Building for our future
Annual Report 2014
The principal objective of Latrobe Regional Hospital, an incorporated body, is to provide public
hospital services in accordance with the principles of the Australian Health Care Agreement
(Medicare) and the Health Services Act 1988 (Vic).
In addition to this, LRH sets other objectives that encompass the shared vision, core values
and strategic direction of the hospital.
Our hospital
In accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for Latrobe Regional Hospital for the year ending 30 June 2014.
Kellie O’Callaghan Chair, Board of Directors
Traralgon West 22/07/2014
Responsible Bodies Declaration
Our front cover
Electrical contractor Kirsten Curry from ELEKNET
shows four year-old Austin Gore some of the work being
undertaken by TS Constructions on the new Mother and
Baby Unit at Latrobe Regional Hospital. We’re building
a more responsive health service for our community
and planning for the next generation of Gippslanders.
Contents
2:
Highlights of our year
3:
Our services
4:
Our shared vision
5:
Building on our strengths:
Message from the
Chair and Chief Executive
7:
Our history.
Our strategic direction
and core values
8:
Organisational chart
9:
Our leadership group
10:
Our Board of Directors
13:
Our staff
14:
Reports: Director Nursing, Midwifery
and Clinical Services.
Director Mental Health.
Chief Medical Officer,
Senior Paediatrician.
Director Corporate
Services.
18:
Our community
20:
Statement of Priorities
26:
Our achievements
Summary of Financial Results
29:
Reporting requirements
31:
Attestations
32:
Additional information
Highlights of our year
GDemand for services has grown with 121,967 patients
admitted, 9157 more than the previous 12 months.
GThe Victorian Government announced $73 million
for a major redevelopment of services including
the construction of a new Emergency Department
and cardiac catheterisation laboratory.
G
Construction continued on several major projects including
the $22 million expansion of the Gippsland Cancer Care
Centre, a new allied health building and a mental health
unit to provide support to women experiencing emotional
problems or having difficulty coping after the birth of their
child.
G
Our specialist clinics began operating from a new
building on the former Traralgon Hospital site.
GFrom a total operating revenue of $192.652 million
we posted an operating surplus of $6.168 million
GOur community donated $652,040 towards new
equipment and services.
G
We launched a new appeal to raise money for our Mental
Health Service and awareness about mental health issues.
GOur dedicated workforce is the largest in Gippsland
Our services
Latrobe Regional Hospital is Gippsland’s specialist referral and trauma centre for a population of more than 240,000.
Located 150km east of Melbourne at Traralgon West in the Latrobe Valley, it is a purpose-built, 261-bed teaching hospital and is being developed as the site for sub-specialty services.
The hospital is fully integrated and offers complete medical services in-house including aged care, elective surgery, emergency care, maternity, mental health, pharmacy, rehabilitation and medical and radiation oncology.
The hospital has four operating theatres and specialises in general surgery, orthopaedic, opthalmology, gynaecology and obstetrics as well as ear, nose and throat surgery and urology.
We treated 121,967 patients in 2013-14. Of those 30,541 were inpatients, 31,646 were seen at emergency and 59,780 were outpatients. Of the patients treated 9161 underwent surgical procedures. We delivered 859 babies including five sets of twins.
LRH has community mental health teams in the Latrobe Valley, Sale, Bairnsdale, Yarram, Orbost, Korumburra, Warragul and Wonthaggi. The Community Residential Care Unit provides supported care to people over a longer term while the Prevention and Recovery Care Unit provides sub-acute residential care for people with mental health issues.
LRH is closely affiliated with Monash University’s School of Rural Health and Federation University and provides placements and clinical experience for students. LRH actively participates in undergraduate teaching and has accredited postgraduate positions across a range of disciplines, including medicine, nursing and midwifery.
LRH employs 1841 staff and has 52 volunteers working in a variety
Our shared vision
We will be a leading regional health
care provider delivering timely,
accessible, integrated and responsive
services to the Gippsland community.
Peter Craighead
Chief Executive
Kellie O’Callaghan
Chair
Message from the Chair and the Chief Executive
Building on our strengths
Over the past year our hospital precinct has been undergoing transformation. From east to west, wherever you look across our site, there is evidence of construction to provide our community with the standard of health care it deserves.
It’s part of our vision - to be a leading regional health care provider. To do that, we need to grow and develop a facility that best meets the needs of Gippsland.
Our vision was recognised by the Victorian Government in April when it announced $73 million for a major project at LRH known as Stage 2a of our Master Plan.
We’ll be able to double the size of our Emergency Department and in a Gippsland first we’ll offer a cardiac catheterisation lab -a life-s-aving service th-at will improve outcomes for p-atients experiencing heart health issues. Stage 2a will also include a new 30-bed acute ward, a 12-bed short-stay unit, two day rooms for endoscopy procedures and a new entrance and admissions area.
We’re future-proofing our hospital to meet demand that grows substantially each year.
This year we treated more than 121,000 patients with 31,646 seen by our Emergency Department staff. Our transfer of patients who arrive at the hospital in an ambulance is better than the state-wide benchmark.
Our elective surgery waiting lists continue to fall with more than 4900 patients admitted for procedures.
We have a dedicated workforce and leadership team who strive to improve the quality of care for people across our region.
Our community too are generous contributors to LRH in so many ways. We have a team of 52 volunteers who work at the hospital on a regular basis, providing important services such as supporting patients and driving them to and from medical appointments.
The generosity of our community gives momentum to our fundraising efforts. Our two year Allied Health Appeal which ended in May raised $479,647. We purchased equipment to improve the quality of life for people recovering from surgery, injuries and serious illnesses such as stroke.
Our attention now turns to our Mental Health Service where we hope to raise money to support projects to aid the recovery of people living with mental health issues. The new appeal is not just about fundraising. We’re hoping the community embraces the appeal theme ‘Talk About It. Make A Difference’, encouraging all of us to increase our understanding of the challenges people experiencing mental illnesses face.
Construction is almost complete on a new mental health unit for mothers and babies. It will provide support to women experiencing emotional problems or having difficulty coping after the birth of their child.
We opened a new $1.1 million building for sub-acute specialist services at the former Traralgon Hospital site. It provides continence and pain specialist clinics and a Cognitive Dementia and Memory Service for people right across Gippsland.
Many people driving past our hospital have watched the expansion of the Gippsland Cancer Care Centre take shape. The $22 million project which includes expanded chemotherapy, radiotherapy and dialysis services is also close to completion.
We look forward to the year ahead when we’ll witness more changes to our hospital site and welcome new infrastructure and services.
We’re building for the future but we’re also building on strengths - our staff and our community.
Millions of dollars of capital works to
expand services at Latrobe Regional
Hospital are being overseen by
General Manager Business Services
Stewart Harper.
Our history
Latrobe Regional Hospital as an entity is a little more than two decades old.
In its short history it has been subject to transformation and expansion, evolving and growing alongside the community it serves.
In its third decade there is again a vision for extensive growth, which will see it continue to provide for the health care needs of the region now and into the future.
