Brhs Ann Rep Web 2010

Bairnsdale Regional Health Service
Annual Report
2009-2010
incorporating Quality of Care Report
...focusing on you
Mission
Leading, shaping and delivering quality health care services to East Gippsland
Vision
To be a key provider of healthcare services in East Gippsland through: Innovation in the delivery of health care services Recognition by its clients as being committed to quality care Working in partnership with other healthcare providers Responsiveness to community needs Recognition by its staff as an employer who values their contributions; and Delivery of cost effective services
Values
Customer Service Respect Teamwork Efficiency
Our motto
...focusing on you
Construction of new Oncology & Dialysis Unit - June 2010
The Bairnsdale Regional Health Service is established under the Health Services Act 1988. The responsible Minister during the reporting period is the Hon Daniel Andrews MP. The Bairnsdale Regional Health Service Annual Report 2009/10 has been prepared in accordance with the Health Services Act 1988, Financial Management Act 1994, Standing Directions of the Minister for Finance (Section 4 Financial Management Reporting) and Financial Reporting Directions (Specifically FRD 22).
CONTENTS
Prole Services President and CEO Report Summary of Strategic Goals Summary of Key Result Areas Financial Results Activity Data Workforce Data Corporate Governance Organisational Structure Organisational Chart
2 3 4 6 7 9 10 12 13 16 17
Management Committees Specialists and Visiting Specialists Financial Donations Life Governors Community Engagement Quality of Care Report of Operations Glossary of Terms Donations / Bequests Index Disclosure Index
18 19 20 22 23 24 30 32 34 35 36
Bairnsdale Regional Health Service 2010 Annual Report
PROFILE
Bairnsdale Regional Health Service (BRHS) provides healthcare services to more than 40,000 people across the East Gippsland Shire covering an area of 21,000 square kilometres. Towns to benet from the services of BRHS include Bairnsdale, Benambra, Bruthen, Buchan, Ensay, Lakes Entrance, Mallacoota, Metung, Omeo, Orbost, Paynesville, Swan Reach and Swifts Creek. Hospital services operate from the main campus in Day Street, Bairnsdale and include acute and post acute services, specialist consulting rooms, dialysis and oncology outpatient services, allied health outpatient services, radiology, pathology and residential aged care facilities. Community health services are located in both Bairnsdale and Paynesville providing outpatient allied health services, Planned Activity Group, and dental services in Bairnsdale. Outreach Planned Activity Groups are also located in Metung, Buchan, Bruthen, Lindenow and Paynesville. Outreach healthcare and education services are also provided throughout the region including allied health services at the Lake Tyers Aboriginal Trust and the Gippsland and East Gippsland Aboriginal Co-operative (GEGAC); outreach midwifery and maternal health, district nursing and in-home palliative care.
BRHS HISTORY
1887 1930 1940 1963 1967 1975 1981 1986 Opening of the Bairnsdale District Hospital Opening of the Orbost Hospital Relocation of the Bairnsdale District Hospital to Day Street (current site) Training facilities for nursing built on site Extension of hospital to facilitate outpatient facilities Name changed to East Gippsland Hospital Opening of childrens ward Completion of building works incorporating radiology, pathology, pharmacy and medical records Opening of new operating theatre Bairnsdale Regional Health Service established as an entity under the Health Services Act 1988 following amalgamation of the East Gippsland Geriatric Centre and East Gippsland Hospital Amalgamation of Community Health Services into the Bairnsdale Regional Health Service Establishment of Sutherland Lodge, dementia specic aged care facility Establishment of Maddocks Gardens residential aged care facility Construction of the new Emergency Department and associated works Extension of the Monash Rural Clinical School Master Planning commenced for construction of Oncology & Dialysis unit, and extension to pharmacy Pharmacy extension completed, construction underway on Oncology & Dialysis unit.
1992 1992
1993
1996 2004 2007 2008 2009
2010
SERVICES
Services offered by Bairnsdale Regional Health Service include:

