Disclosure Index 2. Manner of Establishment and the Relevant Minister 5

Transcription

1 2017

2 Table of Contents Disclosure Index 2 Attestations 4 Manner of Establishment and the Relevant Minister 5 Chair and Chief Executive Report (Incorporating Key Initiatives and Projects) 6 Nature and Range of Services Provided 7 Corporate Governance 8 Organisational Structure 9 Workforce Information 9 Service Performance 10 Summary of Financial Results 11 Details of Information and Communication Technology (ICT) expenditure 11 Details of Consultancies 12 Occupational Health and Safety 12 Occupational Violence 13 Statement of Priorities Part A: Strategic Priorities Statement of Priorities Part B: Performance Priorities Statement of Priorities Part C: Activity and Funding Statements of Compliance and Competitive Neutrality 23 Environmental Performance 24 Additional Information Available on Request 25 Donors and Contributors 26 1

3 Disclosure Index The annual report of Beechworth 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 22H Manner of establishment and the relevant Ministers 5 FRD 22H Purpose, functions, powers and duties 5 FRD 22H Initiatives and key achievements 6 FRD 22H Nature and range of services provided 7 MANAGEMENT AND STRUCTURE FRD 22H Organisational structure 9 FINANCIAL AND OTHER INFORMATION FRD 10A Disclosure index 2 FRD 11A Disclosure of ex-gratia expenses N/A FRD 21C Responsible person and executive officer disclosures FS FRD 22H Application and operation of Protected Disclosure FRD 22H Application and operation of Carers Recognition Act FRD 22H Application and operation of Freedom of Information Act FRD 22H Compliance with building and maintenance provisions of Building Act FRD 22H Details of consultancies over $10,000 (exc. GST) 12 FRD 22H Details of consultancies under $10,000 (exc. GST) 12 FRD 22H Employment and conduct principles 9 FRD 22H Information and Communication Technology Expenditure 11 FRD 22H Major changes or factors affecting performance 11 *FS refers to Financial Statements as enclosed 2

4 Legislation Requirement Page Reference MINISTERIAL DIRECTIONS REPORT OF OPERATIONS FRD 22H Occupational violence 13 FRD 22H Operational and budgetary objectives and performance against objectives FRD 24C Reporting of office-based environmental impacts 24 FRD 22H Significant changes in financial position during the year 11 FRD 22H Statement on National Competition Policy 23 FRD 22H Subsequent events FS 65 FRD 22H Summary of the financial results for the year 11 FRD 22H Additional Information available on request 25 FRD 22H Workforce Data Disclosures including a statement on the application of employment and conduct principles FRD 25C Victorian Industry Participation Policy disclosures 23 FRD 29B Workforce Data disclosures 9 FRD 103F Non-Financial Physical Assets FS FRD 110A Cash Flow Statements FS 10 FRD 112D Defined Benefit Superannuation Obligations FS SD Declaration in report of operation 4 SD Risk management framework and processes 4 9 OTHER REQUIREMENTS UNDER STANDING DIRECTIONS 5.2 SD Declaration in financial statements FS 4 SD 5.2.1(a) Compliance with Australian accounting standards and other authoritative pronouncements SD 5.2.1(a) Compliance with Ministerial Directions FS 11 *FS refers to Financial Statements as enclosed FS 11 LEGISLATION Freedom of Information Act 1982 Page 23 Protected Disclosure Act 2012 Page 23 Carers Recognition Act 2012 Page 23 Victorian Industry Participation Policy Act 2003 Page 23 Building Act 1993 Page 23 Financial Management Act 1994 Page 4 Safe Patient Care Act 2015 Page 23 3

5 Attestations RESPONSIBLE BODIES DECLARATION AS AT 30 JUNE 2017 In accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for Beechworth Health Service for the year ending 30 June /08/2017 Katie Warner Board Member Beechworth Date ATTESTATION FOR COMPLIANCE WITH THE MINISTERIAL STANDING DIRECTION RISK MANAGEMENT FRAMEWORK AND PROCESSES I, Mark Ashcroft, certify that Beechworth Health Service has complied with the Ministerial Standing Direction Risk management framework and processes. Beechworth Health Service s Quality, Risk and Governance Committee verifies this. 29/08/2017 Mark Ashcroft Accountable Officer Beechworth Date ATTESTATION ON COMPLIANCE WITH HEALTH PURCHASING VICTORIA (HPV) HEALTH PURCHASING POLICIES I, Mark Ashcroft, certify that Beechworth Health Service has put in place appropriate internal controls and processes to ensure that it has complied with all requirements set out in the HPV Health Purchasing Policies including mandatory HPV collective agreements as required by the Health Service Act 1988 (Vic) and has critically reviewed these controls and processes during the year. 29/08/2017 Mark Ashcroft Accountable Officer Beechworth Date 4

6 Manner of establishment and the relevant Ministers Beechworth Health Service is incorporated as a Public Hospital and is listed within Schedule 1 of the Health Services Act Responsible Ministers: The Honourable Jill Hennessey, Minister for Health, Minister for Ambulance Services The Honourable Martin Foley, Minister for Housing, Disability and Ageing, Minister for Mental Health. PURPOSE, FUNCTIONS, POWERS AND DUTIES The objectives of the health service are to: 1. Provide public hospital and residential aged care services; 2. Provide health and community services and to work with the communities of Beechworth and surrounding areas to deliver comprehensive, quality health and wellness services in partnership with the community, health professionals and funding bodies; and 3. Pursue activities that are intended to make the health service more efficient. 5

