director of Medical Services in January 2013 and has
fulfilled this role ever since.
Belinda Pavilach (not Pictured) –
Acting Director of Mental Health Services
Belinda Pavilach began her career as a Registered Nurse in
2000 as part of the Graduate Nursing Program at the Mildura
Base Hospital. Belinda chose a career path in Mental Health
and worked as part of the Inpatient Unit as well as in the
Community. She has taken on leadership roles such as Nurse
Unit Manager and Community Services Manager before
becoming the Acting Director this year. Belinda has a double
degree in Nursing and Mental Health and is committed to
a safe, quality, consumer-focused service within a recovery
framework.
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Our Organisational Structure
Ramsay Health
Care Board
Chief Executive
Officer
Personal Assistant
CEO
Director of
Medical
Sevices
Director of
Nursing
Director of
Mental Health
Services
Director of
Corporate
Sevices
Medical Admin.
Manager
Principal Nurse
Educator,
Cancer Care Coordinators
Clinical Director
– Metal Health
Services
Finance Manager
General Manager
Resources &
Facilities
Visiting Medical
Officer
ADON
(Clinical
Operations)
Associate
Director of
Mental Health
Payroll Accounts
Supply Services
Environmental
Services
Quality
Salaried Medical
Officer
Hospital Coordinators/Access
Manager, Wards
1, 2, 3, 4, ICU,
Dialysis/Chemo
Health
Information
Services
Food Services
Policy
Resident Medical
Officers
ADON
(Community
Operations)
Information
Technology
Maintenance
Department
General Manager
– Performance
Improvement
Risk
Infection Control
Pharmacy
Redesign
HMO Manager
Ambulatory
Care, Emergency
Department,
Dialysis/Chemo,
HITH, HARP,
Wound, TCP,
Breast Care
Nurse
Peri Operative
Services Manager
Improvement
Projects
Library
Consulting Suites
Theatre, Day
Surgery,
Recovery, CSSD,
Pre Admission,
Organ
Donation,
Stomal Therapy
Psychiatric Nurse
Consultant,
In-patient Unit
manager, Dual
Diagnosis,
Clinical Nurse
Educator/ECT,
Consumer
& Carer
Consultants
Manager of
Community
Services
OH & S
CYMMS, APMHS,
CCT, Perinatal,
CATT, Triage,
Service Access
Recruitment
Aboriginal
Health Unit
Our Committee Structure
Ramsay Health
Care
Chief Executive
Officer
Human Research
and Ethics
Medical Advisory
Committee and
Clinical Review
Committee
Community Advisory
Board
Medical Staff Group
(Medical Council)
Executive
Management
Committee
Quality Assurance
Sub-Committee
(Patient Care Review)
People, Culture and
Business Committee
Occupational Health
& Safety
Infection Control
Committee
Credentialling
Committee
Clinical Practice
Committee
Drugs & Theraputics
Committee
Specialty Groups
(Craft)
Operating Theatre
Users Group
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Community Advisory Board
From the Chairman
It is now two years since my re-appointment to the Community Advisory Board of the Mildura Base Hospital.
I have been pleased to re-establish my association with the talented team who manage our region’s acute care services.
The excellence of their work and that of their dedicated staff is well reflected in the Government’s independent audits and
the Quality of Care reports.
I also have the privilege of leading a great team who bring to the Board a range of professional knowledge and real
passion.
The past twenty-four months have seen significant development with extensions to our mental health facilities, oncology,
midwifery and the emergency department.
I want to thank the Victorian Health Minister David Davis for his willingness to listen to our needs and his preparedness to
act.
The Minister has made at least four visits to Mildura during this term of the Board and I greatly appreciate his interest and
support.
In the months ahead, we will be looking to increase our bed capacity and in concert with Monash University, we will
establish a Future Plan, which will aim to quantify our region’s requirements up to 2040.
Aside from addressing current needs, our Board recognises that its work must lay a platform for the next generation.
But it’s not just bricks and mortar that require our attention.
Assessing the skill sets needed to fulfil community expectations, demands careful planning in recruitment and professional
development.
Earlier this year, I was delighted to witness the awarding of the first of the Ramsay Health Nursing scholarships at La Trobe
University in Mildura.
These and other activities evidence our hospital’s investment in the years ahead.
To your health,
Adjunct Professor Vernon Knight AM JP
Chair, Mildura Base Hospital Community Advisory Board
Chairman: Vernon Andrew Knight AM JP
Vernon previously served as the Chair of the new Mildura Base Hospital from 2000 to
2006. He holds Degrees and Diplomas in Social Work and Youth Work and an Adjunct
Professorship of La Trobe University.