Acute & Sub Acute Health Dialysis Emergency Services Geriatric Evaluation and Management Medical Medical Imaging Obstetrics Oncology Paediatrics Palliative Care Pathology Pharmacy Rehabilitation Stomal Therapy Surgical Care Theatre
Community Health Adolescent Health Breast Care Cardiac Rehabilitation Community Dental Health Program Continence Advisory Service Diabetes Education Home Based Nursing Service (District Nursing) Hospital Admission Risk Program (HARP) Hospital in the Home (HiTH) Needle Exchange Program Palliative Care Planned Activity Group (PAG) Post Acute Care (PAC) Pulmonary Rehabilitation QUIT program smoking cessation Womens Health
Aged Care Rehabilitation Rehabilitation Physician Residential Dementia Residential High Care Residential Low Care Respite Care
Allied Health Dietetics Equipment Service - Aids and Equipment Program Inpatient Rehabilitation Koori Hospital Liaison Occupational Therapy Outpatient Service Physiotherapy Podiatry Social Work Speech Pathology
Visiting Specialists Audiology Cardiology Cognitive Dementia and Memory Service Gastroenterology General Physician General Surgeon Gynaecology Head, Throat, Neck & Nose Counselling Services Low Fertility Clinic Low-Vision Clinic Neuropsychology Oncology Ophthalmology Orthopaedic Outreach Polio Clinic (bi-annual) Paediatric Surgeon Paediatrician Rehabilitation Cardiologist Renal Physician Rheumatologist Urology Vascular Surgeon
Ancillary Audiology Medical Library Mental Health Orthotics
PRESIDENT AND CEO REPORT
On behalf of the Board of Management, management and staff, we are pleased to present the Annual Report of Bairnsdale Regional Health Service (BRHS) for 2009-10. During 2009-10 BRHS adopted a new strategic plan for the years 2009-2013. The plan builds on BRHSs mission of; leading, shaping and delivering quality health care services to East Gippsland and a summary of the goals and strategies can be found following this report. The plan sets out the pathway for BRHS to build on its services as the opportunities arise over the next four years and to achieve these objectives whilst maintaining core clinical services and operating effectively within the resources we have. The healthcare landscape we operate in is both dynamic and challenging and the Board and management of BRHS are pleased to report that we have successfully met and navigated through these challenges for the benet of all sections of the community. With the ever increasing demands for service provision and costs of healthcare, it is our priority to ensure that BRHS is able to meet as many as possible of the needs of our community. Satisfying these competing demands is a constant and complex challenge for management. Without question the issue of the consulting suites and whether visiting consultants should pay for the use of the rooms and BRHS staff to conduct private clinics was locally controversial. A successful outcome for the visiting consultants and BRHS, in line with accepted industry wide practice, was achieved through the goodwill and co-operation of all parties concerned. In late 2009 BRHS committed $196,000 towards renovating the consulting suites and staff accommodation. This project will be completed in August 2010 resulting in improved reception and waiting areas, air-conditioning, painting, carpeting, blinds and disabled access and toilets etc. In November 2009 BRHS signed a contract with local builder Brooker Builders, for the construction of the much awaited Oncology and Dialysis Unit. Construction has commenced and it is anticipated that the building will be operational in early 2011. This will bring to fruition a project that will have a total budget of 3.5 million dollars which in the main is self funded by BRHS and community fundraising. We would like to acknowledge the wonderful work of the many individuals and companies who have contributed to this project either directly or through the Toonalook Waters Project. Special mention needs to be made of the tireless fundraising efforts and contributions of the Pelicans, the Practical Men of the Village, particularly Mick Campbell & Vin Martin, and Mina Armstrong who donated the land for the Toonalook Waters Project, whose contribution made this project such an outstanding success. In delivering our mission of quality health services BRHS continues to seek independent afrmation of our progress in this area and it is pleasing to report on some signicant outcomes. BRHS Radiology Department successfully undertook accreditation through the Royal Australian and New Zealand College of Radiologists/ National Association of Testing Authority. The BRHS Radiology Department at the time was the only Victorian radiology department to successfully achieve accreditation and is one of only three accredited services in Victoria. BRHSs midwifery service was also reaccredited under the Baby Friendly accreditation scheme. Baby Friendly is an internationally recognised accreditation process and provides reassurance to our community that the services provided are both best practice and benchmarked. Maddocks Gardens, our Aged Care service, was likewise reaccredited by the Federal Government Aged Care Standards & Accreditation Agency. BRHS also commenced year one of a three year program to improve the focus on customer service throughout the organisation. In excess of 200 front line staff undertook customer service training during 2009 and we are condent of building on the gains made to date. The achievements outlined are representative of multiple activities that are undertaken by BRHS staff on a continuous basis. We commend our staff on their achievements to date and encourage their future pursuits in this area. BRHS continues to pursue partnerships for the improved client outcomes and was pleased to have the BRHS and Gippsland Lakes Community Health joint draft work plan, as mentioned in last years report, adopted. This has resulted in a number of joint projects getting under way. BRHS is proud of its many working partnerships which include; the many auxiliaries that provide invaluable service to BRHS, partner organisations, our community advisory committee and the many volunteers throughout BRHS.
Recruitment and retention of skilled staff in the rural setting is an on-going challenge. BRHS has been fortunate to receive funding to facilitate two GP Obstetric registrars, Drs Daniel Otounye and Andrew Linton and we are appreciative of the opportunity to provide this experience and hope that we will be able to provide such programs in the future. In the addition to the Obstetric registrars BRHS was able to secure $125,000 in funding from the Department of Health to review and develop alternative models of care for maternity services. A multi-disciplinary working party consisting of GP Obstetricians and Midwives has been exploring ways we can improve our maternity model of care and the recruitment and retention of both GP Obstetricians and Midwives. We also acknowledge the retirement of Dr. Geoff Brown, who during more than 34 years at BRHS, held roles of Medical Superintendant and Chief Radiologist and we acknowledge his dedication and commitment to the Health Service. BRHS notes the retirement of Mr Ian Roberts and Ms Lidia Thorpe from the Board of BRHS and thanks them for their contribution. Thanks is also extended to the Board who contribute many hours in a volunteer capacity to ensure that the mission, vision and values of BRHS remain at the fore front of our endeavors. BRHS commends the commitment of Board members, staff, medical ofcers and volunteers for their efforts and looks forward to a continuing contribution and partnership in the provision of health services to the East Gippsland community.
Philippa deVoil
President, Board of Management
Wayne Sullivan
Chief Executive Ofcer
SUMMARY OF STRATEGIC GOALS
Innovation in the delivery of healthcare services Develop and promote integration and continuity of care Develop innovative and sustainable service models to meet community needs Develop sub acute services consistent with DoH subacute policy directions Effectively manage discharge planning
Commitment to providing quality care Provide excellence in customer service
Working in partnership
Responding to community needs Enhance the communitys engagement with BRHS services Strengthen capacity in core clinical services
Valuing and developing our workforce Achieve a full workforce compliment skilled to meet service delivery requirements Promote an organisational culture that reects organisational values in all aspects of BRHS activities Ensure staff feel informed, listened to and engaged
Cost effective service delivery
Promote open communication with staff, health service partners and other stakeholders Work with other health service organisations to develop cooperative strategic partnerships Support and strengthen subregional health care partnership forums Develop strong partnerships with teaching and training organisations
Provide efcient services and make best use of existing facilities Develop facilities to meet contemporary health care requirements
Enhance quality practice throughout BRHS
Build recognition and support in the community
Establish a high dependency unit (HDU) within ve years
Develop shared service solutions with other Gippsland health providers Prudently manage nancial, capital and staff resources within the annual health services agreement and funding availability Develop an information technology strategy to support clinical and business improvements
Enhance cultural competence
Provide residential aged care services that best meet community needs
Develop exible and adaptable professional roles to best utilise the workforce and skills available to BRHS
Provide services that are appropriate and accessible to Koori patients, clients and families Progressively implement environmentally friendly policies and reduce the BRHS environmental footprint
6
Progressively develop information systems that link seamlessly with local and regional health services
Improve community health through health promotion, illness prevention and service coordination Advocacy for improved services for our community
Support staff to gain and keep current qualications and experience needed to sustain BRHS service requirements Partner with regional health services to support service delivery and workforce requirements
SUMMARY OF KEY RESULT AREAS
Key Result Area All category 1, 2 and 3 patients presenting themselves to the Emergency Department (ED) are seen within the time performance expectations established by the Department of Health. Benchmark: Category 1 100% seen immediately Category 2 80% seen within 10 minutes Category 3 75% seen within 30 minutes 90% of patients admitted through the ED should not be waiting longer than 12 hours for a bed. The waiting time for outpatient allied health services should not exceed the DH target number of working days. Conservative dental interventions should not exceed the Victorian State target identied by Dental Health Services Victoria. The number of acute care bed days occupied by patients awaiting residential care placement should not exceed 90 days during the month. The overall level of inpatient satisfaction should exceed the performance of BRHSs peer group.
Comment
Compliance Partial
Substantial Whilst there is only a partial compliance, there has been consistent improvement over the nancial year, with the end result being an 82% compliance. BRHS Dental Services has maintained a consistently low waiting period with an average of 11.7 months, compared to the State target of 22 months. BRHS achieved 100% compliance for this target. BRHS score for the individual questions in the patient satisfaction survey varied considerably with some areas being well above peer average, but others below. The overall care index was 77 for BRHS compared to 78 for peer health services. BRHS average rate of medical readmissions was less than 1%. BRHS performance in stage one pressure ulcers was BRHS 0.5, State-wide 0.48, peer group 0.7. In regards to stage two pressure ulcers, BRHS .25, State-wide .65 and peer group .78. Overall pressure ulcer rates per 000 bed days, BRHS .78, State-wide 1.1 and peer group 1.59. Partial
Substantial
Substantial
Partial
The rate of medical readmissions within 28 days should not exceed 10%. The rate of pressure ulcers acquired at BRHS should not exceed 30% of reported cases.
Substantial Partial
No incident during the month should exceed a severity rating more than 6. There are no clinical death reviews outstanding greater than 30 days. Staff agree their contribution to the organisation is valued as assessed via staff survey. BRHS as a value driven organisation is pleased that an average of 77% responded positively in regards to their contribution being valued.
Partial Substantial Substantial
100% of staff have completed a current performance development plan. BRHS has less sick leave, as a percentage of productive hours, than 90% of other agencies participating in the Regional HR Benchmarking exercise. The number of WorkCover claims remaining month end, with time off greater than 10 days and no return to work plan, is zero. There has been an in-house development / applications of IT solutions to improve the efciency of clinical staff time. Nineteen agencies participate in the sick leave benchmarking across Victoria. BRHS has consistently remained in the top 10% of agencies within the survey. BRHS has maintained its compliance with ensuring all WorkCover claims have a specied return to work program developed. Applications include: vaccination booking system; chemotherapy cancer streams statistics reporting; ambulance transport management system; aged care packages management system etc.
Substantial Substantial
Substantial
Substantial
Overall elective surgical day of admission rates should exceed 95%. There should be no YTD variation for any of the top 20 DRGs in comparison to the State average. This key result area measures length of stay for specied medical conditions. In an effort to reduce length of stay based on State guidelines, without compromising patient health, BRHS is consolidating clinical pathways for conditions including chronic obstructive pulmonary disease, chronic heart failure, cellulitis and chest pain.
Substantial Partial
The YTD average length of stay for GEM patients should not exceed the State average. The YTD average length of stay for rehabilitation patients should not exceed the State average. Hospital in the home bed days YTD should constitute 10% of multi day stay bed days. Note: excludes nursery and patient discharged with a postcode outside Bairnsdale/Lakes Entrance catchment. The combined YTD public and private WIES actuals at least exceeds the DH target Signicant gains have been made in regards to this Key Result Area, the target is being amended in line with State average. Whilst the target was not met due to extended periods of absence by our resident general surgeon, the outcome was within the 2% variance as allowed by the Department of Health. The GEM and rehabilitation bed day funding is interchangeable. Although GEM bed days were under target, the shortfall was recovered in rehabilitation bed days.
Substantial Substantial Partial
Partial
GEM bed days at least exceed the DoH target.
Partial
Rehabilitation bed days at least exceeds the DoH target. There is documented evidence that 90% of all multi day stay patients have been asked if they are receiving service from another community provider and that e-notication message has been sent. Eighty percent of all specialist discharges are completed. Financial Outcome. Strategies are in place to address this Key Result Area. Compared to budget, nancial outcome was an improvement of 13%.
Substantial Substantial
Partial Substantial
FINANCIAL RESULTS
The organisation produced an operational surplus of $1,036,000 (2008/09 $2,156,000) before transfers to and from reserves, capital grants and depreciation being applied. During the year BRHS received capital grants of $1,323,000 (2008/09 $1,343,000) and applied a total depreciation amount of $3,856,000 (2008/09 $2,051,000). This resulted in an overall Decit of $1,556,000 (2008/09 surplus $1,385,000).
2010 $000 Total Revenue Total Expenses Overall Surplus / (decit) Retained Surplus / (Accumulated Decit) Total Assets Total Liabilities Net Assets Total Equity 54,816 56,372 (1,556) 27,633 65,521 17,854 47,667 47,667
2009 $000 53,356 51,971 1,385 28,708 66,901 17,679 49,222 49,222
2008 $000 52,200 49,555 2,644 27,171 48,545 15,087 33,458 33,458
2007 $000 50,005 46,218 3,787 24,378 43,281 12,901 30,380 30,380
2006 $000 44,573 43,160 1,413 21,762 39,964 13,370 26,593 26,593
Changes in Prices, Fees, Charges, Rates and Levies

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

Bairnsdale Regional Health Service 2010 Annual Report 9
ACTIVITY DATA
Admitted Patient
Admitted Patient Separations Same Day Multi Day Total Separations Total WIES Total Bed Days 7,886 4,465 12,351 5,904.26 26,535 6,148 200 32,883 0 379 379 0 0 0 0 14 14 7,886 4,858 12,744 Acute Sub-Acute Mental Health Other Total
Non Admitted Patient

Non Admitted Patients Emergency Department Presentations Outpatient Services occasions of services (VACS and Non VACS clinics) Other Services occasions of services Total occasions of service 16,339 9,807 26,146 Acute 16,339 9,807 Sub-Acute Mental Health Other Total 16,339 9,807
Private Patient Initiative

The private patient initiative continued in 2009/10, providing net income of $955,305 an increase of 32.3% compared to the previous nancial year. This initiative is very important for the hospital as it provides additional revenue to the service which is used to supplement government funding.
2010 % of Total Bed Days Total Bed Days 13.69% 32,795
2009 13.99% 32.970
2008 14.13% 34,640
2007 12.47% 32,380
2006 9.15% 30,220
10
Private Patient Net Income

