ANNUAL REPORT - Castlemaine Health · Victoria MT ALEXANDER HOSPITAL ANNUAL REPORT 2009. Our Aim To provide the most effective and efﬁcient physical, emotional and social care possible

MT ALEXANDER HOSPITAL ANNUAL REPORT 2009Incorporating the Quality of Care Report

Living well

Ageing well

MT ALEXANDER HOSPITALCornish Street (PO Box 50) Castlemaine Victoria 3450Telephone 03 5471 1555 Facsimile 03 5472 4546Email [email protected]

Providing a comprehensive range of Health Services to the shires of Mount Alexander, Central Goldfields and Macedon Ranges, Central Victoria

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Our AimTo provide the most effective and efficient physical, emotional and social care possible to those for whom we are responsible.

Our MissionTo enhance the health of individuals and our community by providing the highest standard of skilled and compassionate care within the limitations of the Hospital’s resources, in a climate which is friendly and supportive to patients and staff, and enhances staff commitment, development and morale.

Our ObjectivesPatient Care

To afford relief, including maintenance and cure of, or attention to, any disease or ailment, or any injuries or conditions in the areas of Accident & Emergency, Acute Care, Assessment and Rehabilitation, Day Therapy, Hostel Care, Nursing Home Care, and Community Home Care and Outreach Services to such individuals as are entitled thereto under the Governing Acts.

Community Health

To promote, provide and assist with health education and ill health prevention for the community.

CONTENTS

Year in Brief 1

Overview of Services Provided 2

Report to the Community 3

Performance Measures 4

Financial Summary 5

Our Finance Team 7

Quality of Care Report 8

Our Nursing Directorate 12

Our Community Programs 14

Our Facility Services 18

Our Environment 20

Organisational Chart 21

Corporate Governance 22

Our Staff 24

Visiting Medical Officers 28

Staff Years of Service & 29 Our Social Club

Community Support 30

Fundraising 31

Statutory Compliance 33

Financials 34

Compliance Index 72

Acknowledgements, Local Map, 73 Our New Identity

Reflections ProjectWe are proud to feature some of the photographic portraits and ‘Words of Wisdom’ from the Reflections Project in this Annual Report.

The Reflections Project was an exhibition comprising of 174 photographic portraits of Mt Alexander Hospital Residents which was exhibited across eight venues in Castlemaine in October 2008 during Seniors Week.

In conjunction with the photographic portraits, residents gave quotes which were significant in reflecting on their life experiences. Central Victorian photographer Gail Hardy volunteered her time one day per week over the previous

Staffing

To select staff so that the Hospital can maintain the highest standard of health care through working together in promoting an atmosphere of co-operation and support.

Education and Training

To promote educational and training opportunities for all staff to assist them in the future development of patient care and to provide for the education and training of such persons associated with Hospitals as may be approved.

Evaluation and Research

To engage in programs of evaluation and research for the improvement of health services.

Facilities

To provide adequate, well maintained and safe facilities, equipment and supplies for carrying out investigations and care into ailments, disease, injuries or other conditions affecting the human body.

About this Report

This Annual Report provides performance quality and financial information covering the 2008/2009 financial year and has been prepared in accordance with the Health Services Act 1988, Financial Management Act 1994, Standing Directions of the Minister for Finance and Financial Reporting Direction (Specifically FRD22).

twelve months to photograph the portraits of the residents and collect the quotes.

Project coordinator Lynne Bird, said “This project strengthened partnerships within the community as it provided a link between the Mt Alexander Hospital residents, their families, and the local community.” Lynne acknowledged the time, skills and expertise that photographer Gail Hardy had contributed to ensuring the success of the project.

The photographic portraits are currently on display in all residential units.

Mt Alexander Hospital’s “Reflections Project” was proud to be a joint recipient of the Mount Alexander Shire “Community Event of the Year” Award for 2009.

L to R Lynne Bird and Gail Hardy holding Community Event of the Year award

1Mt Alexander Hospital Annual Report 2009

MT ALEXANDER HOSPITAL ANNUAL REPORT 2009

Key Achievements • OfficialopeningofThompson

HouserefurbishmentandextensionbyTheHonourableBobCameron,MemberforBendigoWest,on31October2008(page3)

• OfficialnamingbyBillO’Donnell,PresidentoftheBoard,ofthefourElleryHouseWingstoAmbrose,Anderson,GrayandReimannWings(page3)

• CommencementoffiveyearServicePlan(page3)

• Upgradeof74computers(page7)• Introductionofnewsoftware

programs–aspartoftheStateGovernment’sHealthSMARTstrategy(page7)

• AccreditationachievedinAgedCareandAustralianCouncilofHealthCareStandards(page8)

• ComplianceachievedwithHome&CommunityCareNationalServiceStandards(page8)

• Increasednumberofsurgicalproceduresperformed(page12)

• Additionalbedsprovidedforclientsawaitingtransitiontoresidentialcare(page12)

• ImplementationofspecialistPalliativeCareService(page15)

• HospitalAdmissionRiskProgramProject(HARP)andHealthIndependencePrograms(HIP)commenced(page17)

• LivingWell–AgeingWellProject(page17)

• RefurbishmentofAcute,RehabilitationWards,Cafeteria,AuditoriumandRenshawHostel(page18)

• Upgradeofelectricalswitchboards(page19)

• InstallationofliftingmachineintheLaundry(page19)

• Reducedwasteusageacrosstheorganisation(page20)

• PenhallHostelsuppliedwith100%greenenergy(page20)

• Developmentofnew3CVEducationCentrewithdedicatedcomputertrainingfacilities (page24)

• ImplementationofNoSmokingPolicy(page26)

• Fundraisingraised$147,000 (page31)

Fundraising ($000’s) 2008/09 2007/08 % Change

Income 147 393 (167.35)

Expenditure 65 75 (15.38)

Surplus 82 318 (287.80)

Staff

NumberofStaffEmployed 613 582 5.33

EquivalentFull-Time 373.24 351.7 6.12

Acute

Patient Separations 2008/09 2007/08

SameDay 1593 1489

Multiday 1709 1453

Total 3302 2942

WIES Fundable Separations

Emergency 1223 1206

Elective 1837 1564

OtherincludingMaternity 157 143

Total 3217 2913

Total WIES (Estimate) 2148 1944

Total Discharged Bed Days 9125 7986

Sub Acute Other

Patient Separations 2008/09 2007/08 2008/09 2007/08

SameDay 0 0 0 0

MultiDay 324 321 18 7

Total 324 321 18 7

Total Discharged Bed Days 7630 8044 433 344

2008/09 2007/08

ResidentBedDays 62999 63153

2008/09 2007/08

BabiesBorn 62 59

Non Admitted Patients

2008/09 2007/08

EmergencyDepartmentPresentations 5359 5065

OutpatientOccasionsofService 32687 29500

Total 38046 34565

Performance at a Glance

Patient Statistics

YEARINBRIEF

Alan Sheehan – Reflection Project


2 Mt Alexander Hospital Annual Report 2009

LowCare(86beds)

• Spencely

• ThompsonHouse

• Penhall

• Renshaw

Community

• DistrictNursingServices

• PostAcuteCareHomeServices

• Support&AgedCareAssessmentService

• AdultDayActivityCentre

• CommunityRehabilitationCentre

• Volunteer&SocialSupportProgram

• Castlemaine&DistrictAccommodation&ResourceGroup(CADARG)

• EarlyInterventionProgram

Client Services

• Medical

• Nursing&PersonalCare

• Welfare/SocialWork

• Podiatry

• OccupationalTherapy

• Physiotherapy

• SpeechTherapy

• Dietetics

• ContinenceManagement

• VolunteerAssistance

• Pharmacy

• Psychiatry

• PastoralCare

• InfectionControl

• RecreationalActivities

• Transport

• Pathology-ProvidedonsitebyGribblesPathology

• RadiologyandUltrasonography-ProvidedonsitebyBendigoRadiology

Acute /Sub-Acute Facilities (65 staffed beds)

• Medical

• Obstetric

• PalliativeCare

• Paediatric

• Rehabilitation

• GeriatricEvaluation&Management

• Respite

• Surgical

• Accident&Emergency

Residential Aged Care

HighCare(90beds)

• ElleryHouse

• ThompsonHouse

Facility Management Support

• EngineeringServices

• SupplyDepartment

• HumanResources

• HealthInformationServices

• InformationServices

• PublicRelations/Fundraising

• FinanceDepartment

• HotelServices

• OccupationalHealth&Safety

• QualityDepartment

Training and Development

• TrainingandDevelopmentApprenticeships&Traineeships

• GraduateNurseProgram

• OverseasRegistrationProgram

• PublicHealthPrograms/HealthPromotions

• StaffEducation/ProfessionalDevelopment

• UndergraduatePrograms

• WorkExperienceProgram

OVERVIEW OFSERVICESPROVIDED

History

2008ThompsonHouseupgraded

2007ElleryHouseopened

2000 NewsteadHostelupgraded

1998RenshawHouseupgraded

1998SpencelyHouseupgraded

1996PenhallHostelopened

1995AcuteFacilitiesrelocated

1995ThompsonHouseopened

1994BuildingProgramlaunched

1986CastlemaineDistrictCommunityHospitalamalgamatedwithAlexandertobecomeMtAlexanderHospital

1959 Mount Alexander Hostels established

1939HalfordStreetHospitalopened

1860CastlemaineBenevolent Asylumopened

1853GingellStreetHospitalopened

“Take life gently. Keep your life bright and healthy” Joan Riemann – Reflections Project

Hans & Joan Riemann

“I was a day patient for (procedure). The level of professionalism

throughout the entire procedure from admission to recovery was

excellent” VPSM Survey



Anderson,GrayandReimannwerenamedafterfourwell-knownmembersofourlocalcommunity,whohadacloseaffinitywiththeHospital.

Asamajorproviderofservicestotheelderly,weareparticipatingintheLongerStayOlderPersonsProject(LSOP),whichwehaverenamedto“LivingWell-AgeingWell”tobetterreflectourphilosophy.ThisprojectframeworkhaspavedthewayfortheintroductionofourHospitalAdmissionRiskProgram(HARP),theHealthIndependenceProgram(HIP)andtheBetterCareforOlderPersons(BCOP)project.Implementationstrategieswithmeasurableoutcomeshavebeenformulatedandenthusiasticstaffrecruited.Theseprojectswillgiveustheopportunitytoprovidebettercareoutcomesforourolder,mostvulnerableclients,manyofwhomsufferfromchronicillnesses.

ThisyearhasalsoseenusembracetheVictorianCharterofHumanRightsintoourculture,policiesandprocedures.Ithaschallengedustonotlosesightoftheconsumerasanindividual,tounderstandtheirneedsandremainawareoftheirrightswithoutbeinglostwithinsystemsandprocesses.Weseektobepersoncenteredinthecarewedeliver.Thisapproach,whilenotnew,allowstheconsumersandtheirfamiliestobetterunderstandandparticipateintheircareplanningandprovision.

Foreveryoneinourcommunity,MtAlexanderHospitalplaysanimportantroleinourlifeasweallstrivetomaintaingoodhealth.Ourhealthservicedeliveredprofessionalcaretoover5,000accidentandemergencypresentations,62births,1,749surgicalproceduresand32,687outpatientoccasionsofservice.Weprovidecomprehensivecommunitybasedservices,highqualityresidentialagedcare,rehabilitationandacutecareservices.WehavealocalBoardofManagementandstaffwhoarecommittedtomeetingthehealthandwelfareneedsofourlocalcommunity.Weworkincollaborationwithotherhealthserviceproviderstoensureaccesstoservicesthroughouttheregion.

OurthemethisyearfortheAnnualReportis“LivingWell-AgeingWell”.Thisisconsistentwithourobjectiveofmeetingthehealthneedsofindividuals,familiesandthecommunityasawhole.Weseektodomorethanjusttreataperson’sillness.

Thisyearhasseentheintroductionofmanynewservices,improvementstosystems,provisionofsoundfinancialmanagement,andcontinuedresponsibilitybothenvironmentallyandethically.TheofficialopeningofarefurbishedThompsonHouseresidentialunitbytheHonourableBobCameronoccurredon31October.Ournew60bedresidentialfacility,ElleryHouse,officiallyhasitsfourfacilitywingsnamedbyourPresidentoftheBoard,BillO’Donnellon27November.ThenamesAmbrose,

Oursuccessesaremany,inallareas,asyouwillseewhenreadingthroughthisAnnualReport.AnextensiveserviceplanningreviewhasbeenundertakenwhichhasprovideduswiththefundamentalelementsneededtoconstructarobustandcredibleStrategicPlan.DuringthisprocesstheBoard,undertheleadershipofPresidentBillO’Donnell,hasprovidedthestewardshiprequiredtoallowtheExecutiveteam,DepartmentalManagersandgeneralstafftochallengethestatusquoandlooktowardsthefutureservicerolethisorganisationcanprovide.