Vernon is currently the CEO of Mallee Family Care, a community based agency which
employs close to 300 staff in a wide range of health and human services. Those services
include Community Mental Health; Disability Training, Employment and Respite Care,
and Early Intervention Services for Pre-school Children with Multiple Disabilities. Awards
include Membership of the Order of Australia, the Australian Centenary Medal, Equity
Trustees CEO Long Term Achiever and a Paul Harris Fellow. He is married with six children.
Mrs Ada Peterson
Ada Peterson is employed at Mallee District Aboriginal Services in the role of Manager of
Community and Housing.
Ada attended the Red Cliffs High School and later completed a Diploma in Community
Education at RMIT Melbourne. Her qualifications include a Certificate in Business
Administration, Critical Incident Stress Debriefing and Management Training Course, Basic
Koori Counselling and DHS Child Protection and Youth Justice Professional Development
Unit (Beginning Practice in Child Protection).
Ada has been actively involved in a number of organisations in Mildura including the
Director Mildura Aboriginal Corporation- Secretary, Convener Mildura Aboriginal
Network, Chairperson Mildura Rural City Council Aboriginal Action Committee, LMML
Advisory Committee, LMARG, Interdepartmental Committee Mildura.
Sr. Marion McDonald
Sister Marion McDonald is a member of the Institute of Sisters of Mercy of Australia &
Papua New Guinea and is currently the Parish Leader of the Catholic Parish of Our Lady’s
in Merbein. Sr. Marion has years of experience in educational leadership and pastoral
ministry.
Sr. Marion has completed TPTC at Mercy College, Certificate in Education Administration,
Diploma in Teaching (primary), Bachelor in Theology and Graduate Diploma of Social
Science.
Sr. Marion is currently a member of the Chances for Children Selection Committee and a
member of the Mildura Base Hospital Ethics Committee
Mr John Tesoriero
John Tesoriero is currently Chair of the Board of Directors, of Lower Murray Water and
until recently, Project managed the development of a business case for the Sunraysia
Irrigation Modernisation Project for the Mildura Development Corporation.
John has extensive experience in the water industry including General Manager, Water
Supply for Southern Rural Water, Chief Executive Officer of the First Mildura Irrigation
Trust and General Manager Western Murray Irrigation.
John is a former Chairperson of the Murray Valley Citrus Board and was previously the
Chief Executive Officer of that organisation.
John previously served on the Mildura Base Hospital Board between 1991 and 1993. He
has a Graduate Diploma of Business (Administration) and is a member of the Australian
Institute of Company Directors
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Mr Gary Nalder
Gary is the Director of Corporate and Compliance at Mallee Family Care and has extensive
experience in Business Management.
Gary has completed an Advanced Certificate in Accounting, Certificate in Financial Services
and Company Director Course - Australian Institute of Company Directors.
Gary is a Board member of Sun Assist Volunteers Helpers Inc and member of the Chances
for Children Management Committee.
Assoc. Prof Fiona Wright
Fiona is Director of the Monash University School of Rural Health in Mildura. Prior to this,
Fiona was a GP registrar in Mildura, as well as Medical Director at Mildura Base Hospital.
Fiona has completed MBBS and BHSc and is a member of the Australian Institute of
Company Directors. She also serves on the Board of the Lower Murray Medicare Local.
Mr Gerald Purchase
Gerald Purchase was born, raised and educated in South Africa. He holds a Master’s
Degree in Clinical Psychology (Rhodes, 1981). After lecturing at University, he emigrated
to Australia, settling in Mildura. After ten years with the Victorian Department of Health
working with young children, he went into private practice. His current research interest in
Neurofeedback.
Mrs Gayle Danson
Gayle Danson is the Service Development Officer at Sunassist Volunteer Helpers Inc. and
has lengthy experience within the Disability and Aged Care Sectors.
She has been elected onto the Executive of the Northern Mallee Primary Care Partnership
for the last nine years
Gayle completed the Company Directors Diploma from the Australian Institute of
Company Directors, Collaborative Case Management course at University of Wollongong
and has undertaken a range of short course within the disability sector. Gayle also has
both teaching and librarian qualifications.
Gayle has been elected Director of MADEC Australia for the last five years, a member of
the MADEC Audit and Risk Committee, Convenor of the MADEC Building and Facilities
Committee and Convenor of the MADEC Nominations Committee.
Mr Dane Huxley
Dane Huxley is Chief Executive Officer of Mildura Base Hospital which is a privately
operated public Hospital. He has extensive public and private Hospital experience.
Dane was born in Melbourne and was educated at Monash University where he obtained
a Bachelor of Arts and a Masters in Business Administration.
Dane has been actively involved in a number of organisations in Mildura and has held
positions as Chairman of the Northern Mallee Primary Care Partnership, Chairman of
the Mildura Rural City Council Audit Committee, Chairman at the Mildura Development
Corporation, Chairman of the Mildura Wentworth Arts Festival and is currently Chairman
of the Project Control Group for the Sunraysia Modernisation Project.