Latrobe Regional Hospital came into existence in July 1991, bringing together the Latrobe Valley Hospital at Moe built in 1972, the Central Gippsland Hospital at Traralgon built in 1956 and St Hilary’s Nursing Home at Morwell.
The organisation was expanded in July 1995 when LRH took over responsibility for the provision of regional mental health services from Hobson Park Hospital at Traralgon. The move was part of a statewide reform of mental health services and resulted in LRH providing inpatient, residential and community-based care.
As LRH continued to grow, it was widely recognised both the Traralgon and Moe campuses required significant upgrades to meet the future demands of the region.
In 1996 Australian Hospital Care Limited (AHC) won the contract to build and operate a new 257-bed, state-of-the-art public hospital and in July 1998 LRH started operation as Victoria’s first privately owned public hospital. Two years later the State Government assumed responsibility for its operation.
In 2006 the Gippsland Cancer Care Centre was opened, further broadening the hospital’s role and reflecting the increasing importance of LRH as a regional health care provider.
Strategic direction
G
Enhance services available to the community
G
Improving service models
G
Improving quality
G
Enabling people
G
Supporting education, training and research
G
Building leadership
GDeveloping infrastructure
GDeveloping partnerships
Core values
GPerson-Centred Care
GWorking together
GExcellence
GIntegrity
Our strategic direction
and core values
Organisational
Chart as at
June 2014
Business Ser vices Financial Ser vices Support Ser vices Sub-Acute Acute Medical Ser vices Clinical Go ver nance Dir ector Corpor ate Ser vices Phar mac y Koori Liaison Fundr aising Public Relations GRICS Br eastScr eenMH Professional Development Unit
Dir
ector Clinical Ser
vices
Chief Medical Officer
Medical Staff
Acute Bed-based Mental
Health
Community Mental
Health
Dir
ector Mental Health
Corpor ate Counsel Gippsland Health Alliance Executive Office Chief Executive Emer genc y Department: - T ambo Acute W a rds: - T yers - T anjil
- Thomson - Tarra - Hospital Co-ordinators
- Operating Theatres - Cardiology - Patient Ser
vices
- Critical Care Unit - Pre-Admission - Staff Development - Clinical Governance - Community Consultation
- HMO Management - Senior Medical Staff - Medical Education & Training - Private Consulting Suites - Business Support - Health Information - Consultant Psychiatrists - Registrars - Medical Officers
- Adult Mental Health T
eams
- Aged Mental Health T
eam
- Child &
Youth
Mental Health Team
- Primar
y Mental
Health & Community Development Team
- Flynn W ard - Macalister W ard
- Prevention & Recover
y Care
Ser
vice
- CRCU - Triage - Consultation Liaison & ED Mental Health Ser
vices
- External Business - Business
Analyst
- Projects & Developments - Biomedical Engineering - Facilities - Patient Liaison - Diversity/ Interpreter - Librar
y
- Finance - Payroll - Contracts - Purchasing &
Supply
- Fleet
- Human Resources - OH&S/ W
orkCover
- Food Ser
vices
- Environmental Ser
vices
- Security - Clerical Ser
vices
- V
olunteers
- Allied
Health
- HITH - Nurse Consultant - Infection Control - W
ound
Management
- Diabetes Educators - Chemotherapy - Dialysis - Radiotherapy Nic
holson:
- Rehabilitation - GEM - Health Independence Program - HARP - P
A
C
Our leadership group
Ministers
The Hon David Davis, Victorian Minister for Health
The Hon Mary Wooldridge, Victorian Minister for Mental Health
Governance
Under the Health Services Act 1998, board directors are responsible for the corporate and clinical governance of Latrobe Regional Hospital on behalf of the State Government of Victoria.
In discharging their responsibilities, the directors are active members of various board committees set up to assist the board in monitoring the operations of the hospital.
GFinance Committee
GAudit and Risk Committee
GRemuneration Committee
GAppointments and Scope of Practice Committee
GHuman Research Ethics Committee
GQuality Committee
GCommunity Advisory Committee
GLRH Foundation
GPopulation Health Committee
In accordance with the by-laws of Latrobe Regional Hospital, the board places great importance on making clear any existing or potential conflicts of interest. Any such conflicts of interest of board directors are officially documented at every meeting of the board and recorded in a Disclosure of Interest Register.
Latrobe Regional Hospital's executive team
from left: Director Corporate Services
Catherine Greaves, Chief Medical Officer
Dr Simon Fraser, Chief Executive Peter
Craighead, Director Nursing, Midwifery
and Clinical Services Amanda Cameron,
Director Mental Health Cayte Hoppner.
Our Board of Directors
Kellie O’Callaghan - Chair
Appointed:2005
Kellie O’Callaghan draws on extensive knowledge and experience in health and human services in the development and management of community-based organisations. She is focused on applying the principles of community engagement and good governance to benefit
communities. Ms O’Callaghan was elected to Latrobe City Council in 2008 and has served as mayor and deputy mayor. She is also the chair of the Clean Coal Victoria Advisory Committee and a non-executive director of Gippsland Medicare Local. Ms O’Callaghan is committed to ensuring the broader Gippsland community has access to quality health services that are well resourced and sustainable.
Qualifications:Bachelor of Arts (Social Science), Graduate Diploma Mental Health Science, Graduate Australian Institute of Company Directors.
LRH committees:Board and Finance Committee and Executive Performance Committee (chair), LRH Foundation (chair), Community Advisory Committee (chair), Human Research Ethics Committee (chair), ex-officio member of Audit and Risk Committee, Appointments and Scope of Practice Committee, Population Health Committee and Quality Committee.
11 board meetings: 11 attended
Ian Gibson - Deputy Chair
Appointed:2009
Ian Gibson holds qualifications in economics, arts, public policy and management. He has extensive experience in strategic planning, local government and governance. Mr Gibson is a board member of the West Gippsland Catchment Management Authority and a sessional member of Planning Panels Victoria.
Qualifications:Bachelor of Economics, Bachelor of Arts, Masters of Public Policy and Management.
LRH committees:Board and Finance Committee (deputy chair), Appointments and Scope of Practice Committee (chair), Audit and Risk Committee (deputy chair), Population Health Committee (chair), Credentials Committee, Executive Performance Committee (member).
11 board meetings: 10 attended
Leah Young
Appointed:2010
Leah Young has experience in business management and governance. She has served on the boards of Gippsland Water and Westernport Water and is currently a board director with Gippsland Medicare Local and the business manager at St Paul’s Anglican Grammar School. Ms Young has experience in local government, finance, corporate services and capital works development.
Qualifications:Bachelor of Business, Graduate Diploma of Business, Company Directors Course Diploma (FAICD), Governance Institute of Australia Certificate in Governance and Administration GIA (Cert).
LRH committees:Board and Finance Committee (member), Audit and Risk Committee (chair), Executive Performance Committee (member).