AppreciationisextendedtoallcurrentBoardmembersfortheircollaborationanddedicationandtopastmembersSpencerBock,CarolynWallaceandSueTurner,youwillbemissed.Toallofourstaff,yoursupportandeffortsaregreatlyappreciated.Theachievementsthisyearareyourbadgeofhonour–wearitproudlybecauseyoucontinuetomakeadifference.TotheMinisterforHealth,DanielAndrews,ExecutiveDirectorRural&RegionalHealth&AgedCareServices,ProfessorChrisBrookandhisteam,RegionalDirectorofDepartmentofHumanServicesLoddonMallee,VicGordonandallhisteam,allourvolunteers,donatorsandthecommunityweservicethankyouforsupportandcollaboration.Itwasandcontinuestobe,greatlyappreciated!

ThefuturewillseeacontinuedgrowthintheprimarycaresectorandaneedforustomeetthechallengesandensurethecontinuedviabilityofMtAlexanderHospital.Ourcommitmentisstrong.MtAlexanderHospitalwillbealeadingruralhospitalwithkeystakeholdercollaborationandlocalcommunitysupportassistingthis success.

BILLO’DONNELL

President

GRAEMWKELLY,PSM

ChiefExecutiveOfficer

REPORT TO THE COMMUNITY

Graem Kelly, CEO Bill O’Donnell, President of the Board



PERFORMANCEMEASURES

Acute Average Length of Stay

0

1

2

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4

5

6

08/09 07/08 06/07 05/06 04/05

08/09 07/08 06/07 05/06 04/05

Total Operations

1200

1300

1400

1500

1600

1700

1800

Rehabilitation Average Length of Stay

0

5

10

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20

25

30

08/09 07/08 06/07 05/06 04/05

400042004400460048005000520054005600

08/09 07/08 06/07 05/06 04/05

0

50100150200250

Colon

osco

py

Gastr

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Knee

Proc

edure

s

Follo

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Endo

scop

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Ches

t Pain

Normal

Vagina

l Deli

very

Catar

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Lens

Proc

edure

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Other

same d

ay H

ealth

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es

Dent

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tracti

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skin

& tiss

ue pr

oced

ures

Top 10 Diagnosis Related Groups (DRG)


0

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08/09 07/08 06/07 05/06 04/05

08/09 07/08 06/07 05/06 04/05

Total Operations

1200

1300

1400

1500

1600

1700

1800


0

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25

30

08/09 07/08 06/07 05/06 04/05

400042004400460048005000520054005600

08/09 07/08 06/07 05/06 04/05

0

50100150200250

Colon

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py

Gastr

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Knee

Proc

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Follo

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Ches

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Catar

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Proc

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s

Other

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ay H

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Issu

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Dent

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Resto

ration

Other

skin

& tiss

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ures


0

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08/09 07/08 06/07 05/06 04/05

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Total Operations

1200

1300

1400

1500

1600

1700

1800


0

5

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15

20

25

30

08/09 07/08 06/07 05/06 04/05

400042004400460048005000520054005600

08/09 07/08 06/07 05/06 04/05

0

50100150200250

Colon

osco

py

Gastrosc

opy

Knee

Proc

edures

Follo

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Endo

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Ches

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Norm

al Va

ginal

Delivery

Cataract &

Lens

Proc

edures

Othe

r sam

e day

Hea

lth Is

sues

Dental

Extra

ction

& Res

toratio

n

Othe

r skin

& tissue

proce

dures

Anadditional6bedsweremadeavailableforpatientsawaitingplacementtonursinghomesorhostels.Thisassistedtofreebedsforourrehabilitationclients.

TheincreaseinColonoscopyprocedureswasduetocontractualarrangementswithBHCG.Aslightdecreaseinthenumberofcataractproceduresfromlastyear,withnormaldeliveriesagainrising.


OurAccidentandEmergencyservicecontinuestoprovideavaluableservicetoourcommunity,witha5.8%increaseinattendancesfrom2007/08.

A&E Attendances

Total Operations Rehabilitation Average Length of Stay

Decreasesinouraveragerehabilitationstayreflectourprofessionalinterventionandcommunity supportprograms.

OperatingTheatreutilisationincreasedthisyearduetocontractswithBendigoHealthCareGrouptoreducetheirwaitinglist.AdditionalfundingalsoreceivedfromtheCommonwealthtoprovidemoresurgicalservices.


0

1

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4

5

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08/09 07/08 06/07 05/06 04/05

08/09 07/08 06/07 05/06 04/05

Total Operations

1200

1300

1400

1500

1600

1700

1800


0

5

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20

25

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08/09 07/08 06/07 05/06 04/05

400042004400460048005000520054005600

08/09 07/08 06/07 05/06 04/05

0

50100150200250

Colon

osco

py

Gastr

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py

Knee

Proc

edure

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Follo

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Endo

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Ches

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Vagina

l Deli

very

Catar

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Lens

Proc

edure

s

Other

same d

ay H

ealth

Issu

es

Dent

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Resto

ration

Other

skin

& tiss

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oced

ures


0

1

2

3

4

5

6

08/09 07/08 06/07 05/06 04/05

08/09 07/08 06/07 05/06 04/05

Total Operations

1200

1300

1400

1500

1600

1700

1800


0

5

10

15

20

25

30

08/09 07/08 06/07 05/06 04/05

400042004400460048005000520054005600

08/09 07/08 06/07 05/06 04/05

0

50100150200250

Colon

osco

py

Gastr

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py

Knee

Proc

edure

s

Follo

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Endo

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Ches

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Normal

Vagina

l Deli

very

Catar

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Lens

Proc

edure

s

Other

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ay H

ealth

Issu

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Dent

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Other

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FINANCIALSUMMARY

Financials in Brief MtAlexanderHospital’sFinancialStatementshavebeenpreparedinaccordancewiththeprovisionsoftheFinancialManagementAct1994.TheserequirementsincorporaterelevantaccountingstandardsissuedbytheInstituteofCharteredAccountantsandCPAAustraliaandothermandatoryprofessionalreportingrequirements.

OurOperatingStatementshowsadeficitnetresultbeforecapitalandspecificitemsfortheyearof$144,000.Thecurrentdeficitisanimprovementonthe$406,000deficitreportedinthepreviousfinancialyear.FormostoftheyeartheHospitaltradedinasurpluspositionthroughveryhighactivityinAcuteandabovetargetactivityinRehabilitation.DuringMayandJuneactivitywascurtailedinRehabilitationduetotheremovalofasbestosandrelatedworks.TheDepartmentofHumanServices(DHS)didagreetofundthecapitalcostsincurredwiththeworks.The$550,000receivedfromDHSkeptincomewellaheadoflastfinancialyear.TheexpenditureincurredisreportedasExpenditureusingCapitalPurposeIncomeontheOperatingStatement.Theworkshoweveralsoleadtoareductioninincomeasoccupancyandprivatepatientnumberswereimpacted.Asaresultoftheloweractivity,weestimatethatinadditiontothecostsincurred,theHospitallostapproximately$314,000inrevenuebasedontheactivitytotheendofApril2009.ContinuingnegotiationsarestillbeingheldwithDHSandweareconfidentofrecoupingatleastsomeofthismoneyandwhenthisisrealiseditwillbereportedasincomeinthe2009- 2010accounts.

One-offpaymentswhichhadsignificantimpactonthisyear’soverallfinancialpositionwereasfollows:

• $400,000transitionalFringeBenefitTax(FBT)fundingrelatingtothepreviousfinancialyear

• $500,000fromtheMonashUniversity–forMedical4thYearTrainingandAccommodation (10yearcontract)

• $238,000fromthejointventurethatexistswithpublichospitalswithintheLoddonMalleeRegiontosupportthedevelopmentofInformationTechnologyinfrastructure

• $55,000frombackpaymentsfromsubsidiesbytheCommonwealthrelatingtoResidentialAgedCare.Theremaybesomefurtherincomestillfromthisintothenext financialyear

Inanalysingfinancialfiguresithelpstolookatratiosandwhatisanorganisation’sworkingcapital(themoneyithasavailable).Workingcapitaliscalculatedbysubtractingcurrentliabilitiesfromcurrentassets.Thismeasuredefinesanorganisation’sliquidity,orshorttermcashposition.

MtAlexanderHospitalthisyearreportedanegativeworkingcapitalresultof$1,924,000whichisanimprovementof$919,000,or32%onlastyear’sresult.Thisimprovementcameinayearofstrongactivityandsignificantminorworksrelatedexpenditure.InfrastructureremainsacriticalissueforMtAlexanderHospitalandincollaborationwithDHS,theBoardandstaffcontinuetoplanfortheimplementationofmuchneededworks.

AnimportantratiotobeconsideredwhenmeasuringourshorttermcashpositionistheCurrentAssetRatio.Thisisderivedbydividingthecurrentliabilitiesintothecurrentassets.ThisyeartherehasbeenanincreaseintheCurrentAssetRatiofrom0.80forlastfinancialyearto0.87thisyear.

Jack Harrington – Reflections Project

TheBoardandManagementareconstantlymonitoringthisasDHSusethisasabenchmark.DHSrequirethatagenciesmakeallpracticableeffortstomaintainaCurrentAssetRatioinexcessof0.70.TheBoardandManagementofMtAlexanderdohoweversetthemselvesagoaltoraisetheCurrentAssetRatioto1.0orabovesoastogivetheHospitalastrongcashpositiontooperatewithin.



TheValuer-GeneraldidreviewallpublichospitallandandbuildingvaluationsacrosstheStateattheendofthisfinancialyear.TheresultforMtAlexanderHospitalwasasignificantincreaseinthevalueoflandandbuildingsof$21,623,000.TheoffsettothisincreasewastotheAssetRevaluationReserve.Therevisedvaluationwillalsoresultinthreefoldincreaseindepreciationfromnextfinancialyear.TheincreaseddepreciationwillhighlighttheevidentcapitalissuesbeingexperiencedbyallatMtAlexanderHospital.

MtAlexanderHospitalBoardandManagementarecommittedtofinancialconstraintandabalancedbudget.Thishasbeenayearinwhichtheorganisationdidexpectagoodresult,butbecauseofthedropinrevenueduringtheasbestosremovalandrelatedworksthiswasnotachieved.TheBoardandManagementarestaunchlycommittedtogoodgovernanceandbecauseofthistheywillbudgettoreturnasurplusbeforecapitalanddepreciationforthe2009-10 financialyear.

Summary of the Financial Results for the Year2009

$000

2008

$000

2007

$000

2006

$000

2005

$000

TotalRevenue(IncludesCapitalItems) 32,782 30,825 29,214 28,390 27,159

TotalExpenditure(IncludesCapitalItems) 32,926 31,231 29,091 28,134 27,041

OperatingSurplus(Deficit) (144) (406) 123 256 118

Total Assets 60,1062 37,773 37,2621 29,517 27,160

TotalLiabilities 15,998 15,380 14,656 13,839 13,383

TotalEquity 44,1082 22,393 22,606 15,678 13,877

“I was a bit emotional – all the nurses took time to listen to me and that

helped a lot. I felt very well taken care of, but I was given enough

privacy” VPSM Survey

• 1ThechangetototalassetsrecognisesElleryHouse

• 2ArevaluationoflandandbuildingwasconductedbytheValuer-General

FINANCIAL SUMMARY CONTINUED

TothecreditoftheBoard,alotofenergywasspentthisfinancialyearre-establishingtheAuditCommitteeasasub-committeetothefullBoard.Thisinvolvedrecruitingtwoindependentmembersontothissub-committee.AlongwiththeBoardmembersthetwoindependentmembersareRichardHetherington(LawsonTaxationServices)andSandraWilson(MountAlexanderShire).ThesechangesaddtotherobustgovernancethathasexistedandpositionsusinlinewithbestpracticeandtheStateGovernment’sFinancialManagementComplianceFramework.



“Know what you’re up for” Beryl Murdoch – Reflections Project

OURFINANCETEAM

TheimplementationofanewFinancialManagementInformationSystemacrossallhospitalswithintheLoddonMalleeRegionisnowwellprogressedaftermuchdiscussion.Fullimplementationistooccuron1October2009andwillresultinmanybenefitstotheHospital,includingincreaseefficiencyandaccuracyofdataentryandreporting.TheimplementationispartoftheStateGovernment’sHealthSMARTStrategy.

DuringtheyeartheBankingServicesweretenderedwiththeBendigoBankprovidingthesuccessfultender.WelookforwardtoforgingstronglinkswiththeBendigoBankinpartnershipwiththecommunityservicesector.

Health Information ServicesTheHealthInformationServiceisresponsibleforthesafekeepingofmedicalrecords,theadmissionanddischargeprocessesandreportingHospitalactivity,internallyandexternally.Inaddition,amajorfunctionoftheServiceistoaccuratelyallocateinpatientepisodestothecorrectDiagnosticRelatedGroup(DRG)whichdeterminestheleveloffinancialreimbursementtheHospitalreceives.InarecentDepartmentofHumanServicesaudittheServicereceivedanexcellentresultof4%DRGchangecomparedtotheStateaverageof10%change.

OurstaffareinvolvedinregionalgroupsandprojectssuchastheLoddonMalleeHealthAlliance(LMHA),HealthInformationManagersGroupandtheLMHAHealthSMARTimplementation.Theseforumsfacilitateinformationsharing,professionalnetworkingandqualitybenchmarkingactivities.