Statement of Priorities
The Victorian Government’s priorities and policy directions are outlined in the Victorian Health Priorities Framework (20122022). In 2013 Mildura Base Hospital contributed to the achievement of these priorities by:.
Priority
Action
Hospital Deliverable
Achievements
Developing a system that is
responsive to people’s needs
• Implement formal
advance care planning
structures and processes
that provide patients with
opportunities to develop
review and have their
expressed preferences for
future treatment and care
enacted
• Adopt Ramsay Health Care
Advanced Care Plan Policy
statement and implement
guidelines throughout the
hospital by June 2014
• Participated in Loddon
Mallee Advanced Care Plan
Steering Committee
• Contribute to area based
planning initiatives that
consider health care across
the care continuum
• Prepare expression of
interest for headspace by
31 October 2013
• Expression of interest
submitted for headspace
October 2013
• Improve thirty-day
unplanned readmission
rates
• Ongoing monitoring of
readmission rates through
hospital craft groups to
maintain current low level
• Review of data collection
systems and processes to
reduce errors
• Review Improving Care
for Aboriginal and Torres
Strait Islander (ICAP) plan
by January 2014 to ensure
actions are within the
framework of Koolin Balit:
Strategic Directions for
Aboriginal Health 20122022
• Improving Care for
Aboriginal and Torres
Strait Islanders’ plan
completed November 2013
Improving every Victorian’s
health status and
experiences
• Identify service users
who are marginalised or
vulnerable to poor health,
and develop interventions
that improve outcomes
relative to other groups,
for example Aboriginal
people, people affected
by mental illness, people
at risk of elder abuse,
refugees and asylum
seekers
• Deliverable has been
reviewed to implement
organisational wide
policies supporting
Advanced Care Planning
by June 2015 as per the
Department of Health
Advance care planning:
have the conversation
strategy 2014-2018
• Mildura Base Hospital
successful as lead agency
in the local consortia for
headspace Mildura April
2014. Planned opening of
service late 2014.
• Monitoring via medical
and surgical craft groups
• Established and
strengthened links with
Mildura District Aboriginal
Corporation and Dareton
Community Health
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cont.
Priority
Action
Deliverable
Expanding service, workforce
and system capacity
• Build workforce capacity
and sustainability by
supporting formal and
informal clinical education
and training for staff
and health students,
in particular interprofessional learning
• Develop whole of hospital
education training
calendar incorporating
Ramsay Health Care
Mandatory E-Learning and
requirements for National
Safety & Quality Health
Service Standards (NSQHS)
• Whole of hospital
education calendar
implemented
• Work collaboratively with
the department on service
and capital planning to
develop service and system
capacity
• Completion of the
Oncology redevelopment
by November 2013
• Successful completion
and opening of new unit
October 2013
• Tender for capital works –
Mental Health, Emergency
Department, Obstetrics
and accommodation for
RMO’s finalised by May
2014
• Tender appointed and all
works commenced
• Develop and implement a
workforce immunisation
policy that builds capacity
and aligns with national
guidelines, including
reference to employment
screening and staff
immunisation assessment
• Implement Workforce
Immunisation Policy by
December 2013
• Workforce immunisation
policy implemented
January 2014
• Reduce variation in health
service administrative costs
• Utilise and analyse the
clinical costing system
and provide analysis to
appropriate staff in a
timely and regular basis
• Periodic review of clinical
costing data throughout
the year
Increasing the system’s
financial sustainability and
productivity
• Determine appropriate
patient and financial
data required to assess
compliance with National
Health Reforms and
provide reports on a
regular basis to key
personnel
Implementing continuous
improvements and
innovation
Achievements
• Draft policy framework
completed for mandatory
E-Learning
• Annual NSQHS education
calendar implemented
• Analysis of Operating
Suite efficiencies through
clinical costing and patient
administration data
• ICU WIES review
conducted in March 2014
• Achieved compliance with
VINAH dataset submission
• Identify opportunities for
efficiency and better value
service delivery
• Implement weekly
Consultant coding rounds
to improve communication
between Health
Information Managers and
Consultants by March 2014
• Review undertaken and
implementation plan
completed
• Support change and
innovation in practice
where it is proven to
deliver more effective and
efficient health care
• Change current Clinical
Handover practice by
April 2014 to conform
to National Safety and
Quality Health Service
Standard 6
• Clinical Handover policy
implemented August 2013
• Introduced ISBAR tools for
safer clinical handover
• Established Clinical
Handover Working Party
to support best practice
and educate staff
Priority
Increasing accountability &
transparency
Action
cont.