1,200,000 1,000,000 800,000 600,000 400,000 200,000 2010 2009 2008 2007 2006
WIES
The Weighted Inlier Equivalent Separations (WIES) is the Casemix instrument that is used by the Victorian Government to fund hospitals. All health services have WIES targets and funding depends on the number of WIES the organisation attains. BRHS WIES target for the year was 6,050 and achieved 5,904 or 146 less than target. The result was heavily inuenced by the fact that we lost our resident surgeon through the year and had to source locum surgeons to continue to provide our services to the community. Although the result is under target it is within an acceptable range.
Target Public Private Renal TAC DVA TOTAL 4,387.00 1,012.00 217.00 27.00 407.00 6,050.00
Actual 4,350.95 987.57 213.27 27.34 325.13 5,904.26
Variance -36.05 -24.43 -3.73 0.34 -81.87
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WORKFORCE DATA
Labour Category Nursing Administration and Clerical Medical Support Hotel and Allied Services Medical Ofcers Hospital Medical Ofcers Sessional Clinicians Ancillary Staff (Allied Health) Dental Ofcers Other Dental Clinicians / Specialists
June Current Month FTE 108.42 79.61 21.93 101.25 3.82 10.18 0 30.92 3.00 .49
June YTD FTE 176.45 76.33 27.05 106.34 2.67 8.82 0 32.44 2.11 .52
The industrial relations environment at BRHS remains stable. BRHS has not experienced any lost time through industrial accidents or disputes. The Human Resources Department at BRHS has worked very closely with the Information Technology Department to redevelop our Workforce Development Software. The new system allows us to better document our staff competencies, allowing us to track mandatory qualications and competencies that staff must meet to provide excellent patient care.
Occupational Health and Safety (OH&S)

The Health Service complies with all its obligations under the Occupational Health and Safety Act 2004. BRHS has in place an OH&S Policy and a Return to Work Policy, it collects information about all OH&S incidents and its OH&S Committee analysed them at every meeting to try to identify trends and to put in place corrective actions to protect the health and safety of all staff, patients and clients visiting our facilities. Over the last twelve months BRHS has performed very well in all OH&S areas of the service. In order to improve Occupational Health & Safety the organisation invested in a software program that allows us to centralise all chemicals Material Safety Data Sheets (MSDS) that the organisation uses. Together with this program the process for purchasing chemicals has been centralised to our supply department, who will be responsible to source not only the chemical but the MSDS required for its safe use.
Whistleblowers Protection Act 2001

Under the provisions of the Whistleblowers Protection Act 2001 (the Act), Bairnsdale Regional Health Service does not tolerate improper conduct by its employees, ofcers or members nor the taking of reprisals against those who come forward to disclose such conduct. Bairnsdale Regional Health Service is committed to the principles and intent of the Act and to the protection of genuine whistleblowers against action taken in reprisal for the making of protected disclosures. In line with this, Bairnsdale Regional Health Service has in place a corporate policy and procedure, which complies with the Act. Disclosures made under this policy will be investigated swiftly, professionally and discretely. A copy of the Act is available for inspection from the Health Services library. The policy is also available to all staff on the BRHS intranet.
12
CORPORATE GOVERNANCE
There was only one change to the Board of Management throughout 2009/10, that being the resignation of Lidia Thorpe.
Board of Management
President Philippa deVoil
Appointed 2001 BA (Admin); Dip App Sc. (Nursing) Former Executive Director of Nursing, served on various government advisory committees. Extensive health service experience including aged care services in public and private sectors at management and board levels. Rotarian and local volunteer.
Vice President Angela Hutson

Appointed 2000 BA (UM); Dip Ed; MBA; Masters in Organisational Leadership; Graduate Dip Business in Entrepreneurship and Innovation; Grad Cert Enterprise Management; Diploma of Frontline Management. Extensive experience in executive management and governance in the public sector. Currently CEO of East Gippsland TAFE.
Treasurer Ken White

Appointed 2009 BBus; CA; GradCert FP Chartered Accountant, Director of Whites Accounting and Taxation Solutions. Extensive experience in public practice accounting, taxation and business management.
Peter Crick
Appointed 1992 Held various bank management positions in the Gippsland region and Tasmania over a 23 year period from 1979 2002. Vice President of the Pelicans community fundraising committee. Signicant association with Freemasonry for over 40 years. Keen gardener and walker.
Dr David Formby
Appointed 2008 MB BS.DCH; FRACP; FRCP; FRACMA; MHA. Former Medical Director Princess Margaret Hospital for Children, Perth, Wangaratta Regional Hospital and Latrobe Regional Hospital. Previous Treasurer and Chairman of the Federal Assembly of the AMA. Former surveyor with the Australian Council of Health Care Standards. Formerly Consultant Paediatrician at Princess Margaret Hospital, Latrobe Regional Hospital and Bairnsdale Regional Hospital. Past President of the Bairnsdale Golf/Bowls Club.
Anoop Chauhan
Appointed 2009 B. Comm., Ll.B., C.A. (Ind), Member CPA Australia; ACHSE; Dip. in System & Program Development / Management, Grad Cert - Human Resources & Industrial Relation Extensive experience in executive management and governance in public and private health sector incl. acute, aged, sub-acute, primary health care etc. at senior executive and board level. Hands-on involvement in business, nancial and corporate strategic planning and policy development/ implementation for over twenty years.
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Ian Roberts
Appointed 2000 Former Regional Manager VECCI, Gippsland. Experience in training and workplace assessment, staff management. Trade qualications in carpentry, current Bail Justice/Justice of the Peace, past President East Gippsland Legacy, past member of Bairnsdale Rotary, and past President Bruthen RSL.
Tony Ward
Appointed 2000 B. Laws; B. Jurisprudence Principal, Wards Barristers & Solicitors Pty Ltd. Married to Sharon, four children. Former Chairman, Nagle College School Council.
Board of Management Attendance 2009/10

P. de Voil A. Hutson K. White A. Chauhan P. Crick D. Formby I. Roberts L. Thorpe T. Ward 8 10 10 7 9 8 10 5 9 of 11 of 11 of 11 of 11 of 11 of 11 of 11 of 11 of 11
Lidia Thorpe
Appointed 2008 (resigned May 2010) Manager, Lake Tyers Aboriginal Training Centre and own business in Aboriginal Events Management. Past member of Government advisory committees, current fellow in Aboriginal leadership in Victoria. Victorian representative to the National Indigenous Body Workshop.
The Board recessed for January 2010
Completed Pharmacy renovation

14 Bairnsdale Regional Health Service 2010 Annual Report
Finance, Audit and Business Development Committee

The Audit and Compliance Committee was renamed the Finance, Audit and Business Development Committee. It is a sub-committee of the Board of Management. The Committee assists the Board in fullling its governance responsibilities relating to, and including, the accounting and nancial reporting processes, external and internal audit functions, the risk management system and legal and regulatory requirements. The Committee meets quarterly. Board Committee members during 2009/10 were: Ken White Angela Hutson Tony Ward Anoop Chauhan
Medical Credentialing Committee

The Medical Credentialing Committee is a sub-committee of the Board of Management. The Committee is responsible for assessing the professional expertise, competence, reputation and authenticity of the qualications of medical staff seeking appointment or re-appointment to the medical staff of BRHS. The Committee meets as required. Board Committee members during 2009/10 were: Peter Crick Philippa deVoil Tony Ward
Community Advisory Committee

The Community Advisory Committee is a sub-committee of the Board of Management. The Committee provides mechanism for local community involvement in the BRHS strategic planning process and local health service delivery. The Committee meets quarterly. Board Committee members during 2009/10 were: Peter Crick David Formby Lidia Thorpe
Quality Audit Committee

The Quality Audit Committee is a sub-committee of the Board of Management. The Committee oversees progress of the strategic quality plan and monitors each dimension of quality, safety, effectiveness and appropriateness to ensure an organisational wide quality program and culture exists. Board Committee members during 2009/10 were: Philippa deVoil Ian Roberts Lidia Thorpe
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ORGANISATIONAL STRUCTURE
Chief Executive Ofcer and Directors

Wayne Sullivan
Chief Executive Ofcer Master of Business; Grad Dip Health Science (Administration); Grad Dip Nursing (Community Health); RN Div 1; Cert of Gerontology; Diploma AICD Company Directors Course; FACHSM; CHE; GAICD. Broad experience within the health sector having commenced as a nurse and in the ensuing 27 years held clinical and management roles in health. Prior to joining BRHS was CEO at Maryborough District Health Service.
Remberto Rivera
Director Corporate Services & Business Development BEcon; Grad.Dip Bus. (Accounting); Grad.Dip. Aged Care Management; MBA; ASA; AHSFMA The Corporate Services & Business Development Directorate at BRHS oversees the nancial management and compliance of BRHS; as well as Human Resources, Facilities Management, Hotel Services, and Health Information Management. In short the directorate provides most of the ancillary services BRHS needs to operate effectively.
Vicki Farthing
Director of Nursing RN; Stomal Therapist; BA Nursing; Grad Dip Health Informatics; Masters, Health Management; FRCNA; AACHSE The Nursing Clinical Services Directorate at BRHS incorporates a wide range of nursing, community and residential aged care services. It is able to provide 24 hour emergency care, general surgical services, obstetric service, district nursing service, provide patient assistance in the management of chronic disease, plan and assist patient discharge and follow-up, pharmacy services and aged care for high and low level residential care needs. The nursing division includes a dialysis unit for patients with chronic renal disease and treats patients requiring chemotherapy agents and manages infection prevention at BRHS.
Megan Morse
Director Allied & Community Health Services B.Pod (Hons); M.Ed. (Ed & Tr); MBA; Grad Cert H.Ec The Allied & Community Health Services Directorate at BRHS provides inpatient and outpatient allied health services at the Day Street campus, in addition to providing outreach services to two Community Health sites. The Ross Street campus accommodates a Dental service, along with Community Health Nursing and the Bairnsdale Planned Activity Group (PAG), one of six PAGs that BRHS manages for local communities. The Paynesville site hosts a similar range of services on a visiting basis, and serves as the base for the East Gippsland Post Acute Care program. The Directorate also includes the Aids & Equipment program, the Consulting Rooms and Medical library.
Ka Chun Tse
MB; BS;
Director of Medical Services The Medical Services Directorate at BRHS supports the development and planning of the medical workforce of Bairnsdale Regional Health Service, as well as the quality of care and clinical governance framework of the Health Service. Medical Services provides advice on the operational management of medical staff in the Health Service, and works collaboratively with East Gippsland Regional Clinical School to promote medical student placements in Bairnsdale.
Lorraine Parsons
(Former) Director Allied & Community Health Services Resigned January 2010 BA (Social Sciences); BSW; Grad Cert Management; MAASW Lorraine joined BRHS in February 2008 after working in the public health sector for 16 years in Victoria and the Northern Territory.
Board of Management
ORGANISATIONAL CHART
Committees
Community Advisory Committee Remuneration Committee Quality Audit Committee Medical Credentialing Committee Finance, Audit & Business Development Committee
Chief Executive Ofcer
Director Corporate Services & Business Development Director of Medical Services

