Annual and Quality of Care Report 2008...2 Colac Area Health Vision Colac Area Health aims to be a...

Colac Area HealthAnnual and Quality of Care Report2008

Respect Integrity Leadership Innovation Quality Partnership

2 Colac Area Health

VisionColac Area Health aims to be a recognised

leader in the development and provision of

responsive, integrated health care.

MissionTo promote the health and wellbeing of the

Colac and district community through the

provision of quality acute, aged, residential

and community services that are accessible,

aff ordable, fl exible and integrated.

Corporate ValuesRespect

Integrity

Leadership

Innovation

Quality

Partnership

Contents Page Vision, Mission and Corporate Values 2Highlights 4High Achievers 4Calendar of Events 4Our Organisation 5Our Services 6Our Performance 7Our Community 8Auxiliaries 8 Bequests and Donations 8Making a Donation 8 Community Partnerships 8 Volunteers/Certifi cates of Service 8Organisational Structure 9Chairman and CEO’s Report 10Strategic Direction 12 Corporate Governance 16 Executive Management Team 17Risk Management 17 Board of Directors 18Clinical Services 21Acute Care Unit 22Corangamarah Residential Aged Care facility 23Preadmission and Discharge Planning Clinic 24Operating Suite 25Day Surgery Unit 26Haemodialysis Unit 26Urgent Care Unit 27 Infection Control 28Pharmacy 29

Page Education Centre 30 Visiting Medical Staff 31 Medical Services 32Health Information 33 Primary Care Services 34Allied Health 34Community Nursing 37Family and Community Services 39 Human Resources 40 Occupational Health and Safety 40 Service Awards 41Staffi ng Profi le 42 Support Services 43 Waste Management 44 Information and Communication 46 Statutory Compliance 47 Disclosure Index 49 Financial Services 50 Certifi cation 51 Auditor-General’s Report 52 Financial Statements 54Sponsors 87Acknowledgements/Publications 87Consumer Liaison 87

Inside

2008 Annual and Quality of Care Report 3

High Achievers Colac Area Health (CAH) congratulates Chris Towers on the successful completion of her Master of Nursing with the publishing of her thesis titled “Secondary school nurses’ and their work providing school based sexual and reproductive health programs in Victorian public schools”. Chris has now completed the clinical and post graduate components required for endorsement as a Nurse Practitioner.

Congratulations to Julie Hallifax and Tamara Holmes for obtaining scholarships to undertake further training in their respective areas of Alcohol and Drugs and Children’s Counselling. Julie obtained a scholarship from Flinders University South Australia to undertake professional development in the area of co morbidity, and Tamara obtained a scholarship from the Australian Rural Allied Health Professionals Network to study a Graduate Diploma in Mental Health Sciences: Child Adolescent and Family Therapies.

Calendar Annual General Meeting - November • 2008Blue Ribbon Foundation Annual • RodeoCorangamarah Art Prize - con.ceit ‘09•

Events

HighlightsOffi cial visit by Hon. Daniel Andrews, MP, Minister for Health, to recognise the refurbishment and naming of former nursing homes Otway Pioneers and Polwarth House Service Centre and Offi cial Announcement of Galvin-McCarthy Administration building

Corangamarah Art Prize - con.ceit ‘07

Relocation of Community Dental Clinic to main campus

Sealing of carpark to facilitate safer, convenient parking for staff and visitors

Colac Otway Business Awards - Employee of the Month Finalist

4 Colac Area Health

Our Organisation Colac Area Health (CAH) provides services to Colac Otway, Corangamite and Surf Coast shires with a catchment population of about 30,000. Colac Area Health is a unique, integrated health service model which provides Acute, Residential Aged Care and Primary Care services. Colac Area Health currently operates an acute public health service (50 beds), Corangamarah Residential Aged Care facility (75 beds), Birregurra Community Health Centre, Community Dental Clinic, Community Nursing incorporating Home and Community Care, Hospital in the Home, Post Acute Care, Palliative Care and an extensive range of Primary Care services.

Our HistoryColac Community Health Services was established on July 1, 1995, by the amalgamation of Colac District Hospital, Colac Area Community Health Centre Incorporated and Colac Housing and Financial Counselling Service. A further amalgamation took place with the Birregurra and District Community Hospital on January 1, 1997. From July 1, 2002 the organisation offi cially became known as Colac Area Health. Colac Area Health commissioned the services of Dr Dawn Peel to document our comprehensive history. Her book “Quality Community Care — Colac District Hospital 1882 to Colac Area Health 2003” was offi cially launched in March, 2004. Colac Area Health commenced a major redevelopment project in December, 2001. Stage 1A comprised the construction of a two-storey building which provided temporary accommodation for the Primary Care staff until 2007 and permanent accommodation for pharmacy and pathology services. This building also includes the Helen Macpherson Smith Trust Conference Centre; an excellent venue for staff education. Stage 1B, the Acute Medical Services building, was completed in February, 2003. This was the fi rst major redevelopment of acute patient services since 1971. This building comprises 15 single rooms, nine twin-share rooms, two four-bed rooms, two birthing suites, seven day surgery beds, Emergency Department, Operating Suite and Central Sterilising Supply Department. In August 2006, CAH completed Corangamarah, a $14 million state-of-the-art Residential Aged Care facility which provides High Level Residential and Respite Care

and comprises 75 beds; 14 twin-share and 47 single rooms and includes a dementia-specifi c unit. Corangamarah has numerous private courtyards, as well as having landscaped gardens for residents and relatives to enjoy. While the facility incorporates large communal gathering areas, there are also private areas for residents to take time out for personal relaxation. In 2008, the fi nal stages of the redevelopment were completed with the refurbishment of Polwarth House and Otway Pioneers and the establishment of a Community Dental Clinic on the main campus.

About ColacThe Colac Otway Shire is one of the most picturesque municipalities in Victoria, covering a diverse area from volcanic lakes, craters and plains in the north, through to the hinterland forests of the Otway Ranges to the Great Ocean Road coastline. The area provides diverse employment through a range of primary industries, tourism and commercial and community services. Colac is the key industrial, commercial and service centre for the Colac Otway and surrounding region with a population of 12,000.


Anglesea

Acute Care• Acute Care• Day Chemotherapy• General Medicine• Haemodialysis• Midwifery Services• Obstetrics and Gynaecology• Paediatrics• Pharmacy • Rehabilitation • Surgery - Dental, General, Gynaecology, Ophthalmology, Orthopaedic, Urology• Urgent Care

Aged Care• High Level Residential and Respite Care

Allied Health • Adult Day Activity Centre • Community Dental Clinic• Community Rehabilitation Centre• Health Promotion• Nutrition• Occupational Therapy• Physiotherapy• Podiatry• Speech Pathology

Community Nursing• Barwon Post Acute Care• Birregurra Community Health Centre• Chronic Disease Management• Community and Adolescent Health• Community Women’s Health• Continence Resource• Diabetes Education• Home Nursing• Hospital in the Home• Lymphoedema Clinic• Palliative Care Nursing/Volunteers• Wound Management Resource

Community Programs• Alcohol and Other Drugs• Colac Community Hub• Children’s Resource Program (Regional)• Drug Diversion Network (Regional)• Family Violence• Gambler’s Help• Supported Accommodation Assistance Program (Regional) • Women’s Health• Youth Development

Family Services• Child FIRST Intake• Family Support• Financial Counselling• Saver Plus Program• Transitional Housing• Women’s Counselling• Youth and Children’s Counselling

Diagnostic Services• Pathology • Radiology/Medical Imaging

Visiting ServicesThere are Visiting Services such as Family Planning, Drink Driver Education Program, Legal Aid, Prosthetics and Orthotics and Geelong Centre Against Sexual Assault.

Co-Located Services• Department of Human Services Child Protection• Diversitat• Neighbourhood Renewal• Pathways PDRSS• Time for Youth

Our Services

6 Colac Area Health

Our Performance 2007/2008 2006/2007 2005/2006 2004/2005 2003/2004 2002/2003

FinancialTotal Revenue 30,293,886 29,421,802 34,497,391 27,362,187 25,165,947 27,835,998

Total Expenditure 29,863,963 28,783,276 27,876,313 27,266,900 25,676,618 24,270,073

Revaluation Increment 821,236 - 5,602,270 - - 2,243,556

Fund Decrease Resulting from

Change in Accounting Policy - - - - - (35,215)

Surplus/(Defi cit) inc. Capital

Income and Unfunded Depreciation 429,923 638,526 12,223,348 95,287 (510,671) 5,774,266

Total Assets 44,355,128 42,905,863 41,823,383 28,938,566 29,007,894 28,617,037

Total Liabilities 6,426,450 6,582,740 6,796,864 6,484,135 6,808,388 5,909,754

Total Equity 37,928,678 36,323,123 35,026,519 22,454,431 22,199,506 22,707,283

StaffFull Time Equivalent 283.41 285.29 285.90 285.60 282.55 283.80

Bed DaysHospital 13,279 14,608 13,417 13,495 13,602 14,809

Average Length of Stay 2.52 2.84 2.67 2.78 3.05 3.32

Aged Care 26,478 26,901 25,418 24,385 25,965 27,713

Births 216 187 179 194 190 168

Operations 2,304 2,168 2,280 2,190 1,999 2,108

Inpatient StatisticsSame Day 2,680 2,649 2,722 2,524 2,231 2,281

Multi Day 2,527 2,484 2,308 2,342 2,231 2,293

TOTAL SEPARATIONS 5,257 5,133 5,210 5,060 4,462 4,574

Weighted Inlier Equivalent Separations (WIES)

2,997 3,144 3,019 2,925 2,822 2,859

Aged Care StatisticsResidents 111 126 127 140 155 112

Urgent CareOutpatient Attendances 7,914 7,296 7,029 6,941 8,091 8,091

Community ServicesTotal Contacts 57,097 57,286 56,951 51,092 52,707 52,531

Total Clients 12,871 9,499 9,422 8,614 8,697 8,666

Patient Fees Outstanding – Outstanding Debtors as at 30 June 2008Under 30 Days

30-60Days

60-90Days

Over 90 Days

Total30/06/08

Total30/06/07

Total30/06/06

Total30/06/05

Total30/06/04

Private 39,768 17,635 8,295 9,142 74,840 60,515 10,251 140,263 80,848

TAC - - - - - - - - -

VWA 7,346 - 5,560 - 12,906 8,999 6,006 7,350 8,684


Our Community

8 Colac Area Health

AuxiliariesColac Area Health (CAH) recognises the valuable contribution of our Auxiliary members over many years. The members have raised thousands of dollars which has enabled CAH to purchase equipment, furnishings and fi ttings to benefi t the community when using the Health Service. In August, 2007 CAH was presented with a cheque for $3,500 by the Colac Auxiliary.

The Birregurra Community Health Centre Auxiliary continues to support the Community Health Centre at Birregurra and provides ongoing fundraising which assists with the purchase of equipment for the Centre.

Bequests and DonationsAs a result of fundraising campaigns, local community members, auxiliaries, volunteers, service clubs and groups, bequests, local businesses and CAH staff have raised in excess of $139,140.

Colac Area Health has been successful in receiving funds from the following philanthropic trusts, bequests and donations:

• Tattersalls Foundation $40,000• Estate RJ Speirs (distribution) $11,500• Perpetual Trustee Co- RP Medical Fund $10,800• Palais Bingo $ 6,000

Making a DonationColac Area Health is very fortunate to receive generous contributions from our community through donations and bequests. We encourage you to consider Colac Area Health when making your Will. If you wish to discuss this further, please contact the Chief Executive Offi cer on (03) 5232 5123. All enquiries are treated with the strictest confi dence.

Community PartnershipsBlue Ribbon FoundationA small but dedicated committee came together six years ago with a novel idea to host a rodeo in Colac. This event became part of the New Year calendar for many, attracting enthusiastic crowds. However due to circumstances beyond our control, the 2008 rodeo was cancelled. Plans are underway for 2009 and this event will continue to raise awareness of this important foundation while raising funds to purchase vital equipment for the Emergency Department at CAH.

VolunteersColac Area Health currently has 209 registered volunteers, excluding palliative care volunteers.

These volunteers continue to be recognised as a vital part of CAH and provide assistance in the following areas:

- Adult Day Activity Program- Childminding- Clerical Roles- Colac Area Health Auxiliaries- Community Hub- Community Programs- Flower Ladies- Pastoral Visiting- Residential Aged Care

Certifi cates of ServiceCertifi cates of Service are awarded to volunteers

on completion of ten years service. Recipients at the Annual General Meeting held in November, 2007, were as follows:

- Mrs. Betty Cadby - Palliative Care- Mrs. Lorraine Evans - Palliative Care- Mr. Michael McGannon - Palliative Care- Mrs. Leona Pekin - Palliative Care

Director Clinical Services

Head Chef


Director Corporate Services

Organisational Structure

Board of

Directors

Chief Executive

Offi cer

The Community

Management Accountant

Financial Accountant

Manager Information & Communication

Manager Health Information Services

Manager Administration Services

Manager Support Services

Clinical Coordinators

Nurse Unit ManagerAcute Care Unit

Manager Pharmacy

Business Nurse ManagerResidential Aged Care

Nurse Unit ManagerOperating Suite

Nurse Unit ManagerUrgent Care

Clinical Educator

Infection Control Nurse

Coordinator No Lift

Coordinator Preadmission & Discharge Planning

--------

Manager Supply

Human ResourcesManager

Manager Payroll Services

Manager Quality & Risk

Manager Allied Heatlh

Manager Community Nursing

Manager Community Programs

Manager Family Services

Director Primary Care

--------------------------------------------------------

In accordance with the Financial Management Act 1994, we are pleased to present the Report of Operations of Colac Area Health (CAH) for the year ending 30 June, 2008. 2007/08 fi nancial year witnessed the conclusion of a decade of facilities redevelopment at CAH with the refurbishment of the former Community Nursing building to be the home of the Dental Clinic. The Clinic commenced operations in its new home in May, 2008. Over the year, the following works were completed as part of the main campus redevelopment project:• Finalisation and occupancy of Polwarth House Service Centre opened by Hon. Daniel Andrews MP, Minister for Health, on 8 February 2008.• Expansion of rehabilitation capacity with the establishment of a bigger more spacious gymnasium enjoyed by many of our community members.• Construction of a sealed car park for visitors and staff , with higher level of safety for pedestrians with marked crossing and signage. The Board was delighted to host the Minister for Health on 8 February, 2008, to announce the naming of the Galvin-McCarthy Building in honour of Drs. Frances Galvin and Jim McCarthy. The occasion was made even more special by having the company of both Frances and Jim who responded to the Minister and outlined many changes and advances they had seen during their professional years. At Board level, 2007/08 was the fi rst year of operation of the Risk Committee established under the governance reforms undertaken during the 2006/07 fi nancial year. One pleasing aspect of the Committee functions is the increased level of understanding and knowledge of CAH’s operations noted by Directors during the year. To support the Risk Committee, a suite of Key Performance Indicators have been developed that contribute to the Committee’s primary functions; to be assured the Health Service is well managed. The introduction of a new budget management system called Power Budget occurred during the latter half of the year, which will facilitate the devolution of operating budget management

across the organisation. 2008/09 fi nancial year will begin to see the benefi ts of providing the right tools for Directors and Managers to better manage the Service. A new payroll system was introduced during the year which will reduce the number of payroll queries from staff and improve morale. The “go live” date for the new system is July, 2008. Education and professional development opportunities are vital for staff of a vibrant progressive organisation. The year saw the establishment of a more sustainable Education Centre within the Clinical Services Program. The Unit will have a wider organisational education activities focus than has been customary. We have been able to attract excellent highly qualifi ed staff to the Unit and look forward to the expanding of relationships with Deakin University over the next decade or so. Colac Area Health enjoys a robust and proactive relationship with Visiting Medical Staff and Practice Managers. In partnership with both Practices, work has begun on development of a combined roster system for on-call arrangements; ambition is for a roster arrangement that is able to be managed with live access for updating capabilities by the Practices. This would greatly assist patients, nursing and medical staff . During 2007/08 the Board provided leadership on the public oral health initiative by supporting and advocating for the introduction of fl uoride to the public water supply. Government is to be congratulated for its Fluoride Policy which will have a marked positive impact on future generation’s health. In March, the Board signed an agreement for the assumption of responsibility of both community dental and former school dental services which have been integrated into one system. Barwon Health Dental Services manage the service, under an agreement; the guidance and management expertise of Dr. Michael Smith and his staff is acknowledged. During 2008/09 CAH will seek to expand dental services capacity. 2007/08 was a very busy year for the Service. Inpatient activities at CAH were one of the busiest with 5257 inpatients being treated, the highest