11 board meetings: 10 attended
Mary Draper
Appointed:2011
Mary Draper is chief executive officer of the Health Issues Centre, Victoria’s health consumer organisation. She was a member of the Ministerial Advisory Committee on the Victorian Health Priorities Framework and the review panel on the Health Services Conciliation and Review Act. Ms Draper chairs the Department of Health’s Participation Advisory Committee and has been on a range of national and state health and social policy committees. She has worked for government, universities, health services and consumer organisations on quality of patient care, safety, consumer participation in health and women’s policy. She has skills in strategy development, policy and organisational development, stakeholder engagement, consultation and facilitation.
Qualifications:Bachelor of Arts, Bachelor of Social Studies.
LRH committees:Board and Finance Committee (member), Quality Committee (chair), Community Advisory Committee (deputy chair).
Elizabeth Board
Appointed:2011 (leave of absence December 2013 to 30 June 2014) Elizabeth Board has qualifications and experience in education, fundraising, arts and business management. She is development director at Camberwell Grammar and runs two small businesses, one in Gippsland and one in Richmond. She has extensive experience in corporate governance and strategic planning. Ms Board is a member of the Australian Institute of Company Directors, a fellow of Educate Plus, a board member of Plus Recruitment and she sits on the boards of a number of not-for-profit organisations in Victoria and Tasmania. She chairs MAS National Ltd, an Australian Apprenticeship Centre.
Qualifications:Master of Education, Bachelor of Arts, Graduate Diploma of Business Management.
LRH committees:Board and Finance Committee (member), Community Advisory Committee (chair July to December 2013), LRH Foundation (member July to December 2013).
11 board meetings: 4 attended
Dr Annie Moulden, OAM
Appointed:2012
Annie Moulden is a consultant paediatrician and the clinical director of innovation and quality at Monash Health. She was previously the director of quality and the clinical lead for patient safety at the Royal Children’s Hospital. Dr Moulden was an executive member of the Victoria Quality Council until 2012 and is a director of Very Special Kids, an organisation which supports the families of children with life-threatening illnesses. Dr Moulden is driven by a need to transform the delivery of healthcare to improve the patient experience and increase the safety and quality of care.
Qualifications:Bachelor of Medicine, Bachelor of Surgery, Fellow of the Royal Australasian College of Physicians, Graduate of the Australian Institute of Company Directors.
LRH Committees:Board and Finance Committee (member), Quality Committee deputy chair), Appointments and Scope of Practice Committee (deputy chair).
11 board meetings: 10 attended
Sean Dignum
Appointed:2012
Sean Dignum is a strategic communication advisor and issues manager with extensive experience in corporate affairs projects and public education campaigns. Mr Dignum’s strategic perspective is informed by extensive experience at the senior level in mainstream media. He is principal of the Melbourne-based advisory firm SDA Strategic and has been a member of boards and committees for diverse business, arts and community organisations.
Qualifications:Bachelor of Arts, Member of the Risk Management Institution of Australia.
LRH committees:Board and Finance Committee (member), Population Health Committee (deputy chair), Audit and Risk Committee (member).
Our Biomedical Engineering team
maintains and repairs medical equipment.
LRH offers a diverse range of career
opportunities and with more than 1800
staff is the largest employer in Gippsland.
Our staff
Health and Safety
Continued focus on improving health and safety in the work environment during 2013-14 has remained clearly on the agenda for staff at LRH. Our employees have worked together and actively reported all known or observed hazards to their immediate supervisor or manager in an effort to achieve excellence in health and safety.
During the year the Victorian Auditor General’s Office (VAGO) conducted an audit on health and safety in Victorian public hospitals. LRH was identified as an appropriate representative for large regional hospitals and participated in the audit. The results confirmed all public hospitals experience similar challenges in the provision of a safe environment for staff, clients and visitors.
As a result of the VAGO audit LRH is now a representative on the Metro and Regional Health OHS Executive which liaises with the Department of Health to facilitate system-wide improvements to occupational health and safety in Victorian public hospitals. This engagement has enabled LRH to participate in stakeholder forums relating to occupational violence (Code Grey) and incident reporting (RiskMan) systems review. During the past 12 months LRH has experienced a total of 286 health and safety incidents which have decreased from 298 in the previous 12 months.
Injury was sustained in 44.06 per cent of the incidents reported, up marginally from 41.3 per cent when compared to the previous 12 month period. This resulted in 43 accepted WorkCover claims of which 26 were standard claims and 17 minor claims.
The WorkCover performance of LRH remains sound as demonstrated by the indicators detailed below. The hospital’s overall performance over the past five years has shown a steady improvement largely due to the adoption of strategic claims management practices.
Health and Safety (continued)
injuries. We are continuing to work on ways to minimise risks to staff and patients through integrated risk management safety systems and incident reporting.
In response to the risk of aggression, the hospital has instigated an organisation-wide Occupational Violence and Aggression Work Group which reports to our Occupational Health and Safety Committee.
To date this group has assessed the risk of violence and aggression across all work areas and locations, commenced the review of the communication and non-violent response education (CARE) program and reviewed the protocols in relation to the use of seclusion and restraint at LRH. We have also made numerous improvements to the physical environment to reduce the likelihood of incidents.
LRH has improved the tracking and monitoring capability of staff compliance of mandatory training in an effort to reinforce safety improvements. During the next 12 months LRH will continue to evolve the capability of the OHS system to sustain and improve the overall safety performance within the hospital.
Resources
In 2013-14 Latrobe Regional Hospital employed 1841 staff across 10 locations throughout Gippsland. The biggest category of employees is nursing staff, which comprises more than half of the hospital workforce.
As at 30 June 2014 staffing levels by labour category were as per the table at the top of this page.
Alignment with public administration values
LRH works with staff to identify desired behaviours and ensures that policy and practice adhere to public sector values and the hospital’s own core values which are approved by the board of directors. Staff are expected to adhere to the Public Sector Code of Conduct for Victorian Public Sector Employees issued by the Public Sector Standards Commissioner. Our Workplace Conduct Policy is consistent with the Charter of Human Rights and Responsibilities Act 2006 (Vic) and promotes the principles of equal opportunity and fair and reasonable treatment of others.
JUNE Current JUNE YTD FTE
Labour Category Month FTE (annual average)
2014 2013 2014 2013
Nursing 608.18 590.43 593.02 582.55 Admin and Clerical 190.89 181.54 188.77 187.49 Medical Support 66.26 57.66 64.81 60.53 Hotel and Allied Services 94.25 112.01 90.61 105.19 Medical Officers 23.02 32.28 29.24 29.81 Hospital Medical Officers 100.68 92.21 94.71 93.82 Sessional Clinicians 17.39 9.91 12.56 9.96 Ancillary Staff (Allied Health) 114.33 109.15 113.05 107.87
Total Staff Employed - FTE* 1215.00 1185.19 1186.77 1177.22 *FTE stands for full-time equivalent positions.