Radiology
Director of Nursing Services
Director of Allied & Community Health Services
Fundraising & Community Engagement
Supply
Medical Clinical Team Leadership / Emergency
ICT
Acute Wards Theatre
Allied Health Koori Liasion Accident & Emergency Rehabilitation Unit Aged Care Hospital in the Home Infection Control Discharge Planning / Clinical Initiatives Direct Nursing Community Programs Pharmacy Diabetes Education Health Promotion Community Nursing Post Acute Care PAG Aids & Equipment Public Dental Medical Library
Finance
Payroll
Intern Supervision (via Medical Clinical Team)
Quality
Education
Hotel Services
Reception
Regional Supply
Facilities
Security
Human Resources
OH&S
Medical Records
Endorsed by CEO May 2010
Medical Consultants Suite
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MANAGEMENT COMMITTEES
Bairnsdale Regional Health Service (BRHS) believes committees are an excellent means of communication and has an active committee meeting structure which provides a valuable means of formal communication. BRHS Management Committees support our role through the exchange of ideas, decision-making, investigation of events, assessment and review of patient care and services, consideration of reports, ensuring legislative or funding requirements are met and overseeing the implementation of plans or policy. All our committees have Terms of Reference and Membership, which set out the role and function of the Committee. Membership for each committee is appropriate for the role and function it performs. The Board sub-committees as listed on page 15. Finance, Audit and Business Development Committee Quality Audit Committee Medical Credentialling Committee Community advisory Committee
The Occupational Health & Safety Committee continues to function within the scope of the Occupational Health & Safety Act. All committee meetings are minuted and available to staff through the intranet.
BRHS Board Quality Audit Committee

Quality Management Committee
Clinical Committees Corporate Committees
Theatre / Anaesthetics & Surgery Committee
Information Management Committee
Report directly to the Board. All clinical and non clinical committees at BRHS report to the Board through our peak committee which is the Quality Management Committee. These committees are listed below. BRHS Quality Management Committee Theatre/Anaesthetics & Surgery Committee Obstetrics & Neonatal Committee Emergency Department & Medicine Committee Pharmaceutical/Transfusion/Infection Prevention Committee Maddocks Gardens Continuous Improvement Committee Ambulatory Care Committee Information Management Committee Corporate Services Committee Occupational Health & Safety Committee Human Resources Committee
Obstetrics & Neonatal Committee
Corporate Services Committee
Emergency Department & Medicine Committee
Occupational Health & Safety Committee
Pharmaceutical / Transfusion / Infection Prevention Committee
Human Resources Committee
Maddocks Gardens Continuous Improvement Committee
Ambulatory Care Committee
During the year each committee has reviewed its Terms of Reference and Membership.
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SPECIALISTS AND VISITING SPECIALISTS AT BRHS
Audiologists Sue Clutterbuck Neil Clutterbuck (ceased June) Sue Luscombe Cardiologists Dr David Bertovic Dr Justin Mariani Dr Meroula Richardson Dr James Shaw Dr Andrew Taylor Head, Neck, Nose & Throat Prof Andrew Sizeland Gastroenterologists Dr David Iser Dr Jeremy Ryan General Surgeons Mr Adrian Aitken Mr Bob Irungu Mr Anamitra Sarkar Mr Clem Smith Gynaecologists Dr Robert McKimm Dr Michael Sedgley Dr Mac Talbot Dr Gareth Weston Nephrologists Dr. David Hooke Prof David Power Oncologists Dr John Scarlett Opthalmologist Dr Pradeep Madhok Orthopaedic / Legal Dr Stan OLoughlin Orthopaedic Surgeons Mr Andries DeVilliers (commenced April) Mr Peter Rehsch Mr Peter Smith Mr Warwick Wright
Paediatricians Dr Peter Goss Dr Jo McCubbin Paediatric Surgeons Mr Chris Kimber Mr Neil McMullen Physician Dr Krishna Mandaleson Rehabilitation Physician Dr David McConachy Renal Physician Dr. David Hooke Rheumatologists Dr Anthony Boers (ceased May) Assoc Prof Peter Ryan Urologists Prof Mark Frydenberg Dr Jeremy Grummet Vascular Surgeon Mr Peter Milne Visiting Medical Ofcers Adrian Aitken Andrew Rutherford Andrew Sizeland Andrew Taylor Animitra Sarkar Ash Arunachalam (RMO) Bob Irungu Clem Smith Daniel Otuonye (RMO) Andrew Linton (RMO) Daryl Smith David Bertovic David Hooke David Iser David McConachy David McConville Elizabeth Boyd Emma Wong (RMO) Gareth Weston Graham Bromwich James Shaw
Jeremy Grummett Jeremy Ryan Jo McCubbin John Scarlett John Urie Justin Mariani Krishna Mandaleson Poh Ng Margaret Niemann Mark Frydenberg Meroula Richardson Michael Sedgley Myles Chapman Naveen Joshi Peter Goss Peter Lindstedt Peter Milne Peter Rehsch Peter Worboys Phillip Sewell Pradeep Madhok Robert McKimm Ross de Steiger Scott Deller Sema Yilmaz Sue George Tomasz Grabinski Wanda Wysocka-Grabinska Warwick Wright Y Echo Jiang (RMO) Gippsland Lakes Community Health District Medical Ofcers serving the Hospital in the Home Program Cunninghame Arm Medical Centre District Medical Ofcers serving the Hospital in the Home Program
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FINANCIAL DONATIONS TO BRHS 2009/2010
Bequests and Estates