7 Chair and Chief Executive Report (incorporating Key Initiatives and Projects) On behalf of the Board of Management we are pleased to present the Beechworth Health Service Annual Report for the year ending 30 June 2017 in accordance with the Financial Management Act The financial year has presented a number of challenges for Beechworth Health Service. In spite of these challenges, much of what has been achieved in the past twelve months has served to reinforce the dedication of our staff and their ability to work together to ensure a sustainable health service moving forward SERVICES Beechworth Health Service has been able to maintain a commitment to its full range of services, across acute, aged care and community programs. We have also maintained and enhanced our commitment to relationships with other service providers for the benefit of patients, residents and staff, e.g. access to telehealth services and to Specialist Geriatrician services with Northeast Health Wangaratta and formal clinical governance support with Albury-Wodonga Health. In responding to the Department of Health and Human Services Targeting Zero, 2016, Quality & Safety in Healthcare report, Beechworth Health Service has proactively sought to review and enhance its existing focus on clinical care across all of its program areas. During the financial year, Beechworth Health Service commenced a schedule of Clinical Grand Rounds and has established a relationship with the NSW Clinical Excellence Commission as well as the Victorian Safer Care Clinical Council. Our local General Practice colleagues continue to provide strong support for Beechworth Health Services clinical service delivery, clinical review and clinical enhancement programs. Further progress has been made on the Aged Care Significant Refurbishment Project. A Project Control Group with the assistance of Designs Plus Pty Ltd, and consumer / resident representation has overseen the development of a substantive amount of preparation work in anticipation of progressing the Project to build phase in the first half of the next financial year. This project will see the majority of the remaining shared bathrooms in Beechworth Health Services residential care program turned into single bathrooms. This work is aimed at benefiting existing and prospective residents, as well as staff work patterns. FINANCIAL Financially, Beechworth Health Service has been able to return a modest surplus and in doing so has recovered from last year s deficit of approximately $38,000. An ongoing commitment to good financial planning has assisted Beechworth Heath Service to continue to focus on opportunities to improve revenue and reduce expenditure. Apart from enhancing our finance and management reporting systems, much of the recognition for our financial year result must go to the hard work of our line managers, department heads and their respective teams. Beechworth Health Service also continues to enjoy the benefits of financial management support from Northeast Health Wangaratta s Finance team. Overall, the very good work in managing our financial position is the result of the commitment of all our staff, volunteers and service partners. This commitment and good work gives Beechworth Health Service confidence in facing and subsequently dealing with new challenges that the next financial year is likely to bring. PLANNING The financial year also saw Beechworth Health Service commence its Service Plan. This work, with the assistance of Birru Health, is scheduled to be completed very soon. This planning process has benefited from the direct involvement of Beechworth Health Services staff, its volunteers, many of its service partners and a number of community groups with whom Beechworth Health Services is looking forward to working with throughout the implementation of the Service Plan. Beechworth Health Services has also provided direct input into the current Indigo Shire Health and Wellbeing Plan. Beechworth Health Services Community Advisory Committee continues to go from strength to strength in terms of its agenda focus and the connection it provides the health services to its community. This connection is reinforced through our Volunteers and through our Community Committee members. WORKFORCE During the financial year, Beechworth Health Service set out to continue to enhance its student placement profile and its commitment to the training and development to staff. In addition, our existing training and development plan has been enhanced to include a focus on family violence awareness. Ongoing commitment to the improvement of immunization rates amongst our staff has seen influenza vaccination uptake rates increase. We have also seen increased subscription by staff to the People Matter Survey, which is now conducted on an annual basis. This provides Beechworth Health Service with feedback from its staff across a range of key themes. ACKNOWLEDGEMENTS Beechworth Health Services has had a number of key staff changes over the past financial year. The transition process associated with staffing changes has been made all the more easy as a direct result of a strong Board of Management and a stable and committed staff base. Beechworth Health Services acknowledges the contribution of Ms. Lisa Pryor who acted in the Chief Executive Officer (CEO) role 6

8 between the departure of the previous CEO and the arrival of Mr. Mark Ashcroft as the new CEO. Beechworth Health Services also welcomed Ms. Carolyn Shaw into the role of Director of Corporate Services but farewelled Ms. Karen Kruger, a long standing member of our corporate team. A number of other clinical and support staff has either joined or left Beechworth Health Service over the past twelve months and their contribution is eagerly anticipated and gratefully recognised respectively. Beechworth Health Services is particularly grateful to all our volunteers, our Mayday Ladies Auxiliary and the numerous local support and carer groups that enhance the service we provide, both directly and indirectly within the local community. Our service exists to enhance the health of our local community. Our people, working alongside our community and with our service partners, represent our capacity to achieve this. Katie Warner Board Member Beechworth Mark Ashcroft Accountable Officer Beechworth Nature and range of services provided Beechworth Health Service is a public funded health service with its principal location in Beechworth, north east Victoria. It serves the eastern aspect of Indigo Shire, including the communities of Beechworth, Stanley, Wooragee, Yackandandah, Tangambalanga and Kiewa Valley. The following services are provided: Acute Acute care unit that is inclusive of an urgent care. Afterhours services are supported by local General Practitioners as well as telehealth access to Northeast Health Wangaratta. Aged Care 60 residential aged care beds. Community Health Diverse range of community health services provided at Beechworth, Yackandandah and Tangambalanga. These services include physiotherapy, occupational therapy, dietetics, diabetes education, podiatry, speech pathology, health promotion, needs assessment, care coordination, and case management. Home and Community Care (HACC) this includes the service provision of district nursing, planned activity groups and podiatry across all of Indigo Shire. Beechworth Health Service is an intrinsic part of the local community and has strong relationships with local educational facilities, community service organisations and neighbouring health providers. 7