Workcover Indicators 2009-10 2010-11 2011-12 2012-13 2013-14
Premium Rate 2.015% 1.813% 1.276% 1.395% 1.307% Industry Rate 1.342% 1.391% 1.379% 1.296% 1.232% Performance Rating 1.501 1.304 0.925 1.076 1.060
The Director Nursing, Midwifery and Clinical Services is a registered nurse with experience at a senior level managing a diverse health care environment. The director is responsible for all the wards of the hospital and same-day services such as chemotherapy, dialysis and allied health services. The position is integral to ensuring LRH continues to improve the healthcare delivered to the community.
Achievements this year include:
GThe performance of our Emergency Department where no patient has stayed for 24 hours. The ED continues to exceed the state target for ambulance transfers and has improved its waiting times despite increased demand.
GSustained high achievements in elective surgery with the number of patients admitted for surgery exceeding targets.
GSuccessful mid-cycle accreditation under the new National Standards with 14 developmental actions upgraded to having been satisfactorily met.
GIntroduction of a student-led clinic under the supervision of a nurse practitioner in collaboration with Federation University.
GRelocation of the Chemotherapy Unit into the Gippsland Cancer Care Centre.
GImprovement in the management of stroke through targeted door-to-needle time for thrombolysis.
GCompletion of the Allied Health redevelopment.
GCommencement of the Residential In Reach program.
GThe development and implementation of the organisation’s Quality Plan.
GImplementation of further redesign principles with the introduction of the Productive Operating Theatre.
GCommencement of capital works for a four-bed High Dependency Unit.
GA number of significant senior nursing management appointments.
GIntroduction of Advanced Care Planning with the appointment of a dedicated project worker.
GContinued involvement with the clinical networks including stroke, emergency, cardiac and maternity and newborn.
GNew Sub Acute Ambulatory Care building completed.
GComprehensive revision of all policies and protocols across the organisation, resulting in a met with merit action Standard 1 Governance.
GCommencement of LRH providing post-acute nursing services.
by Amanda Cameron, Director Nursing, Midwifery and Clinical Services
Report
The Director Mental Health (DMH) is a senior mental health nurse with experience in mental health service management. The DMH leads the mental health team in implementing mental health reform and provides high-level advice as a member of the LRH executive.
There have been a number of improvements in the delivery of specialist mental health services across the Gippsland region.
Some of the key highlights for the year have been:
GConstruction of the new five-bed Mother Baby Unit (MBU) and the development of the therapeutic model of care for the facility. The MBU is due to open in September 2014.
GConstruction of the new six-bed High Dependency and Assessment Unit within Flynn which is due to open in August 2014.
GImplementation of the new Mental Health Act 2014. The reform of the Mental Health Act has been the most significant legislation change for many years and introduces a range of safeguards and oversights for mental health services.
GService-wide implementation of the Choice and Partnerships approach in our Child and Youth Mental Health Service which has led to increased referrals and a reduction in waiting lists.
GPilot implementation of the Optimal Health Program -a recovery-b-ased model of c-are within the -adult ment-al health program. This has been supported by a partnership with St Vincent’s Hospital providing education and supervision.
GImplementation of Dialectical Behaviour Therapy - a specialist program for the treatment of Borderline Personality Disorder.
GCompletion of a literature review for the model of care for the aged mental health program.
GCommencement of our Nurse Practitioner Candidate in Alcohol and Other Drugs in the Emergency Department and two further nurse practitioner candidates in adult and aged community mental health.
GImprovements in key areas of our performance including re-admission rates, pre-admission and post discharge follow up.
GA key focus on reporting rates of restraint and seclusion and targeted work in this area that is leading to a reduction in the use of these restrictive interventions.
GThe appointment of two permanent consumer consultants who bring a wealth of lived experience and knowledge to support our journey to becoming a recovery-oriented service.
by Cayte Hoppner, Director Mental Health
The Chief Medical Officer (CMO) is a medical practitioner with experience in hospital administration. As a member of the hospital executive the CMO provides high-level advice and support on a range of issues. The CMO also supports the senior and junior medical staff, general managers working within the hospital and indirectly the Health Information Unit.
Achievements in medical services this year include:
GThe appointment of a substantial number of new senior medical staff including:
IGeneral Surgeon Mr Ravindran Sivasubramaniam
IGeneral Surgeon Mr KJ Tan
IThoracic Surgeon Mr Cliff Choong
IObstetrician and Gynaecologist Dr Tzippora Ben-Harim
IInfectious Disease Consultant Dr Roy Chean
IGeriatrician Dr Alice Lac
IIntensivist Dr Judit Orosz
IAnaesthetist Dr Hedda Robinson
GThe appointment to leadership roles of:
IPharmacy Manager Kenneth Ch’ng
IA second Emergency Department Co-Director Dr Yaman Al-Azzawi
GRecruitment of a medical management registrar for the second year.
GImplementation of electronic death certificate completion across the organisation.
GExaminations have been held for the Royal Australasian College of Physicians (both adult and paediatric examinations).
GOur relationship with Monash University (medical students) has been strengthened with the appointment of two clinical deans (Assoc Prof Alistair Wright and Dr Cathy Coates) and the sub-regional leadership role of Associate Professor of Rural Medicine Joseph Tam.
GWe have continued with 10 Gippsland Rural Intern Training (GRIT) interns.
GDr Dennis Danso, Clinical Lead and Obstetrician and Gynaecologist resigned in December 2013. He had been with LRH for a number of years and has relocated overseas.
by Dr Simon Fraser, Chief Medical Officer, Senior Paediatrician
The Director Corporate Services provides business and support services to LRH’s clinical and medical departments to ensure the hospital’s smooth and efficient operation.
Key achievements of corporate services throughout the year include:
GContinued redevelopment works on the Gippsland Cancer Care Centre with completion of the first two stages of the project which includes a new hospital entrance, expanded dialysis and chemotherapy units, new office and
administration areas and construction of a third radiotherapy bunker.
GCompletion of the Allied Health redevelopment project which includes expansion of occupational therapy and physiotherapy spaces, a new gym and additional consulting rooms and staff areas.
GCommencement of building works to extend the High Dependency Unit by an additional four beds.
GFinalised the implementation of LRH’s Cultural
Responsiveness Plan and the new Carers Recognition Act action plan.
GCompletion of the final stage of an ICOP (Improving Care for Older People) project, which involved the installation and refurbishment of more than 20 bathrooms.
GEnhancement of the PIP2 software system incorporating an electronic performance appraisal database and centralised mandatory training portal to enable improved monitoring and reporting.
GImplementation of our Aboriginal Employment Plan which has included recruitment of four trainees in theatre, allied health and pharmacy in addition to employment of two
nursing/midwifery cadets.
GDevelopment of a comprehensive business plan for the pharmacy department and implementation of a number of activities including a risk-based approach to clinical pharmacy and adopting lean practices to streamline services.
GOngoing active participation in the Gippsland Aboriginal Health Advisory Committee to develop Gippsland’s Koolin Balit Implementation Plan 2013-15 which incorporates a variety of region-wide projects aimed at closing the health gap.