OurteamalsoprovidesaregularservicetoMaldonHospital,Maryborough&DistrictHealthandtheEastWimmeraHealthService.Coding(DRGallocation)isthepredominantserviceprovidedwithadviceandsupportonotherrecord managementissues.

Supply

Thesupplydepartmentensuresthefacilityhasthesupplies,servicesandequipmentrequiredtoruneffectively.Thesupplydepartmentprocessedover1,300stockordersinthisfinancialyear.TowardstheendofthefinancialyearalotofattentionwasgiventoreviewingprocessesfortheimplementationofthenewFinancialManagementInformationSystem.

Information TechnologyOurComputerSystemsOfficerprovidessupportandmaintenancetotheorganisationforinformationtechnologysystems,includingcomputernetwork,computerhardware,softwareand telephonesystems.

TheuseofcomputersacrosstheHospitalcontinuestoincreasewith74computersbeingupgradedthisyeartomeettheHealthSMARTspecifications.Inadditiontherehasbeenanincreaseinthenumberofprinters,scannersandphotocopiers.Withtheplannedintroductionofseveralnewsoftwareprograms,muchtimehasbeendevotedtominimisingpossiblerisksincludingstafftrainingrequirementsandaccesstocomputers.Thiswillcontinuewellintonextyear.

ProfileByensuringthefinancialviabilityoftheHospital,theFinanceDirectoratecontributestoenhancingthehealthofindividualswithinthecommunity.OurteamsthatcontributetotheabovegoalareFinance,HealthInformationServices,InformationTechnologyandSupply.Clientsincludeourcommunity,ourstaff,otherhospitals,andtheDepartmentofHumanServices.

Quality Outcomes• Significantincreaseinprivate

patientrevenue

• Seventyfour(74)computersupgradedthroughfundingprovidedbytheStateGovernmentHealthSMARTstrategy

• Inclusionofacashflowforecastingandacapitalplanwithinthebudgetprocess

Future Directions• Completingtheimplementationof

newsoftwarefortheAgedResidentialSector

• ImplementationofanewPatientAdministrationSystemsoftware

• ImplementationofanewFinancialManagementInformationSystem

• Introductionofasimplifiedbillingsystemtoassistwithprivatepatientbilling

• Reviewofcommunicationprotocolswithexternalcompanies

• Identificationofstrategiestoreducewaste

• DevelopmentofstrategiestostartmovingtoanelectronicpatientrecordacrosstheHospital

FinanceOurFinanceTeamisresponsibleforAccountsPayable,AccountsReceivable,ResidentTrust,SalaryPackagingandfinancialreporting,includingMaldonHospital.



QUALITYOF CAREREPORT

DistrictNurseshaveundertakensincethelastsurvey.Asaresultofthesurveythereareplansinplacetoreviewadvocacyanddisputeresolutionprocedures.

AfullsurveybytheAgedCareStandardsandAccreditationAgencywasalsosuccessfulinAprilwiththeservicebeinggrantedthreeyearsaccreditationuntil13June2012.Followingfeedbackfromtheagencytherehasbeenaplanforimprovementestablishedincluding;animprovementindocumentationsystems,andestablishmentofmorefrequentresidentsandfamilymeetings.

Cultural DiversityEveryyearMtAlexanderHospitaldevelopsaCulturalDiversityPlantoensureclientsfromnon-Englishspeakingandculturallydiversebackgroundsareprovidedwithhealthcarethatmeetstheirneeds. Thisyear,withthegrowthoftheEastAfricanpopulationinCastlemaine,therehasbeenaconcertedefforttoimproveourpartnershipswiththiscommunity.Initiativesinclude:

• On-siteCulturalCompetencytrainingforstaffregardingrefugeehealthissues

• RepresentationonthelocalRefugeeHealthworkingparty

• CloselinkswiththeCastlemaineAfricanCommunityProjectworkers

• ReviewofLanguageServicesresourcesandproceduretoimproveaccesstointerpreters

• DevelopmentofEastAfricaresourcekitsforallareasoftheservice

• AssistanceprovidedbytheHumanResourcesDepartmentwithjobapplicationprocesses

• Reviewofmenustoensuretheyareappropriatefortheculturesof ourclients

• Facilitytours

• AppointmentofanEastAfricanRepresentativeontheCommunityConsultativeCommittee

Additionally,theservicehasbeenworkingcloselywiththeEthnicServicesCoordinatorfortheregiontoensurethehealthcareneedsofallculturallyandlinguisticallydiversegroups,includingAboriginalandTorresStraitIslanderpeople,aremetinasensitiveandappropriatemanner

Risk ManagementRiskmanagementisanacrossorganisationalactivityandrequiresproactivethinkingandplanningtoreduceriskswherepossible.

DepartmentandOrganisational“RiskManagementPlans”arereviewedandupdatedannually.

OurIncidentReportingprocedureensuresthatallincidentsthatoccuronthepremises,oroccurtostaffwhilstonduty,areanalysedtoidentifyanyactionsthatcanbetakentopreventreoccurrenceoftheincident.

Someexamplesofimprovementsimplementedasaresultofanincident/nearmissinclude:

• PurchaseofamotorisedtrolleytoreducemanualhandlingoflinendeliveredtotheOperatingSuite

• Reviewoftheuseofneedlesforbloodtaking/injectionstoreduce“needlestick”injuries

• Grillfittedoveraheatertoreducetheriskoffire

• Modificationtoofficefurnituretoreduceincidentsofstaffinjuringtheirknees

Planned improvements

• Implementationofimprovedincidentreportingcomputerprogram(RiskMan)whichwillincludeariskregister

• Increasecomparisons(benchmarking)withotherfacilitiesthroughimproveddata

• Introductionofaneedlesafesystemthatreducesthechanceofneedlestickincidents

Thisreportisdesignedtocommunicateanunderstandingofsomeofoursafetysystems,processesandoutcomes.Thetopicsarechoseninconsultationwithstaff,membersoftheCommunityConsultativeCommitteeandothercommunitymembers.

Celebrating our Successful Accreditation ResultsAccreditationisaformalprocessthatallhealthcareservicesarerequiredtoundertaketoevaluatethesafetyandqualityofthecaretheyprovide.

InSeptember2008thefacilitywasauditedbytheAustralianCouncilofHealthcareStandardswhoassessedkeyclinical,corporate,qualityandsafetyaspectsofourservice.Thefeedbackwasverypositivewithfouryearsaccreditationbeinggranteduntil26February2013.ImprovementsplannedasaresultofthesurveyincludethedevelopmentofaDisabilityAccessandInclusionPlan.

TheDistrictNursingServicewasassessedforcompliancewiththeHACC(Home&CommunityCare)NationalServiceStandardsinSeptember.Theresultantscorewas18.3outofapossible20(upfrom16.5whenlastassessedin2003).Thisincreasereflectsthehardworkthe

“Maybe I’m out of touch now, I suppose it’s true, but there was a feeling in the community, it wasn’t spoken of, but you knew that if you needed help with something, people were there”

Alan Bumford – Reflections Project

Patients admitted to our acute and rehabilitation units 2008/9

AboriginalandTorresstraitIslanders 19

Clientswith1stlanguageotherthanEnglish 2

Clientsrequiringaninterpreter 0



prescriptionoradministrationscheduleisreportedandthoroughlyinvestigated.Theorganisationcontinuallyconductsresearchandeducationtoensurethatweareusingthesafestmedicinesandpractices.

Improvements • Medicationblisterpackswere

implementedinElleryHousehighcareresidentialunit.Thissystemwasintroducedtoimprovemedicationsafety,reducewasteandcostandsavetimeforthestaff

Planned Improvements • Reviewoftheadministrationof

SubcutaneousInsulinutilisingguidelinesprovidedbytheVictorianMedicinesAdvisoryCommittee

• Extendtheimplementationofmedicationblisterpackstoallresidentialcareunits

Falls Monitoring and Prevention

Fallscontinuetobethemostfrequentincidentreportedathealthcarefacilitiesworldwide.Allinpatientsandresidentsundergoafallsriskassessmentandhaveanappropriatecareplandevelopedtoreducetheriskoffalls.However,thenumberoffallsthatoccurwithinourorganisationdoescontinuetoriseconsistentwithanincreaseintheageandfrailtyofourclients.

Improvements • Changeinsystemtoensurestaff

remembertogiveinformationsheetstoclientswhoareathighriskoffalling

Planned improvements • Increasedcompliancewith

completionoffallsriskassessmentanddevelopmentofcareplansthrougheducationandincreasedmonitoring

Pressure Ulcer Monitoring and PreventionApressureulcerisdefinedasalesion,orsore,causedbyunrelievedpressure.Pressureulcersareaninternationallyrecognisedclientsafetyproblemandarelargelypreventable.Pressureulcersareassessedandgradeddependingonseverity.Wecompletethreemonthlyauditsonthenumberandseveritythatarepresentwithinourorganisation.Thosemorelikelytodevelopapressureulcerincludetheelderly,malnourishedorimmobileclients,andclientswithanalteredconsciousstate.

Planned improvements • Improvecompliancewithpressure

ulcerriskassessmentcompletionthroughstaffeducation

Infection Prevention and ControlHealthserviceswageaconstantbattletoeliminateorminimiseinfections.Personswhoarerecoveringfromanillness,injuryorsurgeryandelderlyclientsareparticularlyatriskofinfection.Duringtheyearwehavedevelopedplanstoreducetheriskandimpactofaninfluenzapandemicifitoccurredinourregion.Ourauditoriumhasbeendesignatedasareceivingcentreshouldsuchanoutbreakoccur.Recentresearchhasshownthatlanyards(cordswornaroundthenecksofstafftoholdkeysorotheritems)carrybacteria.Asaresult,lanyardshavebeenbannedwithintheorganisation.

Staff Immunisation Division1RegisteredNurse,AndrewLewis,wastrainedasaNurseImmuniserthisyearandhasoverseentheStaffImmunisationProgram.Hand hygiene

Auditsofstaffhandhygienecomplianceareconductedfourtimesayearandshowimprovedresultssincethecommencementofourhandhygieneprojectwhichcommencedin2006withtheimplementationofalcoholbasedhandrub.Cleaning auditsMtAlexanderHospitalhasperformedextremelywellinrecentcleanlinessauditsandclientsurveys.AuditingagainsttheVictorianPublicHospitalCleaningStandardsachievedaresultof96.8%,11.8%higherthantheacceptablestandard.

Clinical GovernanceClinicalGovernanceisthetermusedtodescribeasystematicapproachtomaintainingandimprovingthequalityofcarewithinahealthsystem.OurnewlyformedClinicalServicesCommitteeleadsourcaresafetysystemsandreportstotheBoardofManagement.InMaywecompleteda“ClinicalGovernanceOrganisationalReadinessChecklist”andasaresultupdatedproceduresandguidelinesinrelationtoriskswithintheclinicalareas.Strongemphasisisplacedonareasthathavebeenidentifiedashighriskofharmtoourclients.Theseincludethefollowing:

Adverse and Sentinel Event ProgramAnyincidentthatcausesaseriousadverseoutcometoaclientisclassifiedasanadverseevent;moreseriousincidentsareclassifiedsentinelevents.Wehavehadnosentineleventsthisyear.The20adverseeventsthatwehadweremostlyfracturesafterafall.Everyadverseeventisthoroughlyinvestigatedtoenableustoidentifywhathappened,howitoccurred,andwhatcanbedonetopreventitfromhappeningagain.

Medication Management ProgramMakingsurethateachclientreceivesthecorrectmedicationattherighttimeisastaffresponsibilitythatistakenveryseriously.Anydeviationfromthe

Year Medication errors

2008/9 129

2007/8 167

2006/7 173

2005/6 165

2004/5 151

Falls statistics

Year Number of falls Number of Clients Number of fractures

2008/9 543 280 17

2007/8 494 333 6

2006/7 467 313 9

2005/6 577 351 8

2004/5 526 333 8



engagedmembersrepresentingcarers,peoplewithchronicconditions,thosefromisolatedandruralsettings,andpeoplefromculturallyandlinguisticallydiversebackgrounds.TheCommitteealsoprovidesaforumforCommunityrepresentativestoprovidefeedbackonpromotionalactivitiesandvariousaspectsofservicedeliveryanddevelopment.

Planned Improvements

• CommunityConsultativeCommitteeinputintotherevampingofthehospital’sHealthIndependencePrograms,theCommunityParticipationplanandtheservice’sAccess,DischargeandTransferreview

Monitoring of SatisfactionWetakepartinastate-wideVictorianPatientSatisfactionMonitorSurvey(VPSM)whichaskspeoplewhohavebeendischargedfromtheacuteandrehabilitationservicesaseriesofquestionsinrelationtotheiradmission,participation,complaintsmanagement,physicalenvironmentandoverallcare.

TheVPSMalsomeasuresourperformanceininvolvingconsumers,carersandthecommunityandcollatesintoa“ConsumerParticipationIndex”.Weconsistentlyscoreveryclosetolikesizefacilities.