9 Corporate Governance The organisation has been governed by a Board appointed by the Governor-in-Council, upon the recommendation of the Minister for Health. The main functions of the Board are to guide the entity in accordance with government policy. This involves providing strategic leadership, monitoring performance and ensuring accountability and compliance. BOARD OF MANAGEMENT Ms Katie Warner, President Ms Jennifer Gordon, Vice President Ms Georgina Bladon Ms Anita Goodman (resigned Oct 2016) Dr David Lawrence Mrs Patricia Mom Dr Jacob Schluter Ms Birgit Schonafinger (resigned Dec 2016) Mr Harry Thomas Ms Natalie Willis Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 BOARD MEETINGS (NOMINATIONS IN JULY) BOM Apr 17 May 17 Jun 17 Number Attended K. Warner (President) % J. Gordon (Vice President) No meetings % G. Bladon % A. Goodman Resigned 1 9% D. Lawrence No % P. Mom meetings % B. Schonafinger Resigned 4 36% J. Schluter % H Thomas No meetings % N. Willis % 1= Present 0= Apology LA = Leave of Absence Av. CLINICAL GOVERNANCE COMMITTEE Ms. Jennifer Gordon (Chair) Dr. David Lawrence Ms. Natalie Willis Mr. Bernard Bolan Community Representative Mrs.Anne McDonald Community Representative FINANCE AND AUDIT COMMITTEE Mr. Harry Thomas (Chair) Ms. Georgina Bladon Ms. Katie Warner Dr. Jacob Schluter Mr. Tony Lund Community Representative MANAGEMENT Mrs. Lisa Pryor, Acting Chief Executive (Jul 2016 Aug 2016) Mr. Mark Ashcroft, Chief Executive Officer (Aug 2016 Jun 2017) Northeast Health Wangaratta, Finance Dr. Patrick Giddings, Director of Medical Services Ms. Dyan Hill, Human Resources Manager Mr. Shell Morphy, Quality & Risk Manager Mrs. Lisa Pryor, Director of Clinical Services (Aug 2016 June 2017) Mrs. Linda Earl, Acting Director of Clinical Services (July Aug 2016) Ms. Lynette Pritchard, Acting Services Manager (Jul 2016 Nov 2016) Ms. Carolyn Shaw, Corporate Service Manager (Nov 2016 June 2017) Ms. Kate Marshall, Residential Aged Care Nurse Unit Manager Mrs. Linda Earl, Acute Unit Manager (Aug 2016 June 2017) Mrs. Elizabeth Masters, Acting Acute Unit Manager (July 2016 Aug 2016) Ms. Louine Robinson, Primary Health Team Leader Mrs. Lynda Thompson, DNS/PAG Team Leader 8

10 Organisational Structure BOARD OF MANAGEMENT CHIEF EXECUTIVE OFFICER Executive Assistant / ICT Contracted Director Medical Services Contracted Payroll Services Contracted OH&S Director of Clinical Services Corporate Service Manager Quality & Risk Manager ADONS Food Services Environmental Residential Care ACUTE Maintenance Administration HACC Primary Health Human Resources Payroll Advice Staff Development Infection Control Health Information Manager Workforce Information Labour Category June Current Month FTE June YTD FTE Nursing Administration & Clerical Hotel & Allied Services Medical Officers Ancillary Support Totals Beechworth Health Service ensures a fair and transparent process for the recruitment, selection and promotion of employees. Policies and procedures ensure people are treated fairly with appropriate avenues for grievance and complaint processes. Beechworth Health Service is committed to the application of the employment and conduct principles and all employees have been correctly classified in workforce data collections. 9

11 Acute/Aged Care Service Performance OCCUPANCY UNIT 2012/ / / / /17 Acute/Transition Care 61.71% 62.89% 65.80% 75.02% 79.14% Urgent Care Centre Presentations The Acacias 98.43% 97.96% 96.72% 93.29% 95.36% Stringybark Lodge 97.50% 98.09% 98.41% 94.11% 97.64% HOURS OF SERVICE PRIMARY HEALTH 2012/ / / / /17 Physiotherapy 1,244 1,654 2,593 2, Dietetics Occupational Therapy Podiatry , HACC Podiatry Community Nursing Planned Activity Groups High 9,520 7,392 8,810 8,950 6,856 Planned Activity Groups Core 11,596 11,478 10,224 9,718 11,887 District Nursing 2,849 2,514 2,925 3,157 2,709 10