Deliverable
Achievements
• Prepare for
commencement of
proposed new mental
health legislation in 2014
• Recruit project personnel
by September 2013
• Staff recruited to Project
Officer position
• Facilitate education
forums at a local level
delivered by the Office
of Chief Psychiatrist for
mental health services
staff by December 2013
and ongoing as required
in 2014
• Education forums
presented by project staff
and Office of the Chief
Psychiatrist throughout
2013/14 in preparation for
the new Mental Health Act
implemented July 2014
• Prepare for the National
Safety and Quality Health
Service Standards, as
applicable
• Compliance with Standards
1-Governance, 2Partnering with Consumers
and Standard 3 Infection
Control by July 2013
• Achieved accreditation to
NSQHS Standards 1, 2 and
3 June 2014
• Conduct audits as
determined by the
Australian Commission for
Safety and Quality and
Health Care Workbook
October 2012 (table 8) by
October 2014
• Audits completed as per Australian Commission for
Safety and Quality and
Health Care Workbook
• Voluntary “gap analysis”
of 3 additional NSQHS
standards undertaken
during June 2014
surveillance audit
• Request the accrediting
agency include 3
additional National
Standards in the
surveillance audit June
2014
Improving utilisation
of E-Health and
communications technology
• Ensure that gender
sensitivity and women’s
safety are key in the
delivery of mental health
and alcohol and drug
services
• Redevelop Mental Health
Services Inpatient Unit to
maximise DoH Safety of
Women in Inpatient units
funding by December 2013
• Completed Stage 1 of
Safety of Women in
Inpatient Units - secure
private ensuite upgrade
• Maximise the use of health
ICT infrastructure
• Investigate the feasibility
of electronic records
management by June 2014
• Successful funding
application for the
implementation of an
electronic scanning system
• Stage 2 - security access
to women only corridor
in inpatient unit, due for
completion by December
2014
• Commenced investigation
of suitable scanning
system including Electronic
Medical Record and
Patient Administration
System capability
• Trial, implement and
evaluate strategies that
use E-health as an enabler
of better patient care
• Investigate opportunity
for telemedicine for subacute inpatient services by
March 2014
• Implemented Oncology
telemedicine clinic May
2014
• HARP Telemedicine project
commenced October 2013
15
16
Victorian Services Performance Report
The Department of Health works with Victorian health services to achieve healthcare that is highly reliable, delivered in
partnership with consumers and is based on the best information and evidence, in order to deliver safe, efficient and effective
healthcare to the community.
These reports are generated from the standard statistical information collected by all Victorian Victoria’s public hospitals and
health services.
Detailed reporting data is available at:
http://performance.health.vic.gov.au
Total number of patients admitted to hospital
Jul - Sep 2013
Oct - Dec 2013
Jan - Mar 2014
Apr- Jun 2014
4,496
4,526
4,463
4,492
Patients admitted for same day treatments
Jul – Sep 2013
Oct - Dec 2013
Jan - Mar 2014
Apr- Jun 2014
2,606
2,577
2,604
2,473
Total number of patients attending emergency department
Jul - Sep 2013
Oct - Dec 2013
Jan - Mar 2014
Apr- Jun 2014
7,535
7,241
6,944
7,221
Total number of emergency patients admitted
Jul - Sep 2013
Oct - Dec 2013
Jan - Mar 2014
Apr- Jun 2014
1,175
1,219
1,156
1,236
Emergency department patients treated within time
All patients attending emergency departments are “triaged” or assessed for urgency. Five triage categories have been
established by the Australasian College of Emergency Medicine. These categories indicate the desirable time with which
patients should be treated. This report shows the total number of emergency department patients who were treated within
national triage category desirable treatment times.
01 April 2013 - 30 June 2014
Jul - Sep 2013
Jul - Sep 2013
Oct- Dec 2013
Jan- Mar 2014
Apr-Jun 2014
Total emergency department Category 1
patients treated immediately (Statewide
target 100%)
19
26 (100%)
38 (100%)
19 (100%)
23 (100%)
patients treated within 10 mins (Statewide
target 80%)
476
482 (84%)
423 (87%)
381 (82%)
539 (83%)
patients treated within 30 mins (Statewide
target 75%)
1,970
1,931 (78%)
1,824 (84%)
1,773 (83%)
1,804 (78%)
patients treated within one hour
2,603
2,604 (79%)
2,662 (82%)
2,488 (83%)
2,491 (78%)
patients treated within two hours
767
759 (95%)
917 (94%)
916 (95%)
1085 (93%)
5,835
5,802
5,864
5,577
5,942
Total
Overall care index
Consumer participation indicator
Victoria is transitioning from the Victorian Patient Satisfaction Monitor (VPSM) survey to the new Victorian Health Experience
Survey (VHES). These reports are unavailable at the time of publishing, due to Statewide technical issues.