Chairman and CEO’s Report

10 Colac Area Health

number for the past six years. During the year, 216 babies were born at Colac Area Health (CAH), which was also the highest level of births in the last six years. The Board takes this opportunity to publicly recognise and thank the generous support of many individuals and the business sector in Colac Otway community. In particular, the CAH Auxiliary has once again been a generous source of support which the Health Service has enjoyed for many years. Thank you to all members of the Auxiliary for their continuing support which is truly appreciated. During the year, Family Services staff and Community Nursing staff moved to offi ces in the Polwarth House Service Centre. The reception area has become a vital link and hub for our community with direct access from the new carpark. Polwarth House Service Centre also is home to our co-located colleagues in Child Protection, Department Human Services, Pathways Psychiatric Disability Rehabilitation Support Services and Diversitat. Along with our co-located and visiting services, CAH provides a diverse comprehensive suite of services. During the year we farewelled Mr. John Townsend who resigned his position as Director Primary Care after six years at CAH. We also farewelled Mr. Simon Walter who resigned his position as Director Clinical Services; Simon had been with the Health Service for four years. Ms. Donna Hay was appointed Manager, Human Resources, in October, 2007. Donna brings specialist human resource skills to CAH and has been instrumental in establishing more robust human resource management processes and policies. In January, 2008, Ms. Jillian Dunbar took up the reins as Director Clinical Services in the interim until her appointment to the position in June, 2008. Jillian has brought considerable experience and expertise to the position. Mr. Richard Riordan, as Chairman, Board of Directors, provided leadership to the Board during a year of challenges at both fi nancial and service levels. Richard welcomed two new Directors to the Board; Mr. Max Arnott and Mr. Robert Dalton in February, 2008, and farewelled Mrs. Alison

McDonald who retired from the Board when her term expired in October, 2007. As Chair, Richard guided the Board through changes at Board level and through the fi rst year following the governance reform process. Corangamarah Art Prize - con.ceit ‘07, in aid of Corangamarah, was a highlight in a busy year with a function to announce the winner of the $5,000 acquisitive prize at the Otway Estate Winery and Brewery in October, 2007. This event is becoming well established with wide recognition amongst the art community. A special thanks to Ms. Kate Potter for her unfailing support and belief in the event. A range of activities fi nalising physical redevelopments were overseen by a Project Control Group chaired by Mr. Wayne O’Brien, Treasurer. Wayne has been Chair of the Project Control Group that managed the overall redevelopment for nine years. Mr. O’Brien’s Chairmanship and generous contribution is acknowledged. Healthy Hearts Project Research conducted by Baker Heart Research Institute was a pilot study held in Colac, sponsored by the Rotary Club of Colac, which CAH was delighted to support. The study held from 20 August to 7 September, 2007, screened 548 adults, nearly 1 in 10 of the over 18 population. A big thank you to our community for assisting with such an important Research Project. Many people contribute to the successful operation of CAH; the Chairman, Board of Directors and Chief Executive Offi cer, take this opportunity to recognise and thank all who contributed to the Service during 2007/08 and, in particular, wish to record an appreciation for the work of:• Directors of the Board• Executive Management Team and staff • Program Managers, Team Leaders and staff • Auxiliaries and volunteers• Regional Director and staff , Barwon South Western Region and Central Offi ce staff , Department Human Services• Business community of Colac• Service Clubs• Philanthropic Trusts and Foundations• Colac Otway community.

Geoff IlesChief Executive Offi cer22 September, 2008

Richard RiordanChairman22 September, 2008


Over 2007/08 fi nancial year, the following matters were identifi ed as priorities and actions taken to address:

Management Information SystemsA continuing challenge is the use of timely service data that eff ectively assists with managing of physical and human resources. While improvements and developments have been achieved there still remains a challenge to have a fully integrated system that provides key management information about the organisation. Currently there is no single integrated system that provides Executive Directors and Managers with such an overview. One notable development that emerged out of consumer feedback highlighting the need for better monitoring of food services has been the “Temperature Monitoring System” that provides a rigorous regime of recording that is compared with accepted industry standards. Regular reporting, with 14 and fi ve day comparison reports, are provided to Executive and Managers to ensure standards are met and for the purpose of demonstrating to regulatory bodies accepted industry practices are in place. An established system of measuring activity is in place that provides month on month reviews of performance against funding bodies expected targets. The Board, through the Risk Committee, monitors the activities regularly and seeks guidance and assurance from the Executive on any noted variances in performance from expected achievements. A suite of Key Performance Indicators provide the Risk Committee with an overview not only of activity but also regulatory and quality compliance levels within the organisation.

Team DevelopmentWhile 2007/08 year witnessed the loss of two Executive Directors recruitment success in the second half of the year has brought about stability at Executive level.

Work had continued on from 2006/07 fi nancial year in promoting the Corporate Values of Colac Area Health (CAH) being:Quality, Respect, Innovation, Leadership, Integrity, Partnership. Reform to the Management Team continued to engender a contemporary management culture across the organisation. Focus has been on culture development that is one of pride and pursuit of excellence as a health service; an organisation that people want to join is CAH’s ambition.

Corporate Program Budgets and Power BudgetOver 2007/08 the Executive expanded on the initial work in the previous fi nancial year which has established the base for program budgets introduction in 2008/09 at Director and Manager levels. The work will provide a much more robust internal budgeting process and facilitate internal reviews as part of an organisation sustainability strategy. Budget development work has necessarily involved:- Budgeting education for program managers and team leaders- Budget development workshops to refi ne programs and units budgets- Training in and operation of Power Budget system.

Corporate Systems DevelopmentOne challenge that has been faced by the Executive has been the lack of integrated corporate systems. As indicated in the 2006/07 Annual Report as an objective; 2007/08 saw an investment of resources towards developing an integrated corporate suite of systems that assists with the provision of an entity integrated report for the Management Team. Fundamental building blocks to such an integrated system included:• Implementation of ChrisPay21, that provides current data and contemporary management reports and feeds into budgeting system

Strategic Direction


• Introduction of Power Budget; a stronger fi nancial management reporting system • Integrated activities management system which has commenced with TrakHealth-Clinicals and TrakHealth-Community to replace PJB and other software used in the Primary Care Program• Robust corporate suite that includes: - Addressing legislative compliance through BACeS, - Contracts and Agreements Management system - Credentialed Health Professional Register - Policies and Protocols management through PROMPT.

FacilitiesOver 2007/08 the Board and the community can be justly proud of the facilities development achievement across the organisation. In brief these developments included:• Conclusion of the major redevelopment across Colac Area Health (CAH)• Finalisation of Polwarth House Service Centre• Expansion of gymnasium capacity to support the concept of a stronger rehabilitation and sub acute services in conjunction with Barwon Health – McKellar Centre• Relocation of the Community Dental Clinic onto the main campus site • Establishing the “Blue Shed” as a community meeting facility with kitchen capacity• Establishment of a sealed carpark that provides convenient and safe parking with sound pedestrian access• Building of a more sustainable Education Centre in the former Family Services offi ces• Finalised the plans and submission to the Commonwealth for twelve bed student accommodation facility for Colac• Establishment of the Speirs Meeting Room to provide an executive meeting room for the Board and VIPs with built in technology to assist with presentations.

Operations and ServicesThe provision of monthly documentation and the conduct of the Risk Committee have met Board expectations on the level of information and detail about CAH’s operations to give the Board confi dence in its governance role. Detail provided included:

Residential Aged Care- Resident Classifi cation Scale (RCS) mix management- Comparative revenue analysis- Occupancy management.

Acute Care- Weighted Inlier Equivalent Separations (WIES) targets achievement- Admissions monitoring, both public and private patients- Estimate operating theatre throughput required to reach WIES target for 2007/08 and monitoring of throughput- Measuring acute services revenue generated and the variance from target.

Primary CareAchievement of activity compared with targets for:Major Funded Programs under Primary Care which account for more than 12000 under Home and Community Care and Community Health. Professional services provided include:• Dietetics• Occupational Therapy• Physiotherapy• Podiatry• Social Work• Speech Pathology.Family Services and Community ProgramsWhile measurement of such a diverse range of activities has been challenging at executive management level during 2007/08 fi nancial year, better monitoring of activity occurred for the


Board, showing overall achievement level against target for the following activities:• Alcohol and Other Drugs Counselling Services• Child FIRST – Family Services• Family Support• Financial Counselling• Gamblers Help• Housing Services - Transitional Housing Support• Saver Plus – Partnership• Victims of Family Violence Support• Women’s Health Support.

Governance DevelopmentsAs a follow-up to work reported in the 2006/07 Annual Report, 2007/08 has been the fi rst year of Risk Committee functioning which has been modestly successful. A comprehensive suite of Key Performance Indicators (KPI’s) has been established refl ecting organisation wide operational management of Programs and Units. During the year some modifi cations were made as the Risk Committee became more experienced and comfortable with its role and operations. Currently Colac Area Health (CAH) has 99 KPI’s being reported against on a fi nancial year cycle. A review of the Risk Committee’s operations has been foreshadowed for consideration during 2008/09 fi nancial year. Over the last fi nancial year the fi nancial and activity reporting framework to the Board has been modifi ed. In 2008/09, CAH will be moving away from accreditation by the Australian Council on Healthcare Standards (ACHS) to ISO system; the Aged Care Standards and Accreditation Agency Ltd. will continue for residential aged care.

CommunicationStaff Well informed staff is vital to an organisation that functions 24 hours per day 7 days per week and provides such a diverse range of services as CAH does. The concept of the “Weekly News” has been continued to provide a conduit for keeping staff informed of developments within CAH.

The Executive has endeavoured to maintain a high level of engagement through the Management Team meetings, structured Unit meetings, and operational discussions such as budget development, activity monitoring, policies and protocols. There is always room to improve; communication is generally at the top of the list of criticism of Executive staff in any staff climate survey. Over 2008/09 continued eff ort will be put into providing information to all staff , particularly management information on CAH’s performance, stronger access to operational policies via PROMPT and practice advice. A range of work has been identifi ed to bring human resource policies, processes and procedures up to date which will begin in 2008/09.

BoardAs with 2006/07, during 2007/08 a concerted program has been to ensure that Board Directors have been provided with information and detail to promote discussion and exploration about CAH’s performance in respect of the following:- Financial performance- Legislative Compliance- Service activities achievements against targets- Quality Assurance.

Key Stakeholder EngagementsVictorian Healthcare Association (VHA)Over 2007/08, Colac Area Health increased its level of communication and engagement with the Executive of VHA as the peak body for health services in Victoria. Over 2008/09 this pattern of engagement will continue.

Visiting Medical Staff (VMS)Overall the level of engagement and discussion with the VMS as a group and individually has increased and the relationship with both Corangamite Clinic and Otway Medical Clinic is a positive one.


Over 2007/08 a number of activities has occurred to engage and to inform VMS including:- Chief Executive Offi cer and Director Clinical Services attendance at VMS monthly meetings- Exploration of diff erent models including the engagement of career medical offi cers- Use of KPI’s to inform of trends and performance including:

• Category 2 Triage attendance measures to Urgent Care• Medical Records completion rate• Discussions on the development of combined on-call roster between both Medical Practices• Obstetrics Model development discussions.

MediaColac Area Health (CAH) has a good relationship with local media in particular The Colac Herald and Corangamite Extra. The Chief Executive Offi cer has a regular appointment with The Colac Herald journalists that aids understanding and keeping the community informed of events, developments and achievements during the year. The Health Service has enjoyed a high level of media exposure and good publishing rate of articles and press releases. Over 2008/09 there will be an endeavour to maintain a similar level of engagement.

Department of Human Services (DHS)Colac Area Health has a very eff ective and mature relationship with the DHS built on open, transparent and honest dialogue. The eff orts of the Board and Executive in managing the challenges faced have been topics of positive comment by Regional Offi ce staff .

Strategic ObjectivesColac Area Health Board 2007-2010 Strategic Goals1. Excellence in Service Provision – by providing the right service, at the right time, with best practice.

2. Vibrant well managed Health Service – that is well respected, meets activity targets underpinned by fi nancial sustainability, operational effi ciency, sound management and eff ective governance.3. Sustainable and Progressive Workforce – by promoting a values based environment that promotes staff skills and being an important site for medical, nursing and allied health student experiences and ongoing education.4. Robust organisational environment – that promotes a highly responsive service based on information and knowledge management.5. Contemporary facilities and equipment – to support the provision of relevant, timely service framework.

The focus for 2008/09 will be:Strengthening service profi le with an emphasis on:- Achieving a sustainable obstetrics and midwifery services model.- Establishment of a Health and Wellbeing Clinic- Strengthening sub acute and rehabilitation services.Effi cacy and effi ciency gains- Through reform of internal process and effi ciency gains in:

Patient and client management processes • and systems.Clinical Services operations and functions.• Establishment of a Midwifery Unit.• Reorganisation of Program responsibilities to • clarify decision making.