12 Summary of Financial Results $000 $000 $000 $000 $000 Total Revenue 13,365 13,905 13,189 12,277 14,629 Total Expenses (13,914) (13,993) (13,298) (13,423) (15,036) Net Result for the Year (including Capital & Specific Items) Retained Surplus/ (Accumulated Deficit) (549) (88) (109) (1,145) (407) ,097 Total Assets 32,281 31,951 30,780 28,889 25,926 Total Liabilities 9,751 9,061 7,801 5,801 6,079 Net Assets 22,530 22,890 22,979 23,088 19,847 Total Equity 22,530 22,890 22,979 23,088 19,847 Beechworth Health Service budgeted for an operating surplus of $12,000 for the year. The final operating result is an $81,000 surplus resulting from an increase in Residential Aged Care occupancy and funding, as well as a number of operational efficiency measures during Details of Information and Communication Technology (ICT) expenditure The total ICT expenditure incurred during is $503,138 (excluding GST) with the details shown below. Business As Usual (BAU) ICT expenditure Non-Business As Usual (non-bau) expenditure Operational expenditure (excluding GST) Capital expenditure (excluding GST) $503,138 $0 $503,138 $0 11

13 Details of Consultancies CONSULTANCIES GREATER THAN $10,000 (EXCLUDING GST) In there were 3 consultancies where the total fees payable to the consultant were greater than $10,000. The total expenditure incurred during in relation to this consultancy was $39,323 (excluding GST). Consultant Purpose of Consultancy Start date End date Total approved project fee (excluding GST) Expenditure (excluding GST) Future expenditure (excluding GST) Michael Rhook Financial modelling to support contract negotiations with NEBMHS. 1/07/ /06/2017 $15,333 $15,333 - Biruu Health Consultancy Designs Plus Rachel Bohm Service Planning 1/07/ /06/2017 $19,850 $19,850 $5,970 Aged Care Refurbishment 1/07/ /06/2017 $60,000 $4,140 $55,860 CONSULTANCIES LESS THAN $10,000 (EXCLUDING GST) In there was 4 consultancies where the total fees payable to the consultants were less than $10,000. The total expenditure incurred during in relation to this consultancy was $6,669 (excluding GST). Occupational Health and Safety Beechworth Health Service monitors its approach to workplace health and safety through its Occupational Health and Safety Committee. This Committee also monitors compliance to our commitments as prescribed under the Occupational Health and Safety Act Of significance, Beechworth Health Service s lost time due to injuries experience has improved in both the and annual reporting periods. Furthermore, as a result of Occupational Health & Safety Committee oversight and through the commitment of Beechworth Health & Safety Representatives with staff support, claims lodged with our WorkCover claims insurer for the most recent reporting period, have been classified as minor in nature. The description minor claim means that the reported injury is less, rather than more severe. This claim reporting experience for , represents an improvement on year. LOST TO WORKPLACE INJURY End 2013 End 2014 End 2015 End 2016 End

14 Occupational Violence All Victorian Health Services, including Beechworth Health Service, are required to monitor and publicly report incidents of occupational violence. This follows the Victorian Government s commitment to address occupational violence in healthcare and the Victorian Auditor-General s audit report Occupational Violence against healthcare workers (released in 2015) that identified better awareness of the prevalence and reporting of occupational violence incidents was required. Occupational Violence incidents reported during were as follows: Occupational violence statistics Workcover accepted claims with an occupational violence cause per 100 FTE 0 2. Number of accepted Workcover claims with lost time injury with an occupational violence cause per 1,000,000 hours worked. 3. Number of occupational violence incidents reported Number of occupational violence incidents reported per 100 FTE Percentage of occupational violence incidents resulting in a staff injury, illness or condition 0 0 DEFINITIONS For the purposes of the above statistics the following definitions apply: Occupational violence any incident where an employee is abused, threatened or assaulted in circumstances arising out of, or in the course of their employment. Incident occupational health and safety incidents reported in the health service incident reporting system. Code Grey reporting is not included. Accepted Workcover claims accepted Workcover claims that were lodged in Lost time lost time is defined as greater than one day. 13

15 Statement of Priorities Part A: Strategic priorities In Beechworth Health Service will contribute to the achievement of the Government s commitments by: Domain Action Deliverables Outcomes Quality and safety Implement systems and processes to recognise and support person centred end of life care in all settings, with a focus on providing support for people who choose to die at home. Implement end of life pathways to improve patient care. Review existing processes in line with Care plan for a dying person Victoria. Achieved. Person Centred Care Committee has overseen the development of new guidelines for implementing end of life pathways. Advanced care planning is included as a parameter in an assessment of outcomes including: mortality and morbidity review reports, patient experience and routine data collection. Progress implementation of a whole-of-hospital model for responding to family violence. Develop a regional leadership culture that fosters multidisciplinary and multiorganisational collaboration to promote learning and the provision of safe, quality care across rural and regional Victoria. Include Advanced Care Planning in mortality review criteria, patient experience surveys and routine data collection. Work with Goulburn Valley Health to implement the Strengthening Hospital Response to Family Violence initiative. Satisfy the White Ribbon accreditation process. Monitor the application of newly introduced screening and referral pathways. Beechworth Health Service will continue to participate in regional based groups, such as the Hume Region Nurse and Midwife Education Group, and collaborate with regional partners. Achieved. Mortality and Morbidity review process considers advanced care plan uptake and directives. Director of Medical Services (DMS) oversees reviews and outcome recommendations. Achieved BHS met with GV Health who presented the Strengthening Hospital Responses to Family Violence (SHRFV) Service Model, including the 2 overarching principles or Gender Equality and Sensitive Practice. The 6 key elements of work to ensure successful implementation were discussed and project resources shared. A BHS work plan has been developed and key staff have been identified to lead the SHRFV work to increase capability and capacity of managers and staff to identify and respond to family violence and build networks with local service networks. Training staff to build capacity and capability is a critical element of the SHRFV model, however all foundation elements will be in place prior to staff training commencing. Train the trainer sessions will be provided by GV Health in Achieved. Membership maintained on various regional clinical leadership groups. Initiated development of East Hume patient flow collaborative. 14