Erica Cromwell Trust Estate of Letitia Maynard Ian & Jeannie Cooper-Brown $5,523.59 $319.93 $93,341.13
Lindenow Lioness Club Lions Club of Lakes Entrance Paynesville Bowling Club Paynesville Hospital Auxiliary Paynesville RSL Paynesville Uniting Church Friendship Shed Riviera Quilters Inc $10,050.00 $2,142.00 $28,083.51 $313,990.70 St Johns Anglican Op Shop Urban Funk Dance
$700.00 $500.00 $350.00 $1,000.00 $100.00 $2,000.00 $1,000.00 $550.00 $1,502.00
BRHS Auxiliaries
Bower Birds EGH Fund Raising Group Paynesville Pelicans Pelicans Interest Toonalook Waters proceeds
Individuals
Rebecca Ah Chow KN & J Alexander $10.00 $100.00 $100.00 $2,511.80 $1,000.00 $50.00 $4.00 $200.00 $15.00 $8,000.00 $50.00 $20.00 $100.00 $50.00 $165.00 $50.00 $20.00 $20.00 $1,000.00 $200.00 $20.00 $45.00 $1,000.00 $50.00 $1,000.00 $20.00 $2,250.00 $30.00 $50.00 $110.00 $50.00
Business Sector
Allan Corrie Painting Bairnsdale Golf Club Bairnsdale RSL Sub Branch Bairnsdale Windscreens Brooker Builders Pty Ltd Bunnings Warehouse Collins Booksellers D A Johnson Dahlsens Dulux Group GSI House & Gift James Yeates & Sons Pty Ltd King & Heath Reg Biggs Safetech Slap Architects Tyco Healthcare Whiters Street Glass & Glazing Woolworths Bairnsdale Social Club $100.00 $2,101.00 $1,150.00 $200.00 $250.00 $5,000.00 $250.00 $250.00 $100.00 $405.00 $2,000.00 $736.90 $893.30 $50.00 $200.00 $100.00 $250.00 $585.41 $200.00 $428.05
R & S Alexander Anonymous Wilhelmina Armstrong E MacArthur Glenn Baberton GH Barnett Mrs MJ Bell Carol Beveridge R & F Bills Mr Brennan John Brookes Mr & Mrs Bryant Kylie Peter & Jayne Bud Mr & Mrs Burrowes Jean Butcher L & V Calvert MD Campbell John & Maureen Campbell Kath Cassidy Ron Claridge Joyce Clemm Alan & Christine Clyne Stan M Collins
Community Groups
Bairnsdale Day Centre BRHS Flower Auxiliary Community Nursing CWA CWA High Country Branch Kilmany Remote Family Services
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$700.00 $3,000.00 $6.50 $500.00 $100.00 $110.00
Maureen Connolly Gweneth Cooper Janine Cooper Allan Cracknell Deirdre Crick R & W Cunningham
Marie Curtis Tanya & Simon Dalley Ellen Davies Deller Donations Philippa de Voil Ruth Engel Nicola Fanning Jim Ferguson Jan & Mike Finn Ken Firth KS Ford Dr David Formby Robert Franck T & M Goode MF Greenwood Mr & Mrs Grifths JB Guerin Mrs A M Guy Elise Hall Ken Hall K & M Hanley AC & LE Harrington Maureen Hartigan Dael & Leo Heirman Mark Hocking WD Holden Mrs I Hutton Lorraine Jennings Shirley Keamy TP Keyte Bertha Khote Ros Kleinitz Elizabeth Lade Elizabeth Leadoux & Family SM & PM Logan June Mackie Arthur Thomas Martin Ron & Roma Martin Marijke Mascas Michelle McNairn Merle McRae Barry Mills Wayne Morgan
$100.00 $30.00 $75.00 $5,879.35 $100.00 $50.00 $50.00 $65.00 $30.00 $50.00 $400.00 $100.00 $1,000.00 $100.00 $10.00 $50.00 $40.00 $20.00 $20.00 $7.00 $135.00 $40.00 $10.00 $200.00 $100.00 $548.27 $20.00 $20.00 $20.00 $100.00 $100.00 $50.00 $50.00 $100.00 $30.00 $20.00 $4,000.00 $100.00 $100.00 $20.00 $1,500.00 $50.00 $20.00
RA Murphy Karen Nattrass B & R Nicholes Betty Noris A Norman & Family Carl Poeschel Millicent Reggardo WA & GM Roberts Dr Jeremy Ryan M E Sanders Noel Scott Ken Simpson Sizeland Donations Joyce Smiley Gus & Jennifer Sperti Lois Stewart & Friends Denis & Rosalie Stringer Ian & Gwen Strobridge Wayne Sullivan Gail Swankie Leigh & Marc Tricard Spiros Tsetsos John & Mendy Urie Anthony Veale Mary Waites Tess Walker Norma Ward Mary Wassink Sara Wayman Matthew White Laurel Wilesmith Jennelle Wilkes/Paul Start Elaine Winterbottom & Family The Young Family Friends of Joyce Young
$100.00 $50.00 $50.00 $50.00 $40.00 $100.00 $20.00 $100.00 $500.00 $50.00 $50.00 $100.00 $5,558.55 $50.00 $500.00 $420.00 $50.00 $50.00 $100.00 $20.00 $220.00 $1,000.00 $1,000.00 $100.00 $100.00 $50.00 $100.00 $50.00 $500.00 $300.00 $10.00 $100.00 $50.00 $500.00 $950.00
Philanthropic
Collier Charitable Foundation $50,000.00
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LIFE GOVERNORS
Bairnsdale District Hospital opened in 1887. In 1940, the hospital moved to its current site in Day Street. In 1975, the hospital changed its name to East Gippsland Hospital and then again in 1992 to its current name Bairnsdale Regional Health Service. The East Gippsland Geriatric Centre and East Gippsland Hospital were amalgamated from this date. 1890 1890 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 Pre1917 1919 1919 1921
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William Bird John Kennedy Smith HT Arthur Richard G Brownlow Mrs Richard Brownlow GH Cole John Connelly F Eastwood HB Gibbs WB Giles Sharp Halmshaw Mrs WL Harris Mrs Hawkes John Holford Frank V Holloway HF Holloway J Hutchison John King JH Lawler J Laurent Mrs Mudie A Murray Mrs John Mills AJ McKenzie PJ OConnor J OKeefe GB Osborne Hon William Pearson GW Peart Mrs George Ross E Saunders Angus Shaw Mrs James Stewart Mrs E Twentyman Mrs W Winkelmann W Garlick TW Murphy John Reid
1921 1922 1922 1923 1923 1923 1923 1925 1926 1927 1927 1928 1928 1928 1928 1928 1928 1930 1930 1930 1930 1930 1930 1930 1930 1931 1931 1932 1932 1933 1933 1934 1934 1934 1934 1935 1935 1936 1936 1937 1937 1938 1938 1938 1938 1939 1939 1939 1939 1940
AT Bieri Alex McPherson EJ Williams Mrs H Bankin WP Craig EJ Roder C Healey Miss Irene Leonard Mrs H Wood Mrs L Dawe Mrs A Goodman Robert Gilder Harry Hopkins Mrs C Neal THC Johnson Mrs Mary Liddell Ernest Lindeman Mrs J Bull AJ Gilsenan EP Burke F Healey Mrs T Mathieson Mrs RJ Loveridge JW Marriott A McPherson JG Stanway MT Walsh Mrs L Jemmeson Mrs E Ross LR Skipworth W Garlick Roy Rieper F Rogerson Mrs W Vickers Mrs A Leask Mrs Grace Douglas Miss Elizabeth Bull AW Collins Mrs S Stein Mrs AE Bell Lord Nufeld Dr Charles J Alsop Mrs R Alsop Arthur Dyer Mrs V Glen W Buchanan Mrs W Buchanan Mrs Clancy Mrs HJ Arthur Mrs R Meek
1940 1940 1941 1941 1941 1941 1941 1941 1941 1941 1941 1941 1941 1941 1941 1941 1943 1943 1943 1943 1943 1943 1943 1943 1943 1943 1943 1943 1943 1944 1944 1944 1944 1944 1944 1944 1945 1945 1945 1945 1945 1945 1946 1946 1946 1946 1946 1946 1946 1946
VV Vincent Mrs VV Vincent Mrs T Varney N Dunn JG Clapperton H Clues B Chadwick Mrs G Baker WD Gibbs Mrs AJ Gilsenan Miss BJ Hollingsworth PC Murray Miss Julia OShea Mrs EM McCann Mrs M McNeill Mrs PE McPherson Mrs J Dean Miss Grace Buse Mrs J Appleton Mrs Patten Mrs T Willhelme C Moon Mrs N Norris Mrs TW Murphy Mrs R Calder Mrs ME Martin Mrs C Meddings Mrs TK Lloyd TK Lloyd Mrs AE Bieri CW Pittman Mrs WJ McCormack P McFarlane HR Growcott Mrs E Kidd Joseph Lay J Doyle Kay Donoghue HC Reynolds LJ Taylor Miss E Stokes Mrs AC Yandle Mrs BE Thewlis J OC Davies Rev A McMillan Miss Margaret Johnston Mr AT Gunn Dr A Robertson CE Goodman W ODoherty
1946 1947 1947 1947 1947 1948 1950 1950 1951 1951 1953 1953 1954 1954 1954 1955 1955 1955 1955 1955 1957 1959 1959 1961 1963 1965 1965 1968 1968 1968 1969 1969 1970 1970 1972 1972 1973 1974 1975 1976 1979 1979 1987 1992 1992 1992 1992 1992 1993 1993
A OLeary FH Redman Mrs V King Mrs Jean Lafsky Mrs E McLaren Glynn D Timmins FL Johnston W Thatcher Mrs Judy Beatty John Spirason Mrs Betsy Cathcart Mrs Jean Loud S Telfer Ian Thatcher Leonard Rule CR Holman Ben Ogden Mrs Anne F Ikin Arthur Winter Mrs Flora Brumby Mrs B Watson Mrs Margaret Latimer Mrs Phyllis Rodgers-Wilson Rev Canon GFD Smith Mrs Isabel (Doris) Savige Thomas Hansen PJ Thompson Victor Cole Dr Thomas OBeatty Mrs Mary Nicholls Mrs M (Peg) Bailey Joe Alvin Rex Foard Kenneth Beynon Miss Eileen OLeary William Rodgers-Wilson Gordon Arthur Henry Smith Clement John Sharp Miss Margaret McIntyre Mrs Margaret Sheehan William McCallum Robert Bosworth DM Yeates Alan Glass Mrs Thelma Glass Ron Nation Albert Rodd Mrs May Winnett Ian Campbell Brian Hopkins
1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1993 1994 1994 1994 1994 1994 1995 1995 1996 Pre2006 Pre2006 Pre2006 Pre2006 Pre2006 Pre2006 Pre2006 Pre2006 Pre2006 2008 2008
Peter Engel Robert Mansell Milton Murphy GJ Foard Ewan Logan Helen M Schutt (Trust) Mrs GF Barter LG Tipper J Siggins Miss JH Scott FH Ray J Parker Rev DM Muller Mrs DM Mitchell W Meade J Leatham Mrs E Ingle EGR Horseld Miss JH Holford JW Hawksley Mrs Patricia Evans MBE WH Elridge Mrs J Court HN Cox KL Cook M Campbell Mrs MA Cameron AE Boucher W Bills Derek Dahlsen Ray Holloway Mrs P Lane T Grass Mrs A Grass Ms T Gillies Dr F Malatt Mrs K Heath Mr E Dahlsen Mr T Eager Mr WH Eldridge Mr R Gregory Miss JH Holford Mr P Lay Mrs R Marsh Mrs M McRae Mrs M Winnette Dr James Evans Mr Michael Padula
Community Engagement
In 2009/10 Bairnsdale Regional Health Service delivered two newsletters to the general community, providing an overview of news and events at our organisation and they presented an excellent opportunity to disseminate information relating to acute, sub-acute and community health services at BRHS.
The 2009-2013 Strategic Plan was also nalised during the year, with copies available to the public from the hospital or on the BRHS website.
The Health Service also updated the community through media releases in the local papers on issues such as the progress of the Toonalook Waters project, the building of the new Oncology & Dialysis Unit, the pharmacy extension, donations to the Health Service, accreditation achievements, fundraising events, community health services and more.
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QUALITY OF CARE
Infection prevention
Infection prevention is very important to hospital staff and the community. BRHS has an Infection Prevention Coordinator with expert knowledge to assist staff, patients and visitors to minimise infection risks. The Infection Prevention Coordinator helps by: Developing policies and procedures to help staff know what to do about infection prevention Minimising the risks to patients, staff and visitors from infection transmission Reducing the risk that a patients existing infections may spread Observing and examining high risk procedures to reduce risks Ensuring that infection prevention standards are met Education of staff, patients and visitors about infections and prevention strategies Managing outbreaks of infections such as gastroenteritis and inuenza when they occur so they do not spread to others.
Moment 1 Before touching a patient Moment 2 Before a procedure Moment 3 After a procedure or body uid exposure Moment 4 After touching a patient Moment 5 After touching a patients surrounding (bed, medical equipment).
Bloodstream infections continue to be monitored with a priority focus on Staphylococcus aureas bacteraemias. Rates remain extremely low and well within the accepted rate for health services of equivalent size. Surgical site infections continue to be monitored with the main focus being on caesarean sections. There have been two infections reported for the year. Results from all infection prevention activities are reviewed by doctors, nurses, and other relevant staff to work out the best way to reduce the risks identied. All staff work with the infection prevention coordinator and reduce the risk of infection by making appropriate changes to practice. Education for the staff has continued to be a focus especially in the health of our staff and minimising exposures. Hand washing is the single most important activity that minimises risk of infection for staff, patients and visitors in hospitals and in the community. You can and should ask staff members caring for you Have you washed your hands?
Along with other hospitals in Victoria, BRHS continues to review/audit areas of infection risk with the Victorian Nosocomial Infection Surveillance System (VICNISS). VICNISS monitors infections patients get while in hospitals. Included in this auditing are areas such as: Hand Hygiene (washing your hands) Infections you may get in your blood stream Infections you may get in your wound after surgery Infections that are resistant to treatment (multi-resistant organisms) Staff injuries from exposure to blood or body uids Staff compliance with vaccination requirements.
Hand washing compliance has had a strong focus within BRHS throughout this year. This national initiative through the Australian Commission on Safety and Quality in Healthcare has a target of 65% compliance across Victoria for the 2010-2011 year. During the audit period every person who steps into the patient area is monitored. BRHS has performed well in the audits conducted for the 2009-2010 year with results equal to and above the Victorian expected compliance rate for the period. The 5 Moments of hand washing are observed in the audit to make sure they occur and at the required standard. The 5 moments are:
How Clean is Your Hospital?