During2010therewillbeanIntroductionofnewstringentcleaningstandardsandsystemswhichincludesincreasedfrequencyofauditingwithinhighriskareas

Food Safety

MtAlexanderHospitalhasarigorousFoodSafetyPlanwhichaimstoreducetheriskofconsumerscontractingfoodpoisoningandgastroenteritisfromfoodsservedonthepremises.Thereareproceduresinplacetomonitorallincominggoodswithcorrecttemperatures,usebydatesandquality.Foodtemperaturesareregularlycheckedandrecordedtoensurecorrecttemperatureproceduresareadheredto.AnInternalFoodSafetyAuditisconductedthreetimesayeartoidentifykeyareasastheyrelatetotheFoodSafetyPlan.TheFoodSafetyPlanwasauditedinMaybyCateringandHospitalityManagementServiceswithnoreportablerecommendations.

Communication and Consumer ParticipationCommunity ConsultationTheCommunityConsultativeCommitteewasestablishedin2005toincreasecommunityparticipationindecisionmakingabouthealthcareservices.Earlierthisyeartherecruitmentprocess,membershipandmeetingformatfortheCommitteewasreviewedwiththeaimofensuringrepresentationfrommany differentgroups.

InlinewiththeDHSreport“Thedoingitwithusnotforus–Participationinyourhealthservicesystem2006–09”,theConsultativeCommitteeactively

Number of staff immunised

2009 2008 2007 2006 2005

Influenza 269 243 159 174 148

HepatitisAandB 6 19 14 14

Audited hand hygiene compliance

Unit 2009 2008 2007 2006

GeroeAcuteUnit 75.23% 65% 58% 12%

ConnollyRehabilitationUnit 89% 68% 54% 20%

VPSM results-Overall satisfaction with hospital stay

Wave 16Sep08-Feb09

Wave 15Mar08-Aug08

Wave 14Sep07-Feb08

Wave 13Mar07-Aug07

Wave 12Sep06-Feb07

MAH 82 87 82 81 81

Similarsizehospitalmean 83 84 81 82 82

Statemean 78 79 78 78 78

Year % Compliance

(85% is the required pass rate)

2008/9 96.8

2007/8 97.25

2006/7 96.00

2005/6 96.92

2004/5 95.00

Mt Alexander Hospital

Similar sized organisations

ConsumerParticipationIndex

82 83

Inaddition,weconductourowninternalsurveyforresidentsinourResidentialAgedCareUnits.Thisyear237surveysweredistributedand150surveyscompleted.Fourvolunteersassistedtheresidentswithcompletionofthesurveywhichresultedinamuchhigherreturnrate.

Excellentresultswerereceivedaswellasmanysuggestionsforimprovement.

Asaresultofcommentsmadewithinthesurveythefollowingimprovementshavebeenmade:

• Individualresidentshavehadtheirmenureviewed

• Hairdresserandmassageservicesprovidedforindividuals

• Activitiesprogramreviewed

• Medicationsreviewedforaresidentwhofelttheyweretakingtoomanytablets

• Furtherdisseminationofminutesofresidentmeetings

QUALITYOF CAREREPORTCONTINUED

“My mother was treated with professionalism, compassion, care and dignity. The staff at Mt Alexander Hospital were wonderful in every way” VPSM Survey



Health PromotionArangeofhealthpromotionstrategiesoccurredthisyearincluding:• ImplementationofNoSmoking

Policy• MtAlexanderHospitalstaff

competedwithotherregionalorganisationstogetthemost“steps”clockedupasameansofpromotingexerciseinthe“BiggestWalkerChallenge”

• OnsitehealthpromotiondaysforJeansforGenesday,CancerCouncilandtheChildren’sMedicalResearchInstitute

• PhysiotherapystaffprovidededucationsessionsonHeartHealth,FallsPrevention,HealthyBonesandContinencetotheCastlemaineSeniorCitizens

• “GoforyourLife-JustAddFruitandVegProject”resultedinpromotionoffruitandvegetableconsumptionacrosstheShire

• Provisionofinformationsessionstostaffandcommunityduringpalliativeweek,May2009

• FoothealthweekwascelebratedinOctober2008withprovisionofcommunityandstaffeducationsessionsandfoothealthscreeningsbyourpodiatrydepartment

Planned Improvements • Launchingofanewprogramfor

stafftoencouragegeneralwellbeing–“FitforLife-FitforWork”

Continuity of CareOurfacilityisabletooffermanycareservicesbothonsiteandwithinthecommunity.Manyofouracutepatientsarefollowedupafterdischargewithrehabilitationservices,orcarewithintheirhomeseitherthroughourDistrictNursingServiceorCommunityAgedCarePackages(CACP).CommunityAgedCarePackagesarecoordinatedpackagesofcommunitycareservicestohelpourpeoplewithcomplexcareneedstocontinuelivingintheirownhome. EachCACPisdesignedforanindividualpersonandisbasedontheir particularneeds.ToaccessCACP,clientsarerequiredtohaveanassessmentcompletedbytheAgedCareAssessmentService(ACAS)locatedatthefacility.ADoctorcanprovideareferraltothisservice,orthe

Inaddition,clinicalprogramsareindividuallyevaluatedthroughclientsatisfactionsurveys.Departmentsareincreasinglyimplementingannualsatisfactionsurveysasawayofevaluatingtheirservicewithintheorganisation.

Feedback ManagementFeedbackfromourconsumersassistsustoidentifyandsolveproblemswithinourservices.A“CustomerFeedback”formisondisplayinallareasandweencourageconsumerstousethisformtoprovideuswithcompliments,comments,suggestionsandcomplaints.Thisyearweprovidedanadditionalincentivetoencouragecustomerstocompletea“CustomerFeedback”formwithasixmonthly“luckydraw”beingheld.Allcontributors’nameswereplacedinadrawwiththewinnerbeingawarded$100.Thissubstantiallyincreasedthefeedbackwereceived.Duringtheyearwereceived227compliments,28comments,23suggestionsand40complaints.AllcomplaintsareinvestigatedbytherelevantDirectorandformalfeedbackisalwaysprovidedtotheauthor.Duringthisyearthefollowingchangesoccurredinresponsetocustomerfeedbackandcomplaints:• Alterationofcustomermenus• Reviewofair-conditioning• Installationofadditionalshelving• Staffcounselledregardingtheway

theycommunicatewithclients• Alterationincleaningschedules

withinalowcareresidentialunitWeencourageinnovationfromcustomersandstaffandasanalternativetothe“CustomerFeedback”formwealsohavereadilyavailablea“BrightIdeas”form.Duringtheyearwereceived40brightideas;29fromstaff,1fromcommunitymembersand10anonymousones.Asaresultof“BrightIdeas”thefollowingchangeshaveoccurred• Reviewofprovisionofnewspapers

tocustomers• Introductionofanadditional

electronicformtoreducepaperusage

• Atrialoffittedsheetsinresidentialunits

Joyce’s StoryThree and a half years ago Joyce was referred to CACP.

Care Manager, John Mathews, visits Joyce once a month and keeps in touch by phoning her regularly assessing ,monitoring and reviewing Joyce’s needs to enable her to continue living at home.

“John is an absolutely wonderful and caring man, who I consider a friend, and a professional and when I need help he helps me.” Joyce says

Joyce has a personal alarm system and a reading monitor, which had been organised by John. He has also assisted in sourcing services for Joyce which include a gardener, to mow her lawns, and Home Care, which includes house cleaning and shopping. As Joyce’s needs change so the services may be changed. John ensures her care is being provided appropriately and Joyce is able to make informed choices about the services she requires.

The CACP service makes a real difference in assisting our clients in living well and ageing well within their own home environment.

ACASteamcanbecontacteddirectlybytheclient,ornextofkin,bytelephoningtheCACPmanageron54711468.Afteraclientisconsideredtobeeligible,theyareputonawaitinglistandinformedassoonasapackageisavailable.MtAlexanderHospitalhasfundingtoprovide20clientswithCommunityAgedCarePackages.JohnMathew’sroleofCACPCoordinatorensuresthehighestqualityserviceisprovidedtoourclientsreceivingaCACP.



OURNURSINGDIRECTORATE

Future Directions• Investigationofpossible

chemotherapyanddialysisserviceprovisionwillcontinue

• ImplementationoftheStrengtheningCareOutcomesforResidentswithEvidenceprojectasdevelopedbytheDepartmentofHumanServices

• Implementationoftheelectronicdocumentationsystemcalled“ManagementAdvantage”withinResidentialAgedCareareas.Therewillalsobeareductionintheneedforapaperbasedmedicalrecordwhichbringsenvironmentalbenefits

• Areviewofrehabilitationservicesisplannedforthenextyear.Inparticular,aspecialitystreamincaringforpeoplewithmovementdisorderssuchasParkinson’sandMotorNeuronediseaseswillbedeveloped

• ExtendtheruralmedicalworkforcepartnershipwithBendigoHealth

Increase in Surgical ActivityInresponsetodemandforservices,andthroughtheprovisionofextrafundingfromtheStateandFederalGovernments,wehaveincreasedthenumberofsurgicaloperationsby35to40permonthsinceSeptember2008.Mostofthisincreaseisinendoscopicprocedures,suchasgastroscopyandcolonoscopytoscreenforcancerandothermedicalproblems.

Extra Beds for Nursing Home Type PatientsInJanuary2009,weincreasedthenumberofbedsavailable(bysix)intheRehabilitationUnittoaccommodatethenumberofpatientswhowereawaitingaplaceinaresidentialcarefacility.Inaddition,wedesignatedonebedforplannedrespiteadmissionssofamiliescouldplan,bookandtakeaholiday.

Return to Practice Program and Initial Registration of Overseas RecruitsOurfirstReturntoPracticeprogramfor2009commencedon16February.ThiswasalsothefirsttimewehaveofferedthecourseincorporatingoverseasregisterednurseswhoareseekingtoobtainregistrationtoworkinAustralia.Weareabletooffereightpositionspercourseandhaveplannedtoofferthreecoursesperyear.Inthisfirstintake,wehadtwoDivision1nursesandfiveDivision2nursesseekingtore-entertheworkforce.Wehopetorecruitseveralofthesestaffintoournursingteamatthecompletionoftheprogram.OuroverseasrecruitwasfromthePhilippinesandhasfamilylivingintheMelbournemetropolitanareawheresheishopingtofindemploymentatthecompletionofourprogram.

BothtypesofcandidatesgenerateincomefortheHospital.TheVictorianGovernmentsponsorstheReturntoPracticestaffupto$2,200percourseandtheoverseasrecruitspayatotalof$12,000(inclusiveofaccommodationcosts)toparticipateintheprogram.Thecoursewillgenerallytakeapproximately12weekstocomplete.Candidatescanundertaketheclinicalcomponentonafull-timeorpart-timebasisandmustcompleteaminimumnumberofclinicalhoursandundertakethetheoreticalcomponenttoachievere-registration.

ProfileTheNursingDirectorateoverseesnursingserviceswithinResidentialAgedCare(HostelandNursinghome),Rehabilitation,AcuteMedicalandSurgical,MidwiferyandAccidentandEmergencyservices.

Quality Outcomes• Increasednumberofoperations

performed• Additionalbedsprovidedforclients

awaitingtransitiontoResidentialCare

• RelocationofresidentsfromMaldonHosteltoRenshawHouse

• Reductioninaveragelengthofstayofinpatients

• IntroductionoftheLivingWell-AgeingWellProject

“Help out with other people as much as you can”

Frances Thompson – Reflections Project

“The staff could not have been more helpful, thoughtful or sympathetic during my day surgery” Comment received 3 December 2008



Wecontinuetoreceiveinquiriesfromnursesaroundtheworld,predominantlyAfricancountries,seekingtogainemploymentandlongertermresidenceopportunities inAustralia.

Strengthening Care Outcomes for Residents with Evidence (SCORE) Project

TheSCOREprojectaimstofacilitatesustainableimprovementinclinicalandcarepracticesinResidentialAgedCareservices.MtAlexanderHospitalhasbeenchosenastheLoddonMalleerepresentativetoparticipateinthisproject.

SueNicholson,theNurseUnitManagerofElleryHouse,hasagreedtobetheResearchFellowforoursiteandimplementthechangesintoElleryHouse.Thefirststageoftheworkisdevelopingstandardisedcareprocessesintenareasofclinicalrisk.Thesecondstageinvolvesthepilotingoffourofthesestandardisedcareprocessesineachofthepublicsectorresidentialagedcareservices.

Maldon Hostel RelocationThefinalpieceofthemajoragedcarefacilitiesredevelopmentpuzzlefellintoplaceon31July2008,withMaldonHostelresidentsrelocatedtoRenshawHouse.Theresidentsareenjoyingtheirnewbeds,roomsandprivatebathrooms.Newfurniturewaspurchasedtocelebratetherelocation.

Clinical Resource UnitTheClinicalResourceUnitestablishedlastyearhasnowbeenevaluated.ThisUnitprovidesaflexibleworkforceavailabletocoverlongtermleaveabsencesandadhocabsences.Theevaluationdemonstratedacostsavingof$27,000duringtheevaluationperiod(datawascompared18weekspriorto18weeksposttheimplementation).Asaresult,apermanentworkforceisemployedwhichensuresflexibilityacrosstheorganisationtofilltheareasof greatestneed.