16 Domain Action Deliverables Outcomes Use patient feedback, including the Victorian Healthcare Experience Survey to drive improved health Consumer representatives to sit on all operational committees. Establish terms of reference for the Achieved Consumer representation enshrined in all Committee membership remits. outcomes and experiences through Consumer Advisory Committee. Consumer Advisory Committee a strong focus on person and Establish a reporting schedule for active family centred care in the planning, Victorian Healthcare Experience delivery and evaluation of services, The annual Victorian Healthcare Survey to be reviewed within and the development of new Experience Survey report is the Beechworth Health Service models for putting patients first. presented to the Person Centred committee structure. Care Committee (PCCC) each September. The PCCC reports to the Quality and Safety Committee and through to the BOM. Develop a whole of hospital approach to reduce the use of restrictive practices for patients, including seclusion and restraint. Maintain a restraint-free status across all Beechworth Health Service clinical services. Deliver education in line with Beechworth Health Service s restraint-free policy and the Victorian Charter of Human Right for new staff within the orientation program and in a refresher program for existing staff. Refresher program to be incorporated into the staff development plan. Achieved Beechworth Health Service maintains a commitment to a restraint free environment. Restraint free policy profiled within policy of the month program. Restraint education included on the annual staff development plan. Access and timeliness Identify opportunities and implement pathways to aid prevention and increase care outside hospital walls by optimising appropriate use of existing programs (i.e. the Health Independence Program or telemedicine). Implement the Hume Chronic Care Strategy priorities by adopting the expanded chronic care model to prevent avoidable presentations and admissions. Improve access to highest need population cohorts. Work with the Primary Health Network to support the delivery of Health Pathways with local General Practitioners. Participate in service collaborative like the current Diabetes collaborative. Provide education to staff of the referral pathways to Health Independence Programs within the Eastern Region Rural areas of Goulburn and Ovens Murray. Identify additional opportunities to engage health providers via telemedicine. Achieved. Hume Chronic Care Strategy implemented with a focus on avoidable presentations and admissions. Various key staff members engaged in the development of Health Pathways, led by the Primary Health Network. Beechworth Health service staff member is the current chair of Hume Diabetes Collaborative. Education to staff on referral pathways to Health Independence Programs provided. New telehealth applications in general medicine handover in early stages of development. 15

17 Statement of Priorities Domain Action Deliverables Outcomes Develop and implement a strategy to ensure the preparedness of the organisation for the National Disability and Insurance Scheme and Home and Community Care program transition and reform, with particular consideration to service access, service expectations, workforce and financial management. Collaborate with key stakeholders to prepare and implement the National Disability and Insurance Scheme (available from October 2017) and Home and Community Care transitions. Participate in regional based meetings and forums. Achieved. Continue to integrate My Aged Care into existing policy and processes. Collaboration for service planning reaffirmed through consumer and service partner engagement in BHS Service Plan NDIS and aged care reform planning incorporated into service planning process. Engaged in regional meetings and forums at CEO, clinical, quality, finance, ICT and compliance themes. Ongoing integration of My Aged Care reform directions into existing BHS policy guidelines as appropriate. Supporting healthy populations Support shared population health and wellbeing planning at a local level - aligning with the Local Government Municipal Public Health and Wellbeing plan and working with other local agencies and Primary Health Networks. Ongoing collaboration with planning activities of local health agencies, local government and primary health networks to ensure improved local health and wellbeing. Achieved. Service Plan engaged local health agencies, local government and primary health networks. Focus on primary prevention, including suicide prevention activities, and aim to impact on large numbers of people in the places where they spend their time adopting a place based, whole of population approach to tackle the multiple risk factors of poor health. Expand the community wide resilience project for children into the following localities Yackandandah, Kiewa, Tangambalanga, Osbourne's Flat, Allan's Flat and surrounds, in partnership with local schools and local government. Achieved. Expanded the community wide resilience project for children into the following localities Yackandandah, Kiewa, Tangambalanga, Osbourne s Flat, Allan s Flat and surrounds, in partnership with local schools and local government. Develop and implement strategies that encourage cultural diversity such as partnering with culturally diverse communities, reflecting the diversity of your community in the organisational governance, and having culturally sensitive, safe and inclusive practices. Implement the first phase actions of Beechworth Health Service s organisation wide diversity plan. Achieved. Implemented the first phase actions of Beechworth Health Service s organisation wide diversity plan and monitored through BHS s Person Centred care Committee. 16