- By the conduct of a program of internal reviews and structural reform.- By embedding improved processes.- To support the Visiting Medical Staff model of operations by recruitment of Career Medical Offi cers with a priority for staff with Obstetrics and Emergency training- Building on existing relationships with Barwon Health to provide a sustainable range of services.


Colac Area Health (CAH) is a Victorian public sector organisation incorporated under the Health Services Act 1988 and operates under the provisions of this Act.

The Minister responsible for the administration of the Health Services Act is the Minister for Health, Hon. Daniel Andrews MLA. Colac Area Health is accountable through the Board of Directors (BOD) to the Minister for Health.

Colac Area Health is governed by a eight person BOD appointed by the Minister. Board members are appointed for periods up to three years and serve in a voluntary capacity.

Governance refers to arrangements in place to administer, manage and monitor services provided. In past years the focus of the Board’s governance obligations was in management and fi nancial areas.

Today, public health service providers are required to be more transparent and accountable to the community in their governance obligations, such as clinical governance and risk management.

The functions of the Board of Directors are:• To conduct the Service in a manner that is consistent with the Mission Statement and the Health Services Act 1988• To establish reporting mechanisms to monitor the performance, reports and audit processes of the Service and to ensure that they comply with the Financial Management Act 1994• The general governance of the Service• To maintain proper accountability to government by close observation of all legislative requirements, ensuring that the Service meets or exceeds targets as agreed in the Health Services Agreement and complies with all standards governing the Service• To ensure compliance with legislative requirements governing Health Services and promote a safe, eff ective, appropriate and consumer orientated service within this legislative framework • To annually review the past twelve months’ activities and set future direction• To refl ect the needs of the community and to communicate policy and strategic direction by consultations, publications and promoting the profi le of the Service • To ensure that the Service provides a range of appropriate services, promotes excellence and supports educated, competent staff

• To promote good working relationships with Government Departments. Colac Area Health is addressing the governance issues associated with Health Service delivery to:• Meet community expectations by achieving quality health service delivery• Ensure there are corporate and clinical standards for accountability and leadership within the Service• Address the management and identifi cation of risks and hazards by implementing a comprehensive clinical and non-clinical risk management system. • Ensure staff and facilities are assessed, reviewed and credentialled.

Board Orientation and EducationOrientation and Board Education has been undertaken by attendance at sub-regional forums conducted by the Department of Human Services (DHS).

This education is directed at clarifying the roles and accountability of Board members in providing eff ective governance of their agencies.

Colac Area Health has continued to be a leader in developing an integrated Health Service delivery model.

Underpinning the philosophy of this model is providing access to a range of appropriate services for rural communities.

Project Control GroupEff ective Board Governance required members of the Board and the Executive Management Team (EMT) to participate in the Project Control Group (PCG) which oversaw the Redevelopment Project. Representatives from DHS Regional Offi ce, Capital Management Branch, Architects, Project Managers and the Quantity Surveyor received reports on construction progress. It is timely and appropriate at the conclusion of the redevelopment project to recognise the contribution and professional support aff orded Colac Area Health (CAH) by Kevin Hughes, Capital Management Branch, Department of Human Services (DHS), over many years.

Corporate Governance


Executive Management Team L-RJillian Dunbar, Director Clinical Services, Garry Ellis, Director Corporate Services,

Donna Hay, Manager, Human Resources and Geoff Iles, Chief Executive Officer.

Executive Management TeamThe Board of Directors has delegated the operational activities of Colac Area Health to the Chief Executive Offi cer (CEO), the Executive Management Team (EMT) and staff in accordance with the Instrument of Delegation and the Health Services Act 1988 (Division 4 Section 33).

Risk ManagementI, Geoff Iles, certify that Colac Area Health has progressed risk management processes during 2007/08 fi nancial year consistent with the Australian/New Zealand Risk Management Standard and has an internal control system in place that enables the executives to understand, manage and satisfactorily control risk exposures. The Risk Committee verifi es this assurance and that the risk profi le of Colac Area Health has been critically reviewed in the last 12 months.

Geoff IlesChief Executive22 September, 2008 Colac

Committee StructureThe Board has established a committee structure which complies with the Health Services Act 1988 and fulfi ls the requirements of the Board and the Mission Statement to ensure that policies set in place are community and client-focused. The following are sub-committees of the Board:

Risk CommiteeThis committee receives reports from the Executive Directors which refl ects compliance with accounting standards and mandatory reporting requirements along with service activities and quality initiatives. Monthly monitoring of the fi nancial performance of the Service is undertaken by the committee as are all aspects of both the internal and external programs.

Medical Appointments Advisory CommitteeThis committee makes recommendations to the Board on medical appointments.

Medical Staff CommitteeThis committee provides monthly reports on particular matters of clinical nature.

Clinical Services Advisory CommitteeThis committee provides advice on clinical services development.


Board Directors

Cr Anthony Graham, Senior Vice-PresidentAdv Dip. Disability Work, Dip. FMI, Dip. Tas, Adv. Cert. R.A.C.S, Cert. IV Workplace and TrainingTony has been a member of the CAH Board for several years, including three years as Chairman. Tony has represented our service over the past seven years as an elected Councillor with the Rural and Regional Health Division of the Victoria Healthcare Association (VHA) and was appointed as a Director of the Board of Management of VHA in 2004. Currently he works as a training and development consultant with Royal Melbourne Institute of Technology (RMIT). Tony has been elected as Chairman, Regional and Rural Council VHA. In 2008 Tony was appointed as a Councillor Colac Otway Shire.

Mr Wayne O’Brien, TreasurerB.Com, C.A., C.P.A.Wayne is a Chartered Accountant and has been a principal of a local accounting fi rm for 17 years. Before returning to Colac, Wayne worked with a large accounting fi rm in Melbourne with secondments interstate and overseas. Wayne is an active squash and tennis player and has a wide involvement in community aff airs. Wayne has served on the board for nine years which has included terms as Chairman and Treasurer. During this period Wayne has overseen all stages of the major redevelopment projects which commenced in 2001 and concluded in May 2008.

Mr Richard Riordan,ChairmanB.Bus. (Management)Richard is a local businessman, having returned to Colac after completing a degree in Business Management at Monash University. Richard has been active in the local community, having been involved on the committees of management for the local Business and Retailers Association, Adult Education Board, Lake Foreshore Committee and local sports club. Richard is an enthusiastic supporter of improving and developing community services in Colac and has been the driving force behind the establishment of con.ceit Corangamarah Art Prize.

Term of appointment: 1 March, 2007 to 30 June, 2008

Board and Committee attendance:Board 12 of 13 Risk Committee 7 of 10

Term of appointment: 1 November, 2004 to 30 June, 2008


Term of appointment: 1 November, 2004 to 30 June, 2008



Mrs Alison McDonald,Junior Vice-PresidentB.A. (Hons) Food and Accommodation Management, Cert. III Small Bus. Management, Master of Teaching (Primary) Alison resides at Birregurra and is a partner in a family farming business. As a former member of the Birregurra Advisory Committee she contributed to the development of the Birregurra Community Health Centre. She is actively involved in the community as a member of the Birregurra Health Auxiliary, together with past and ongoing participation at committee level with the local pre-school and primary school. She is currently teaching full time at Birregurra PS. Alison did not seek reappointment when her term of appointment expired in November, 2007.

Mr Anthony BaldwinTony is a self-employed businessman and dairy farmer. He has an interest in quality assurance procedures, fi nancial management and strategic planning. Tony is actively involved in the community as a member of the Rotary Club of Colac and Elliminyt Primary School and Trinity College Parent Committees.

Ms Kathryn McBrideDip. Fine Arts (ceramics), Grad Dip. Education, Dip. of ManagementKathryn is employed by City of Greater Geelong as Coordinator Care Services. She is currently a committee member of Villamanta Disability Legal Service and Swan Marsh Hall. Kathryn has previously held positions on Arts Colac and Colac Community Development Association and Disability Managers Association.

Term of appointment: 1 November, 2004 to 31 October, 2007Board and Committee attendance:Board 3 of 4 Risk Committee 1 of 4






Mr James Ryan B.A., L.L.B.Jim is a partner of a local law fi rm and a Life Member of the Law Institute of Victoria. He was a Councillor of the City of Colac for nine years and Colac Otway Shire for eight years, during which time he held the position of Mayor for three terms. Jim is president of the Colac and District Cricket Association and Colac Turf Club, a committee member of Colac Do Care Inc., and is actively involved in community aff airs.

Mr Robert Dalton Diploma of Education, Bachelor of Arts, Bachelor of CommunicationBob is employed as Chief Executive Offi cer of Skills Connection and has extensive corporate management background and experience. Whilst Bob has only been a resident of Colac for the past three years, he has made a signifi cant contribution to the community as a Member of Otway Business Inc., Colac Community Enterprise and Otway FM Community Radio Special Development Group.

Mr Max ArnottAdvanced Diploma of Financial Services, CFP Certifi ed Financial PlannerMax is a Certifi ed Financial Planner who established the business Adviser Group FP by bringing together advisers and staff from Colac, Geelong, Hamilton and Albury into a diversifi ed business. This Group is now one of the top ten practices for the Licensee of MLC/Garvan Financial Planning Vic/Tas States. Max is an active member of the community having been awarded a Life Membership of the Apex Club of Colac, and is currently a member of the Rotary Club of Colac West, State Delegate of MLC/Garvan Advisory Board, and Treasurer of Otway Business Inc.

Board Directors

Term of appointment: 1 November, 2005 to 31 October, 2008


Term of appointment: 26 February, 2008 to 30 June, 2010


Term of appointment: 26 February, 2008 to 30 June, 2010



Clinical ServicesIt is with great pleasure I present my fi rst annual quality report as Director Clinical Services. Whilst having occupied this position for a period of only fi ve months at the end of this reporting cycle, I refl ect on the challenges, achievements and highlights in clinical services over the entire previous twelve months and in doing so acknowledge the eff orts of my predecessor Simon Walter who resigned from the position in December, 2007. The focus and goal has been to develop a team orientated learning environment within a culture of respect, integrity, innovation, leadership, quality and partnerships. The outcome will be an organisation of choice for the recruitment and retention of highly qualifi ed and motivated staff . This year has been a year of capacity building; providing staff with the opportunities, qualifi cations and equipment to facilitate the provision of safe, contemporary quality care to the community. This will continue to be a work in progress. Critically refl ecting on the way we do things and looking for opportunities for improvement has instigated reviews of varying degrees in many areas of Clinical Services. An external review of the culture in Clinical Services was undertaken in February by RTK Resolutions. This review identifi ed areas of concern in relation to behaviours among some staff that did not comply with the Values of the organisation. Several recommendations were put forward by the consultants, including responsibilities of the Executive. Staff involved in the review have also been involved in planning the ‘way forward’ in a collaborative eff ort to achieve our goal. Whilst this review was somewhat confronting for all concerned, it has provided an excellent platform to move forward and I sincerely thank all staff who participated and contributed in this challenging quality initiative. I believe we have come a long way as a result of this review. The introduction of the PROMPT system has been a quality initiative project that, while still in its infancy stage and requiring further development, has far reaching benefi ts not only for the Clinical Services staff including medical staff , but staff organisationally wide. PROMPT facilitates a

robust policy and protocol system that provides contemporaneous gold standard practice. This is an invaluable resource for rural health services and can only serve to promote best quality practice in rural areas. This year Colac Area Health (CAH) has nominated a sponsor for the ‘Focus on Variation’ Project facilitated by the Victorian Health Service Management Innovation Council. This provides us with an opportunity to benchmark performance against like size health services in an anonymous format. We look forward to progressing this Project in 2008/2009 The development of a ‘learning’ environment is essential for CAH with the prospect of medical students from Deakin University placed at the organisation in 2010. This will be an exciting time for all staff to be closely aligned to Deakin University, bringing with it valuable opportunities for professional development. Added to this, discussions are taking place for the placement of midwifery students and peri-operative students at CAH. I would like to take this opportunity to acknowledge the following senior staff who have resigned their positions at CAH this year and thank them sincerely for the contributions they have made to the organisation: Simon Walter, Pamela Matheson, Donna Field, Tasha Parker and Lynda Inglis. We welcome to the organisation Wendy Penney and Deborah Payton. My sincere appreciation goes to all staff in Clinical Services. I thank you all for the support you have provided to me since my appointment. I am impressed with the dedication to the provision of quality care and look forward to an exciting year ahead. Department Managers and Associate Managers have provided informative reports on each of their departments and I commend these reports to you for an insight into the contribution these areas make in the delivery of quality care.

Jillian M DunbarDirector Clinical Services

Jillian DunbarDirector Clinical Services



Acute Care UnitThis busy Unit provides care to patients admitted with acute medical and surgical conditions as well as maternity, paediatric and palliative care. A large team of dedicated nurses work collaboratively with medical and allied health staff to provide patient centred, holistic care. This graph identifi es the trend of increased acute care patient throughput from 2004 to 2008.