GCoordination and completion of a joint tender for provision of banking services
GFurther development of a comprehensive Asset Management Plan which incorporates both medical and non-medical equipment.
GIntroduction of a variety of measures to improve the quality of our food services including changeover of receptacles to improve food temperatures. A dietician and speech pathologist have had input into menus and meal evaluations to improve nutrition and texture. Patient surveys have been used to measure variety, quantity and taste of meals.
GOur Environmental Services Department achieved an overall hospital score of 95 per cent in its annual Department of Health cleaning audit.
by Catherine Greaves, Director Corporate Services
Report
Volunteers give freely of their time
Our community
Why does a 17 year-old school student choose to help patients at LRH rather than spend time with her friends?
Why do former chemotherapy patients return to the Gippsland Cancer Care Centre to support people undergoing treatment?
There is something special about people who freely give up their time to help others.
We have a band of 52 volunteers who support patients, their families and hospital staff.
There are 19 volunteer drivers who transport patients unable to drive themselves to an appointment at the hospital or access public transport. On average the drivers transport more than 30 patients a week.
General volunteers provide valuable support throughout the hospital. They’re friendly faces offering books and magazines to patients, handing out meals and hot drinks to people undergoing chemotherapy or dialysis and supporting family members sitting with a patient in the Emergency Department. There are even volunteers who run a maintenance program to keep tyres and wheels on wheelchairs in tip-top shape.
Some of our volunteers are retirees. Others have a close connection to the hospital or just an inherent desire to reach out to people in need.
Our volunteers contribute many skills and so much expertise to our service.
We’re striving to provide a quality health service to the region and we’re proud our community is part of that journey. IPictured above, Mike Forehan has dedicated many years
of service to LRH as a volunteer driver.
IPictured below, volunteer Carmen Cook provides support to the Gippsland Cancer Care Centre and maintains its wig library.
Our generous community contributed $652,040 over the past year to enable the purchase of equipment to improve the quality of care for patients at Latrobe Regional Hospital and the Gippsland Cancer Care Centre.
The figure includes $163,210 raised by our Allied Health Appeal in 2013-14. The appeal was launched in 2012 and closed at the end of May. It raised a total of $479,647 towards equipment such as adjustable electronic walking rails and electric wheelchairs to support people recovering from surgery, injuries and serious illnesses.
Our attention has now turned to our Mental Health Service. Contributions to the LRH Mental Health Appeal will fund a number of important projects including the redevelopment of the outdoor courtyards in the hospital’s Flynn Unit and the creation of sensory rooms to promote positive changes in the life of a person with mental health issues.
The Mental Health Appeal has embraced the theme ‘Talk About It. Make A Difference’ to raise awareness about mental health issues and the services available to people across Gippsland.
A major event supporting the Mental Health Appeal was the 2014 WIN Network Traralgon Marathon in June. We were delighted the marathon organisers, Traralgon Harriers donated $17,500 to the new appeal, having also contributed to the Allied Health Appeal in 2013.
Our community also dug deep to support the 2013 Christmas Appeal donating $72,404 which has funded the purchase of an adjustable operating table.
Gippsland broadcasters TRFM and Gold 1242 rallied to our aid to run the annual LRH Gala Ball in October last year. The glittering event had been put on hold due to funding constraints however TRFM and Gold 1242 stepped in to stage it on our behalf, raising $98,613.
We can’t overlook the many people and businesses in our community who have made in-kind contributions of goods, services and their time.
Star FM’s Give Me 5 for Kids campaign is another example of community goodwill which has provided financial support to children seeking treatment and rehabilitation for illnesses and injuries.
IPictured above, proceeds from the WIN Network Traralgon Marathon supported the LRH Mental Health Appeal. The marathon is Australia’s oldest.
Continued support for fundraising and events
Our community
Part A: Strategic Priorities
Statement of Priorities
The Victorian Government’s priorities and policy directions are outlined in the Victorian Health Priorities Framework 2012-2022. In 2013-14 Latrobe Regional Hospital contributed to the achievement of these priorities by:
Priority Action Deliverable Strategies/Actions
Developing a system that is responsive to people’s needs.
GImplement formal advance care planning structures and processes that provide patients with opportunities to develop, review and have their expressed preference for future treatment and care enacted.
GIn partnership with other local providers apply existing service capability frameworks to maximise the use of available resources across the catchment.
GInvestigate the suitability of incorporating Advanced Care Planning with the Pathway for Improving the Care of the Dying.
GEstablishment of Mother-baby service at LRH. GEstablishment of an in-reach residential program. GIn progress.
Advance care planning project worker recruited.
Improving every Victorian’s health status and
experiences.
GImprove 30 day unplanned readmission rates.
GConsider expansion of electronic discharge summaries to all local GP practices.
GIn progress.
BOSSNet system set up to email or auto fax discharge summaries to medical clinics. Education and rollout of new system scheduled for August/September 2014.
GConsider new models of care and more coordinated services to respond to the specific needs of people with priority clinical conditions.
GComplete Allied Health redesign which will identify opportunities for future models of care.
GIn progress.
Patient flow monitored during Allied Health redevelopment and SACS development. Plan to connect more medical clinics to discharge summaries system. Generate internal referral to SACS services.
GIn progress.
Building works due for completion September 2014.
Model of care developed. Development of operational guidelines underway. Recruitment process underway. GCompleted. Service commenced.
Priority Action Deliverable Strategies/Actions
GComplete stage 2 of Gippsland Cancer Care Centre and plan for the increased service provision.
GIn progress.
Oncology consulting now operating from level one of the Gippsland Cancer Care Centre. Building works scheduled for completion August 2014.
GImplementation of a clinical pathway with Central Gippsland Health Service for orthopaedic patients from pre-admission to rehabilitation.
GCompleted.
Pathway now in use.
GOptimise alternatives to hospital admission.
GIn-reach residential care program implemented.
GCompleted.
RIR care program is treating patients in their designated care facility.
GComplete review and commence the delivery of a home-based nursing service.
GCompleted.
Post-Acute Care Nursing Service commenced.
Expanding service, workforce and system capacity.
GSupport excellence in clinical training through productive engagement in clinical training networks and developing health education partnerships across the continuum of learning.
GIn partnership with the Gippsland Clinical Training Network and Monash University School of Nursing establish student-led primary clinic and enhance use of simulation teaching environments.
GIn progress.
Primary Care Clinic open three days a week. Nursing students have commenced rotations through the clinic.
GWork collaboratively with the department on service and capital planning to develop service and system capacity.
GReview of Masterplan. GCompleted.
Stage 2a of Masterplan revised.
GCommence tender and construction of a four-bed High Dependency Unit.
GIn progress.
Tender awarded. Construction continues. Fit-out progressing.
GComplete construction of four additional Mental Health High Dependency beds.
GIn progress.
Building works due for completion August 2014. Development of
therapeutic model underway.
Improving every Victorian’s health status and
experiences
Priority Action Deliverable Strategies/Actions
GLead and contribute to the implementation of system improvements, partnerships and collaboration within the Gippsland region.
GIn progress.