Cleaning standard audits are undertaken regularly and completed in accordance with the Department of Health Cleaning Standards for Victorian Health Facilities 2009. The audit results indicate that cleaning processes in place are suitable, as the cleaning outcomes (Scores) are well above the Acceptable Quality Levels (AQL) required for each risk category. Risk Categories Very High Risk Areas High Risk Areas Location and Frequency of Audit Monthly Operating Theatres, Central Sterilising Supply Unit Monthly - Emergency Department, acute wards, pharmacy, oncology, dialysis Quarterly Dental Services, Rehabilitation areas, residential accommodation, day activity centres, medical imaging (X-Ray), waiting rooms, public areas including toilets. Acceptable Quality Level (AQL) 90
Patient Satisfaction at BRHS - Results of 2009-2010 Survey

BRHS takes part in an annual patient satisfaction survey. The survey is undertaken to inform us, from the patients view, what we do well and how we can improve. A company contracted by the Department of Health called UltraFeedback collects the information through questionnaires it sends to patients that have been discharged from BRHS. If you do receive a questionnaire from UltraFeedback, we encourage you to complete it and return it to them in the envelope provided. Your opinion is important to us.
BRHS
Hospital Category B
All Hospitals
85 77 85 78 81 77 78 74 76 78
Key: All Hospitals = All Public Hospitals in Victoria Group B Hospitals = Rural Hospitals similar in size and patient mix to BRHS
78 76 82 78 80 75 76 79
78 77 82 79 80 76 77 80
Average of Overall Care Access and Admission General Patient Treatment and Related Information Complaints Management Physical Environment Discharge and Follow-up Consumer Participation
Moderate Risk Areas
All areas/issues that are identied are noted during the audit are actioned by cleaning staff immediately or within 24hours. The last patient satisfaction survey let us know that our cleaning standards meet patients approval. We welcome any feedback from you about the cleanliness of the hospital and if you visit, please let a staff member know about your concerns.
Thirty nine percent (39%) of BRHS patients who were sent the survey completed and returned it to UltraFeedback. Group B hospitals, of which BRHS is one, had 37% of patients return surveys. Patients were very satised with most aspects of their stay at BRHS. We are performing in line with the Category B hospital average. The majority of patients reported that they were helped a great deal by their stay at BRHS and felt that the length of time spent in hospital was about right.
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High performing scores were obtained for the following items: The courtesy of the nurses The courtesy of the doctors The cleanliness of the room where patients spent most of their time Being treated with respect Areas where we could most improve include: facilities for storing belongings - availability, security and ease of use; privacy in the room where patients spent most of their time; and waiting room comfort. These ndings are supported by comments made by patients, with 8.4% mentioning facilities for the question what could the hospital do to improve the care and service it provides to better meet the needs of the patients? We are working out ways to improve in each of the areas and will monitor how we have met your needs when the next survey is done in 2011.
Falls Prevention
Slips, trips and falls can happen to anyone but they are more common and more signicant as we get older. It is easy to dismiss falls as part of getting older or just not concentrating, but they are often warning signs that something is just not right. It is important to discuss all falls with your doctor. Falls are a common problem and are often the reason why people come to hospital. The Good News Many falls are preventable Injury from falls can be minimised Aging does not have to mean loss of independence The reasons or causes of falls are known as RISK FACTORS. Some people are more likely to fall than others because they have more risk factors. Risk factors for falls include: Poor eyesight Reduced balance, weak muscles, stiff joints Less feeling in your legs Slower reaction times Some health problems such as stroke, Parkinsons disease, arthritis, postural hypertension (low blood pressure when you stand up), dizziness, diabetes, dementia, problems with your waterworks or bowels (incontinence), poor nutrition (not eating enough, not eating a balanced diet or drinking enough water) Even short term sicknesses (the u and other infections) or surgery can increase your risk of falling Medicines some types of medicines can increase your risk of falling, including those you may take for sleeping, anxiety or depression
Continuous Improvement and Accreditation

BRHS is committed to continuous improvement and in the last year has undergone external reviews by a number of external agencies. These reviews have conrmed that improvement is ongoing, and we have successfully met all requirements against the following standards: In June 2009 we were reviewed against the Evaluation and Quality Improvement Program where we underwent self assessment of our clinical care in the acute services of BRHS. Feedback from the Australian Council on Healthcare Standards was very positive and comments have been used to make improvements in the 2010 Organisation Wide review. November 2009 saw us assessed against the Post Graduate Medical Council standards. These standards review us as a teaching hospital for junior doctors. The results were positive and suggestions for improvement have been actioned. The Aged Care services were reviewed by the Aged Care Standards and Accreditation Agency. Aspects of care reviewed included, management systems stafng and organisational development, health and personal care, resident lifestyle and physical environment and safe systems. The feedback has been positive and full three years accreditation granted.
Falls prevention is a priority at BRHS. Total BRHS Falls 2009-2010

60 55 50 45 40 35 30 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
In the last year there has been an eighteen percent (18%) reduction in falls. Serious injury from falls remains stable. There are a number of approaches we have to help recognise if you have a high risk of falls. These approaches will reduce the risk, and they are: Risk assessments (asking you questions about the risk factors above) Accommodating those at risk in adjustable height beds Use of alert devices that let staff know when you are getting up, so they can come and help you The Pharmacist will review the tablets you are taking If appropriate, refer you to the No Falls preventative exercise program Talk with you/your family/carer about ways that you can reduce your risk of falls, particularly when you return home Review the suitability of your walking aids on occasions your needs may change If you have had a fall at home that requires you to come to hospital we will arrange a visit to check the safety of your home and work with you to improve your safety if required
You will be able to manage your health and medications a little easier if you know the following about the medications you are taking: Is this a new medication that I havent taken before? What is my medication for? How much medication do I take? When and how do I take my medication? How long do I take my medication for? Can you take it with food or other medications? How should I store my medication? What do I do if I miss a dose? What are the common side effects and what should I do if I think I have side effects?
Co-ordination of the Ambulance Victoria / Department of Health / BRHS Falls referral program has enabled clients across East Gippsland who fall, but are not transported to hospital, to receive follow up in the community eg initial phone contact by Integrated Care Coordinator and offered referral to physiotherapists. Liaison with GPs and Community Care Case Managers who may not be aware their client has had a fall is also considered.
Nursing and medical staff are required to explain what your medication is for and answer any questions you may have about your medications. Medication safety is very important to the staff at BRHS and there are many strategies in place to reduce the risk of medication incidents occurring, including: All nurses have an annual test for medication safety. All staff are required to ask you what is your name, and check your armband, name and check that the tablet prescribed matches the name and tablet recorded on the prescription as well as the tablet bottle. BRHS uses the same prescription document as the rest of Australia. This standardisation means that doctors, nurses and pharmacists Australia wide use the same form, which reduces the risk of errors occurring. An expectation about medication safety is given to all new staff when they begin employment.
Bairnsdale Regional Health Service 2010 Annual Report 27
Reducing Medication Errors

Prescribing (what the doctor does), dispensing (what the pharmacist does) and administering of medication to the patient (what the nurse does) is the most common activity undertaken in hospitals. Managing medications is a very complex task and requires hospital staff, patients and carers to work closely to make it safe. What Can You do to make Taking Medications Safer? It is very important that you know and tell staff about any previous side effects or bad reactions to any medications or if you have any allergies. It is also a good idea to tell them about any over the counter medications or tablets you are taking or considering taking as they may react with tablets the doctor prescribes.
Medication incidents are discussed with staff involved and corrective actions are taken. Education about medication safety is ongoing and includes a newsletter from pharmacy with topics from the Department of Health or learnings from incidents that have occurred. Interruptions to medication rounds are kept to a minimum. Distractions / loss of concentration while giving medications is known to be the biggest contributing factor to medication incidents. Nurses are currently trialling an apron with Medication Round - Do not Disturb on it in order to reduce interruptions.
Preventing Pressure Ulcers