Mental Health Services
Service hours provided to consumers of community mental health services
01 January 2013 – 31 March 2014
Jan - Mar 2013
Apr- Jun 2013
Jul- Sep 2013
Oct - Dec 2013
Jan - Mar 2014
Apr - Jun 2014
3,845
3,696
3,479
3,267
3,652
3,369
17
18
Managing Risk
Mildura Base Hospital has continued to utilise the
Victorian Health Incident Management System (VHIMS) in
collaboration with Ramsay Health Care and the Victorian
Department of Health.
VHIMS provides the hospital with a standard electronic
method (which is used within all Victorian public hospitals) of
reporting, recording and tracking incidents that occur within
the health setting (RiskMan). This ensures that if things go
wrong, the hospital has a procedure in place for reporting
and managing clinical incidents.
All clinical incidents and near misses are reported into
the RiskMan database which promotes timely and effective
communication and subsequent review of incidents/events.
VHIMS not only encourages the collection of relevant
details about clinical incidents, but also ensures that
pertinent strategies/initiatives are undertaken to ensure
patient safety is maintained and that any identified issues
are addressed to prevent and/or minimise the likelihood of a
similar incident occurring again.
Compliments and complaints received
(July 2013- June 2014)
25
20
15
10
5
0
Jul
Aug
Sep
Oct
Nov
Dec
Complaints
Jan
Feb
Mar
Apr
May
Jun
Compliments
Complaints and Compliments
Comparison of annual data
Clinical Incidents
During 2013 - 2014 clinical related incidents accounted for
72% of all reported incidents. Utilising the standardised
VHIMS incident severity rating (ISR) score – severe, moderate,
mild and no harm/near miss to categorise incidents the
hospital had the following incidents reported:
• Severe = 1% clinical incidents
• Moderate = 4% clinical incidents
• Mild = 45% clinical incidents
• No harm/Near miss = 50% clinical incidents.
60%
50%
40%
30%
20%
10%
0%
Severe
Moderate
Mild
No harm / Near
miss
Non-clinical related incidents (OH&S and Hazards)
accounted for 28% of all reported incidents. The hospital
also utilises this same database to record reported Consumer
Feedback (compliments and complaints).
Feedback
(Complaints and Compliments):
The hospital appreciates all feedback about the services that
are provided and the manner in which they are delivered. All
feedback is seen by the hospital as an opportunity to improve
performance and service delivery. Feedback provides the
hospital with information about the patient/consumer
experience (both positive and negative).
As with incident notification, the hospital also utilises the
Victorian Health Incident Management System (VHIMS) to
record and monitor reported patient/consumer feedback
(compliments and complaints). The RiskMan database
(Feedback module) of VHIMS enables electronic recording
of feedback details, the seriousness/severity of the feedback
and the outcome for the patient/consumer. This provides a
streamlined approach to ensure that feedback is recorded,
investigated and followed up in a timely manner and provides
an appropriate resolution to the patient/consumer. It also
allows the hospital to effectively report and track feedback
received. The hospital’s reporting processes also ensures that
monthly reports are provided to the hospital’s Executive Team
and Community Advisory Board.
In early June 2013, the hospital implemented a new brochure
titled “Tell us about your experience – Patient/Consumer
Feedback”. The brochure provides some basic information
about who our patients and /or families may talk to if they
have any concerns or are unhappy about any aspect of their
healthcare. The brochure also provides some more specific
details about how to provide formal feedback to the hospital,
which may be either a compliment, suggestion or complaint.
Reportable Information
Compliments & Donations
We received 116 compliments in 2013-14. The Hospital welcomes open communication and seeks
feedback from our clients to assist in the implementation of quality improvement processes. We also
received 26 financial donations from various community members and organisations, and no donation/s
in kind.
Occupational Health & Safety
A strong safety culture exists within all areas of Mildura Base Hospital. The hospital complies with the
Occupational Health and Safety Act 2004.
Mildura Base Hospital monitors safety through management systems to ensure the safety and wellbeing
of consumers, patients, staff, visitors and contractors.
All safety matters are reported to the Occupational Health and Safety Committee, which reports to the
Executive team.
The OH&S department generates accurate and comprehensive reports to enable monitoring of the
Hospital performance at an organisational level.
Fire Audit Compliance
Fire Audits were completed at Mildura Base Hospital and met all relevant standards.
Whistleblowers Protection Act
Mildura Base Hospital received no disclosures for 2013/2014.
The purpose of the Act is to encourage and facilitate the making of disclosures of improper conduct by
public officers and public bodies.
Freedom of Information Requests
The Mildura Base Hospital processed 192 completed requests for information under the Freedom of
Information Act during the period 1 July 2013 to 30 June 2014. The response time for all requests was
within the 45-day timeframe specified under the Act.