18 Domain Action Deliverables Outcomes Improve the health outcomes of Aboriginal and Torres Strait Islander people by establishing culturally safe practices which recognise and respect their cultural identities and safely meets their needs, expectations and rights. Implement the first phase actions of Beechworth Health Service s organisation wide diversity plan with a specific focus on the following for Aboriginal and Torres Strait Islander people: Achieved. Raise the profile of National Aboriginal and Islander Day Observance Committee week within the organisation. Review the organisation signature to incorporate the acknowledgment of Aboriginal and Torres Strait Islander people. Actively recruit Aboriginal and Torres Strait Islander people to the Community Advisory Committee. Commenced incorporation of Acknowledgement of Country at significant meetings and events. National Aboriginal and Islander Day Observance Committee (NAIDOC) week profiled in organisation via social media and internal communication modes, local primary school artwork created in the theme of NAIDOC week displayed across the organisation. Organisation signature now incorporates the acknowledgment of Aboriginal and Torres Strait Islander people. Invitation made ongoing to Aboriginal and Torres Strait Islander people to join the Community Advisory Committee. Drive improvements to Victoria's mental health system through focus and engagement in activity delivering on the 10 Year Plan for Mental Health and active input into consultations on the Design, Service and infrastructure Plan for Victoria's Clinical mental health system. Actively participate in the project to establish telemedicine links into the Kerferd Mental Health triage team. Achieved. Actively participating in the planning for the development and enhancement of telehealth links for the management of mental health triage processes. Using the Government's Rainbow equality Guide, identify and adopt actions for inclusive practices' and be more responsive to the health and wellbeing of lesbian, gay, bisexual, transgender and intersex individuals and communities. Implement the first phase actions of Beechworth Health Service s organisation wide diversity plan with a specific focus on the following for lesbian, gay, bisexual, transgender and intersex communities: Raise the profile of lesbian, gay, bisexual, transgender and intersex within the organisation. Review the organisation signature to incorporate the acknowledgment of lesbian, gay, bisexual, transgender and intersex communities. Achieved. Organisation signature now incorporates the acknowledgment of lesbian, gay, bisexual, transgender and intersex communities. 17

19 Statement of Priorities Domain Action Deliverables Outcomes Demonstrate implementation of Review the recommendations Achieved. the Victorian Clinical Governance from the Duckett review and Policy Framework: Governance the Beechworth Health Service for the provision of safe, quality clinical governance framework healthcare at each level of self assessment survey, conduct the organisation, with clearly a gap analysis of Beechworth s documented and understood roles existing clinical governance and responsibilities. Ensure effective framework and establish an action integrated systems, processes and plan accordingly. leadership are in place to support the provision of safe, quality, accountable and person centred healthcare. It is an expectation that health services implement to best meet their employees' and community's needs, and that clinical governance arrangements undergo frequent and formal review, evaluation and amendment to drive continuous improvement. Governance and leadership Targeting Zero 2016 recommendations reviewed and a gap analysis completed referencing BHS s existing clinical governance framework. Revised BHS s Clinical Governance Charter with a focus on the revised Victorian Clinical Governance Framework guidelines. Key Targeting Zero 2016 recommendations currently being implemented into policy and practice. Contribute to the development and implementation of Local Region Action Plans under the series of statewide design, service and infrastructure plans being progressively released from Development of Local Region Action Plans will require partnerships and active collaboration across regions to ensure plans meet both regional and local service needs, as articulated in the statewide design, service and infrastructure plans. Through Beechworth Health Service s planning process, inclusive of local regional service partners, complete a review of capital and service requirements for the next five years to align statewide planning for infrastructure investment. Achieved. Service Plan commenced in conjunction with a defined financial sustainability plan. Local regional service planning partners consulted throughout the Service Plan planning process. Ensure that an anti-bullying and harassment policy exists and includes the identification of appropriate behaviour, internal and external support mechanisms for staff and a clear process for reporting, investigation, feedback, consequence and appeal and the policy specifies a regular review schedule. Educate 100% of new and existing staff regarding the organisations bullying and harassment policy, code of conduct and associated performance management processes. Ensure all policies and procedures comply with the anti-discrimination and occupational health and safety regulatory compliance. Achieved. Orientation for new staff incorporates a focus on BHS s bullying and harassment policy, code of conduct and associated performance management processes. Policies and procedures revision incorporates compliance analysis with the anti-discrimination and occupational health and safety regulatory compliance. 18

20 Domain Action Deliverables Outcomes Board and senior management ensure that an organisational wide occupational health and safety risk management approach is in place which includes: (1) A focus on prevention and the strategies used to manage risks, including the regular review of these controls; (2) Strategies to improve reporting of occupational health and safety incidents, risks and controls, with a particular focus on prevention of occupational violence and bullying and harassment, throughout all levels of the organisation, including to the board; and (3) Mechanisms for consulting with, debriefing and communicating with all staff regarding outcomes of investigations and controls following occupational violence and bullying and harassment incidents. Establish a Healthy Workplace Working Party to give effect to the Healthy Together Victoria Workplace Achievement Program. Occupational Health and Safety Committee to continue to work through initiatives including consolidating all incident reporting regarding occupational violence and aggression into a single database to enhance organisational analysis, and revising the terms of reference for the Occupational Health and Safety committee to ensure that a representative mix of staff are engaged in the organisational Occupational Health and Safety strategy. Achieved. Healthy Workplace Working Party established. Occupational Health and Safety Committee have established a defined occupational violence and aggression agenda item and has reviewed its terms of reference to cater for the inclusion of a focus on occupational violence and aggression. Implement and monitor workforce plans that: improve industrial relations; promote a learning culture; align with the Best Practice Clinical Learning Environment Framework; promote effective succession planning; increase employment opportunities for Aboriginal and Torres Strait Islander people; ensure the workforce is appropriately qualified and skilled; and support the delivery of high quality and safe person centred care. Review the workforce plan and ensure it meets changing workforce needs and best practice. Achieved. Workforce plan reviewed. 19