Funding received for implementation of Regional Sustainable Hospitals Plans.
Aged Care project commenced.
Clinical Pathways Project and Medical Recruitment Project underway. EOI progressing for Gippsland Regional maternity and Newborn Planning project.
Increasing the system’s financial sustainability and productivity.
GReduce variation in health service administrative costs.
GIntroduce the Productive Operating Theatre and continue the rollout of the Productive Ward.
GIn progress.
Team established and training complete. Project ongoing.
Implementing continuous improvements and innovation.
GDevelop and implement improvement strategies that better support patient flow and the quality and safety of hospital services.
GDevelopment of a strategic action plan by the Mental Health Services, incorporating an education and communication strategy, to enable the new legislation to be implemented in 2014.
GIn progress.
Implementation plan completed. Policy and procedure review completed.
Staff training underway. Patients under involuntary status advised of changes to legislation.
HIU position recruitment underway.
Increasing accountability and transparency.
GPrepare for commencement of proposed new mental health legislation in 2014.
GStage 2 of CHARM Chemotherapy Clinical Decision Support and Management software across five regional chemotherapy sites.
GIn progress.
Extensive development, configuration and testing completed. Software live at BRHS and on track at LRH, WGHG, GSHS and CGHS. Improving utilisation of e-health and communications technology.
GTrial, implement and evaluate strategies that use ICT as an enabler of better patient care.
GIntegrate risk management systems with the National Safety and Quality Health Service Standards.
GIn progress.
Improved reporting of quality and safety indicators implemented at all levels.
Clinical audit schedule developed.
LRH Risk Management framework under review by VMIA.
GImplement systems that support streamlined approaches to clinical governance at all levels of the organisation.
GCooperative regional or sub-regional approach to pharmacy.
GIn progress.
New Pharmacy Director commenced at LRH. Pharmacy Business Plan approved.
Pharmacy Managers Network commenced.
GIdentify opportunities for efficiency and better value service delivery.
Part B: Performance Priorities
Statement of Priorities
Financial Performance
Operating Result Target 2013-14 actuals
Annual operating result ($'m) $1.0m $6.168m
WIES Activity Performance Target 2013-14 actuals
Percentage of WIES (public and private) performance to target 100 97%
Cash Management Target 2013-14 actuals
Creditors <60 days 40
Debtors <60 days 45
Access Performance
Key performance indicator Target 2013-14 actuals
Emergency Care
Percentage of Ambulance transfers within 40 minutes 90 92
NEAT - Percentage of emergency presentations to physically leave the emergency department for admissions to hospital, be referred to another
hospital for treatment, or be discharged within four hours (July - December 2013) 75 67
NEAT - Percentage of emergency presentations to physically leave the emergency department for admissions to hospital, be referred to another
hospital for treatment, or be discharged within four hours (January - June 2014) 81 66
Number of patients with length of stay in the emergency department
greater than 24 hours 0 0
Percentage of Triage Category 1 emergency patients seen immediately 100% 100%
Percentage of Triage Category 1 - 5 emergency patients
seen within clinically recommended times 80% 76%
Elective Surgery
Percentage of Urgency Category 1 elective patients treated within 30 days 100% 100%
NEST - Percentage of Urgency Category 2 elective surgery patients treated
within 90 days (July - December 2013) 80% 99%
NEST - Percentage of Urgency Category 2 elective surgery patients treated
within 90 days (January - June 2014) 88% 98%
NEST - Percentage of Urgency Category 3 elective surgery patients treated
within 365 days (July - December 2013) 94.5 99%
NEST - Percentage of Urgency Category 3 elective surgery patients treated
within 365 days (January - June 2014) 97 99%
Number of patients on the elective surgery waiting list 935 896
Number of Hospital Initiated Postponements (HiPs)
Service Performance
Key performance indicator Target 2013-14 actuals
Elective Surgery
Number of patients admitted from the Elective Surgery waiting list - quarter 1 1,311 1,255
Number of patients admitted from the Elective Surgery waiting list - quarter 2 1,194 1,276
Number of patients admitted from the Elective Surgery waiting list - quarter 3 993 1,065
Number of patients admitted from the Elective Surgery waiting list - quarter 4 1,213 1,317
Critical Care
ICU Number of days below agreed minimum operating capacity 0 0
Quality and Safety
Health Service Accreditation Full compliance Achieved
Residential aged care accreditation Full compliance Achieved
Cleaning standards Full compliance Achieved
Cleaning standards (AQL-A) 90 98
Cleaning standards (AQL-B) 85 95
Cleaning standards (AQL-C) 85 93
Health care worker immunisation - influenza 75 75
Hospital acquired infection surveillance No outliers Outliers
Hand Hygiene (rate) 70 85
SAB rate per occupied bed days < 2/10,000 0.2
Victorian Patient Satisfaction Monitor: (OCI) (July to December 2013) 73 Achieved
Consumer Participation Indicator (July to December 2013) 75 Achieved
Victorian Hospital Experience Measurement Instrument (January to June 2014) Full compliance Achieved
People Matter Survey Full compliance Achieved
Maternity
Percentage of women with prearranged postnatal care 100 100
Mental Health
28 day readmission rate (%) 14 16
Adult mental health post-discharge follow-up rate (%) 75 82
Adult mental health seclusion rate per occupied bed days < 15/1,000 8
Aged mental health post-discharge follow-up rate (%) 75 82
Aged mental health seclusion rate per occupied bed days < 15/1,000 0
CAMHS post-discharge follow-up rate (%) 75 87
CAMHS seclusion rate per occupied bed days < 15/1,000 N/A
Part B: Performance Priorities (continued)
Statement of Priorities
Part C: Activity and Funding
Statement of Priorities
Funding type Activity achieved
Acute Admitted
WIES Public 16,906
WIES Private 1,313
Total WIES (Public and Private) 18,219
WIES Department of Veteran Affairs (DVA) 112
WIES Transport Accident Commission (TAC) 349
TOTAL WIES 18,680
Acute non-admitted
Emergency Services - Non Admitted 31,646
Specialist Clinics 34,932
Sub Acute Admitted
Rehab Public 11,334 Rehab Private 2,151 Rehab DVA 379 GEM Public 5,784 GEM Private 1,214 GEM DVA 798
Palliative Care Public 1,210
Palliative Care Private 337
Palliative Care DVA 54
Transition Care - Residential 5,688
Transition Care - Home Based 5,366
Subacute Non-admitted
Victorian Artificial Limb Program 601
Health Independence Program 24,035
Health Independence Program - DVA 212
Mental Health Services & Drug Services
Mental Health Inpatient 14,514
Mental Health Ambulatory 64,487
Mental Health - Residential (CRCU) 3,563
Mental Health Service System Capacity N/A
Mental Health Sub Acute (PARCS) 1,934
Summary of Financial Results
Our achievements
Summary of significant changes in financial
position in 2013-14
During the 2013-14 financial year, the Victorian State Government through the Department of Health provided $37.7 million in operating grants, $121.8 million in activity-based funding payments via the National Health Funding Administrator and other Commonwealth grants totalled $12.1 million. The Victorian State Government also provided $13 million towards targeted capital works and equipment.