The number of patients treated in this Unit continues to increase on a yearly basis, staff are therefore always looking for ways of ‘working smarter’ whilst improving the delivery of our care. The variety of conditions of patients admitted to this Unit places additional demands on nursing staff to have a broad knowledge and experience. Education and Professional development opportunities are therefore very well accepted by our staff and advantage is taken of the various internal and external education sessions. Nine Division 1 nurses completed the Certifi cate in Advanced Life Support and four Division 2 nurses completed the Medication Endorsement Certifi cate. All staff on the Unit are competent in Basic Life Support and ‘No Lift’ techniques and a number of staff have undertaken the Intravenous Cannulation Competency. The nursing staff in this Unit are very involved in supporting the Graduate Nurses in their transition from a Graduate Nurse to a competent and confi dent nurse. Two of our Graduate Nurses have remained on staff this year. Our midwives have been extremely busy this year with a record number of births for six years (as shown in the graph opposite). On one occasion

fi ve babies were born in seven hours. This was a hectic night for our midwives but went without a hitch thanks to our very competent and calm staff . Numerous study days and courses have been attended by the midwives with several undertaking the Advanced Life Support in Obstetrics (ALSO) course. This is a two day course for all maternity care providers including physicians and provides the knowledge and skills required to eff ectively manage potential emergencies during the perinatal period. Midwives are looking forward to the development of a collaborative model of care between Medical and Midwifery staff to ensure maternity services are sustainable in Colac. Our Acute Care Unit has received numerous pieces of equipment over the past year including:• Portable Oxygen Saturation and Vital Signs Monitoring Machines.• Maternal and Foetal Monitors, Foetal Dopplers with Probes, Thermometers and Digital Scales.• Shower Chairs. A continuous quality improvement culture in the Acute Care Unit, means we are reviewing our practices and service with improvement in mind on a daily basis. Many initiatives have been introduced this year in the provision of patient care. Review of Discharge Planning, Care Plans, Clinical Pathways, Policies and Procedures have resulted in improved practices.Sue Spowart,Acting Nursing Unit ManagerAcute Care Unit


Corangamarah Residential Aged Care FacilityOur facility will be two years old in August 2008. We continue to make improvements for our residents and this year we have focused on creating a more ‘home-like’ environment. We have encouraged residents, family and friends to bring in special personal belongings for the residents’ rooms. A garden especially designed for our dementia suff erers has been requisitioned; shade sails have been erected in the garden areas; air conditioners have been installed in the passage ways and refurbishment to the front entrance has been planned. We value suggestions on how to improve the environment and the care provided in Corangamarah. To facilitate this, an Aged Care Forum has been organised; the fi rst of regular forums. This will allow relatives of existing and past residents, an opportunity to provide valuable feedback, to ensure we are meeting the needs of our residents, families and friends. We believe involvement of families and friends in our residents’ care is paramount for their health and psychosocial welfare. Added to this, we have reviewed the ‘Complaints, Compliments and Comments’ process at Corangamarah to ensure access to this process by everyone involved in the care and welfare of our residents. All staff in Corangamarah have attended education sessions on the process. The review of this process will ensure a timely response to any complaints or suggestions, and follow up with the resident or complainant to ensure the problem has been addressed to their satisfaction where possible. The conversion to a new food production system created enormous challenges for us this year. Many complaints were received from staff and residents in relation to the quality of the meals and we received a visit from representatives of the Aged and Community Care Branch, Department of Health and Ageing as a result of registered complaints. We welcomed the opportunity to undertake a complete review of the menu, production and plating of the meals provided in Corangamarah. A Working Party was established and a monitoring and feedback

system implemented to continually monitor and improve the quality of the meals provided. A new menu was developed and implemented and modifi cations were made to the food production equipment. Whilst residents express high levels of satisfaction of the meals now served, meals will continue to be monitored on a daily basis, evaluation of the menu satisfaction is ongoing and the Working Party will continue to meet to discuss how we can continue to improve the meals for our residents. I would like to express my appreciation to our Head Chef and all catering staff involved in making such signifi cant improvements to the meals we now serve to our residents. I have been impressed with the dedication of all staff to rectify this problem and improve the care to our residents. I also extend my appreciation to the residents and their families and thank you for your contribution and patience during this challenging time. Another challenge for staff this year was the transition to a new Aged Care Funding Model (ACFI). Staff must be complimented on the smooth transition from the old to the new which involved considerable education, assessments and documentation. I would like to acknowledge our Administration Manager, Financial Accountant, Business Manager, and Clinical Nurse Manager, Residential Aged Care, for making this possible. Compliance to required documentation and assessment is essential for CAH to receive funding for the care and services we provide. Recreational and social activities for our residents rate as a high priority, and staff in Corangamarah, led by the Diversional Therapist and Activity Co-Ordinators take pleasure in providing a variety of activities and outings throughout the year. One of the highlights was the Corangamarah Ball which gave staff , residents, family and members of the community the opportunity to enjoy the atmosphere of an old time Ball. Our dementia suff erers enjoy the activities and companionship provided through the introduction of the ‘Sundowners Program’ in West Wing. This is a seven day a week program, provided at a time when residents tend to become restless. A Diversional Therapist provides activities to assist residents to relax and this has proven to be a most successful and valuable program in the care of these residents.


A signifi cant achievement for this year was the development of a Philosophy of Care for Corangamarah. All staff had the opportunity to have input into this statement. Several versions were drafted. This Philosophy of Care underpins in every aspect, the way we care for our residents and will be framed and proudly displayed in our facility and referred to regularly to ensure we abide by our ‘philosophy’.

Staff in Corangamarah are fortunate to have access to ongoing education through installation of the ‘Aged Care Channel’. Aged care education is provided through this medium three times a day on a fortnightly basis. Internal ongoing education through CAH’s Education Centre will be planned for the year ahead to enhance opportunity for professional development of staff . Many of our Division Two Registered Nurses have completed the Medication Endorsement Certifi cate. We congratulate them on this wonderful achievement and look forward to many more of our staff completing this certifi cate next year. Lynda Inglis resigned from her position as Business Manager in June to take up a more senior role in Geelong. We wish Lynda success in her new position and extend our appreciation to her for her commitment to the care of residents during her time at Colac. Esteelia Marcucci has been appointed to this position until a permanent appointment is made.

Again this year we have grieved the passing of some of our residents. Our condolences are extended to respective families and friends. We have also welcomed new residents and feel honoured to have the opportunity to make their time with us at Corangamarah a happy and homely one.Jillian DunbarDirector Clinical Services

Preadmission and Discharge Planning ClinicThe Preadmission and Discharge Planning Clinic (PADPC) is integral in the seamless transition from admission to discharge for our patients. Surgical patients are preadmitted to the hospital by attending the Clinic in person or by telephone interview. A Discharge Plan is initiated and patients are provided with the relevant information about their procedure. At this interview, referrals to other health professionals such as, Physiotherapists and Occupational Therapists are arranged, as required. Attendance to the Clinic provides patients with the opportunity to meet staff and familiarise themselves with the Day Surgery and Acute Care Units and raise any questions or concerns they may have in relation to their hospital stay. The Preadmission Co-Ordinators make every eff ort to allay patients’ anxiety in an endeavour to make their hospital visit as pleasant and comfortable as possible. This past year 1197 patients were preadmitted of which 327 attended in person and 870 were interviewed by telephone. Preadmission Co-Ordinators are also involved in Working Parties and Committees and the development and implementation of policies, clinical pathways and audits, relevant to admission and discharge tools and processes. Audits based on the Eff ective Discharge Strategy Guidelines, conducted twice yearly, identify what we do well and where we can improve in our Discharge Planning. The Victorian Patient Satisfaction Monitor (VPSM) also provides valuable feedback, from a patient perspective, on our performance of admission and discharge.

Philosophy of Care

We off er residents and their families a respectful and compassionate

home-like environment.

We promote an holistic approach to care and foster high

standards of accountability, honesty and integrity.

Our professional care is off ered to all without discrimination.

We strive for an environment where all staff are supported and

valued for their contribution to the team.


The VPSM graph (right) dentifi es the level of overall patient satisfaction. Colac Area Health (CAH) patient satisfaction levels are higher than overall state hospitals and comparable sized hospitals. The year ahead will see a review of our current Discharge Planning process to ensure we are meeting patient and family needs and legislative compliance to provide quality outcomes for our patients. Both Co-Ordinators completed the Advanced Care Planning training with one taking on the role of Advanced Care Planning Resource Nurse for CAH. This past year we have oriented four nursing staff members to the role of Preadmission and Discharge Co-Ordinator to provide leave support for the Clinic.Julie Trigg RN Div1/Jenny Lang RN Div1Preadmission/Discharge Planning Co-Ordinators

Operating SuiteColac Area Health provides an extensive range of surgical procedures to the local community and surrounding districts, including General, Obstetric, Endoscopic, Orthopaedic, Urological, Gynaecological, Ophthalmic and Dental Procedures. This is made possible by our two committed Colac based General Surgeons, GP Anaesthetists and eight Visiting Specialist Surgeons. Advances in Laparoscopic surgery performed at CAH result in patients being discharged earlier and have the ability to return to work sooner than with conventional surgery.

Surgical Procedures 2003-2008 The graph depicts increase in Surgical Procedures performed at CAH from 2003-2008.

Staff are always appreciative of new equipment to assist in the provision of quality care in the Operating Suite and acknowledge the support

of the Executive and Department of Human Services for the purchase of the following items of equipment:• Electric Operating Table• Gas assisted Lithotomy Stirrups• Autoclavable Laparoscopic Camera• 30 Degree Telescope• Fluid Warming Unit• Portable Patient Monitor• Two Anaesthetic Machines with Entropy• Machine Update for Attest Biological Indicator Test• Mattresses for Patient Transfer Trolleys. We are committed to continuously reviewing the way we provide our service and how we can improve. As a result we have implemented several quality initiatives throughout the year, for example:• ‘Wash checks’ for instrument washer monitoring• ‘Heli-checks’ for hollow load challenge testing for pre-vacuum steam sterilisers• Reusable convective warming blankets for pre- warming patients in the Day Surgery Unit• Vital Patient Management System• Rapid Infusion Kits• Trial of Disposable Patient Control Analgesia Pumps• Post Acute Care Unit Discharge Criteria• Day Surgery Unit Intravenous Disposal The commitment of Operating Suite staff to education must be commended. This year has been no exception. As well as mandatory organisational education, staff have undertaken education in Anaesthetic Emergencies; Operating Room and Post Acute Care Unit

Nursing; Anaesthetic Crisis Management at the Crisis Resource Management Centre, Monash University; Endoscopic Cleaning and Maintenance Sterilisation; and attended various workshops on orientation to new equipment. The Central Sterilising Department is integral to the smooth functioning of the Operating Suite. Surgeons, Anaesthetists and Perioperative Nurses depend on staff in this Unit for cleaning, maintenance and sterilisation of surgical, anaesthetic and monitoring equipment and for the availability of this equipment in a timely manner. Added to the Operating Suite responsibilities, this Department also provides a sterilisation service for the organisation and to medical clinics and other community services. Staff maintain stringent infection control and sterilisation standards, and undergo an annual audit of AS4187 standards. Evidence of the sterilisation of all articles is audited and is available to ensure quality sterilising services.Amanda Tout RN Div1Nursing Unit ManagerOperating Suite

Day Surgery UnitThis Unit is often the ‘face’ of Surgical Services at Colac Area Health (CAH). The Day Surgery Unit prepares patients for operations and surgical and

medical procedures and receives patients post operatively for day surgery. Patients are admitted to this Unit prior to undergoing their procedure. Staff in this Unit work in concert with Preadmission/Discharge Planning Co-Ordinators, Operating Suite and Acute Care Unit staff to facilitate a seamless episode of care for patients and pride themselves on the welcoming environment they create for the patients. The Victorian Patient Satisfaction Monitor reports excellent satisfaction levels by patients who have been cared for by the staff in this Unit. Quality activities have included: Review of Day Surgery Clinical Pathway, update of Patient Information Sheets, Location Audit – fi nding Colac Area Health and the Day Surgery Unit, Disposal of Infectious Waste Audit, Bowel Return Audit for Colonoscopy patients. Staff continue to update their skills and professional development opportunities by attending internal and external education sessions. In the past year all staff have commenced Intravenous Cannulation Competencies and attended an update in Anaesthetic Emergencies, Pharmacology and Trauma Management for Operating Room and Post Acute Care Unit Nurses. Two new staff members were also orientated to the Unit.Jenny Lang RN Div1/ Pauline Kerr RN Div1Associate Unit ManagersDay Surgery Unit


Nursing staff celebrate International Nurses Day with morning/afternoon tea in the staff Cafeteria.

Haemodialysis UnitThe Haemodialysis Unit provides a vital service to patients suff ering renal disease in the community and surrounding districts. The unit comprises three machines and operates three days per week dialysing up to six clients each week. Currently fi ve of these patients are dialysed three days per week. The service is a satellite service from Barwon Health and we are extremely appreciative of the valuable support they provide to us through staff education, equipment and machine maintenance. This year they supplied a ‘backup’ dialysis machine to minimise the risk of service interruption to our clients in the event that one of our existing machines requires repair. This enhances the service delivery to our clients preventing the necessity of travelling to Geelong in the event of unavailability of a machine due to malfunction. Added to this, Barwon Health has provided the Unit with a laser printer and BOSS software which enables staff to access clients blood results and implement essential treatment interventions without delay. Infection control compliance is paramount in the care of our clients and we have introduced the use of a ‘hand rub’ disinfectant for the use of staff , patients and visitors to minimise the risk of transmission of infection. The purchase of a new hydraulic lifting trolley has assisted us in manual handling. Three new staff members have been orientated to the Unit for unexpected leave replacement which ensures staffi ng sustainability of the service and staff attend education sessions on a regular basis at Barwon Health to ensure currency of skills and contemporary practice. All our clients complete ‘satisfaction’ surveys. These provide us with extremely important feedback and we look forward to receiving any suggestions on how we can improve our service. We were delighted to receive the donation of a lovely print from a past client’s family, in recognition of the care provided by the staff in the Unit. This hangs proudly on the wall for the pleasure of our staff and clients.Kerrie Anderson RN Div 1/Helen Morrissy RN Div 1Associate Nursing Unit ManagersHaemodialysis Unit

Urgent Care UnitPatient attendances for Urgent Care continues to increase on a yearly basis. This year 7778 presentations were recorded as requiring assessment, treatment and referral as appropriate. Triaging of all patients presenting to the Unit is an essential function that underpins the delivery of care. It is a decision making and communication tool that ensures patients are treated according to the clinical urgency of the presenting condition. The Australasian Triage Scale (ATS) is a nationally accepted scale used to categorise patients. All staff in Urgent Care attended education sessions conducted by the Department of Human Services this year on Emergency Triage. The Needle and Syringe Exchange Program service provided by the Urgent Care Unit continues to provide a vital and well utilised service. This Program assists in minimising the risk of transmission of blood-borne viruses such as HIV and Hepatitis B and C to the community. To enhance this service we have installed an external disposal bin to facilitate the safe disposal of needles. This initiative will promote a safe environment and is also available for use by the general community.

Needle Exchange Program


Discharged from Urgent Care 5603Transfers for higher level of care 184Referred to General Practitioner 573Admitted to Hospital 1418

Urgent Care Presentations 2007/08


Following the Safe Active and Independent Living Project (SAIL), an initiative of the Department of Human Services, we have introduced a screening program for older persons at risk of falls that present to the Urgent Care Unit. All patients 50 years and older admitted to hospital and patients 65 years and older who are discharged home from the Urgent Care Unit are screened. The aim of the program is to reduce the frequency and severity of falls and related injuries. Two hundred patients presented to the Urgent Care Unit over the past year with injuries resulting from a fall. The employment of additional nursing staff for the Unit has enabled nursing staff to be based in the Unit on a 24 hour basis. This has enabled the establishment of a rotating roster for staff over the three shifts, thereby providing opportunity for staff to attend education sessions for skill acquisition and maintenance.Delia Melville RN Div1Nursing Unit ManagerUrgent Care Unit

Infection ControlInfection Prevention and Control continues to have a high priority at Colac Area Health (CAH). All staff across the organisation have an awareness of the importance of infection prevention and control by attending orientation and education sessions and actively participating in the process. The Infection Control Consultant is also involved with the Regional Infection Control Practice Group (RICPRAC) and provides a consultancy service to health services in the Sub-Region of Barwon South-Western Region.