Sub Contracts
We confirm that under 7.3 (c) of the Amended and Restated Management Agreement that no material
sub-contracts have been entered into since the Hospital opened. The following list constitutes the
major sub-contracts:
•
Chemtronics Biomedical Engineering – Biomedical Engineering
•Country Fire Authority – Fire Equipment Maintenance
• Sunraysia Waste – Hospital Waste
•Spotless Linen – Hospital Linen Services
•BOC Gases – Medical Gasses
•Ofsys – PABX System
•St John of God Health Care Inc – Pathology Services
•Mildura Medical Imaging Services – Radiology Services
•AE Atherton – Steriliser Maintenance
• Health Technologies – Vital Patient Management System
• Schneider – Building Management Systems.
19
20
Visiting Medical Officers
DENTISTRY
Medicine
Dr Paul Danenberg
Dr Jayant Kapoor
Dr Paul Nakhla
Dr Michael Robinson
Dr Daniel Tankard
Dr Terry Cook
Dr Alan Soward
Oral /
Maxillofacial
Surgery
Obstetrics /
Gynaecology
Dr Kevin Spencer
Dr Timothy Probert
Dr Stephen Gibbons
Radiology
Dr Lloyd Hale
Assoc Prof Ian Pettigrew
Dr Kimberley Sleeman
Dr Christopher Barry
General Practice
Orthopedic Surgery
Dr John Buckley
Dr Aqeel Chalabi
Dr John Dyson-Berry
Dr Gerald Murphy
Dr Brian Murphy
Dr Anthony Weller
Mr Douglas Gardiner
Surgery
Pathology
Mr Kevin Chambers
Dr Irene Kaiboni
Mr Salim Chaloob
Dematology
Dr Owen Harris
Urology
Dr Peter Liodakis
Dr Peter Milne
Dr Alex Cato
Vascular Surgery
Mr Peter Milne
Dr Michael Shepherd
Dr Michael Petrucco
Staff Consultants
Anaethesia
Medicine
Dr Alison Walker Dr Thara Ramkumar
Dr Antony Parakkal
Dr Tushar Indulkar
Dr Kumari Santhi
Dr Vasant Mani
Dr Divy Dua
Dr Alok Gupta
Emergency Medicine
Dr Dan Turner
Dr Mark Wadsworth
Dr Arvind Byka
Dr John Russell
Medical Oncology
Dr Divy Dua
Obstetrics /
Gynaecology
Dr Shabana Kapadia
Dr Raj Kumarasamy
Orthopaedic
Surgery
Surgery
Dr Willard Bepete
Mr Ali Estakhri
Mr Rotimi Afolabi
Paediatrics
ENT Surgery
Dr Lakshman Doddamani
Dr Chellam Kirubakaran
Dr Paul Tembo
Dr Peter Van Vuuren
Psychiatry
Dr Jenny Majoor
Dr Hieu Pham
Hospital Medical Officers
Registrars
Dr Atheel Badir
Dr Lavanya Duggirala
Dr Ashwini Enigo
Dr Andy Henry
Dr Deepa Venugopal
Dr Mandeep Kaur
Dr Dilruba Wadud
Dr Roshni Sonawane
Dr Aseel Marioud
Dr Janitha Gunathilaka
Dr Amin Rashid
Dr Prasad Waduge
Dr Mou Bose
Dr Eswari Byka
Dr Palitha Wijekoon
Dr Nick Lai
Dr Mina Nessim
Dr Mahima Indulkar
Dr Marne Estacio
Dr Sadia Uzair
Dr Jade Knights
Dr Dharminder Singh
Dr Omar AbdelRahman
Dr Sarath Attanayake
Dr Satheesh Gabriel
Dr Jane Neyland
Dr Narendra Duggirala
Dr Anirban Rashid
MBH Interns
Dr M Rasin Bhuiyan
Dr Tebogo Jabane
Dr Kevin Phang
Dr Jia Yew
Mildura Base
Hospital Staff
Mental Health Services
Chief Executive Officer – Mr Dane Huxley
Manager of Community Services – Steven Carr (Acting)
Medical Services
Nurse Unit Manager, Mental Health Inpatient Unit – Ed Tracey
Director of Medical Services – Dr Alison Walker
Team Leader: CATT Team – Tom Sutcliffe
Director of Emergency Department – Dr Dan Turner
Team Leader: Continuing Care – Melissa Kennelly (Acting)
Director of Anaesthesia – Dr Alison Walker
Manager Child and Youth Mental Health Services
– Kathy Crouch
Clinical Services
Director of Nursing – Simone Heald
Associate Director of Nursing (Clinical) – Claire Eaton
Associate Director of Nursing (Community Services)
– Angela Imms (until June 2014)
Perioperative Services Manager – Katrina Allen
General Manager: Performance Improvement – Janet Hicks
Clinical Consultant Infection Control – Liz Hume (until March
2014)
Director of Mental Health – Belinda Pavilach (Acting)
Clinical Director of Mental Health Services
– Dr Jennifer Majoor
Associate Director of Nursing – Chris Hermans