Rehabilitation & Acute ServicesConsiderableworkinthelastyearhasresultedinreducingtheaveragelengthofstayfrom26daysin2007/08to24days2008/9intheRehabilitationUnitbyplanningsmartertherapyprogramsforeachpatient.

StaffandpatientscopedadmirablyduringaneightweekrelocationwhilsttheRehabilitationandAcuteUnitswererefurbished.

Areviewofmaternityservicesisunderwaywithearlydatashowingthatthereisawillingnessandcapacitytoincreaseservicestothelocalcommunity.FurtherworkwilldetermineanenhancedroleformidwivestosupportthegeneralpractitionerworkforceandexaminehowwecanhelpinrelievingthedemandsplacedonBendigoHealth.

Baby boy Colin Burke born in March 2009 at Mt Alexander Hospital

Baby girl Isla Rose O’Connor born in January 2009 at Mt Alexander Hospital

Baby girl Kate Wilson born in June 2009 at Mt Alexander Hospital

“I felt very fortunate to be able to be able to have my children in my local hospital with such good quality care and no “big hospital bustle” ”

Quote from a Maternity satisfaction survey



OURCOMMUNITYPROGRAMS

• CompliancewiththeHACCNationalServiceStandards-DistrictNursingService

• RestructuringoftheOut& OutClub

Future Directions• AppointmentofaHealth

IndependenceProgramsManager• Toimproveinterdisciplinary,

collaborativecareplanning,andincreaseengagementinserviceplanninganddevelopmentwithlocalserviceproviders

• Ensurethatpractitionersareeducatedinself-managementpracticesinchronicconditions

• Streamlineserviceco-ordinationbyincreasingtheuseofelectronicreferrals

• Extendtheuseofadermatoscopewithinthepodiatrydepartment.Thisinstrumentallowsexaminationoffreckles/moleswhichwillassisttheearlydiagnosisofskincancers

• ImplementationofaSharedCareProtocolinmedicationadministrationinthecommunitybetweentheDistrictNursingServiceandtheShire’sHomeandCommunityCarepersonal careworkers

ProfileOurCommunityProgramsstaffarecommittedtoprovidingaservicethatisevidencebased,goal-orientated,anddemonstratestheprinciplesofselfmanagementandclient-centredpractice.Staffprovideanextensiverangeofservicesincludingmultidisciplinaryinpatientandoutpatientrehabilitation,assessment,treatment,andsocialsupportacrosstheGoldfields,MacedonRangesandMountAlexanderShires.

Quality Outcomes• HospitalAdmissionRiskProgram

ProjectManagerappointedandimplementationplandeveloped

• HealthIndependenceProgram(HIP)implementationcommenced

• IntroductionofanelectronicAgedCareClientRecordSystem

• “GoforYourLife”JustAddFruitandVegProjectselectedtobehighlightedinthe“AFairerVictoria”AnnualReport

• Relocationofphysiotherapygym• Extensionofnineextraplaces

withintheEarlyInterventionProgram

• ImplementationofthespecialistPalliativeCareService

Allied HealthThefacilityisveryfortunatetohaveastrongprofessionalalliedhealthteamwho,togetherwiththecommunityandotherserviceproviders,provideanexceptionalrangeofservicesaimingtoachievethebestpossiblehealthoutcomesfortheirclients.Ourteamprovidesphysiotherapy,occupationaltherapy,podiatry,speechpathologyanddieteticswithaccesstoaneuropsychologyandpsychologyservice.Thereisanemphasisonhealthpromotionandeducationaswellastheprovisionofindividualandgroupinterventions.

Duringtheyearworkhasbeencompletedbyouralliedhealthteamonthe“LivingWell-AgeingWell”Project,theHospitalAdmissionRiskProgramandtheimplementationofHealthIndependenceProgramsGuidelinesdevelopedbytheDepartmentofHumanServices(moredetailon Page17).

Physiotherapywasprovidedtwodaysperweekto“Scope”whichisaBendigobasednot-for-profitorganisationprovidingdisabilityservicestochildrenandadultswithphysicalandmultipledisabilities.TheexerciseclassesandgroupsprovidedintheCommunityRehabilitationCentrehavebenefittedfromupgradedequipmentprovidedthroughadditionalRehabilitationAmbulatoryCarefundingandtheMAHS(MoreAlliedHealthServices)providedahalfdayaweekofphysiotherapyservicestoMaldonHospitalresidents,fundedbytheDivisionofGeneralPractitioners.

TheOccupationalTherapyDepartmentreceivedHomeandCommunityCare(HACC)fundingtoworkcollaborativelywiththeMountAlexanderShiretodevelopaprogramwhichiscompliantwiththeHACC“ActiveLivingModel”.Theaimistoassistclientslivinginthecommunitytoremainintheirownhomesandprovideservicestoenablethemtoremainindependentandsafe.

Local children participating in the “Go for Your Life” Just Add Fruit and

Veg Project



Support and Assessment ServicesTheSupportandAgedCareAssessmentService(ACAS)wasformerlytitledtheWelfareDepartment;thisserviceencompassestheAgedCareAssessmentServiceandwelfaresupportroles.ThedepartmentchangedtheirtitleinMarch2009.

ToreduceduplicationofdataentryanelectronicAgedCareClientRecordSystemandelectronicdelegationsystemwasimplementedforhighandlowcareresidents,respite,andcommunitypackageclientinformation.ThissystemwasimplementedbyBendigoHealthCareGroupandenablesstafftocorrespondelectronicallywithBendigostaff.

Early InterventionTheEarlyInterventionserviceprovidesmultidisciplinarycareforchildrenuptosixyearsold.AsaresultofafundingincreasereceivedfromtheDepartmentofEducationandEarlyChildhoodDevelopment,theservicehasbeenextendedbynineplacestonowaccommodateanaverageof36childrenintheprogram.TosupporttheseadditionalplacestheprogramhasextendedtheteacherpositionandemployedanotherOccupational

Therapist.Additionalaudiovisualequipment,fundedbytheCommonwealthBank,waspurchasedtoassistwiththeprogram.

District Nursing/Palliative Care/Post-Acute Care

Theseservicesdeliverpersonalandnursingcaretoclientswithintheirownhomessevendaysaweek.

TheservicehasbeenexpandedtoprovidededicatedPalliativeCareNurseswithpostgraduatespecialisteducationtoprovidecareforclientsintheirownhome.TheservicesofaPalliativeCareSpecialistwhohasjustcompletedpostgraduationstudieshasbeenutilisedandMerrillCole,PalliativeCareConsultant,hasalreadycompletedherMastersandaimstobeendorsedasaPalliativeCareNursePractitionerintheverynearfuture.Bothofthesespecialiststaffmembersworkcollaborativelywiththeclient’sownGeneralPractitionersandotherhealthcareproviderstoensure optimalcare.

TheDistrictNursingServicewasassessedforcompliancewiththeHACCNationalServiceStandardsinSeptember.Theresultantscorewas18.3outof20.

TheSpeechPathologyDepartmenthasbeeninvolvedinmanyprojectsduring2008-09including:

• The“FoodandFluidModificationProject”whichintroducesthenewAustralianstandardisedterminologyanddefinitionsfortexturemodifiedfoodsandfluidsacrossallunitsinthehospital

• The“VolunteerMealtimeAssistanceProject”involvedaself-trainingpackageandtrainingdeliveredbyaspeechpathologisttoallvolunteerswhoassistresidentsatmealtimes

• ApraxiaofSpeechProjectisapilotprojectthroughLaTrobeUniversityexaminingaspecifictypeofspeechtherapyforpeoplefollowingunilateralcriteria

ThePodiatryDepartmentandMountAlexanderShirepersonalcarershaveworkedcollaborativelyonaFootCareProject.Thecarersweretrainedbypodiatrystafftoidentifycommonfootproblemsandcutnailssafely.

TheDieteticDepartmenthaveoverseenseveralprojectsincluding:

• Significantchangestothetypesoffoodsupplementsprovided,whichhasresultedinimprovedquality,supplyandacostreductionforcommunityclients

• A“GoforYourLife”JustAddFruitandVegProject”encouragedpartnershipsbetweenfruitandvegetableretailers,majoremployers,communitygroupsandlocalschools.TheaimwastoencourageandpromotefruitandvegetableconsumptionacrosstheShireandthiswasachievedwithatotalofover20,000servesoffruitandvegetablesgivenout

• AModifiedTextureProjectcommencedinFebruary2009.ThisisacollaborativeeffortbetweenFoodServices,DieteticsandSpeechPathologyDepartmentswiththeaimbeingtointroducenewlydevelopedAustralianGuidelinesfortexturemodifiedfoodsandfluids

Adult Day Service couples enjoying a respite holiday in Echuca



workingwelltogetherandanevaluationiscurrentlyunderway.TheprogramissupportedbyStLuke’sBendigowithagrantprovidedfortheimplementationofthisaspectoftheHomelessnessActionPlanStage2.

TherehasbeenanincreasingdemandforhousingassistancefromtheSudanesecommunitywithtwelveclientscurrentlyreceivingsupport.

Adult Day Service/ Volunteer & Social SupportTheAdultDayServiceprovidesrespiteservicesforcommunitycarersandplannedactivitygroupsforcommunitymemberswithaneligibledisability.

The“OutandOutClub”,whichprovidesactivitiesforyoungerclientswithdisabilities,hasbeenrestructuredwiththegroupsizesbeingreducedtoenableincreasedindividualactivities.

TogetherwiththeVolunteerandSocialSupportDepartment,an“AprilFools

GalaDay”wasarrangedforthebenefitofclientsandinvitedguestsfromMountAlexanderShiresocialsupportprograms.

TheVolunteer&SocialSupportManagerhasworkedcollaborativelywiththeTransportDepartmenttointroduceaservicecriteriaandfeestructureforvolunteerandHospitaltransport.

NationalVolunteersWeekwascelebratedwitha“Laugh,LearnandLetLooseDay”beingheldfortheMtAlexanderHospitalvolunteers.

Successfulrespiteweekendsareheldregularly.Positivefeedbackcontinuestobereceived.

Continence ServiceThisservicehasbeenrelocatedandnowhasanofficeandtreatmentroomwhichallowsconsultationinamoreprivateandcomfortableenvironmentandcloserliaisonbetweenstaff.Afulltimecontinencenurseandparttimecontinencephysiotherapistprovideassessmentandtreatmenttoadultswhosufferfrombladderorboweldysfunction.Referralsareacceptedfromdoctor,casemanageror selfreferral.

CADARG (Castlemaine and District Accommodation and Resource Group)

CADARGassistswithaccessingaccommodationforthosepeoplewhoneedsupport.

DuringthepasttwelvemonthsCADARGstaffhavebeendevelopingtheYouthHousingInitiativewhichisnowoperating.Theleadtenantandyoungpeopleintheprogramare

OURCOMMUNITYPROGRAMSCONTINUED

“Family is family”

Alan & Elsie Cole – Reflections Project

“Dear Virginia,Thank you for including us in the long week-end respite holiday. It was really superb; even the weather was fantastic.

Fran Van Rooen & Chris Jeffcott were wonderful support, and were always there to help us. They spoiled us & went well beyond the call of duty to ensure our comfort & that we had everything we could wish for.

The morning tea & lunch we had on the way to Yarrawonga were delicious. The units were comfortable and practical, even if not specifically for ‘disabled’. We all coped very well. The living area was very good with suitable heating in the living area, and was great for socialising for breakfast and an evening meal and board game. The two Clubs we dined at for evening meals provided really good meals.

We all loved the Pioneer Museum, the Antique Clock Display, the Op Shop where we all hunted for bargains; and the Church Fete where we were able to browse around before enjoying Devonshire tea. We all enjoyed sitting in the sun with no wind while we had our barbeque lunch and watched some boats and fishermen at the edge of the lake. Fran & Chris did the work while we relaxed and felt very lazy. We had time for some walks, and needed them to burn off a few of the calories we had consumed. We called in to a nearby winery and helped the economy by spending a little to bring some home. And on Sunday we visited the old historic homestead and gardens before again having a wonderful Devonshire morning tea out in the garden before starting our journey home.

It was a most enjoyable week-end and our best wishes and thanks go to all concerned, we are most appreciative of the opportunity to be part of such a great adventure that is available through our marvellous hospital,

Sincerely yours, Carer”

Letter from Carer to Virginia Harken ADS Coordinator



• Providedself-managementtrainingforanumberofthealliedhealthandnursingstaff

• Publishedaquarterlynewsletterthatrepresentsclientviews,providesinformationforthecommunityaboutpersoncentredcare,healthindependenceandchronicdiseaseselfmanagement

ThefocusoverthenextyearwillbeensuringthebasicprinciplesofthePersonCentredCaremodelofservicedeliveryforolderpeoplearedemonstratedthroughoutallareasofourservice.Theseare:

• Basedonstrongevidenceandhaveafocusonmaintaining,improvingandpreventingdeteriorationinhealthandqualityoflife

• Recogniseandaddressolderpeople’scomplexneeds

• Respectfulandrecogniseindividualdifferencesandspecificneeds

• Deliveredinacoordinatedandtimelymanneracrosscaresettings

• Unnecessaryadmissionandextendedhospitalstaysforfrailelderlypeopleareavoided

• Focusedonthecareneedsofolderpeople

• Aimtoprovidecareforolderpeopleinthesettingthatbestmeetstheirneedsandpreference

(takenfromAge-friendlyprinciples andpractice,AustralianHealthMinisters’AdvisoryCouncil,2004).