Hand HygieneFor the past few years CAH has been involved, along with other public hospitals, in improving hand hygiene compliance to prevent the spread of infection within health care facilities. As part of this focus we have been ensuring our staff have quick and easy access to hand hygiene products. Visitors are also becoming more aware of how germs are spread on hands and can be seen using the alcohol based hand rub when coming in and out of the hospital.

In 2007, the Hon. Daniel Andrews MP, Minister for Health, launched the “Start Clean” – Victorian Infection Control Strategy. This is a four year comprehensive strategy in the prevention, detection and management of health care associated infection. Part of this focus is on maintaining the improvements made in hand hygiene. Hand Hygiene Victoria was established following on from the Victorian Quality Council Project and the coordinating centre is based at Austin Health. Recently introduced has been the “5 Moments” for Hand Hygiene which is currently being promoted through the Acute Care Unit. The current compliance rate measure is 55% and at CAH we are achieving above this rate.

Equipment Sterilisation The Central Sterilising Department, located in the Operating Suite, is a very important functional area within our Operating Suite as it processes the instruments that are used for surgery. Audits are conducted annually to measure compliance with Australian standard AS/NZS 4187: 2003. The audit includes cleaning, disinfecting and sterilising reusable medical and surgical instruments and equipment and maintenance of associated environments in health care facilities. These are compared through the Rural Infection Control Practice Group (RICPRAC) with similar sized hospitals. Comparative Compliance rate for sections 7 & 8:• 2007 – 98%• 2008 – 99%

VaccinationWe off er a full vaccination program to our health care workers according to recommendations from the National Health and Medical Research Council. These include Hepatitis B immunization and annual Infl uenza immunization. Each year we have been working to improve the uptake of Infl uenza vaccination. All residents in Corangamarah are off ered an annual Infl uenza vaccination.


Multi-Resistant Organisms (MRO)These organisms can be a problem in many hospital settings as some “strains” of bacteria have developed resistance to many antibiotics. We continue to screen patients coming from metropolitan hospitals for Methicillin Resistant Staphylococcus Aureus (MRSA) to minimize the spread of antibiotic resistant bugs. If MRSA is detected, necessary precautions are instituted and relevant education and information provided for the patient and family. Through good hygiene practices and prevention programs we are continuing to maintain a safe environment for our staff , patients and visitors.Ann Gray RN RM Div1Infection Control Manager

Pharmacy2007/08 sees Pharmacy services continuing to explore new avenues of service scope and delivery through its commitment to professional development and novel service platforms.Our Pharmacy Technicians have completed Certifi cate III Studies in Health Service Pharmacy and 2008/09 begin their Certifi cate IV studies, allowing Technicians to further assist Pharmacists through the admission and medication allocation process to acute inpatients. This represents a whole new opportunity in ‘smoothing’ the admission process relational to medication management and freeing the Pharmacist to concentrate specifi cally on knowledge value adding to the patient, doctor and other healthcare professionals. Our Pharmacist continues to support and maintain:- Inpatient care- Outpatient services (including pharmacotherapy services)- Specialist services (including the Highly Specialised Drugs Program)- Primary Health Care Programs (including Well Women’s Clinic, Family Services and self referrals)- Shared Care services (with members of our community who require complex shared care with a Teaching or specialist health service or hospital)

- Clinical support to allied health, nursing and other professionals The Pharmacist is committed to continuing professional development which supports these clinical services as well as the leadership and management support he provides to the Health Service. To further this end the Pharmacist is working with the allied health team to create a clinical review forum allowing allied health professionals to refl ect on cases and best practice as well as discuss issues of common interest. The Patient Satisfaction Survey again demonstrated a high degree of patient satisfaction with the Pharmacy service. Further a survey of medication sheets ordering the anticoagulant Warfarin were shown to be within the compliance parameters of the NSW Therapeutic Assessment Group Indicator for this medication. The Pharmacist, in consultation with the Director of Clinical Services, Clinical Educator and the Manager, Information and Communication Technology is piloting an online forum format for working up pharmaceutical advisory issues. This allows for input from a wide number of stakeholders across the organisation before seeking medical input potentially reducing the time from idea inception to action.David WaltersPharmacy Services Manager

Education CentreThe Education Centre has benefi ted from Colac Area Health’s (CAH) commitment to develop a culture of learning throughout the organisation, with the aim of recruiting, retaining and training highly skilled staff to deliver quality contemporary care to the community. The delivery of education and training is now supported by a computer laboratory, skills station, resource library and facilities for audio-visual presentations. We are looking forward to the arrival of ‘Resus Annie-Cardiac Simulator’ manikin and accessories to enhance our skills station to facilitate the maintenance of Advanced Life Support and Basic Life Support skills acquired by staff throughout the year.


Additional staffi ng resources enable the provision of more frequent education sessions which are open to all areas across the organisation. The Centre also accommodates the Infection Control Nurse and we welcomed the relocation of the Quality, Risk and Special Projects Manager to our Centre this year. Infection Control, Quality and Risk are entwined in organisational education and will enhance the service we provide to staff . We are also extremely proud of the high level of skills and qualifi cations of staff working within the Centre. Collaboratively, we are well equipped to provide quality education. The Graduate Nurse Program provides graduate nurses with broad experience by rotations through the Acute Unit, Corangamarah, Community Nursing, Urgent Care, Perioperative Services and Lorne Community Hospital. This Program currently supports seven graduate nurses and will be reviewed and revised in the coming year to further improve the opportunities for graduates to consolidate their knowledge and skills and to develop into competent, confi dent nurses. We support the aim of the organisation in striving for the reputation of best Rural Graduate Nurse Program, evidenced by the broad range of skills and professionalism of nurses at the completion of the Program. Our Program will equip all graduates with the skills and experience to pursue their career aspirations. Colac Area Health also supports eight trainees who are undertaking their Division Two Registered Nurse Certifi cate IV in Health (Nursing). Traineeships provide an excellent opportunity for the application of theory into clinical practice in a supportive environment. Many students from schools, TAFEs and Universities have undertaken placements at CAH throughout the year. Allied Health and Nursing staff have been integral in supporting these students and have provided them with an understanding of our integrated health service and the various health professionals that support it. Internal education sessions have been conducted on a regular basis for organisational wide staff . Many workshops such as ‘Searching and Appraising Evidence’; ‘Advanced Life Support’; and

‘Development of Computer Skills’; have been well received. Provision of education via technology is becoming more prevalent. Videoconferencing enables current, evidence-based information to be provided by experts in the fi eld. Electronic learning is an advancement in the provision of education that will enable all staff at CAH access to education in a more fl exible manner. This year the Education Centre has developed a range of education packages that are now available to Nursing staff . This self-directed learning approach, in conjunction with education sessions, has enhanced nursing knowledge and clinical skills throughout the organisation. We have had many achievements this past year, however two highlights should be promoted. Firstly, co-ordination of Advanced Life Support Training for Registered Nurse Division 1. Twenty-one Nurses undertook the Advanced Life Support (ALS) with all being deemed competent. This is an excellent result for all concerned. The second highlight of note is the successful completion of the Medication Endorsement Certifi cate undertaken by many of our Division 2 Registered Nurses. These staff are now qualifi ed to administer medications within their scope of practice. In the coming year, the Education Centre will undergo further development as it aims to continue to create a learning environment and provide more extensive education across the organisation with the promotion of best practice, contemporary, quality care.Anna Reilly Clinical EducatorEducation Centre


Visiting Medical Staff Dr. M.P. Alexander, M.B., B.S., F.R.A.C.G.P., M.B.A. (Resigned November 2007) Dr. A.F. Appelbe, M.B., B.S., F.R.A.C.P. Dr. M.D. Bardsley, M.B., B.S., F.R.A.C.G.P., D.R.A.N.Z.C.O.G., M.R.A.N.Z.C.O.G. (Appointed July 2007)Dr. D. Borsos, M.B., B.S., D.R.A.N.C.O.G.Dr. A. Brown, M.B., B.S., F.R.A.C.G.P., D.R.A.C.O.G., F.A.C.R.R.M., Dip. Sports Medicine Dr. J.M. Brown, M.B., B.S., D.R.A.N.Z.C.O.G, F.R.A.C.G.P., F.A.C.R.R.M. (Appointed March 2008)Dr. M.D. Brownstein, M.B., B.S., F.R.A.C.G.P., D.R.A.N.Z.C.O.G., F.A.C.R.R.M. Dr. D.M. Buckley, M.B., B.S., D.A., D.R.C.O.G.Mr. K. Chao, M.B., B.S., Dip. R.A.C.O.G., F.R.A.C.S.Dr. M.T. Connor, M.B., B.S., F.R.A.C.G.P., Dip. R.A.C.O.G., A.C.C.A.M.Dr. C.P. Cooper, M.B., B.S., F.R.A.C.P.Dr. C.B.E. Davis, R.F.D., M.B., B.S., M.B.A., A.F.C.H.S.E. Dr. T.R.C. Fitzpatrick, M.B., B.S., M.F.M., Dip. R.A.C.O.G. (Resigned May 2008)Dr. I. Grant, M.B., B.S., F.R.A.C.G.P., F.A.Ch.P.M. (Appointed October 2007)Dr. G.L. Gray, M.B., Ch.B., D.R.C.O.G.Dr. K.R. Griffi ths, M.B., B.S., D.A., D.R.C.O.G., D.C.H.Mr. R. Grills, M.B., B.S., F.R.A.C.S. Dr. P. Hanson, M.B., B.S., F.F.A.R.A.C.S, F.A.N.Z.C.A. Dr. P.H. Hewson, M.D., F.R.A.C.P., M.B., B.S. (Resigned July 2007)Dr. B. Huang, M.B., B.S. (Appointed December 2007)Dr. D.M. Jones, M.B., B.S., D.A., D.R.C.O.G.Dr. T.W. Jones, M.B., B.S., U.C.H.M.S. (Resigned February 2008)Dr. D. Kerr, M.B., B.S., F.A.Ch.P.M. (Appointed October 2007)Dr. G. Kunjidapaadhum, M.B., B.S., D.T.C.D, G.R.A.C.G.P (Appointed April 2008)Dr. V. Lee, M.B., B.S., M.Med, F.R.A.C.S., F.R.A.N.Z.C.O.Dr. R. Llave, M.D.Dr. T.J. Lowe, M.B., B.S., D.R.A.N.Z.C.O.G.C., F.A.C.R.A.M., B.A.Mr. P.C. Lugg, M.B., B.S., F.R.A.C.S.Dr. I. Mackay, M.B., B.S., D.A., Dip. R.A.C.O.G., F.R.A.C.G.P.Dr. P.J. Madden, M.B., B.S., D.A., D.R.C.O.G.Dr. V. Makkada, M.B., B.S., D.M., F.M.G.E.M.S., F.R.A.C.P. (Appointed March 2008)Dr. A. Mander, M.B., B.S., F.R.A.C.P. (Resigned March 2008)Dr. P. Martin, M.B., B.Ch., B.A.O., M.Med., F.A.Ch. P.M. Mr. T.W. Mason, M.B., B.S., F.R.C.O.G., F.R.A.C.O.G.Dr. S.J. Menzies, M.B., B.S., M.Med, D.R.C.O.G., F.R.A.C.G.P.Dr. L.G. Munro, M.B. B.S., M.A.C.P. Pt 1 Mr. D.L. Murphy, M.B., B.S., F.R.A.C.S. Dr. R. McLennan, M.B., B.S., F.R.C.P., F.R.A.C.P.Dr. P.J. Nice, M.B., B.S., D.A., D.R.C.O.G.Dr. D.C. Robert, M.D., F.R.C.S. (Edin) Dr. W. Rouse, M.B., B.S., F.R.A.C.G.P, D.R.A.N.Z.C.O.G., Grad Dip. Rural G.P. (Resigned May 2008)Dr. E.W. Ryan, M.B., B.S., F.R.A.C.P. Dr. R.R. Sarkis, M.B., B.S. Mr. J.W. Skelley, M.B., Ch B., F.R.A.C.S., F.A. Orth. A.

Dr. R.H. Solly, M.B., B.S., F.A.N.Z.C.A (Appointed July 2007)Mr. C.S. Sutherland, M.B., B.S., F.R.C.S. (Edin), F.R.A.C.S.Dr. M. Uddin, M.B., B.S. (Appointed March 2008)Dr. A. Wong, M.B., B.S., F.R.A.C.G.P., D.R.A.C.O.G., F.A.C.R.R.M., Grad. Dip. R.M. Symbion HealthVisiting Radiologists:Dr. C.M. Blecher, M.B., B.S., F.R.A.N.Z.C.R., D.D.UDr. J.N. Chamberlain, M.B., B.S., M.R.A.C.R., F.R.A.N.Z.C.R., D.R.A.C.O.G.Dr. A.D. Felber, M.B., B.S., D.D.R., F.R.A.N.Z.C.R.Dr. P.E. James, M.B., B.S., M.Med, F.R.A.N.Z.C.R (Resigned 2008)Dr. W.J. Rogers, M.B., B.S., F.R.A.C.G.P., F.R.A.N.Z.C.RDr. C.S. Woodward, M.B., B.S., F.R.A.C.R.

St. John of God PathologyVisiting Pathologists:Dr. H.J.M. Armstrong, M.B., B.S., F.R.C.P.A.Dr. G.P. Davey, M.B., B.S., F.R.C.P.A.Dr. D.W. De Leacy, M.B., B.S., B.Sc., F.R.C.A.P.A. (Resigned June 2008)Dr. H.J. Fairweather, M.B., B.S., F.R.C.P.A. (Appointed June 2008)Dr. O.C. Harris, M.B., B.S., F.R.C.P.A.Dr. G.R. Kelsey, M.B. Ch.B., F.R.C.P.A. (Appointed June 2008)Dr. C.M. Pilbeam, M.B., B.S., B.Med.Sc., Ph.D., F.R.C.P.A., M.I.A.C. (Resigned June 2008)Dr. M.E. Robson, M.B., B.S., F.R.C.P.A.Dr. R.L. Spokes, M.B., B.S., F.R.C.P.A.Dr. G.W. Swinton, M.B., B.S., F.R.C.P.A.Dr. D.R. Trethewie, M.B., B.S., F.R.C.P.A. (Resigned June 2008)Dr. S.L. Wallace, M.B., B.S., F.R.C.P.A.