Revenue from operating activities before capital and specific items showed an increase of 3.8 per cent from the previous financial year. Revenue received included carry-over funding totalling $2 million, which is scheduled for disbursement in 2014-15.
Total expenses from services supported by the Health Service Agreement increased by 4.6 per cent from 2012-13. Supplies and consumables increased by 9.2 per cent, employee costs increased by 5.1 per cent and all other non-salary labour costs increased by 1 per cent.
Operating activities provided a net cash inflow of $22.6 million with a net cash outflow of $15.3 million from investing and financing activities, resulting in a net increase of $7.3 million in cash held. Cash and cash equivalents at end of financial year totalled $45.5 million.
Two capital works projects commenced during 2013, a four-bed extension to the Mental Health high dependency unit and a five-bed Mental Health Mother and Baby Unit. These projects have a combined cost of $5.3 million and are funded by the Victorian Government.
Other major capital works projects continued during the year including the Gippsland Cancer Care Centre (GCCC) and Allied Health upgrade. The Allied Health upgrade was completed in February 2014 while the GCCC is on track to be completed in August 2014.
LRH has completed a number of other building projects funded within the hospital at an estimated cost of $6.5 million. Funding for all current projects includes $32.4 million from the Commonwealth and Department of Health and the balance of $9.8 million from hospital reserves.
An independent valuation of the hospital's land and buildings was performed by the Valuer-General Victoria to determine the fair value of the land and buildings. The valuation, which conforms to Australian Valuation Standards, was determined by reference to the amounts for which assets could be exchanged between knowledgeable willing parties in an arm's length transaction. The valuation was based on independent assessments.
The final WIES results show that our public/private WIES throughput finished below target by 548 WIES (-2.92 per cent). Compensable and other WIES finished 59 WIES up from target bringing the overall WIES throughput to 489 WIES (-2.55 per cent) under in our combined WIES targets.
There were no events subsequent to balance date which may have had a significant effect on the operations of LRH in subsequent years.
Our achievements
2013/14 2012/13 2011/12 2010/11 2009/10
$'000 $'000 $'000 $'000 $'000
Total Operating Expenses 186,482 178,297 168,851 157,743 148,511
Total Operating Revenue 192,650 185,321 174,706 165,133 153,881
Net Operating Result Before Capital and
Specific Items Surplus/(Deficit) 6,168 7,024 5,855 7,390 5,370
Net Capital and Specific Items 4,770 5,134 (1,804) (950) (6,275)
Net Result for the Year Surplus/(Deficit) 10,938 12,158 4,051 6,440 (905)
Retained Surplus/(Accumulated Deficit) 59,425 50,058 37,617 33,563 27,593
Total Assets 193,758 160,245 147,803 138,240 129,871
Total Liabilities 45,243 40,801 40,517 35,005 33,299
Net Assets 148,515 119,444 107,286 103,235 96,572
Total Equity 148,515 119,444 107,286 103,235 96,572
Summary of Financial Results for the preceding four Financial Years
Total approved Expenditure Future
Purpose of project fee 2013-14 expenditure
Consultant consultancy Start date End Date (excluding GST) (excluding GST) (excluding GST)
Wellbeing Nutrition Speech & Dietetics
& Dietetics Workshop & DVD Production May-14 Oct-14 $9,206 $8,206 $1,000
Concept4 Solutions GRICS Strategic Plan Stage 3 & 4 Jun-13 Sep-13 $5,500 $5,500 $0
Details of individual consultancies
Summary of Financial Results (continued)
2013/14 2012/13
Number of consultants used to a value greater than $10,000 0 2
Number of consultants used to a value less than $10,000 3 1
Total cost of consultants used to a value less than $10,000 $17,706 $4,200
Consultancies engaged during 2013-2014
A number of consultants were contracted to work for Latrobe Regional Hospital in 2013/14. As required by the Victorian Industry Participation Policy Act 2003, a summary of the extent of contractual costs or consultants is provided below.
Our achievements
Summary of Financial Results (continued)
Under 30 Days 31 - 60 Days 61 - 90 Days Over 90 Days Total 30/06/14 Total 30/06/13
Private 235,065 257,151 3,201 51,174 546,591 195,165
Transport Accident Commission 0 0 0 32,188 32,188 10,750
Victoria WorkCover Authority 21,240 19,055 0 15,386 55,681 93,620
Other Compensable 6,470 8,724 0 12,994 28,188 14,809
Residential Aged Care 8,930 4,955 31,245 0 45,131 9,700
Total 271,705 289,885 34,446 111,742 707,779 324,045
Patient debtors outstanding as at 30 June 2014
Average Collection Days
2014 2013
Private 60.55 36.00
Transport Accident Commission 134.21 116.00
Victoria WorkCover Authority 226.94 102.00
Residential Aged Care 51.97 49.00
Reporting requirements
Financial Management
The information requirements listed in the Financial Management Act 1994 (the Act), the Standing Directions of the Minister for Finance under the Act (Section 4 Financial Management Reporting) and Financial Reporting Directions have been prepared and are available to the relevant Minister, Members of Parliament and the public upon request.
Government Advertising
LRH did not engage in any government advertising campaigns reportable per FRD 22E for 2013-14.
Building Act 1993 Compliance
LRH complies with the building and maintenance provisions of the Building Act 1993/Standards for Publicly Owned Buildings; building and maintenance provisions of the Building Act. We obtain building permits for all new projects where required and certificates of occupancy or certificates of final inspection for all completed projects.
LRH controls properties located at the corner of Princes Highway and Village Avenue, Traralgon West and within the Princes Street, Washington Street and Garden Grove precinct in Traralgon. A number of administrative and residential services are provided from these properties. LRH owns and occupies an additional five buildings located at the Traralgon West campus which operate as specialist consulting clinics and administration offices. LRH also provides non-residential health services from 10 properties not under its direct control. These are located throughout Gippsland. A further 34 properties are used as residential accommodation for staff, 15 of which are under the control of LRH and 19 that are leased from private vendors and not under the control of LRH.
LRH ensures all buildings owned or occupied by staff or patients meet the standards for essential safety measures. Likewise, all LRH buildings are audited annually for compliance against the occupancy certificate and building regulations.
Victorian Industry Participation Policy
LRH complies with the intent of the Victorian Industry Participation Policy Act 2003. The Act requires local industry participation in supplies wherever possible, taking into consideration the principle of value for money and transparent tendering processes.
For the financial year ending 30 June 2014 LRH:
Gdid not commence any new contracts that require disclosure
Gcompleted one regional building contract for the hospital’s $5 million Allied Health upgrade, meeting all VIPP
commitments
Gcontinued to deliver on the $22 million Gippsland Cancer Care redevelopment which is due for completion in the second half of 2014.
National Competition Policy
Latrobe Regional Hospital has observed and complied with all requirements of the Victorian Government competitive neutrality (CN) policies (as amended) for all significant business activities.