21 Statement of Priorities Domain Action Deliverables Outcomes Create a workforce culture that: (1) includes staff in decision making; (2) promotes and supports open communication, raising concerns and respectful behaviour across all levels of the organisation; and (3) includes consumers and the community. Tailor the Beechworth Health Service service planning approach to include opportunities for staff to directly contribute to strategic decision making. Achieved. Review the application of the Hardwiring program across the organisation with a focus on its contribution to organisational values, culture and communication. Consumer consultation and/ or representation on 100% of committees or working groups. Service Plan consultation facilitated direct staff engagement. Organisational values assessment framework incorporated into all BHS committee agendas. Hardwiring program reviewed with ongoing hardwiring directions being developed with a commitment to the DHHS Health Improvement Capability Quotient Tool. Consumer representation enshrined in all Committee membership remits. Ensure that the Victorian Child Safe Standards are embedded in everyday thinking and practice to better protect children from abuse, which includes the implementation of: strategies to embed an organisational culture of child safety; a child safe policy or statement of commitment to child safety; a code of conduct that establishes clear expectations for appropriate behaviour with children; screening, supervision, training and other human resources practices that reduce the risk of child abuse; processes for responding to and reporting suspected abuse of children; strategies to identify and reduce or remove the risk of abuse and strategies to promote the participation and empowerment of children. Apply the overview of the Victorian Child Safe Standards guidelines across existing Beechworth Health Service policy with a specific focus on identification of areas of risk, development of appropriate screening mechanisms and referral processes, and formalise child safety within the staff education schedule. Achieved. Completed revision of BHS policy to incorporate Victorian Child Safe Standards guidelines. Child safety code of conduct has been developed and included in policy. The Child Safety policy has been incorporated into the policy of the month program. Implement policies and procedures to ensure patient facing staff have access to vaccination programs and are appropriately vaccinated and/or immunised to protect staff and prevent the transmission of infection to susceptible patients or people in their care. Strengthen pre-employment processes to ensure compliance with vaccination policy and clinical guidelines. Monitor vaccination rates through the Infection Prevention and Control Committee and report compliance through the clinical governance committee. Achieved. Pre-employment processes ensure compliance with vaccination policy and clinical guidelines. Staff vaccination rates are monitored through Infection Control Committee and reported through the Committee for Quality and Safety in Healthcare. 20

22 Domain Action Deliverables Outcomes Further enhance cash management Partially achieved. strategies to improve cash sustainability and meet financial obligations as they are due. Financial sustainability Complete significant refurbishment project for residential care to qualify for the significant refurbishment uplift and to enhance the fabric of Beechworth Health Service s aged care facilities and position Beechworth Health Service as an aged care facility of choice within the aged care community. Significant pre-build preparation work has been completed by the Significant Refurbishment Project Control Group. Significant refurbishment works currently in tender phase. Actively contribute to the implementation of the Victorian Government s policy to be net zero carbon by 2050 and improve environmental sustainability by identifying and implementing projects, including workforce education, to reduce material environmental impacts with particular consideration of procurement and waste management, and publicly reporting environmental performance data, including measureable targets related to reduction of clinical, sharps and landfill waste, water and energy use and improved recycling. Undertake replacement program of all existing halogen and incandescent lighting. Achieved. Complete replacement mapping completed for halogen and incandescent lighting replacement with LED lighting at BHS. Demonstration room with replacement LED lighting established. 21

23 Statement of Priorities Part B: Performance priorities QUALITY AND SAFETY PERFORMANCE Key Quality and Safety Performance Indicator Target Actual Accreditation Compliance with NSQHS Standards accreditation Full compliance Full compliance Compliance with the Commonwealth s Aged Care Accreditation Standards Full compliance Full compliance Infection prevention and control Compliance with cleaning standards Full compliance Full compliance Submission of infection surveillance data to VICNISS Full compliance Full compliance Compliance with the Hand Hygiene Australia program 80% 89.3% Percentage of healthcare workers immunised for influenza 75% 95% Patient experience Victorian Healthcare Experience Survey data submission Full compliance Achieved Victorian Healthcare Experience Survey patient experience Quarter 1 95% positive experience Full Compliance* Victorian Healthcare Experience Survey patient experience Quarter 2 95% positive experience Full Compliance* Victorian Healthcare Experience Survey patient experience Quarter 3 95% positive experience Full Compliance* Victorian Healthcare Experience Survey discharge care Quarter 1 75% positive response Full Compliance* Victorian Healthcare Experience Survey discharge care Quarter 2 75% positive response Full Compliance* Victorian Healthcare Experience Survey discharge care Quarter 3 75% positive response Full Compliance* *Less than 42 responses were received for the period due to relative size of the Health Service. GOVERNANCE AND LEADERSHIP Key performance indicator Target Actual People Matter Survey - percentage of staff with a positive response to safety culture questions 80% 95% FINANCIAL SUSTAINABILITY Key performance indicator Target Actuals Finance Operating result ($m) Trade creditors 60 days 30 days Patient fee debtors 60 days 42 days Adjusted current asset ratio Number of days with available cash 14 days 30 days Asset management Basic asset management plan Full compliance Full compliance 22