A pressure ulcer (also known as a pressure sore or bed sore) is an area of skin that has been damaged due to unrelieved pressure. A pressure ulcer may look minor, such as redness on the skin, but they can hide more damage under the skin. Where are they found on the body? Pressure ulcers usually occur over bony areas, especially heels, buttocks and toes. These diagrams show you where pressure ulcers occur in various positions or postures. When sitting: tail bone (coccyx) buttocks (ischium) backs of heels elbows shoulder blades
The number of incidents relating to medication prescribing, dispensing and administration has remained stable when compared to the previous year. There have been no serious patient complications arising from medication incidents. BRHS Medication Incidents 2009 -2010
When lying on your back: the back of your head shoulder blades tail bone (coccyx) elbows heels toes
If you would like written information about your medication, the pharmacist will be happy to give it to you, and the nurses and doctors will be happy to answerer any questions. Please ask them.
When lying on your side: ear side of your shoulder pelvis hip knee ankle bones (malleolus) Who gets pressure ulcers? Anyone conned to a bed or chair, who is unable to move, has loss of sensation, loss of bladder or bowel control, poor nutrition or is unwell is at risk of getting a pressure ulcer. The signs to look for (especially on skin over bony areas) are: Red / purple / blue skin, blisters, swelling, dryness or dry patches, shiny areas, cracks, calluses, or wrinkles
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The signs to feel for are: Hard areas, warm areas, or swollen skin over bony points What can we do? The best thing you can do is relieve the pressure by keeping active, and changing your position frequently, whether you are lying in bed or sitting in a chair. If you are unable to move yourself, the staff will help to change your position regularly. Special equipment such as air mattresses, cushions and booties are available and may be used to reduce the pressure in particular places. Looking after your skin Keep your skin and bedding dry. Let staff know if your clothes or bedding are damp. Let staff know if you have any tenderness or soreness over a bony area or if you notice any reddened, blistered or broken skin. Avoid massaging your skin over bony parts of the body. Use a mild soap and moisturise dry skin. Pressure ulcer prevention and monitoring is an ongoing process at BRHS, and is an important part of care for all our staff. BRHS Total Pressure Ulcers - July 2009 - June 2010
that ensures the food is safe for human consumption. This process of kitchen safety includes proper storage of food items prior to use, maintaining a clean environment when preparing the food, and making sure that all equipment is thoroughly clean and free of bacteria that could lead to some form of contamination. Preventing cross contamination is also an important aspect of food hygiene. Cross contamination can occur when cooking and preparation utensils are used with more than one type of food at a time. For example, if the knife used to debone a raw chicken breast is also used to chop lettuce for a salad, there is a risk that contamination will occur and possibly lead to food poisoning. Staff that work in the kitchen play a vital role in providing patients, staff and visitors with nutritious meals that are safe to consume. BRHS serves approximately 21,000 meals to patients each year and also have a staff and visitor cafeteria which is well patronised. As a health Service we undergo Food Safety Audits by the East Gippsland Shire. The Food Safety Audit is an in-depth analysis of the following processes: Receiving food/ingredients, storage, preparation, cooking, holding, transportation to area for consumption, staff training, food recall and record keeping. There is a focus on how food is handled, hygiene of those handling food, cleaning and sanitising of equipment used in food preparation, and the temperature control of food, contributes to the safety of our food. The design and construction of the premises, oors, walls ceiling xtures, ttings and equipment are also assessed to make sure we meet required standards for food safety. The East Gippsland Shire Audit indicated that compliance was reached in all areas. In addition to the Shire Audit, kitchen staff monitor food safety standards on a meal by meal and monthly basis and this assures us that our food is safe and at the required standard. Our patient satisfaction survey conducted this year told us that patients were very satised with the temperature of hot meals, the quality of the food and the amount of food provided.
The number of pressure ulcers has reduced by 17% in the past year. We contribute information to the Department of Health about our pressure areas and our rate of patients who get pressure areas when in hospital is half that of similar sized hospitals.
Meeting the Standards for Safe Food Handling/Hygiene

Food hygiene is a broad term used to describe the preservation and preparation of foods in a manner
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REPORT OF OPERATIONS
Responsible bodies declaration

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

At the date of this report, Management is not aware of any events that have occurred subsequent to balance date that may have a material impact on the results of the next reporting period.
Philippa deVoil
Bairnsdale 16th August 2010
President, Board of Management
Attestation on Compliance with Australian/New Zealand Risk Management Standard

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

The reporting period was affected by the fact that the service lost its general surgeon for around 30% of the year, this meant that the organisation had to rely on locum surgeons at a much higher cost. This issue also affected our ability to completely meeting our WIES targets consequently reducing the income level of the service.
Revenue Indicators
Average Collection Days 09-10 Private TAC VWA Other Compensable Residential Aged Care 49 83 78 7 47 08-09 44 86 41 32 48
Wayne Sullivan
Accountable Ofcer
Debtors outstanding as at 30 June 2010

Under 30 days Private TAC VWA Other Compensable Residential Aged Care 467,834 2,677 0 0 134,824 31 - 60 days 134,870 0 1,483 247 14,301 61 - 90 days 44,807 270 0 0 3,373 Over 90 days 140,173 1,220 2,205 421 16,528 Total 30/6/2010 787,684 4,168 3,687 668 169,027 965,234
Total 30/6/2009 307,896 20,476 13,506 3,797 154,040 499,715
Building Act 1993

Bairnsdale Regional Health Service complies with the building and maintenance provisions of the Building Act 1993.
Freedom of Information Act 1982

The Freedom of Information Act 1982 (the FOI Act) gives people the right of access to information held by Bairnsdale Regional Health Service and applications for access to information and records are processed in accordance with the FOI Act by the Health Information Manager under delegation from the Director of Medical Services. Health Services charge a fee for Freedom of Information (FOI) requests in accordance with the guidelines set by the Department of Justice. Fees for Medico-Legal requests are also received. The revenue for this nancial year is $2,117.40. The Freedom of Information Application Fee is waived for those applicants holding a health care card. Type of request Freedom of Information Medico-Legal Total Number Processed 113 43 156
Consultancies
There were 21 consultancies in this nancial year (18 in 08/09), these consultancies included: Strategic Planning, Board training, Executive training on emergency procedures and development of training modules for dealing with clients exhibiting challenging behaviours. These consultancies cost $184,025 and no one consultancy cost more than $100,000 Consultancy Details Number of Consultancies Total $ of Consultancies Number of Consultancies > $100,000 $ 18 161,813 0
National Competition Policy

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

I, Wayne Sullivan, certify that Bairnsdale Regional Health Service has put in place appropriate internal controls and processes to ensure that reported data reasonably reects actual performance. The Bairnsdale Regional Health Service has critically reviewed these controls and processes during the year.
Victorian Industry Participation Policy Act 2003