Freedom of Information
Latrobe Regional Hospital provides access to documents held by the hospital in accordance with the Victorian Freedom of Information Act 1982.
Freedom of Information requests 1 July 2013 - 30 June 2014
Requests received 320
Access granted in full 277
Access granted in part 1
Access denied in full 0
Not yet finalised* 14
Not finalised in 2012-13^ 7
Other# 28
* A decision with regard to release had not been made at 30/6/2014
^indicates valid requests not finalised in 2012-13
that were finalised during 2013-14
#indicates requests that were withdrawn,
Reporting requirements
(continued)
Protected Disclosure Act 2012
LRH’s General Manager Support Services is the Protected Disclosure Officer for the purpose of the Protected Disclosure Act. During 2013-14 there were no disclosures of corrupt or improper conduct as defined by the Act.
Carers Recognition Act 2012
LRH recognises the principles of the Carers Recognition Act 2012 and has incorporated these into the hospital’s Consumer, Carer and Community Partnership Policy. The hospital established an implementation plan to educate, promote, integrate and evaluate our progress against the principles of the Act and this has been fully implemented. LRH received no disclosures under this legislation during 2013-14.
Environmental Performance
LRH is committed to the principles of sound environmental practice to protect and enhance the environment for future generations. The implementation of sustainable practices in the activities that LRH undertakes will be managed through the environmental management system and the environmental management plan.
The following key activities are helping us to achieve environmental sustainability at LRH:
GThe introduction of a committee specific to the task of sustainable and environmental management.
GReduction of waste through sound purchasing initiatives, responsible recycling, minimisation of water use and the reduction of energy use.
GRequiring staff and others who work on behalf of LRH to adopt environmental best practice and adhere to legal requirements regarding environmental protection.
GTraining staff to be vigilant in identifying risks to the
environment and creating an avenue to report environmental risks as well as environmental best practice initiatives.
GImplementing initiatives that have a sustainable conscience and lead to a reduction in our environmental footprint.
GDeveloping a program that monitors LRH’s core business and its performance against defined environmental targets and objectives.
Attestations
I, Peter Craighead, certify that the Latrobe Regional Hospital has risk management processes in place consistent with the AS/NZS ISO 31000:2009 (or an equivalent designated standard) and an internal control system is in place that enables the executive to understand, manage and satisfactorily control risk exposures. The Board of Directors verifies this assurance and that the risk profile of the Latrobe Regional Hospital has been critically reviewed within the last 12 months.
Peter Craighead Chief Executive
Traralgon West 22/07/2014
I, Peter Craighead, certify that the Latrobe Regional Hospital has complied with Ministerial Direction 4.5.5.1 - Insurance.
Peter Craighead Chief Executive
Traralgon West 22/07/2014
I, Peter Craighead, certify that the Latrobe Regional Hospital has put in place appropriate internal controls and processes to ensure that reported data reasonably reflects actual performance. The Latrobe Regional Hospital has critically reviewed these controls and processes during the year.
Peter Craighead Chief Executive
Traralgon West
Attestation on Data Integrity
Attestation for compliance with the Ministerial Standing Direction 4.5.5.1 - Insurance
Attestation for compliance with the Australian/New Zealand Risk Management Standard
Additional information (FRD 22E)
In compliance with the requirements of FRD 22E Standard Disclosures in the Report of Operations, details in respect of the items listed below have been retained by Latrobe Regional Hospital and are available to the relevant Ministers, Members of Parliament and the public on request (subject to the Freedom of Information requirements, if applicable):
(a) A statement of pecuniary interest has been completed;
(b) Details of shares held by senior officers as nominee or held beneficially;
(c) Details of publications produced by the Department about the activities of the health service and where they can be obtained;
(d) Details of changes in prices, fees, charges, rates and levies charged by the health service;
(e) Details of any major external reviews carried out on the health service;
(f) Details of major research and development activities undertaken by the health service that are not otherwise covered either in the Report of Operations or in a document that contains the financial statements and Report of Operations;
(g) Details of overseas visits undertaken including a summary of the objectives and outcomes of each visit;
(h) Details of major promotional, public relations and marketing activities undertaken by the health service to develop community awareness of the health service 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 health service 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 health service, the purposes of each committee and the extent to which those purposes have been achieved;
(l) Details of all consultancies and contractors including consultants/contractors engaged, services provided, and expenditure committed for each engagement.
Disclosure Index
The annual report of Latrobe Regional Hospital is prepared in accordance with all relevant Victorian legislation. This index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.
Report of Operations
Charter and purpose
FRD 22D Manner of establishment and the relevant Ministers 7, F7
FRD 22D Objectives, functions, powers and duties 3
FRD 22D Nature and range of services provided 3
Management and structure
FRD 22D Organisational structure 8
Financial and other information
FRD 10 Disclosure index 33
FRD 12A Disclosure of major contracts 29
FRD 21B Responsible person and executive officer disclosures F7
FRD 22D Application and operation of Protected Disclosure 2012 30
FRD 22D Application and operation of Carers Recognition Act 2012 30
FRD 22D Application and operation of Freedom of Information Act 1982 29
FRD 22D Compliance with building and maintenance provisions of Building Act 1993 29
FRD 22D Details of consultancies over $10,000 27
FRD 22D Details of consultancies under $10,000 27
FRD 22D Employment and conduct principles 13
FRD 22D Major changes or factors affecting performance 26
FRD 22D Occupational health and safety 13
FRD 22D Operational and budgetary objectives and performance against objectives 23, 24
Legislation requirements
Page reference
Report of Operations (continued)
FRD 24C Reporting of office-based environmental impacts 30
FRD 22D Significant changes in financial position during the year 26
FRD 22D Statement of availability of other information 32
FRD 22D Statement on National Competition Policy 29
FRD 22D Subsequent events F7
FRD 22D Summary of the financial results for the year 26
FRD 22D Workforce Data Disclosures including a statement on the application of employment and conduct principles 13
FRD 25B Victorian Industry Participation Policy disclosures 29
FRD 29 Workforce Data disclosures 13
SD 4.2(g) Specific information requirements Inside front, 3
SD 4.2(j) Sign-off requirements Inside front
SD 3.4.13 Attestation on data integrity 31
SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 31
SD 4.5.5 Risk management compliance attestation 31
Financial Statements
Financial statements required under Part 7 of the FMA
SD 4.2(a) Statement of changes in equity F5
SD 4.2(b) Comprehensive operating statement F3
SD 4.2(b) Balance sheet F4
Financial Statements (continued)
Other requirements under Standing Directions 4.2
SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements F1
SD 4.2(c) Accountable officer’s declaration F1
SD 4.2(c) Compliance with Ministerial Directions 29, F1
SD 4.2(d) Rounding of amounts F7
Legislation
Freedom of Information Act 1982 29
Protected Disclosure Act 2001 30
Carers Recognition Act 2012 30
Victorian Industry Participation Policy Act 2003 29
Building Act 1993 29