Visiting Dental Staff Dr. P. Hou, B.D.Sc.Dr. J. McEwan, B.D.Sc. Dr. M. Trotter, B.D.Sc.Dr. N.J. Trotter, B.D.Sc.Dr. H. Voronina, B.D.Sc. Barwon Health Dental Staff

Royal Australian College of General Practitioners Registrar ProgramDr. H.H.S. Chew, M.B. B.S. (February 2007 – February 2008)Dr. K.H. Loo, M.B., B.S. (February 2008 – February 2009)Dr. F.D. Maxwell, M.B., B.S. (February 2007 – February 2008)Dr. J.M. Ngui, M.B., B.S. (February 2008 – February 2009)Dr. B. Nguyen, M.D. (February 2008 – February 2009)Dr. F. Okedara, M.B., B.S., D.R.A.N.Z.C.O.G. (February 2006 – January 2008)Dr. R.G. Organas, M.B., B.S. (February 2005 – February 2008) Dr. F. Polani, M.B., B.S. (February 2008 – February 2009)Dr. M. Saka, M.B., Ch.B. (February 2007 – February 2008)Dr. M.M. Saka, M.B., Ch.B.(February 2007 – February 2008)Dr. M. Zhang, M.B., B.S., PhD. (February 2008 – February 2009)

Medical ServicesDr. Danny Jones continued his excellent work as Chairman of the Visiting Medical Staff until the October 2007 meeting of that body, when we were fortunate to have Dr. Justin Madden take over that role. Both these doctors have provided exemplary service to Colac Area Health and to the Executives working with them. My thanks to both. Congratulations are also extended to Dr. Jones who received an “Outstanding Service to Rural Communities Award” from the Rural Workforce Agency of Victoria. This prestigious Award acknowledges his contribution to medical services in Colac during the past 21 years and is extremely well deserved. I would also like to recognise the contribution of Dr. Max Alexander, Executive Director of Medical Services at Colac Area Health. Dr. Alexander commenced in February 2005, and resigned from the position in November 2007. I made reference in last year’s report as to the dearth of new procedurally trained GPs joining the work force generally, and in Colac in particular. While the Deakin Medical School’s curriculum and modus operandi is geared towards correcting this issue, there is an inevitable delay of years before their graduates will be able to contribute towards solving this problem. Coincidentally, we look forward to receiving the fi rst Deakin medical students mid way through 2010. In a welcome move, there has been a fundamental change in the provision of after hours services this year, with both practices joining forces to help provide ongoing obstetric care. This has been a diffi cult task, much assisted by the doctors’ willingness to look at alternative ways to their previous methods of the organisation of their practices. Just at the end of this reporting period, agreement was reached with the Visiting Medical Staff , for the hospital to explore the possibility of employing GP Registrars/Career Medical Offi cers. With the right appointees there would be a contribution to the areas of particular medical shortage.

We welcomed the following Visiting Medical Staff who have provided services to CAH during the past year:

Dr. M. BardsleyDr. J. BrownDr. I. GrantDr. B. HuangDr. D. KerrDr. G. KunjidapaadhumDr. V. MakkadaDr. R. SollyDr. M. Uddin

We thank the following for their service, whom we farewelled during 2007/08:Dr. M. AlexanderDr. T. FitzpatrickDr. P. HewsonDr. T. JonesDr. A. ManderDr. W. Rouse

Dr. Ed DavisConsultant Director of Medical Services

Dr Ed Davis, Consultant Director Medical Services

Dr Justin MaddenChairman Visiting Medical Staff


Health InformationHealth Information Services is responsible for reporting a number of Key Performance Indicators (KPIs), Daily Inpatient Statistics, unplanned readmission rate, medical records – coded cases rate, completed discharge summary ratio and numbers of medical records audited. The KPI target of completing coding of all discharges within 11 days of the end of the month has in the main been achieved each month except two over the last fi nancial year. The department has participated in two external audits of coded records within the last year, and a Department of Human Services (DHS) audit of some 63 records. The fi nal results of the DHS audit are still pending. Two staff attended the ICD-10 –AM sixth Edition, held by the National Coding Centre in preparation for the changes to coding guidelines and books as from 1 July, 2008.

Freedom of InformationFreedom of Information (FOI) applications are handled though this department and totalled 35 for the year. Of those 35 applications up until 30 June, 2008, 29 were granted, two were refused being due to no records being held for that particular applicant, three are pending approval and one application was withdrawn. Thirty three applications were for personal information and two applications were for non-personal information. A total of $716 was collected in application and photocopying fees. Health Information Services has processed nine Subpoenas to present medical records to various courts and nine Coroners cases throughout the year.

The introduction of the Clinical Review Sub-Committee has initiated a number of ongoing reviews of unplanned readmissions, deaths, transfers to major hospitals and patients remaining in over 35 days. New procedures have been introduced to ensure complete documentation is maintained for records processed through the Coroners Offi ce.

Future DirectionsA major review of patient / client record systems within Colac Area Health will be undertaken by this department with a view to consolidating record systems into an integrated system within existing boundaries.Roslyn EdsallHealth Information Manager


An overall goal of the Program within Colac Area Health (CAH) is to support a wide range of individuals and families though the diverse services provided across four teams:• Allied Health• Community Nursing• Family Services• Community Programs The untiring eff orts of a committed staff are acknowledged during what has been a challenging twelve months.Another Move ! Polwarth House – An opportunity for stronger alignment and integration: As part of CAH’s program of consolidating services on the main campus site in Colac, the refurbishment of Polwarth House provides the new home for Family Services, Community Nursing, Palliative Care and Regional Networkers. The shift occurred in October, 2007. Joining the team in Polwarth House has been our co-located colleagues in Child Protection – Department Human Services, and Pathways Psychiatric Disability Rehabilitation Services. The refurbishment represents a milestone in achieving a more integrated service system and improved alignment between services.

Allied HealthThe Allied Health Team provides services in Nutrition, Rehabilitation, Physiotherapy, Podiatry, Occupational Therapy, Speech Pathology, Adult Day Activities in a community setting and organisational wide Health Promotion. The clinical services are available in Acute Care, Residential Aged Care and Primary Care. Several services are contracted out to other agencies and assist to maintain a clinical presence in surrounding districts, as well as Colac and the Colac Otway Shire.

Expansion of Community Rehabilitation CentreSignifi cant changes took place in the Community Rehabilitation Centre during 2007/08, not the least being the relocation of client services to four major new spaces, eff ectively increasing the area available by 400%.

During 2007/08, $125,000 was provided by Department Human Services (DHS) for equipment identifi ed as being necessary to assist in the provision of an excellent service. New clinical areas include two gymnasiums, enabling groups to be conducted in one while individual clients simultaneously receive therapy in another. A separate group room is used for discussion groups and programs that do not require use of the gym or occupational therapy areas. An extremely well appointed occupational therapy training room for activities of daily living has been created with space for all activities of daily living and most personal activities. Planning work has commenced on a rehabilitation and mobility garden which Occupational Therapists will use for therapy activity for clients. We are fortunate to have three separate treatment rooms, a workroom/splint room, a functional bathroom/laundry and a nurse/doctor interview room to complete the rehabilitation complex.The main gymnasium is available for staff use during client free periods. Rehabilitation Programs• Cardiac rehabilitation is an eight week open program run continuously throughout the year. During 2007/08, 64 people were able to benefi t from these lifestyle focused sessions.• Pulmonary rehabilitation program is a nine week open program run continuously through the year.• A weekly balance group.• A weekly maintenance group.• A large and expanding orthopaedic group.

Physiotherapy ServiceThe redevelopment of Polwarth House has provided ideal private treatment areas for the Physiotherapists to cater for people with a wide variety of musculoskeletal, respiratory and neurological disorders. Physiotherapists were involved in treating over 1000 diff erent clients with approximately 3500 treatment sessions across acute care, aged care and community services.


Primary Care Services

Physiotherapy groupsHand Clinic• Water based exercise group• Respiratory Clinic•

Occupational Therapy ServiceA focus for occupational therapy is to keep people safe and in their own home environment. Occupational Therapists are involved in Falls Prevention strategies and programs, as well as individualised home safety checks. Occupational Therapists completed over 2300 consultations with 553 clients during 2007/08 and continue to be involved in an extensive range of services to the Colac Otway community, including rehabilitation.

Nutrition ServiceDuring 2007/08 dietetics services was expanded to accommodate bi-monthly routine nutrition reviews for all dialysis clients. Community Information Handouts for weight advice and meal plans that include accurate analysis were developed. Cookbooks developed and produced by Colac Area Health (CAH) have been reprinted due to community and staff demand. The Healthy Lifestyles Program funded a copy for each disability accommodation facility in Colac district. Positive feedback was received, including a dialysis client who said they were fantastic because there are low salt recipes and the sodium content is listed, making it easy to choose appropriate foods. Other activities included:• Healthy Women, Healthy Weight -The fi rst program

has been completed with evaluation proceeding.• Fluid Balance - a small project, in partnership with

Acute Care Unit, that aims to improve nursing staff and patient understanding of fl uids to more accurately record fl uid balance for patients while in the Acute Care Unit.

• Healthy Eating articles in Colac Herald – regulararticles as part of the ‘Kids in the Kitchen’- great publicity!!

• Monthly Supermarket Tours for clients, as well as specifi c groups such as Cardiac Rehabilitation participants.

Our two dietitians were responsible for over 2700 consultations with 780 clients.

Speech Pathology TeamSpeech Pathology Department works closely with local services in both preschool and school settings to improve the outcomes for children with communication diffi culties. The Team are members of the local Preschool-School Transition Network that hosted a series of workshops on the topic of Cued Articulation for Teachers. The workshops were very well attended; teachers showed great enthusiasm and reported they would be interested in similar professional development activities. Speech Pathologists provided consultations to 310 clients with nearly 1600 contacts, excluding direct work in school settings during 2007/08.

Other Allied Health NewsDuring 2007/08 peer education meetings were held every three weeks. Hosted by Allied Health staff they provided a forum for health professionals to meet and debate various health topics, recent research and medical literature. At the fi rst meeting, the annual Roberta Hay Award, in recognition of her contribution to Allied Health in Colac, was introduced. Roberta, who had previously worked with the District Nursing team at Colac District Hospital in the 1950’s/60’s, pioneered the role of a full-time Social Worker as a Welfare Sister. She occupied this position from 1973 until her retirement in 1993. Her colocation with other Allied Health staff , and broad role within Colac District Hospital, endeared her to all her work colleagues.


Community members welcomed the opportunity to view the refurbishment of the former nursing home during an Open Day of Polwarth House Service Centre

Adult Day Activity Centre “Garden Expo”The Adult Day Activity Centre held a “Garden Expo” in December 2007 to showcase the talents of its clients when their beautiful garden and festive season creations were put on display. Offi cially opened by Colac Area Health (CAH) Chief Executive Offi cer, the exhibition included crystal sun catchers, plants, mobiles, paintings, table decorations, knitted items and various other handmade gifts. A lavish afternoon tea was provided, with a variety of entertainment, including a fl ower arrangement demonstration. Numerous raffl es and lucky door prizes ensured that many people went home winners and the day was thoroughly enjoyed by the many family members and friends in attendance. All Adult Day Activity programs promote self esteem, confi dence and a sense of belonging and this well planned function was a wonderful example of providing an outlet for keen and talented participants.

PodiatryThe Podiatry service extends across all care areas of Colac Area Health (CAH). The service to Birregurra Community Health Centre increased from one to three afternoons each month in response to growing needs in the district. Demand for podiatry services has increased with the opening up of more aged care beds in Colac. During the fi nancial year 692 clients received over 2000 service contacts.

Health PromotionColac Area Health’s aim is to promote and further develop an integrated approach to health promotion across the organisation’s operations. Over the 2007/08 fi nancial year a key task has been the continued implementation of the three year integrated health promotion plan. The plan commenced in 2006 and will conclude in June 2009. The three key priority areas are:

o Reducing Tobacco Related Harmo Healthy Eating and Physical Activityo Mental Wellbeing

Important services such as the Smoking Cessation Clinic have been conducted as part of a planned approach to developing sustainable programs addressing our key priority areas. Other health promotion groups have included:• No Falls Exercise Program• Men’s Vintage Achievers• Huff ‘n’ Puff • Strength Training• Better Health Self Management. During 2008/09, the last year of the current health promotion plan, CAH will be working with partner organisations within Colac and across the Barwon Sub-Region to determine agreed priority areas for the next three year integrated health promotion plan, which will commence in July 2009.

Australian Early Development IndexThe Australian Early Development Index (AEDI): Building Better Communities for Children is a population measure of young children’s development from a teacher-completed checklist and measures fi ve developmental domains:o Language and cognitive skillso Emotional maturityo Physical health and wellbeingo Social competenceo Communication skills and general knowledge Under the project, two hundred and seventy nine children in their fi rst year of full-time schooling within the Colac Otway Shire were assessed during 2007/08.


AEDI is a population-based measure with a focus on a population rather than the individual. A population based approach means that important factors that impact on a child’s health and development, such as community factors and the broader social environment, are taken into account. For Colac Otway Shire the results showed 65% of the children were performing well in one or more domain. However, 28% of the children were vulnerable in one or more domains. The AEDI results presented at an Early Childhood Conference in Colac on 17 April 2008 stimulated an exploration of new ways in which schools, early childhood services and local agencies can work together to ensure children are provided with the best possible start in life.

Colac Community Dental ClinicThe Colac Community Dental Clinic has achieved a milestone this year in May with the much anticipated move from the Hart Street Clinic to a newly developed four chair clinic, onsite in Miller Street. The current model of integrated community dental health and the successful ongoing collaborative partnership between Colac Area Health (CAH) and Barwon Health has enabled the Colac community to access a public service of enviable quality. The service has met 2007/08 productivity expectations and funding targets.

Key Performance Indicators 01/07/07 – 30/06/08 Ave/monthNumber of clients 4981 415Number of visits 6231 519Number of treatments 16880 1406

Oral HealthColac Area Health received funding from Dental Health Services Victoria to coordinate the Smiles 4 Miles Program with Otway Health and Community Services and the Corangamite Shire. Each service formulated an oral health promotion plan and worked with their preschool communities to align oral health promotion messages with those of good nutrition, healthy lifestyles and active play.Pauline MaunsellAllied Health Manager

Community NursingIn December 2007, Community Nursing moved from Miller Street to the redeveloped Polwarth House Service Centre, which was a positive development for staff and clients alike.

ServicesCommunity Nursing has twenty-nine dedicated and professional staff working across two campuses; Colac and Birregurra, delivering twelve community service activities as detailed on Page 6.

PartnershipsDuring the fi nancial year the Community Health Nursing team working in partnership with other Programs, Colac Otway Shire and colocated services such as Diversitat, provided in excess of 19000 contacts to more than 1500 clients and families. The Community Nursing teams have worked collaboratively with other healthcare providers and community groups including: • Colac Police• Education Department• Department of Human Services - Disability Services. to provide innovative activities and programs, such as the Kinder Capers Program; a health promotion activity aimed at introducing children attending the local kindergartens to the Health Service and embrace the opportunity to promote health and wellbeing. The team has continued to provide successful Programs to community groups including:• Puberty Clues• Mum’s on the Move• Bubs at the Hub• Strength Training Group• Beechey Trail Trek.