24 Part C: Activity and funding Funding type Activity Acute Admitted Public WIES 280 Private WIES 86 TOTAL PPWIES (Public & Private) 366 DVA WIES 7 TAC WIES 0 Statement of compliance and competivite neutrality FREEDOM OF INFORMATION In accordance with the Freedom of Information Act 1982, this institution has appointed the Chief Executive as the Freedom of Information Officer and requests for information are processed in accordance with the Legislation. There were 2 Freedom of Information (FOI) requests received by Beechworth Health Service during PROTECTED DISCLOSURE ACT 2012 Beechworth Health Service has applied and operated in accordance with the Protected Disclosure Act 2012 to the establishment of procedures for making, handling and notifying any disclosures. No disclosures have been received in CARERS RECOGNITION ACT 2012 In accordance with the Carers Recognition Act 2012, Beechworth Health Service has complied with the provisions through ensuring that all staff and volunteers respect and recognise carers, support them as individuals, recognise their efforts and dedication, take into account their views and cultural identity, recognise their social wellbeing and provide due consideration of the effect of being a carer on matters of employment and education. VICTORIAN INDUSTRY PARTICIPATION POLICY ACT 2003 Beechworth Health Service has no items relevant to the Act during the reporting period BUILDING ACT 1993 Beechworth Health Service complies with the provisions of the Building Act 1993 in accordance with DHS Capital Development Guidelines (Minister for Finance Guideline Building Act 1993/ Standards for Publicly Owned Buildings 1994/Building (Interim) Regulations 2005 and Building c of Australia 2004). FINANCIAL MANAGEMENT ACT 1994 Beechworth Health Service complies with the provisions of the Financial Management Act 1994 in accordance with the Department of Treasury and Finance s Financial Management Framework and related guidance to assist the public sector ensure sound financial management of public resources SAFE PATIENT CARE ACT 2015 Beechworth Health Service complies with the requirements of the Safe Patient Care Act 2015 in accordance with its obligations under the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement COMPETITIVE NEUTRALITY In accordance with government policy Beechworth Health Service has ensured that during competitive neutrality requirements per the Competitive Neutrality Policy Victoria and subsequent reforms were met. 23

25 Environmental Performance Beechworth Health Service has undertaken a number of initiatives to improve its environmental performance. Initiatives to reduce the consumption of utilities such as LPG, electricity and water have continued during Measures to reduce waste and increase recycling have been introduced. 140, , ,000 80,000 60,000 40,000 20,000 0 ELECTRICITY BHS Jul Jul Sept Oct Nov Dec Jan Feb Mar Apr May Jun kwh Cost $ 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 LPG BHS Jul Jul Sept Oct Nov Dec Jan Feb Mar Apr May Jun Litre Cost $ 2,000 1,800 1,600 1,400 1,200 1, WATER BHS Jul Jul Sept Oct Nov Dec Jan Feb Mar Apr May Jun Kilolitre Cost $ 24

26 Additional Information Available on Request In accordance with FRD 22H (Section 6.19) details in respect of the items listed below have been retained by Beechworth Health Service and are available to the relevant Ministers, Members of Parliament and the public on request (subject to the freedom of information requirements, if applicable): Declarations of pecuniary interests have been duly completed by all relevant officers; Details of shares held by senior officers as nominee or held beneficially; Details of publications produced by Beechworth Health Service about itself, and how these can be obtained; Details of changes in prices, fees, charges, rates and levies charged by Beechworth Health Service; Details of any major external reviews carried out for Beechworth Health Service; Details of major research and development activities undertaken by Beechworth Health Service that are not otherwise covered either in the Report of Operations or in a document that contains the financial statements and Report of Operations; Details of overseas visits undertaken including a summary of the objectives and outcomes of each visit; Details of major promotional, public relations and marketing activities undertaken by Beechworth Health Service to develop community awareness of its services; Details of assessments and measures undertaken to improve the occupational health and safety of employees; General statements on industrial relations within Beechworth Health Service and details of time lost through industrial accidents and disputes, which is not otherwise detailed in the Report of Operations; A list of major committees sponsored by Beechworth Health Service, the purposes of each committee and the extent to which those purposes have been achieved; Details of all consultancies and contractors including consultants/contractors engaged, services provided, and expenditure committed for each engagement. 25

27 Other Information Donors and Contributors Donations and bequests assist Beechworth Health Service to maintain its high standard of services to residents and the community. For we acknowledge the financial contributions of: OVER $500 Auxiliary of Beechworth Health Service Beechworth & District Community Bank Commercial Club Albury Latipsoh Appeal 2016 Ritchies IGA Beechworth Anonymous $500 AND UNDER Beechworth Branch of Red Cross Beechworth Football Club Beechworth Lodge Beechworth Uniting Parish Carpe Diem Coca Cola In memory of Bernie Delaney In memory of Bob Stone In memory of Keith Stone John Eldrid Kathy Dolny Kiosk Mr & Mrs Turley My Health my Life Rotary Club of Beechworth Tate Funeral Services BEECHWORTH COMMUNITY CHRISTMAS LUNCHEON 24 Seven Events Beechworth Barrowthon The Highlanders Team Beechworth Branch of Red Cross Beechworth Community Childcare Centre Beechworth Community Support Beechworth Correctional Centre Beechworth Kindergarten Beechworth Lions Club Beechworth Men s Shed Beechworth Montessori School Beechworth Primary School Beechworth Soldiers Memorial Hall Committee Beechworth Sweet Company Beechworth Taxis Bendigo Bank Christensen Orchard Christmas Day & pack up Deborah Peel Indigo Shire Jim Jam Foods Salvation Army Sandra Williams St Joseph s Beechworth Tom & Erin Powell Volunteers (coordinate, set up, assist on the day) 26

28 27

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45 ,004 1,

46

47

48

49 - 282

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100