TheCommunityRehabilitationCentre(CRC)willalsobeworkingtowardimprovementstoensurecompliancewithHealthIndependenceProgram(HIP)GuidelinesdevelopedbytheDepartmentofHumanServices.

TheHIPguidelinesaimtoreduceduplication,ensureaseamlessjourneyfromoneservicetoanotherandoffermorecomprehensivecareforourShire’smostvulnerableclients.Inpracticalterms,thesechangeswillinclude:

• Theintroductionofadefinedpointofentryandanintakeclinicianwhowillreviewallnewclientsneedsthatmayimpactupontheirhealth

• Allocationofakeyworkertocoordinatecareforpeoplewithchronicandcomplexconditions

• Increasingtheuseofsharedcareplansandcaseconferencing

• EnsuringallprogramsandserviceswithinCRCareinformedbyaselfmanagementapproach

• Broaderuseofe-referralandcommunicationtoolstoensurebettercommunicationbetweenCRCclinicians,GPs,CommunityHealthandShireservices

Living Well- Ageing WellLivingWell-AgeingWellisakeythemefortheworkwehaveundertakenthisyearandforwhatwehaveplannedfornextyear.WehaveobtainedFederalfundingtodevelopandimplementtwoprojectsthataimtoimprovecareforolderpeopleby:

• Developinganagefriendlyenvironmentthroughoutthefacility,inparticularforthoseover65yearsofage,andindigenousclientsover45yearsofage

• Increasingawarenessandprovisionofpersoncentredcare.Personcentredcareplacestheclientandtheirfamily/careratthecentreofthecareexperience.Thisensuresthatcareprovidedisresponsivetoindividualdifferences,culturaldiversity,levelofabilityandpersonalpreferences

• Minimisingfunctionaldeclineinparticularinrelationtomobility,continence,medication,depression,delirium,dementia,nutritionandskinintegrity.Additionalstrategieswillbedevelopedtoreduceriskacrosstheseareasandpromotemaintenanceofindependencewherepossible

• Improvingmanagementofcomplex/chronicdiseasesaimingtodecreaseinhospitaladmissionsandemergencydepartmentpresentations

Inordertoachievetheabovethefacilityhas:

• Employedtwoprojectmanagerstooverseetheprojects

• EmployedaRegisteredNurseDivision1whowillcoordinatecareforclientsover65yearswithcomplexneedsassociatedwiththeirchroniccondition

• Reviewedassessmentandcareplanningtoolstoensureclientandcarergoalsareemphasised

• Developedastrategytoimplementcollaborativecareplanningthatactivelyinvolvesthepatient,carerandtheirhealthcareproviders

Eligible clients who have a chronic condition can be referred to the

Hospital Admission Risk Program (HARP) via Phone (03) 5471 1673, Fax (03)

5471 1674 or the Connecting Care Website www.connectingcare.com

Beverley Shears riding bicycle in the Botanical Gardens



OURFACILITYSERVICES

• Excellentresultsonexternalfoodsafetyandcleaningaudits

• Installationofanewindustrialdishwasherforthemainkitchen

• Upgradingofelectricalswitchboards

• Removalofasbestos

• Purchaseoftwonewvehicles-anadditionalsedanandarazorbackvehicle

• Installationofaliftingmachineinthelaundry

• Installationofagourmetselfservehotdrinkmachineincafe

Future Directions• Reviewtheappropriateuseofall

vacantoralteredbuildingspacesthathaveresultedfromcompletionoftheBuildingProgram

• RefurbishSlaterHouse(formerlyMaldonHostel)

• Developmentandimplementationofathreeyearplanfortherepaintingoftheexternalsurfacesofallbuildings

• Investigatepurchaseofequipmenttofacilitatecleaningandmaintenanceofhighpointsinbuildings

• Installationofadditionalsecuritycameras

• Investigationoftheprovisionoffittedsheets

Transport ManagementTheTransportDepartmentprovidesclienttransportandcourierdeliveryservices.

OverthepastyeartheDepartmenthasestablishedaworkingpartnershipwithMountAlexanderShireandcontinuedprovidingservicestotheHospital’svolunteerservice.Thisincreasesefficienciesbysharingtheworkloadbetweentheserviceprovidersandenablesclientstobeallocatedtoaservicemodelthatisresponsiveto theirneeds.

InpartnershipwiththeLocalCommunityHealthCentreacommercialarrangementhasbeenintroducedtoprovidetransporttolocalresidentsfourtimesayeartoattendappointmentsattheBendigoRegionalWomen’sHealthClinic.

AnewvehiclewascommissionedinMay.Thedesignofthepassengersectionwasreconfiguredtoprovidemoreseatingandspaceforanadditionalwheelchair.ThevehiclehasincreasedfuelefficiencyandcomplieswiththehighestEuropeanEmissionControlStandards.Thesefeaturesandthereconfigureddesignofthevehiclewillcreateoperationalefficienciesalongwithimprovedpassengercomfort.

AclientsatisfactionsurveyconductedontheexternalHospitalTransportservicesprovidedanoverallsatisfactionratingof97%.

Environmental ServicesThestafffromtheEnvironmentalServicesDepartmentprovidesflexibleandhighqualitymealdeliveryandcleaningservices.

Tofacilitatecleaning,anewelectricscrubberwaspurchasedforuseintheKitchen.Amotorisedequipmenttrolleywaspurchasedtoassistinthemovementofequipmentandgoods.ToassistincleaningnewcarpetintheRehabilitationandAcuteunits,newvacuumcleanersandanadditionalcarpetshampoomachinewerealsopurchased.

Food ServicesOurbusykitchenprovidesover750wellbalancedmealstoinpatients,residents,staff,visitors,MaldonHospitalandmealsonwheelsrecipientseachday.

Thesupplyofsomefoodproductswasretenderedduringtheyearwiththeresultbeingthatcostswerekepttoaminimum,orinsomeinstances,werereduced.

Theuseoffoodportioncontrolproductswasincreasedduringtheyeartoassistwithwasteminimisation.

ProfileTheGeneralServicesDirectorateprovidesservicestoensuretheeffectivemanagementofassetsandfacilities,transport,provisionofmeals,generalandspecialistcleaning,wastedisposal,recyclingandsecurityservices.Theseservicesareprovidedtoallinternaldepartmentsinthefacilityaswellastosomeexternalorganisations.

Quality Outcomes• Refurbishmentoftwoofthe

Hospital’sresidencesinpreparationforsixthyearMonashmedicalstudentswhowillbeplacedinthelocalGeneralPracticesinCastlemaine

• RefurbishmentoftheCafeteria,Auditorium,RenshawHostel,AcuteandRehabilitationUnitsandseveraloffices

• Provisionofadditionalbenefitstopatientswhousetheirprivatehealthinsurance,includingdressinggowns,toiletriesandalternativemealchoiceandphonecards

Don Gordon - Reflections Project



clientswhilsttherenovationswereundertaken.Inaddition,newcarpetwaslaidinbothunits,fundedbyafederalgrant.

TofurtherpromotetheuseoftheHospital’sAuditoriumforbothsocialandmeetinguse,thewoodenfloorwascoveredwithcarpet,thewallspainted,heatingandcoolingfacilitiesupgradedandtwolargeplasmatelevisionscreenshungfromtheceiling.Thisnowprovidesthefacilitywithanadditionalexcellenttrainingandfunctionsfacility.

AStateGrantof$186,000enabledtheupgradingofelectricalswitchboardsthroughoutthefacilityincludingtheprovisionofearthleakageprotectiontoimprovesafety.

Linen ServicesTheMtAlexanderHospitalLinenServiceprovideswashing,ironingandrepairstogeneralbedding,bathroomanddininglinenandclient(particularlyresident’s)personalclothestoallinternaldepartmentsandseveralexternalcustomers.

AlinenbaghoistwasinstalledintheLaundrytoreducetheriskofinjurytostaffwhilstliftingbags.

Thishasstreamlinedtheprocessformanaginglinenbagsandhasprovidedasaferworkingenvironmentforouremployees.

Overthepastyeartherehasbeenanincreaseinthenumberofexternalclientsusingthelaundryservices.

ContractsInJuly2008,MtAlexanderHospitalwassuccessfulintheirtendertoprovideHotelServicestoMaldonHospital.ThecontracthaspreviouslybeeninplacebetweenthetwoagenciesandcoverstheprovisionofGeneralService’sstaffandsupplies,includingconsumablesandlaundry.

TheCafeteriarefurbishmentincludedtheinstallationofanewrangeofequipmentwhichhasfacilitatedtheprovisionofawiderrangeoffoodproductsincludinggourmethotdrinksavailableafterhours.CafeteriaManagerDanielleEvansretiredandwasreplacedbyBjindiHeath.PatronageoftheCafeteria,bybothstaffandexternalvisitors,hasincreasedsubstantiallyfollowingtherefurbishmentandexpansionofservices.

Anew$110,000dishwasherwasinstalledinthemainkitchen,replacingonethatwasoverfifteenyearsold.Duringthechangeovertime,staffembracedalternativearrangementswhichensuredmealserviceswerecontinuedwithoutinterruption.

ThefacilitywassuccessfulinobtainingathreeyearcontracttocontinuetoprovidemealsfortheMountAlexanderShireMealsonWheelsProgram.

SecurityTheHotelServicesManageroverseesthefacilitysecurityprogram.AdditionalsecuritystrategiesincludedtheinstallationofadditionalsecuritycamerasinPenhallHostel,ElleryHouseandAccident&Emergency(fundedbyaStageGrant)andthereconfigurationoftheentrancetotheAccidentandEmergencyDepartmenttoenableadesignatedwaitingareaseparatedfromtheAcuteWard.

Duringtheyeartherewere9securityincidentswhichwereallinvestigatedappropriately.

EngineeringTheEngineeringDepartmentoverseesbuildingworks,maintenanceandthefacilitiesfiresafetyemergencysystems.

OneofthelargestprojectstoimpactonpatientsandstaffwastheremovalofasbestosintheAcuteandRehabilitationunit’sceilings.Theremovalofsheets,reinstatementofceilings,installationofoverheadsprinklers,paintingandotherstructuralimprovementswerecompletedbyclosingeachwardforaperiodoffourweeks.ThevacantTolstrup(formerlyaNursingHomeUnit)wasusedtohouse

Sarah’s StorySarah’s association with Mt Alexander Hospital began as a Year 10 Work experience student in the Kitchen. She then worked as a casual over the school holidays. She is now employed by the Hospital as a 1st year Apprentice Cook and is five months into her apprenticeship. Sarah recently received second place in the Aus TAFE Culinary Trophy cooking competition. She now progresses to the State final in Melbourne. This is a great achievement for a 1st year Apprentice.

“I love cooking and really enjoy working at the Hospital, it is like one big family everyone gets in and works hard.”Sarah said.

Sarah has a variety of experience offered to her within her daily tasks. These tasks may include preparation work for meals which will have between 200-300 serves, working in the Hospital cafeteria making sandwiches and coffee or decorating a birthday cake for one of the Hospital’s valued Aged Care Residents.

“I am able to suggest ideas and contribute.”

“Thanks to the Hospital for the opportunity and especially to all those who were involved in reviewing systems to accommodate this apprenticeship.”

Sarah Chislett



OUR ENVIRONMENT

MtAlexanderHospitalendeavourstoprovideexcellentservicestoourclientswhilstminimisinganynegativeimpactsontheenvironment.Weareactivemembersofthe“MainesPower”Projectwherebywe,togetherwithotherkeyindustriesintheMountAlexanderShire,haveacommitmenttoreducing

• Energyandwaterusage

• Waste

• Greenhousegasemissions

Water ConsumptionAsaresultofworkfundedthroughaCommunityWaterGrantwehavebeenabletoreduceourwaterusageinexcessof1,200kLthisyear.Thisisexpectedtoincreaseinthefuture.

Theconsumptionofourthreeutilitieshasalldecreasedbyover5%fromlastfinancialyear.PenhallHostelisnowsuppliedwith100%greenenergywhichbringsourtotalgreenenergyacrosstheHospitalto15%.Ourtargetof30%reduction(from2006levels)inCO2generationby2010isalsoontarget.

Waste ManagementStaffhaveanongoingcommitmenttoreducewastewherepossible.

Duringtheyearwehaveincreasedtheamountofpaper,metals,plasticsandbatteriesforrecycling.

Future Directions• Evaluationof2009energyaudit

• Conductwaterusageaudit

• Ongoingmonitoringtoensuresustainabilityprinciplesareintrinsictoserviceprovisionwherepossible

• Applicationforadditionalfundingtofacilitateenvironmentalsustainabilityinitiatives

Energy ConservationEnergyreducingstrategiesandworksoverthepastyearinclude:

• Theinstallationofvariablespeeddrivestothechillercondensingunitfans.Thisnotonlyreducesenergyconsumption,butalsoreducesthenoiselevelonstartupandwaterconsumption.