Manager Aged Persons Mental Health Services
– Leesa Bradshaw
Nurse Unit Managers (NUM)
Emergency Department – Mrs Leanne Dellar
Intensive Care Unit – Mrs Sue Hale
Maternity Services (Ward 1) – Rachel McDowall / Cheree Jukes
Paediatrics/Medical (Ward 2) – Ros Roberts
Medical / Surgical (Ward 3) – Kristjan Hobbs
Clinical Consultant Infection Control – Kaye Gathercole (from
March 2014)
Rehab/Aged Care (Ward 4) – Deanne Matotek
Corporate Services
Chemotherapy – Narelle Wadsworth
Director of Corporate Services – Julia Morgan
Finance Manager – Adam Stevenson
Network and Systems Administrator – Greg Orr
Health Information Services Manager – Sharon Smith
Supply Services Officer – Rod Moore
Renal Dialysis – Lynn Pike
Hospital Coordinators
Access Manager – Annette Wilson
Hospital Coordinator – Annie Lynch
Hospital Coordinator – Jill Nihill
Hospital Coordinator – Sianne Nicholds
Support Services
Hospital Coordinator – Julie Holland
General Manager: Resources & Facilities – Mr Don Palazzo
Hospital Coordinator – Kris Hopkins
Hotel Services Manager – Mr David Grenfell
Hospital Coordinator – Richard Wilke
Maintenance Officer – Mr Barry Jemmeson
We ta ke p
rid
in our work e
a nd
actively se
ek
wa ys of do
ing
thing s bett
er.
21
22
Attestation of Data Integrity
I, Dane Huxley certify that Mildura Base Hospital has put in place appropriate internal controls
and processes to ensure that reported data reasonably reflects actual performance. Mildura Base
Hospital has critically reviewed these controls and processes during the year.
Dane Huxley
Attestation of compliance with Australian/
New Zealand Risk Management Standard
I, Dane Huxley certify that Mildura Base Hospital 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 audit committee verifies this assurance and that the risk profile of Mildura Base
Hospital has been critically reviewed within the last 12 months.
Dane Huxley
FINANCIAL SUMMARY
FOR THE YEAR ENDED 30 JUNE 2014
The Comprehensive Operating Statement, Statement of Financial Position and Statement
of Cash Flows which has been drawn from Mildura Base Hospital’s audited financial
statements for the year ended 30 June 2014 is set out below.
MILDURA BASE HOSPITAL (OPERATOR)
COMPREHENSIVE OPERATING STATEMENT
Notes
2014
$
2013
$
1, 1a
94,722,284
90,786,248
(53,251,289)
(12,272,602)
(15,137,993)
(11,500,888)
(92,162,772)
(50,731,247)
(12,981,408)
(13,772,977)
(10,289,951)
(87,775,583)
NET PROFIT BEFORE TAX
2,559,512
3,010,665
Income tax expense
(774,500)
(910,432)
NET RESULT FOR THE YEAR
1,785,012
2,100,233
-
-
1,785,012
2,100,233
Revenue from operating activities
Employee expenses
Non salary labour costs
Supplies & consumables
Other expenses from operating activities
Total expenses from operating activities
Other comprehensive income
TOTAL COMPREHENSIVE INCOME FOR THE YEAR
1
23
24
STATEMENT OF FINANCIAL POSITION
AS AT 30 JUNE 2014
2014
$
2013
$
ASSETS
Current Assets
Cash and cash equivalents
Receivables
Inventories
Prepayments
32,077,847
784,256
181,414
2,475
25,844,069
465,442
618,329
Total Current Assets
33,043,517
26,930,315
Non Current Assets
Net deferred tax assets
4,502,921
3,830,881
Total Non Current Assets
4,502,921
3,830,881
37,546,438
30,761,196
871
9,972,962
9,193,816
5,668,620
7,891,495
Total Current Liabilities
19,167,649
13,560,115
Non Current Liabilities
Employee benefits
4,478,512
5,085,816
Total Non Current Liabilities
4,478,512
5,085,816
TOTAL LIABILITIES
23,646,161
18,645,931
NET ASSETS
13,900,277
12,115,265
EQUITY
Accumulated surpluses
13,900,277
12,115,265
TOTAL EQUITY
13,900,277
12,115,265
TOTAL ASSETS
LIABILITIES
Current Liabilities
Bank overdraft
Payables
Employee benefits
2
STATEMENT OF CASH FLOWS
2014
$
2013
$
Receipts