Equipment SupportColac Area Health was successful in a submission to the Department Human Services - Disability Minor Works and Equipment Grant, to purchase specialised equipment which will improve women’s healthcare


services provided by the Community Health Nurses and Visiting Medical Offi cers. The generous support of the Department is acknowledged.

Sustainable Farm FamiliesSustainable Farm Families is an initiative of Western District Health Service and delivered in partnership with the Department of Primary Industry. Colac Area Health has provided ongoing support to this initiative since inception with participation from Executive Directors on the original steering committee. Two senior staff undertook the original facilitator training; both have continued to support Western District Health Service in the delivery of the Program across the State and into Northern Queensland. During 2007/08 fi nancial year Colac Area Health (CAH) was successful in an application for initial funding to provide the Program to our local community. A third staff member undertook the facilitator training, and in February 2008 the team delivered the Program to 23 local dairy farming families. The Program was well attended and well received by the participants, and CAH has received confi rmation of a successful second round of funding to off er the Program again in February 2009.

Palliative CareCommunity Nursing said farewell to Geraldine Gartland in February 2008, a long term employee of the Health Service. Geraldine was our Palliative Care Clinical Nurse Specialist for the past eight years; we thank Geraldine for her commitment and contribution and wish her well in her retirement. We extend our gratitude and sincere thanks to the Palliative Care Volunteers who continue to work with our team to support families and individuals faced with grief and loss. This component of the service is integral to the care of clients and families dealing with end of life. The Department of Human Services provided funds during the 2007/08 fi nancial year for “After-Hours Community Palliative Services” to improve access to ‘After-Hours’ care for clients cared for in their home or in the community. Equipment has been purchased under the program to respect clients choice to be cared for at home with safety and integrity.

Birregurra Community Health CentreThe community of Birregurra is utilising the purpose built gymnasium at the Birregurra Community Health Centre very well. The gymnasium was built with the generous bequest from the Estate of the late Jack Whittaker. The success of the gym at Birregurra is the result of the dedication and commitment of the Birregurra Advisory Committee to meet the needs of the community.

Health Independence Support Program 2007/08 marks the expansion of the management of Chronic Disease Programs off ered within the Health Service. The innovation of the “Health Independence Support Program”, a developing Program that emerged from the collaborative work of staff members across Primary Care. The new initiative off ers an exciting opportunity to the community to improve access to services and off ers an increased level of case management for consumers who utilise multiple services within the Health Service.

Professional DevelopmentCommunity Nursing, supported by the Executive Management Team and external agencies continues to value the ongoing education of staff members and the pursuit of best practice. During 2007/08 fi nancial year we had presentations by fi ve staff members at three national conferences including National Breast Care Conference, National Wound Care Conference and the National Continence Conference. The attendance of staff at a national forum has been a pivotal part of our strategic direction to address succession planning in specialty areas and the continuation of provision of these essential services. Anita WhytcrossCommunity Nursing Manager


Family and Community ProgramsChoosing just a small number of activities to highlight from Community Programs is diffi cult given the achievements that the workers accomplish on a day-to-day basis. The quality and diversity of the programs and services enhance the health and wellbeing of the community with a strong and co-ordinated approach to service delivery and planning. A list of services are outlined on Page 6.

Youth TeamOne of the best examples of an integrated approach to service provision at Colac Area Health (CAH) is the Youth Team. This team has been a strong and dynamic team for a number of years, planning, developing and providing a number of exciting and innovative programs to the local community. The team brings together workers from three program areas in Primary Care with a diverse range of skills and experiences relating to youth services. The team consists of Adolescent Health Nurses, Children’s Counsellor, Alcohol and Other Drugs Worker, and delivers programs for young people aged 12 – 18 years. Health promotion is a strong focus; the team has been very creative in developing programs that explore many challenges confronting young people and their families. The programs include “safe partying”, “standard drinks”, “sexual health and reproduction” and “risk and resiliency”, and are very popular with the local secondary schools, enabling a partnership approach between CAH and the education sector. The team has a strong presence in schools across the Shire, including Apollo Bay and Lavers Hill, with active support provided at the Apollo Bay Music Festival during the year. Team members worked over two evenings providing clinical support in a “Chill Out” tent. The support was greatly valued by the local community and the Colac Otway Shire Events Co-ordinator wrote “The professional support provided by the staff from Colac Area Health was greatly appreciated and quite obviously required. Assistance and guidance provided to the young people……undoubtedly ensured their safety.”

Family Violence Prevention ProgramFamily Violence Prevention Program was funded by VicHealth in 2007 under the Respect & Responsibility: Ending Violence against Women to raise awareness around Family Violence, particularly in relation to the impact of Family Violence on the workplace. The Project commenced in October, 2007 and activities included the White Ribbon Campaign in November 2007, development of a Family Violence Policy for CAH, education and training opportunities and activities for staff , creation and dissemination of an attitudes survey together with the distribution of posters and brochures. The Project ends in October, 2008, by which time – it is anticipated – the policy, awareness raising and staff training will be embedded in organisational culture.

Rotary Club of Colac West, Family Support Partners ProjectThe Family Support Program has been a very appreciative benefi ciary of a “Partners Project” by the Rotary Club of Colac West. The project this year focused on literacy improvement. The Rotary Club of Colac West approached Colac Area Health to be its partner in this project and generously donated funds to the Family Support Program to purchase children’s books. The Family Support Program provides support to vulnerable families and children, including those who are particularly disadvantaged. The books serve as an engagement tool for workers when developing a relationship with the parents and children. Using the books in a variety of ways, but particularly to model and encourage parents to read to their children. The Partners Project will be a great enhancement to the Program and will provide access to books for a number of young children who may otherwise not have had the opportunity.Marg WhiteFamily and Community Programs Manager


Human ResourcesThe Human Resources Department exists to provide services, advice and support to Colac Area Health (CAH) managers and staff in relation to all human resource functions. This includes payroll and salary packaging activities, as well as workforce planning comprising recruitment and selection, staff training and development and performance management. The Department is also responsible to ensure the organisation and its employees meet the legislative requirements outlined in Employee and Industrial Relations Regulations including Occupational Health and Safety (OHS) and Equal Employment Opportunity (EEO). The Department consists of 4.7 Full Time Equivalent (FTE) including the Manager, Human Resources, Payroll Coordinator, Payroll Offi cer, Human Resources Coordinator and Human Resources Administrator. The team is extremely dedicated to serving the best interests of the organisation and delivering outcomes that are in accordance with the organisation’s Vision of being recognised as a leader in the development and provision of responsive, integrated health care.

Our Corporate ValuesThe CAH Corporate Values of respect, integrity, leadership, innovation, quality and partnerships are extremely important in the way the human resources team operates and they proactively promote the values throughout the organisation. Upon commencement at CAH the team ensures that new members of staff are aware that these organisational behaviours exist and are expected of all our employees by including them as part of the orientation package. These Values are also apparent through the delivery of our service and included in the advice and support that we off er to managers and employees.

Payroll and Salary PackagingThe CAH payroll service is currently responsible for the fortnightly payroll for approximately 471 employees at CAH and one other local agency. The service was extended to include an additional agency as well, however, this arrangement ceased during the year.

In addition to the payroll service, the Unit is also responsible for delivering the salary packaging program to CAH employees. This program off ers considerable benefi ts to employees enabling staff to access taxation benefi ts which can increase their take-home pay. At 30 June, 2008, 308 CAH employees, which comprises approximately 74% of the total workforce, chose to utilise the salary packaging service. The decision was made during the year to purchase a new payroll system given the arrangement with the current system provider was due to cease on 30 June 2008. Considerable work has been completed over the past year setting up the new system, “Chris 21”, to ensure we are ready to “go live” on the fi rst pay period of the new fi nancial year. The team will continue to work on the system in the new fi nancial year to further develop its eff ectiveness. It is also intended to implement an “Employee Self Service” in the coming months enabling employees to access their own payroll information on-line.

Occupational Health and SafetyOccupational Health and Safety (OHS) continues to be a high priority of CAH as signifi cant work has been completed to ensure we meet our obligations under the Occupational Health and Safety Act 2004. The OHS Committee has convened on a monthly basis with health and safety representatives and, managers have been required to complete quarterly audits of their areas. Colac Area Health has facilitated visits from WorkSafe over the year and staff have attended locally conducted WorkSafe information sessions. The OHS systems, policies and procedures will continue to be reviewed and updated throughout the next year to ensure they remain current with legislative requirements and that CAH meets employer obligations.

Donna HayHuman Resources Manager


Staff Recruitment and OrientationStaff recruitment continues to be an ongoing challenge to ensure the organisation recruits the highest calibre of staff through a fair, open and transparent process. The human resource team takes pride in its recruitment principles that demonstrate fairness, credibility, equal employment opportunity and merit.It is extremely important to ensure newly recruited employees are orientated to the organisation appropriately. The Human Resources department has orientated 110 new and current staff over the past year to ensure they are familiar with Colac Area Health (CAH) processes, policies and procedures. The one day program comprises speakers from diff erent areas of the organisation and contains information regarding human resources activities, infection control, safety and quality systems, information technology, privacy and confi dentiality, emergency response and CPR, No-Lift and Family Violence. The program will continually be reviewed and updated to ensure the most current information is conveyed to staff .

Promoting Skills DevelopmentColac Area Health continues to focus on skills enhancement and emphasises the advantages of developing current staff to ensure succession planning for the future. Over the last year graduate programs, traineeships and apprenticeships were off ered in nursing, food services, administration and dental services.

Reward and RecognitionEmployee of the Month ProgramIn April 2008, an Employee of the Month Program was implemented to recognise our star performers. The award is given to an individual each month who has demonstrated exceptional performance within their position at CAH. This includes promoting and carrying out our Corporate Values – partnerships,

innovation, leadership, integrity, quality and respect– as well as showing superior customer service, initiative or expertise within their position. The following employees were recipients of this award in 2007/08:• April - Adam Lamanna (Information and Communications Technology Support Offi cer)• May - Lillian Duggan (Midwife) and Jan Hall (Food and Domestic Services Assistant)• June - Michelle Carmody (Associate Nurse Unit Manager Acute Care Unit) The award will continue throughout the next fi nancial year and the organisation looks forward to publishing the winners for 2008/09 in the next Annual Report.

Service AwardsCertifi cates of Service are awarded to staff and Visiting Medical Staff on completion of 15 years service. Recipients at the Annual General Meeting held in November, 2007 were as follows:

Mrs. Donna Chandler - Corporate DivisionMs. Faye Fox - Corporate Division Mrs. Debbie Park - Clinical DivisionDr. George Gray - Visiting Medical Staff

Industrial RelationsThroughout the year the Nurses (Victorian Public Health Sector) Multiple Business Agreement expired and discussions took place between the Victorian Hospitals Industrial Association (VHIA) and the Australian Nurses Federation (ANF) for a new agreement. Negotiations were fi nalised in March and the terms and conditions of the new agreement came into eff ect. Representatives from CAH worked well with the representatives from the ANF to ensure changes were implemented and will continue to work on this throughout the next fi nancial year. The Health Services Union of Australia – Health Professionals and the Health Services Union of Australia – Medical Scientists, Pharmacists and Psychologists certifi ed agreements also expired during the year and discussions took place between the VHIA and relevant Union bodies to negotiate new agreements as well. Negotiations for both agreements were not fi nalised before 30 June, 2008.


Adam Lamanna accepting the Certificate of Recognition from Geoff Iles, CEO, when announced the inaugural Employee of the Month recipient in April.

Service Improvement Administration Casual PoolIn order to assist managers cover expected and unexpected staff absences in the administration areas, an Administration Casual Pool was developed for managers to access ensuring services are maintained in periods of staff absence. The pool is coordinated by the Manager, Administration Services who provides administration relief when staff are on leave. To date the casual pool has been successful in assisting managers cover periods of leave to ensure services are upheld at all times.

Equal Employment Opportunity (EEO) StatementColac Area Health (CAH) considers EEO principles as imperative to ensure compliance with the guidelines set out under the State Services Authority. The “Code of Conduct for Victorian Public Sector Employees”, which outlines public sector values and the reasons for the code, was distributed to each staff member during the year. Colac Area Health has demonstrated commitment to these standards by ensuring EEO principles are included as standard practice for recruitment, training, transfer and promotion opportunities. All vacant positions within CAH are advertised internally (as a minimum) on our website as well as on our noticeboards. Colac Area Health aims to promote a discrimination-free work environment which fosters employee respect and working relationships with many behavioural policies in existence, as well as grievance procedures as an avenue for re-dress if required.

Staffi ng Profi leAs at 30 June, 2008, our staffi ng profi le was made up of the following components:

Whistleblowers’ Protection Colac Area Health is committed to the aims of the Whistleblowers’ Protection Act 2001. In accordance with the requirements of the Act, CAH has in place a policy to facilitate the making of disclosures under the Act. For the year 2007/08 no disclosures were made.

Donna HayHuman Resource Manager

LABOURCATEGORY

JUNE 08CURRENT

MONTH FTE

JUNE 08YTD FTE

JUNE 08CURRENT MONTH

HEAD COUNT

Nursing 152.44 147.70 233

Administration and Clerical 33.17 32.60 43

Medical Support 26.32 25.94 35

Hotel and Allied Services 54.02 54.12 73

Ancillary Staff (Allied Health) 22.27 23.05 34

TOTAL 288.22 283.41 418


Support Services oversees the following areas, and also has the responsibility for fl eet management, contract management, security and signage.

Food Services• Acute patients• Residential Aged Care residents• Staff • Visitors• Meetings• Meals on Wheels• Emergency Service meals• Prisoner meals.

Environmental Services• Cleaning to Wards, Operating Suite and Emergency Departments• Cleaning to Corangamarah Residential Aged Care facility• Cleaning to Community Dental Clinic • Cleaning to Pathology and Medical Imaging [contract]• Porter/courier service • Assist where required with furniture and equipment relocation• Linen distribution• Personal linen to Corangamarah Residential Aged Care facility• Waste Management.

Engineering Services• Preventative and breakdown maintenance• Plant and equipment service• On-Call service 24 hours per day 7 days per week• Garden and surrounds• Bus driving • Assist where required with furniture and equipment relocations.

Supply Department• Management of the procurement process for all consumables and equipment items required to support the operations of Colac Area Health (CAH).

AchievementsAudit of Cleaning Services In accordance with requirements, an external audit was conducted at CAH on 1 April, 2008. Results are shown in the table below. Congratulations to the environmental staff for achieving excellent results with the external audit of acute facilities at CAH. With the opening of Polwarth House Service Centre for Primary Care staff and the relocation of the Community Dental Clinic, staff again demonstrated the willingness to accept change and continue to provide excellent service.