• FittingoftheNorthWingsupplyfanwithavariablespeeddriveenablingfancontrolstrategiestoreduceheatingandcoolingpowerconsumption

• TherefurbishmentoftheAcuteandRehabilitationUnitshasresultedinreplacementof105ceilinglightswithnewenergyefficient(T5)lights.Thisimprovesthelightinglevelsinthecorridors

• Improvementsinenergymanagementsystems.ThemaincomponentofanenergymanagementsystemistheDirectDigitalControl(DDC)whichprovidesinformationtoacomputerwhichcontrolstheair-conditioningandotherenergyusingmechanicalplant.Thisnewtechnologyisreplacingouroldpneumaticsystemandhasbeensuccessfullyretrofittedtothetheatreair-conditioning.

Powerconsumptionisalargepartofourrunningcostsandstaffareremindedthatwecanallcontributebyswitchingofflightsandcomputerswhennotinuse.

“Take one day at a time and treat others as you would like to be treated yourself”

Thelma Turton – Reflections Project

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CORPORATEGOVERNANCE

PRESIDENTMr Bill O’DonnellBA,LLBSolicitor,NotaryPublicandMediator

Appointed01/03/1993AppointedPresidentFeb2007/Jul2008AppointmentExpires30/06/2011

Ms Elizabeth GraingerTrainedInfantTeachersCertGradDip,SpecialEd

AssistantPrincipalAppointed01/11/2006AppointmentExpires30/06/2012

VICE PRESIDENTMr Glenn Sutherland BA,DipEd,GradDipEdAdmin, GradDipMgmtRetailerandTrainingManager

Appointed01/11/2004AppointedVicePresidentJul2008AppointmentExpires30/06/2010

VICE PRESIDENT (Past)Mr Spencer BockLLBSolicitor(Retired)Appointed01/11/2002AppointedVicePresidentFebruary2007AppointmentExpires30/06/2009Retired24/07/2008

TREASURERMr Ian McKenzieBachofPharmacyPharmacist/WineMaker

Appointed01/11/2002AppointedTreasurerFeb2007/Jul2008AppointmentExpires30/06/2010

BOARD MEMBERSMs Lee BowerBSc(Monash)Employment&TrainingConsultant

Appointed01/11/1998AppointmentExpires30/06/2011

Ms Jude JacksonTrainedPrimaryTeachersCertGradDip,SpecialEd(Retired)


Ms Sue TurnerBScDipofManagementBusinessConsultant/Caterer

Appointed01/11/2006AppointmentExpired30/06/2009

Ms Caroline WallaceMasterofPublicPolicy&Mgt,GradDipEd,BAPolicyOfficer

Appointed01/07/2008AppointmentExpires30/06/2010Resigned25/09/2008

Mr Rob WallerCEA(REIV)EstateAgencyDirector


Mr Bruce Johnsen BScBiology,GradDipComputing AccountExecutive

Appointed01/11/2003 Appointmentexpires30/06/2009

Dr Les FitzgeraldRN,RM,Dip(Teach),BAEd, MNursePhDSeniorLecturerinHealthSciences




Executive ManagementTheDirectorsmeetwiththeChiefExecutiveOfficereveryMondaytodiscussstrategicissuesrelatingtothemanagementoftheorganisation.

Board of Management Structure and FunctionThefunctionoftheBoardofManagementistooverseethegovernanceoftheHospitalandtoensurethattheservicesprovidedbytheHospitalcomplywiththerequirementsoftheHealthAct1988andtheBy-LawsoftheHospital.

MembersarerequiredbytheActtoactwithintegrityandobjectivityatalltimes.Theyarerequiredtodeclareapecuniaryinterest,whenapplicable,duringBoarddebateandwithdrawfromproceedings.Therewerenooccasionsthatrequireddeclarationthisyear.

ConflictofinterestisdeclaredduringBoardproceedings,inaccordancewiththeBy-Lawsoftheservice.

Boardmembersserveinavoluntarycapacityanddonotreceivepayments.

Anumberofsub-committeesconsistingofBoard,Staff,VisitingMedicalOfficersandmembersofthecommunityhavebeenformedtoadviseandrecommendonrelevantmatters.

TheBoardofManagementmeetsonthefourthThursdayeveningofeachmonth(exceptJanuary)todealwithaformalagendaandreportsontheHospital’sperformanceasreportedbytheChiefExecutiveOfficerandeachoftheDirectors.Meetingscommenceat7.00pmintheBoardRoom,Level4oftheHospitalandareopentothepublic.

TheBoardaccepted,withregret,theretirementofourVicePresident,MrSpencerBockandexpressedappreciationforhisvaluablecontributiontotheHospital.

TheBoardalsoacceptedtheretirementofSueTurnerandtheresignationofCarolynWallaceandthankedthemfortheircontributiontotheHospital.

Board of Management membership of Sub-committeesCredentials & Medical Appointments Advisory CommitteeMrBillO’Donnell(Chairperson)MsLeeBowerMrLesFitzgeraldMsElizabethGraingerMrBruceJohnsenMrGlennSutherland

Project Control GroupMrGlennSutherland(Convenor)MsJudeJacksonMrBillO’Donnell(exOffico)Ms Sue TurnerMsLeeBower(Alternate)

Chief Executive Officer Evaluation CommitteeMrBillO’Donnell(President)MrGlennSutherland(VicePresident)MrIanMcKenzie(Treasurer)

Audit CommitteeMrGeoffVendy(Convenor)MsJudeJacksonMrIanMcKenzieMs Lee TurnerMsLeeBower(Emergency)MrRichardHetherington(Independent)MrPeterStemp(Management)MrDavidPell(Consultant–EvolveAccounting)MrTimTuena(Consultant–EvolveAccounting)

CHIEF EXECUTIVE OFFICERMr Graem Kelly, PSMBAAppSc,GradDipRuralHealth,AdvDipBus,RN,AFCHSE,MAICD,AIMM,FARLF

Appointed2008

DIRECTOR OF GENERAL SERVICES AND DEPUTY CEOMr Graeme HillDipAcc,CertBusStudies(HospAdmin),PNA,GradDipBusManag,FACHSE

Appointed1990

DIRECTOR OF NURSINGDr Ann AllenbyRN,CertOncNsg,CertSteril&InfControl,MedSt,DN,MRCNA,CertBusiness&Admin

AppointedNovember2003

DIRECTOR OF COMMUNITY SERVICES Mrs Rhonda WilliamsRN,BPubHealthAdmin

Appointed2008

DIRECTOR OF FINANCIAL SERVICES Mr Geoff VendyBBus(Acc)

Appointed2008

DIRECTOR OF HUMAN RESOURCES Mr Mark KesperDipCivilEng

AppointedOctober2003



Education and TrainingMtAlexanderHospitalaimstopromoteeducationandtrainingopportunitiesforallstafftoensurethattheydevelopandmaintaintheskillsrequiredtoperformtheirvariousrolesandtoassisttheminreachingtheirindividualgoals.

Allstaffarerequiredtoattendastaffdevelopmentdayannually,wherebasiccompulsorytrainingisdelivered.ThisincludesEmergencyProcedures,InfectionControlandManualHandling.Inadditiontothis,manystaffhaveadditionaltrainingand/orcompetenciesthatmustbecompletedeachyear.Thismayincludespecificclinicaltrainingandcompetencies,foodhandlingandtraininginthesafehandlinganduseofchemicals.Therehasbeena29%improvementinattendanceatcompulsorytrainingfromthepreviousyear.

Professionaldevelopmentcontinuestobeanimportantcomponentoftheeducationandtrainingprogram.Thisassistsstafftofulfiltheirprofessionaleducationalrequirementsandensuresthatclientsreceivethebestpossiblecare.Avarietyofopportunitiesareprovidedincludingeducationsessions,studydays,practicalsessions,clinicalsupportandlearningpackages.

Trainingfacilitieshavealsobeenvastlyimprovedwiththedevelopmentofthe3CVEducationCentre,whichincorporatesadedicatedcomputertrainingfacilitywithlaptops.ThisfacilityishiredoutcommerciallyfortrainingproviderswithintheRegion.Extensiverefurbishmenthasincludedoverheadprojectors,digitaltelevisionscreensandrecarpetingoftheAuditoriumasatraining/meetingroomforvenuehire.

Pharmacist,HeatherPersons,wassuccessfulinherMastersqualificationinClinicalPharmacy.

Recruitment and Achieving RetentionThroughouttheyear,MtAlexanderHospitalhassuccessfullyrecruitedfivenewtraineesandapprentices,providingopportunitiesforyoungpeopleenteringtheworkforce.Thishasproventobeverysuccessful,withallnewrecruitshavingasmoothtransitionintotheiremploymentandaddingadimensionofyouthtoourworkforce.

ProfileTheDirectorate’sprinciplefocusistoensuretheHospitalrecruitsandretainsaworkforceofprofessionalanddedicatedemployeeswhoareabletoperformtheirdutiesinasupportiveworkenvironment.Weaimtodevelopacultureofstaffworkingtogethertocreateaworkplacethatvaluesandrewardsinitiative,accountabilityandco-operation.

Quality Outcomes• IntroductionofCambron,an

electronicPerformanceAppraisalSystemwhichincludesatrainingdatabase

• Recruitmentoffiveapprentices/trainees

• Updatedtrainingfacilitiesincludingtheestablishmentofadedicatedcomputertrainingfacility,includingten laptops

• ReviewandimplementationofServiceAwards

• AccreditationfromNursesBoardVictoriatodeliverReturntoPracticeandInitialRegistrationofOverseasNursesprograms

• Reviewoftertiarystudentplacementprogram

• ImplementationofaTotallySmokeFreeworkplace

• Implementationof“AgedCareChannel”educationandtrainingpackage

Future Directions• Revisionandupdatingofstaff

positiondescriptionsintonewlydevelopedformat

• Developmentofamanagementtrainingprogram

• ImplementationofacorporatewardrobeanduniformsacrossallareasoftheHospital

• Reviewofadministrationandclericalroles

• Implementationofanewtrialelectronicrosteringsystem-KRONOS

• ExtensionofWellBeingprogramthroughimplementationof“FitforLife–FitforWork”program

OURSTAFF

TRAINEES FROM LEFT TO RIGHT

• Sarah Chislett is working as an Apprentice Cook in the Kitchen and Cafeteria

• Lauren Farr is working as an Administration Trainee in the Finance Department

• Sam Medlyn is employed as a 3rd year Electrician in the Engineering Department

• Sharlene Lendon is employed as an Administration Trainee in the Pay Office

• Kate Jermyn is working as an Administration Trainee in Human Resources



MtAlexanderHospitalnowhasthreeContactOfficerswhoarethefirstpointofcontactforstaffrequiringinformationandsupportinrelationtobullyingandharassment.

Credentialing and Certification of StaffAcomputerisedsystemofrecordingqualifications,experience,registration,membershipofprofessionalbodiesandprofessionalstandingforourmedicalstaffwasintroducedthisyear.Thisensuresthattheseitemsarethoroughlycheckedoncommencementandregularlythereafter.AllmedicalstaffappointmentsareoverseenbytheCredentialingCommittee,comprisingmembersoftheBoardofManagementwithprofessionaladviceandsupportprovidedbytheDirectorofMedicalServices.

Proceduresareinplacetoensurethatnon-medicalstaffalsohavetherelevantskillsandregistrationrequiredtoensurethatqualityandsafeservicesareprovidedtoourclients.

AllnewstaffandvolunteersarerequiredtoundergoaPoliceRecordsCheckpriortocommencement.Thesechecksarecompletedatleasteverythreeyearsforallexistingemployeesandvolunteers.

Industrial RelationsTherehasbeennolosttimeduetoindustrialdisputesintheHospital.TheStaffConsultativeCommitteemeetseachmonthtodiscussfuturechangesindirectionandtoprovideanavenueforemployeesandUnionrepresentativestotableanyconcerns.TheintroductionofmonthlyDepartmentHeadandquarterlyAllStaffmeetingshasimprovedcommunicationsignificantly.EnterpriseBargainingPaymentshavebeenmadeduringtheyearasperGovernmentpolicyandconsistentwithVictorianHospitals.

Pastoral Care ServicesPastoralCareattendstothespiritualnatureofthepersoninthehealthcareenvironment,payingattentioninparticulartothespiritualissuesthatariseinthecontextofillness,suffering,lifeanddeath.

PastoralcareisavailableonsiteattheHospitalbythePastoralCareCoordinator,andisavailabletoallpatients,residents,theirfamiliesandstaffmembers.Allinteractionsareconductedinasensitive,person-centredandnon-religiousmannerandrequestsforsupportcanbemadeviaReceptionornursingstaff.

MinistersfromvariousdenominationsalsovisittheHospitalonaregularbasisandconductweeklyprayerservicesatvariousresidentialcareunitsforpatientsandresidents.

SpeciallytrainedVolunteerscalledListeningCompanionsarealsoavailabletopatientsandresidentswhomayrequireextrasupportorsomeonetotalktoinaconfidentialmanner.

MtAlexanderHospitalprovidesindependentandconfidentialcounselingandsupporttoallstaffasrequired,throughourEmployeeAssistanceProgram.Feedbackhasindicatedthatstaffwhohaveaccessedtheservicehavefoundittobeofvaluetotheminprovidingaconfidentialandsupportiveenvironment.