Operating grants from government
Patient fees
GST recovered from ATO
Other
100,694,681
4,076,422
2,520,860
1,837,184
90,121,043
3,517,367
2,756,804
845,022
Payments
Employee benefits paid
Fees for service - Medical Officers
Payments for supplies and consumables
GST paid to ATO
Other
NET CASH FLOWS FROM OPERATING ACTIVITIES
(52,351,920)
(12,354,377)
(14,077,894)
(9,113,279)
(14,099,185)
7,132,492
(50,279,273)
(12,962,196)
(13,896,715)
(7,817,314)
(12,156,366)
128,372
-
-
(7,135,838)
(7,135,838)
(128,472)
(128,472)
NET DECREASE IN CASH HELD
(3,346)
(100)
CASH AT BEGINNING OF YEAR
2,475
2,575
CASH AT END OF YEAR
(871)
2,475
CASH FLOWS FROM OPERATING ACTIVITIES
CASH FLOWS FROM INVESTING ACTIVITIES
CASH FLOWS FROM FINANCING ACTIVITIES
Advance of funds to related parties
NET CASH FLOWS USED IN FINANCING ACTIVITIES
3
25
26
NOTE TO THE FINANCIAL STATEMENTS
1. REVENUE
HSA
2014
$
Revenue from Operating Activities
Government grants
- Department of Human Services
- Commonwealth Government
Patient and resident fees (refer Note 2c)
Indirect contributions by Department of Human
Services
Other revenue from operating activities
Total Revenue from Operating
Activities (refer to Note 2a)
Non
HSA
2014
$
HSA
2013
$
Non
HSA
2013
$
Total
2014
$
Total
2013
$
86,495,816
2,765,677
3,561,560
82,270,474
2,041,237
3,431,798
-
-
86,495,816
2,765,677
3,561,560
82,270,474
2,041,237
3,431,798
735,476
1,587,876
735,450
1,163,755
719,413
1,899,231
1,587,876
1,454,863
93,558,529
90,066,835
1,163,755
719,413
94,722,284
90,786,248
Other
2014
$
Total
Entity
2014
$
1a. ANALYSIS OF REVENUE BY SOURCE
Admitted
Patients
2014
$
Revenue from Services Supported by
Health Services Agreement
Government Grants:
- Department of Human Services
- Commonwealth Government
Patient and Resident Fees (refer note 2c)
Other
Sub-Total Revenue from Services
Supported by Health Services Agreement
Hospital and Community Initiatives
Business Units
Property income
Private Practice
Supported by Hospital and Community
Initiatives
Total Revenue from Operating Activities
Outpatients
2014
$
56,057,939
2,074,258
2,204,595
528,444
4,669,593
165,941
1,349,782
42,274
14,201,344
525,478
133,874
11,566,940
7,183
30,884
-
86,495,816
2,765,677
3,561,560
735,476
60,865,236
6,227,590
14,860,696
11,605,007
-
93,558,529
-
-
-
-
505,113
658,642
505,113
658,642
60,865,236
6,227,590
14,860,696
11,605,007
1,163,755
1,163,755
1,163,755
94,722,284
Admitted
Patients
2013
$
Health Services Agreement
Government Grants:
-Department of Human Services
-Commonwealth Government (Other)
Indirect contributions by Department of
Human Services
-Insurance
Patient and Resident Fees (refer note 2c)
Other
Supported by Health Services Agreement
Hospital and Community Initiatives
Business Units
Property income
Private Practice
Supported by Hospital and Community
Initiatives
Total Revenue from Operating Activities
Mental
Health
2014
$
EDS
2014
$
Outpatients
2013
$
Mental
Health
2013
$
EDS
2013
$
Total
Entity
2013
$
Other
2013
$
55,886,607
1,592,165
3,729,310
102,062
12,180,414
347,010
10,474,143
-
-
82,270,474
2,041,237
990,835
1,978,647
518,434
63,515
1,313,819
33,233
215,951
112,992
317,575
139,332
70,791
-
1,587,876
3,431,798
735,450
60,966,688
5,241,939
12,856,367
11,001,841
-
90,066,835
-
-
-
-
439,608
279,805
439,608
279,805
60,966,688
5,241,939
12,856,367
11,001,841
719,413
719,413
719,413
90,786,248
4
Working with the community
to achieve the best health outcomes
MILDURA BASE HOSPITAL
Ontario Avenue,
Mildura Vic 3500
Telephone (03) 5022 3333
Facsimile (03) 5022 3228
www.ramsayhealth.com.au
A MEMBER OF THE RAMSAY HEALTH CARE GROUP

2013 - 2014 - Mildura Base Hospital

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