Area2006 2007 2008

Areas Audited Score

Areas Audited Score

Areas Audited Score

Group A -Very High RiskOperating Suite, ICU 8 96% 11 100% 8 95%

Group B–High and Moderate RiskCSSD, Sterile Supply areas, Emergency Dept, Pharmacy clear area, Wards etc

17 97% 23 100% 18 97%

Group C – Low RiskLaboratories, Mortuary, Medical Imaging, Waiting Rooms, Administration

1 96% 3 100%

Totals 26 96.4% 37 100% 26 96.5%

ALL areas meet the Cleaning Standards Acceptable Quality Level (AQL)

Support Services

Audit of Food Safety ProgramLegislation requires that an external audit of the Food Safety Program be conducted. The audit of Colac Area Health (CAH) was completed on 24 January, 2008. There were seven non-notifi able areas requiring corrective action. These were attended to and certifi cates were issued on 21 February, 2008.

Food ServicesAs noted above, food service is provided to various areas in and around CAH, as well as external contract provision. The following is a summary of the number of meals provided during 2007/2008.

Meal Summary 2007/2008 Meals %Acute 35205 19.23Corangamarah 107508 58.72Operating Suite 2500 1.37Cafeteria 7735 4.22Adult Day Activity Centre 2725 1.49Functions 5127 2.80Day Surgery Unit 2221 1.21Meals on Wheels 18007 9.83Other 2068 1.13

Total 183096 100.00

Waste ManagementColac Area Health is a member of the Barwon Waste Wise Healthcare Network and is certifi ed as Waste Wise with assistance from Barwon Regional Waste Management Group. Colac Area Health was the fi rst healthcare facility in Victoria to receive Waste Wise Certifi cation in 1999. A waste

management action plan has been developed based on the principles of reduce; reuse and recycle. Annual waste audits are conducted for general, clinical and related waste streams. Colac Area Health is very proud to be certifi ed as Waste Wise. In our industry there are certain items which are single-use in order to meet infection control standards. We continue to strive to achieve improvements and to build on our earlier initiatives. There are no toner cartridges, saline bottles, paper or cardboard included in Colac Area Health’s general waste - these materials are all recycled. In addition, confi dential documents are shredded and recycled, garden waste is composted and laundry chemical packaging has been reduced through bulk purchasing. Colac Area Health staff support the eff ort to remain Waste Wise through their work to correctly segregate waste at the point of generation. Contamination of bins has almost been eliminated; an essential component of eff ective recycling.

Supply DepartmentIn accordance with the Vision and Mission Statement of Colac Area Health, the Supply Department off ers a wide range of services to “promote the health and wellbeing of the Colac and District community”. Over recent years the department has expanded from providing basic services to meeting the requirements of a complex health facility which includes acute, residential aged care and primary care services.


In response to the needs of the wider community, the department off ers supplies and services to a number of external organisations, including:• Lorne Community Health Service, Hesse Rural Health, Cobden Health Service and Colanda Centre• Transport Accident Commission (TAC) clients• A number of Department of Human Services facilities in and around Colac. The supply of goods and services to individual clients of Colac Area Health is another area of major value and importance to clients and the community. This support to the continuum of care includes the provision of dietary supplements, continence aids, wound care products and the hire and loan of rehabilitation equipment. It is recognised that to continue to respond to the needs of the community and the health service, the Supply Department must integrate the many time saving advantages made available by new technology. To this end it is intended to introduce on-line requisitioning and ordering procedures that will further increase the department’s effi ciency and ability to grow with the organisation.Trevor NelsonSupport Services Manager



Information and CommunicationThe Colac Area Health (CAH) Information and Communication Technology (ICT) staff (Manager and ICT Offi cer) manage all the ICT functions at CAH. 2008 is a year of consolidation, following the rollout of a number of large projects in 2007. The Personal Computer (PC) and laptop fl eet size has increased slightly to 210 PCs and laptops, with 460 staff having access to email applications. For some time now, CAH has been participating in a project which has seen the introduction of an experimental Bedside Entertainment System Technology (BEST), which replaces traditional televisions with a touchscreen monitor mounted on an adjustable “arm”. The major benefi ts of this system, over that of a traditional system, include:• Austar – 15 channels of Pay-TV• A selection of movies which can be streamed to any monitor – similar to the system employed in many hotels• A large selection of music video clips• Internet access. As mentioned, the system is not as yet fully functional and will most likely change in the future as new uses are determined and abilities explored. Some current ideas being looked at are:• Custom CAH content, e.g. patient information, maps, health promotion material, etc.• The ability for staff and/or patients to plan their menu choices at the bedside• The possibility of doctors using the system to record progress notes. Currently the system is in place for all 43 Acute Care Unit beds as well as the 7 Day Surgery Unit beds. Late 2007 saw the streamlining of CAH’s hardcopy device fl eet to almost 100% photocopier / laser printer based.

The fl eet is now maintained under a facilities management agreement which has provided the following benefi ts to CAH:• Greatly reduced number of hardcopy devices - from around 80, down to 30• Devices are multifunction, which provides photocopying, faxing, scanning, emailing• The speed, capabilities and effi ciency of the fl eet far surpasses older laser/inkjet printing technology• Savings of approximately 20% over the older laser/inkjet printing technology• The ability to more actively monitor and manage usage levels amongst various departments. Future ICT directions at CAH includes some strategic and innovative changes:• Migration to a completely integrated Active Directory Services model – the technology which drives security and access to the network. Colac Area Health is currently participating in such a model managed by SWARH (South West Alliance of Rural Health), and is a primary driver for maintaining and updating the model so other regional health agencies can join. The eventual goal of this model is to go statewide – one health network and services model to supply the entire State of Victoria.• Colac Area Health will be participating in a new IT Services Strategy for the region, which will include the provision of IT Services to all health services in our geographic region. This is an initiative being mandated by the Department of Human Services.Randall HoseInformation and Communication Technology Manager

Statutory ComplianceLegislative ComplianceBased on legislative information received, Colac Area Health (CAH) has complied with all Acts and Regulations. Legal advice provided on behalf of Victorian Healthcare Association indicates that there is no longer a requirement for public hospitals to include a full list of Acts and Regulations in the Annual Report.

National Competition PolicyColac Area Health complied with all government policies regarding competitive neutrality.

Compliance with Building ActColac Area Health complies with the Building Act 1994 under guidelines for publicly owned buildings issued by the Minister for Finance 1994 in all redevelopment and maintenance issues.• Building Inspections Standards Assessment Colac Area Health facilities have been the subject of a fi re audit by a Fire Services Engineer. The scope of that audit considerably exceeded the scope of an inspection by a Building Surveyor in line with the Minister for Finance’s Guidelines.• Arrangements Regarding Registered Building Practitioners The Board of Directors requires all building professionals engaged on building projects to be registered with the Building Practitioners Board or be Registered Architects.• New Buildings It is required that a building permit be issued at the completion of each building project. That action ensures that new buildings and work in existing buildings conform to building standards and that the ten year liability cap is invoked. During the year, the following works were undertaken to ensure comformity with the relevant standards.Building Works NumberOccupancy Permits Issued 1Works in construction and the subject of mandatory inspection NilMaintenance NumberNotices issued for rectifi cation of substituted buildings requiring urgent attention Nil

ConsultanciesThere was one consultancy totalling $28,178 undertaken at Colac Area Health during the 2007/08 fi nancial year.

Fees and ChargesColac Area Health charges fees in accordance with relevant Department of Human Services directives.

Financial Management Compliance Framework (FMCF)The Financial Management Compliance Framework (FMCF) was introduced from July 1, 2003 and applies to all Victorian Public Sector (VPS) entities. The Framework has been established to ensure that all VPS entities have implemented appropriate systems to ensure that public resources are used in an effi cient, eff ective and responsible manner. Colac Area Health is working to ensure that full compliance is achieved. Colac Area Health will continue to review its performance, policies and procedures to ensure that the Service is operating in an eff ective and responsible manner.

Pecuniary InterestMembers of the Board of Directors are required to notify the President of the Board of any pecuniary interest which may give rise to a confl ict of interest as defi ned in accordance with the Directions of the Minister for Finance. All declarations of pecuniary interest have been completed and are available on request to the relevant Minister, Member of Parliament and the public.

Services Contracted OutThe range of Services contracted out has remained unchanged during the 2007/08 fi nancial year.


Statutory ComplianceAdditional Information StatementThe following information, where it relates to Colac Area Health and is relevant to the fi nancial year 2007/08 is available upon request by relevant Ministers, Members of Parliament and the public:

(a) A Statement of pecuniary interest has been completed.(b) Details of shares held by senior offi cers as nominee or held benefi cially.(c) Details of publications produced by the department about the activities of the entity and where they can be obtained.(d) Details of changes in prices, fees, charges, rates and levies charged by the entity.(e) Details of any major external reviews carried out on the entity.(f ) Details of major research and development activities undertaken by the entity that are not otherwise covered either in the Report of Operations or in the document that contains the fi nancial report and the Report of Operations.(g) Details of overseas visits undertaken including a summary of the objectives and outcomes of each visit.(h) Details of major promotion, public relations and marketing activities undertaken by the entity to develop community awareness of the entity and its services.(i) Details of assessments and measures undertaken to improve the occupational health and safety of employees.(j) General statement on industrial relations within the entity and details of time lost through industrial accidents and disputes, which is not otherwise detailed in the Report of Operations.(k) A list of major committees sponsored by the entity, the purposes of each committee and the extent to which the purposes have been achieved.


Disclosure Index

The Annual Report of Colac Area Health is prepared in accordance with all relevant Victoria legislation. This index has been prepared to facilitate identifi cation of the Department’s compliance with statutory disclosure requirements.

Legislation Requirement Page Reference

Ministerial DirectionsReport of Operations - FRD GuidanceCharter and purposeFRD 22B Manner of establishment and the relevant Ministers......................................................16FRD 22B Objectives, functions, powers and duties............................................................................16FRD 22B Nature and range of services provided................................................................................ 6Management and Structure FRD 22B Organisational Structure............................................................................................................... 9Financial and Other InformationSD 4.2(j) Accountable Offi cer, signed off Report of Operations....................................................10SD 4.5.5 Risk Management Compliance................................................................................................17FRD 22B Operational and budgetary objectives and performance against objectives.......12FRD 22B Statement of merit and equity................................................................................................ 42FRD 22B Workforce Data Disclosures......................................................................................................42FRD 22B Occupational Health and Safety............................................................................................. 40FRD 22B Summary of the Financial Results for the year.................................................................. 7FRD 22B Signifi cant changes in fi nancial position during the year............................................. 57FRD 22B Major changes or factors aff ecting performance............................................................. 12FRD 22B Subsequent Events...................................................................................................................... 86FRD 22B Application and operation of Freedom of Information Act 1982...............................33FRD 22B Compliance with building and maintenance provisions of Building Act 1993..... 47FRD 25 Victorian Industry Participation Policy disclosures........................................................N/AFRD 22B Statement on National Competition Policy........................................................................47FRD 22B Application and operation of the Whistleblowers Protection Act 2001...................42FRD 22B Details of consultancies over $100,000................................................................................47FRD 22B Details of consultancies under $100,000.............................................................................47FRD 22B Statement of availability of other information..................................................................48FRD 10 Disclosure Index............................................................................................................................49FRD 11 Disclosure of ex-gratia payments...........................................................................................67FRD 21A Responsible person and executive offi cer disclosures................................................... 83Financial Statements - FRD GuidanceFinancial Statements required under Part 7 of the FMASD 4.2(b) Operating Statement...................................................................................................................54SD 4.2(b) Balance Sheet.................................................................................................................................55SD 4.2(b) Statement of Changes in Equity..............................................................................................56SD 4.2(b) Cash Flow Statement...................................................................................................................57SD 4.2(c) Accountable offi cer’s declaration............................................................................................51SD 4.2(c) Compliance with Australian accounting standards and other authoritative pronouncements..........................................................................................................................58SD 4.2(c) Compliance with Ministerial Directs......................................................................................58SD 4.2(d) Rounding of amounts.................................................................................................................58LegislationFreedom of Information Act 1982.............................................................................................................................33Whistleblowers Protection Act 2001........................................................................................................................42Victorian Industry Protection Act 2003..................................................................................................................N/ABuilding Act 1993............................................................................................................................................................47Financial Management Act 1994...............................................................................................................................58Audit Act 1994..................................................................................................................................................................52


Financial ServicesThe entity fi nancial result for 2007/2008 was a surplus of $0.430m. Excluding capital income and depreciation, the operating result was a surplus of $0.248m. This compares to an entity result in 2006/2007 of $0.638m and an operating result of $0.130m. The fi nancial year 2007/2008 has been one of consolidating our fi nancial systems to provide a platform for producing timely and accurate fi nancial statements. We have continued the development of our budgeting system, which will enable monitoring of the fi nancial position at department level, with managers heavily involved in analysis and reporting. There has also been a signifi cant eff ort applied to reviewing and updating fi nancial policies and procedures.

Features of 2007/2008With the support of Department of Human Services funding, the following capital projects have been completed:• Finalisation of the refurbishment of Otway Pioneers and Polwarth House Service Centre.• The building previously occupied by Home Nursing has been completely redeveloped to enable the Community Dental Clinic to move to the main campus. This was achieved in May 2008, completing the objective of having all major services consolidated on the one site.• The previously unsealed main car park has been sealed, marked and landscaped, with a total capacity of 75 car parks, including disabled and short term parking bays.

The Future• In March 2008 a new funding system (the Aged Care Funding Instrument) was introduced for Residential Aged Care facilities. The funding mechanism used by this system is quite diff erent to that previously used, so adapting to and monitoring the changes will be required to assess the impact on Colac Area Health’s fi nances.• Further development of devolved budgets and involvement of managers in assessing fi nancial performance. To assist in the understanding of the relationship between the organisation’s operations and fi nancial position, a more wide ranging suite of Key Performance Indicators and other measures will be provided to managers.• An increased focus will be placed on reviewing and updating fi nancial policies to ensure compliance with legislation and standards. Although reporting a surplus for 2007/2008, the result included a signifi cant amount of grant income received during the year, for which expenditure will be incurred in 2008/2009. The Board of Directors, Executive and Staff will focus their work to ensure that the current levels of services are maintained and improved into the future. Signifi cant progress has been made to ensure the structures within the organisation will support the development of services to meet community expectations. We would like to acknowledge the support of the Department of Human Services during the past year, and also pass on our thanks to the staff of Colac Area Health for their commitment in what has again been a challenging year.

Garry EllisDirector Corporate Services


Garry Ellis Director Corporate Services

Annual and Quality of Care Report 2008...2 Colac Area Health Vision Colac Area Health aims to be a...

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