BRHS did not commence or complete any contracts to which the VIPP Act 2003 would apply.
Wayne Sullivan
Accountable Ofcer
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GLOSSARY OF TERMS
Accreditation Acute Care
To audit and give credentials to.
HARP
Care that is generally provided for a short period of time to treat a certain illness or condition.
Hospital Admission Risk Program that enhances and develops preventive models of care focused on people with chronic and complex conditions to prevent inappropriate emergency presentations or admissions.
Cardiac
HiTH
Relating to, situated near, or acting on the heart.
Hospital in the Home. The provision of hospital care in the comfort of the persons own home.
Chemotherapy
A type of pharmacotherapy used in the treatment or control of disease, particularly cancer.
Intern
A physician gaining supervised practical experience in a hospital after graduating from medical school.
Dementia
A usually progressive condition marked by the development of multiple cognitive decits.
Midwifery
The act of assisting at childbirth.
Dialysis
Nosocomial (as in VICNISS) Obstetric
The process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein also called hemodialysis.
Acquired or occurring in a hospital
Relating to, or associated with, pregnancy and childbirth.
Dietetics DVA
The science of diet and nutrition.
Occupational Therapy
Department of Veterans Affairs.
Treatment aimed at assisting people overcome limitations caused by injury or illness, enabling people to participate in the activities that have meaning to them.
Gastroenterology
A branch of medicine concerned with the structure, functions, diseases, and pathology of the stomach and intestines.
Oncology
A branch of medicine concerned with the investigation, diagnosis and management of people with cancer.
Geriatric
Ophthalmology
A branch of medicine that deals with the problems and diseases of old age and aging people.
A branch of medical science dealing with the structure, functions, and diseases of the eye.
Governance
Orthopaedic
The way in which decisions important for the future of organisations are taken, communicated, monitored and assessed. It includes the processes an organisation has for holding managers accountable and measuring performance.
A branch of medicine concerned with the treatment of the musculoskeletal system.
Paediatrics
A branch of medicine dealing with the development, care, and diseases of children.
HACC
Home and Community Care
PAG
Planned Activity Group
32
Palliative
A concept of care which provides coordinated medical, nursing and allied services for people who are terminally ill, delivered where possible in the environment of the persons choice, and which provides physical, psychological, emotional and spiritual support for patients and for patients families and friends.
Stoma
An articial permanent opening especially in the abdominal wall made in surgical procedures.
Sub-acute care
Pathway
Goal-oriented interventions aimed at assessing and managing often complex conditions to maximise independence and quality of life for people with disabling conditions.
Clinical pathways are standardised, evidence-based multidisciplinary management plans, which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for an homogenous group of patients.
TAC
Transport Accident Commission
Toonalook Waters
Physiotherapy
House constructed, and auctioned, to raise funds for the new Oncology & Dialysis unit.
The treatment of disease by physical and mechanical means such as massage, regulated exercise, water, light, heat and electricity.
VICNISS VWA
Victorian Nosocomial Infection Surveillance System
Podiatry
The medical care and treatment of the human foot.
Victorian Workcover Authority (now known as WorkSafe Victoria)
Pressure Ulcer/Area
An area of skin that has been damaged due to unrelieved pressure.
WIES
Weighted Inlier Equivalent Separations Unit of payment for acute admitted care.
Radiology
A branch of medicine concerned with the use of radiant energy (as X-rays or ultrasound) in the diagnosis and treatment of disease.
WorkSafe Victoria
Formally Victorian Workcover Authority
Registrar Renal
An admitting ofcer at a hospital
Of or relating to the kidneys or the surrounding area
Source: Merriam Webster Medical Dictionary (online); Pocket Macquarie Dictionary; Stedmans Medical Dictionary.
Social Work
Social work is committed to the pursuit of social Justice and addresses situations of personal distress and crisis. Social work is informed by an understanding of human development and behaviour and of complex social structures and processes.
Speech Pathology
The study and treatment of human communication disorders including disorders of speech, language and swallowing.
33
DONATIONS / BEQUESTS
The generosity of the community by their nancial donations and volunteer support, to Bairnsdale Regional Health Service enables us to provide equipment, amenities and care that would normally be beyond our budgetary scope. It is through these donations that we have purchased many pieces of equipment this year, such as thermometers, trolleys, treatment chairs, oxygen equipment and more. Thanks to everyone who contributed during 2009/2010.
To make a donation, call the BRHS Cashier on 5150 3413 and make a donation by credit card over the phone or join the BRHS Donor Program by completing the form below and sending it to BRHS Donor Program, PO Box 474, Bairnsdale VIC 3875.
First name Company name Address Hm phone Email All donations over $2 are tax deductible. I would like my donation to support the: Purchase of equipment Specic equipment as arranged with BRHS
Surname
Suburb Other phone
P/code
Please accept my contribution of (circle): $1000 $500 $250 Other
34
INDEX
A
Accreditation Acute Care Auxiliaries 4, 23 ,26 3, 7 4, 20, 34
K
Key Result Areas 7
L
Life Governors 22
B
Brooker Builders 4, 20
M
Maddocks Gardens Medication Errors Midwifery 2, 4, 18 27 2, 4
C
Cleaning Community Advisory Committee Consulting Suites Continuous Improvement 25, 29 4, 15 4 18, 26
O
Obstetric Registrars Occupational Health & Safety Oncology 5 12, 18 2, 4, 23, 25
D
Dental Department of Health Dialysis District Nursing Donations 2, 7, 12, 25 5, 25, 27, 28, 29 2, 4, 23, 25 2, 3, 9 20, 23, 34
P
Palliative Care Pathology Patient Satisfaction Pressure Ulcer Private Patient Initiative 7, 25, 29 7, 28, 29 10
E
Emergency Department 2, 7, 10, 18, 25
F
Falls Prevention Financial Results Food Hygiene 26 9 29
Q
Quality of Care 24
R
Radiology Rehabilitation 2, 4 8, 19, 25
G
GEGAC Gippsland Lakes Community Health Goals, Summary of Governance 2 4, 19 6 13, 14, 15
S
Strategic Plan 4, 23
H
Hand Hygiene 24
T
Toonalook Waters 4, 9, 23
I
Infection Prevention 18, 24
W
WIES Workforce Workcover 8, 10, 11, 30 6, 12 8
35
DISCLOSURE INDEX
The Annual Report of the Bairnsdale Regional Health Service is prepared in accordance with all relevant Victorian legislation. This index has been prepared to facilitate identification of the Departments compliance with statutory disclosure requirements.
Legislation Requirement Page Reference
MINISTERIAL DIRECTIONS REPORT OF OPERATIONS
Charter and purpose FRD 22B FRD 22B FRD 22B
Manner of establishment and the relevant Ministers Objectives, functions, powers and duties Nature and range of services provided
Frontcover 2 3
Management and structure FRD 22B
Organisational Structure
16
Financial and other information FRD 10 FRD 11 FRD 21A FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 22B FRD 25 SD 3.4.13 SD 4.2(j) SD 4.5.5 Disclosure index Disclosure of ex-gratia payments
36 n/a 30 31 12 31 n/a 31 30 12 9 9,30 Backcover Frontcover 31 30 9 12 n/a 31 30 30
Responsible person and executive officer disclosures Application and operation of Freedom of Information Act 1982 Application and operation of Whistleblowers Protection Act 2001 Compliance with building and maintenance provisions of Building Act 1993 Details of consultancies over $100,000 Details of consultancies under $100,000 Major changes or factors affecting performance Occupational health and safety Operational and budgetary objectives and performance against objectives Significant changes in financial position during the year Statement of availability of other information Statement of merit and equity Statement on National Competition Policy Subsequent events Summary of financial results for the year Workforce Data Disclosures Victorian Industry Participation Policy Disclosures Attestation on Data Integrity Report of Operations, Responsible Body Declaration Attestation on Compliance with Australian / New Zealand Risk Management Standard
Legislation
Requirement
Page Reference
FINANCIAL STATEMENTS Financial statements required under Part 7 of the FMA SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements SD 4.2(b) Comprehensive Operating Statement SD 4.2(b) SD 4.2(b) SD 4.2(b) SD 4.2(c) SD 4.2(c) SD 4.2(d) Balance sheet Statement of Changes in Equity Cash Flow Statement Accountable officers declaration Compliance with Ministerial Directions Rounding of amounts
Finance8 Finance4 Finance5 Finance6 Finance7 Finance1 Frontcover Finance9
Legislation Freedom of Information Act 1982 Whistleblowers Protection Act 2001 Building Act 1993
31 12 31 31 Finance1
Victorian Industry Participation Policy Act 2003
Financial Management Act 1994
Contact Details
Bairnsdale Regional Health Service PO Box 474, Bairnsdale VIC 3875 Ph: (03) 5150 3333 Fax: (03) 5152 6784 Email: email@brhs.com.au Website: www.brhs.com.au Hospital 122 Day Street, Bairnsdale VIC 3875 Community Health Centres Ross Street, Bairnsdale VIC 3875 Shop 19, The Esplanade, Paynesville VIC 3880 Residential Aged Care Maddocks Gardens, McKean Street, Bairnsdale VIC 3875 Sutherland Lodge, McKean Street, Bairnsdale VIC 3875 Planned Activity Groups Ross Street, Bairnsdale VIC 3875 Ph: (03) 5152 0222
Acknowledgements
Design & Printing Egee Printers P: (03) 5152 5055 F: (03) 5152 1387 E: egee@egee.com.au W: www.egee.com.au Photography Jets Photography P: 0419 169 859 E: jetsfoto@bigpond.com External Auditors Auditor-General, Victoria Internal Auditor Grant Thornton
Bairnsdale Regional Health Service PO Box 474 Bairnsdale VIC 3875 Telephone (03) 5150 3333 Facsimile (03) 5152 6784 Email email@brhs.com.au www.brhs.com.au

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Bairnsdale Regional Health Service

incorporating Quality of Care Report

Construction of new Oncology & Dialysis Unit - June 2010

Bairnsdale Regional Health Service 2010 Annual Report

1996 2004 2007 2008 2009

Bairnsdale Regional Health Service 2010 Annual Report

Services offered by Bairnsdale Regional Health Service include:

Ancillary Audiology Medical Library Mental Health Orthotics

Bairnsdale Regional Health Service 2010 Annual Report

PRESIDENT AND CEO REPORT

Bairnsdale Regional Health Service 2010 Annual Report

President, Board of Management

Chief Executive Ofcer

Bairnsdale Regional Health Service 2010 Annual Report

SUMMARY OF STRATEGIC GOALS

Commitment to providing quality care Provide excellence in customer service

Cost effective service delivery

Enhance quality practice throughout BRHS

Build recognition and support in the community

Establish a high dependency unit (HDU) within ve years

Enhance cultural competence

Bairnsdale Regional Health Service 2010 Annual Report

SUMMARY OF KEY RESULT AREAS

Partial Substantial Substantial

Bairnsdale Regional Health Service 2010 Annual Report

Substantial Substantial Partial

GEM bed days at least exceed the DoH target.

Bairnsdale Regional Health Service 2010 Annual Report

Changes in Prices, Fees, Charges, Rates and Levies

Completed Toonalook Waters home

Non Admitted Patient

Private Patient Initiative

2010 % of Total Bed Days Total Bed Days 13.69% 32,795

2009 13.99% 32.970

2008 14.13% 34,640

2007 12.47% 32,380

2006 9.15% 30,220

Bairnsdale Regional Health Service 2010 Annual Report

Private Patient Net Income

Actual 4,350.95 987.57 213.27 27.34 325.13 5,904.26

Variance -36.05 -24.43 -3.73 0.34 -81.87

Bairnsdale Regional Health Service 2010 Annual Report

Occupational Health and Safety (OH&S)

Whistleblowers Protection Act 2001

Bairnsdale Regional Health Service 2010 Annual Report

Vice President Angela Hutson

Treasurer Ken White

Bairnsdale Regional Health Service 2010 Annual Report

Board of Management Attendance 2009/10

The Board recessed for January 2010

Completed Pharmacy renovation

Finance, Audit and Business Development Committee

Medical Credentialing Committee

Community Advisory Committee

Quality Audit Committee

Bairnsdale Regional Health Service 2010 Annual Report

Chief Executive Ofcer and Directors

Chief Executive Ofcer

Director Corporate Services & Business Development Director of Medical Services

Director of Nursing Services

Director of Allied & Community Health Services

Fundraising & Community Engagement

Medical Clinical Team Leadership / Emergency