Aspartofourcommitmenttorecruitmentandfuturehealthcareprovision,theHospitalplacesanemphasisonstudentplacements.IndevelopingrelationshipswiththeUniversities,therehasbeenaconsiderableincreaseinstudentplacementsfrompreviousyears. Theseplacementsincluded27MedicalStudentsfrombothMelbourneUniversityandMonashUniversity,49Division1andDivision2NursingStudentsfromLatrobeandVictoriaUniversity,12AgedCareStudentsand28Year10WorkExperienceStudentsfromanumberofschoolsthroughouttheareaincludingCastlemaine,Bendigo,Gisborne,BoortandKyneton.

Areviewwasconductedofstudentplacementprocedures,whichresultedinthedevelopmentofbookletsforYear10WorkExperienceandallotherstudentplacements.TheHospitalprovidesaccommodationforstudentsandourEngineeringDepartmenthasrefurbishedthetwostudentaccommodationhousesthisincludedpainting,carpeting,remodellingofbathroomsandairconditioning.

Feedbackfromstudentsandeducationproviderscontinuestobepositive,withmanycommentsbeingmadeonhowsupportiveandcommittedourvariousstaffaretodevelopingtheskillsandknowledgeofstudentsacrossallareas.ThisisanexcellentwaytoensurethatMtAlexanderHospitalcanattractandretaingraduatesinthefuture.ThesupportprovidedbylocalGeneralPractitioners,RuralAmbulanceVictoriaandCommunityHealthtothestudentprogramisalsogreatlyappreciatedbytheHospital.

Equal Employment Opportunity (EEO)MtAlexanderiscommittedtotheprinciplesofmeritandequityintheworkplace.WecontinuetobeanEEOemployerinanenvironmentwhichweendeavortomaintainfreefromdiscriminationandharassment.Toenhancethis,threestaffweretrainedasPreventionofBullyingandHarassmentContactOfficersutilisingtheHumanRightsandEqualOpportunityCommission.

“Work hard all your life” Ted Landsborough – Reflections Project



Occupational Health and Safety (OHS)On1March2009,MtAlexanderHospitalimplementedatotalSmokeFreepolicy,prohibitingsmokinginallbuildingsandoutdoorareaswithintheboundariesoftheHospitalgrounds,withsomeexceptionsallowedforourAgedCareResidents.AllMtAlexanderHospitalsitesarenow“TotallySmokeFree”inordertocreateahealthier,cleanerandsaferenvironmentforclients,visitors,staffandvolunteers.InpreparationforgoingSmokeFree,agreatdealofworkwasundertakenindevelopingandimplementingstrategiesincludingincreasedsignage,accesstoQuitSmokingeducation,resourcematerialsfromQuitVictoria,availabilityforresidents,patientsandstafftoaccessNicotineReplacementTherapy.

RiskmanagementcontinuestobethedrivingforcebehindOHSimprovement.TheimminentintroductionofRiskManInternational ®,anonlineincidentreportingsystem,willenhancethisprocessasallincidentswillbeautomaticallygeneratedandlinkedtotheriskregister,basedontheriskrating. Thissystemwillalsoimprovetheprocessingofincidentreportsasalertswillautomaticallybegeneratedtotheseniormanagersbasedonpre-determinedlevelsofrisk.ThisprogramwillalsoallowforbenchmarkingopportunitiesthroughouttheLoddonMalleeRegion,improvedstandardreportingmethodsandtrackingcapabilitiesfromendtoend.

TheOccupationalHealth&SafetyCommitteeandtheSafePractice&EnvironmentCommitteehavemergedtoformanewcombinedcommitteetitledtheSafety,Health&Environment(SHE)Committee.OnsitetrainingforfivenewlyelectedHealth&SafetyRepresentativeswasconductedearly in2009.

FollowingreviewoftheOHSinductionprocessandOrientationDayprogram,theinductionsessionhasbeenincludedintotheOrientationDay.Asaresult,compliancewithOHSinductionhasincreaseddramaticallytonearly100%compliance.

Forthegreaterpartoftheyear,theorganisationandthestaffhasbeenfreefromseriousinjuries.

Aworkinggrouphasbeenestablishedtodevelopsuitablestrategiestoaddressthenumberofmanualhandlinginjuriesthathavebeenoccurring.TheWorkingGrouphasrecommendedthattheorganisationexpandthestaffWellBeingprogramandactivelypromotesaprogramtitled“FitforLife–FitforWork”.Severalinitiativeshavebeendevelopedandthesewillberolledoutlaterin2009.

Newequipmentcontinuestobetrialedandpurchased.TheHospitalnowhastwobatterypoweredmotorisedtrolliestoaidinthedeliveryofstoresandsuppliesandpickupofsoiledlinen. Athirdhasbeenorderedandwillbedeliveredearlyinthenewfinancialyear.TheLaundryhasinstalledanoverheadbaglifterinthesoiledlinenroomtoreducetheamountofmanualhandlingofsoiledlinenbagsandhasalsoinstalledanewdryerandwasher,bothwhichhaveimprovedsafetyfeaturesovertheoldermachines.Severalnewcomputerworkstationshavebeeninstalledasaresultofergonomicassessmentsandareviewofoffices.Theamountofbariatricrelatedequipmentcontinuestoincreaseasdoesthenumberofelectricbedsthroughouttheorganisation.

Staff Survey Onceagain,MtAlexanderHospitalparticipatedinthePeopleMatterSurvey.ThissurveyisdesignedtogainfeedbackfromemployeesontheirperceptionsofhowwellthePublicsectorvaluesandemploymentprinciplesareappliedwithinourorganisation.Thesurveygathersinformationaboutabroadrangeofemploymentareassuchasjobsatisfactionandthewayourmanagersandworkgroupsoperate.ThissurveyisconductedacrossVictoriainthePublicSector.The2008resultsshowedasignificantimprovementfrompastyears,particularlyintheareasofmerit,fairandreasonabletreatment,EqualEmploymentOpportunityandavenuesofredress.

Directorate Full Time Part Time Casual Total

Male Female Male Female Male Female Male Female

CEO 1 2 - 2 - - 1 4

MedicalServices 1 2 1 4 38 9 40 15

Nursing 14 25 14 186 5 62 33 273

CommunityPrograms

5 20 5 43 1 1 11 64

Finance 6 7 1 14 1 - 8 21

GeneralServices 31 23 13 57 5 6 49 86

HumanResources 2 4 1 1 - - 3 5

TOTAL 60 83 35 307 50 78 145 468

WorkCover Days

Year

Days

Compensation.

Paid

08/09 480

07/08 294

06/07 253

05/06 1076

WorkCover Premiums

Year Premium

08/09 $414,971

07/08 $353,124

06/07 $303,883

05/06 $346,053

OURSTAFFCONTINUED



Chief Executive OfficerMrGraemKelly,PSM:BAAppSc,GradDipRuralHealth,AdvDipBus,RN,AFCHSE,AIMM,FARLF

Deputy Chief Executive OfficerMrGraemeHill,DipAcc,CertBusStudies(HospAdmin),PNA,GradDipBusManag,FACHSE

Quality Projects Manager

MsChristineMitchell,RN,RM,BHSci,AdvDipBusMgmt

Senior Projects Administrator

MsHelenMinkevicius,RN,BHlthSci(Nurs),PeriOperCert,AdvDipBusMgmt(AppointedFeb2008)

MEDICAL SERVICESDirector of Medical Services

DrAlbertIp,MBBS,MBA

Infection Control

MsDiHuggins,RN,CertIVAssess&WorkplaceTraining

Pharmacist

MrsHeatherParsons,BPharm,MasterofClinicalPharmacy

MEDICAL OFFICERSRehabilitation Senior Medical Officer

DrRobertLong,MBBS,FRACGP,Dip(Obs)RACOG,BEd

Medical Officer

DrRichardAlexander,MBBS,FRAGP,Dip(Obs)RCOG,GradDipPallMed

DrRosamundStobie,MBBS,FRACGP,DRANZCOG,ECFMG

NURSING SERVICESDirector of Nursing

DrAnnAllenby,RN,CertOncNsg,CertSteril&InfControl,MedSt,DN,MRCNA,CertBusinessAdmin

Deputy Director of Nursing

MsKateHarrington-O’Brien,RN,RM,BHlthSci,GradDipHlthSci(Pub&CommHlth),MasterHlthSci,ChemotherapyCert,PalliativeCareCert,DipBus(ImpactLeadership)(CommencedSep08)

Supervisors

MrsValBrereton,RN,RM,CertMat ChildHealth

MsBarbGregory,RN

MsJillianKong,RN,RM,GradDipHlthMgt

MsKaySmith,RN,RM,BNurs

MsKayeWilliamson,RN

Nurse Unit Managers

MrCraigDeLacy,RN,RM,BN

MrsHeatherHarris,RN

MsSueNicholson,RNMrsLeanneNorris,RN,PeriOperCert

MsJanSwift,RN,CertRehab,CertCont&CertMgt

Hostels Manager / Manager Residential Aged Care

MrsMargaretKay,RN(June2008– Aug2008)

MsTrishSiemering,RN(Div2)(AppointedAug08)Clinical Nurse Educator

MsLindaMcKennaRN,GradDipCritCare

Recreation

LynneBird,BEd,PostGradCCD

COMMUNITY PROGRAMSDirector of Community Services

MrsRhondaWilliams,RN,BPubHealth

District Nursing

MsBarbaraBleicher,RN,GradDipNsgSciinHm&Com,AdDipBusMan,CertIV Train&Assess

MsMerrillCole,RN,DipHlthSci(Nurs),MasterofNursing(Palliative),MRNCA

Continence Advisor

MsPamGracie,RN

Adult Day Service

MsVirginiaHarkin,RN,NDN(UK),GradDipHealthSci(CommHealth)

Chief Dietitian

MsLeeMason,BS,GrDipDiet,MDaA,MAPD,APD(ResignedMar09)

MsSallyMitchell,BS,Diet (AppointedMar09)

Early Intervention Program

MsDeannaBlakeley,BSpeechPath

Community Support Coordinator

MsBMuscat,DipWelfare,BA (ResignedOct08)

Volunteer & Social Support Manager

MsRosemaryNicholas,RN,RM,DipF/LineMgt,BSSocScience,AssDipSocWelfare(CommencedNov08)HARP / HIP Program Manager

MsJessicaNeale,BSN,BAComm,PostGradMentalHlth,RuralHlth (CommencedFeb09)

Chief Occupational Therapist

MsAllisonMast,BAppSci(OT),GradDipInfant&ParentMentalHealth (ResignedNov08)

Acting Chief Occupational Therapist

LizDenniston,BAppSci(OT) (AppointedDec08)

Chief Podiatrist

MsRachelFry,BPod,GrdCertDiabetes

Chief Speech Pathologist

MissKerrynJames,BSpeechPath

Support & ACAS Manager

MrsDonnaBrook,RN,GradDip HealthAdmin

Social Worker

MrPhilBlackwood,BA(HONS),BSW,GradDipSocSci(Psyc)

CADARG Coordinator

MrCarlHarvey,BSW&Humanities

FINANCE SERVICESDirector of Finance

MrGeoffreyVendy,BBus(Acc)

Accountant

MrPeterStemp,MBA,BBus(Acc)CPA,ASA

Acting Chief Health Information Manager

MsHeatherPaulet,BAppSc(MRA),AdvDipBusMgmt(AppointedSep2008)

Project Officer

MrsDarrylO’Bryan,BAppSc(MRA)(AppointedSep2008)

Computer Systems Officer

MrLeonWilliams,AssocDipInfoProc

Supply Officer

MrPeterCox

GENERAL SERVICESDirector of General Services

MrGraemeHill,DipAcc,CertBusStudies(HospAdmin),PNA,GradDipBus ManagFACHSE

Engineering Services Manager

MrRoderickWoodford,DipEng,DipBus

Hotel Services Manager

MrRobertSchroeder,AdvDipMgt

Public Relations / Fundraising Coordinator

MsFranTaylor

Transport Officer

MrFrankCarroll

HUMAN RESOURCESDirector of Human Resources

MrMarkKesper,DipCivilEng

Human Resources Officer

MsAngelaTurley,BBus(HR/Mark),CertIVAss&WorkplaceTraining,DipProjMgt

Occupational Health & Safety Officer

MrAndrewGibson

Pay Officers

MrsChristineVanDerPoel

Training Officer

MrsJudySpraggRN(ResignedOct08)

Acting Training Officer

MsBreeHodge(AppointedNov08)

Pastoral Care Coordinator

MrRobertMaioDipPastoralMinist; MastPastCounsel,BA

SENIORSTAFF LISTING



AnaesthetistsDrABradshaw,MBBS,FANZCA

DrPBuncle,MBBS,FANZCA

DrACzuchwicki,MBBS,FANZCA

DrSDobell,MBBS,FANZCA(AppointedJun2009)

DrLHamond,MBBS,FANZCA

DrSHams,MBBS,DipObs,FANZCA

DrJHarding,MBBS,FANZCA

DrPMazur,MBBS,FANZCA

DrAMcCarthy,MBBS,DA,FARCS(London),DRACOG,FRACGP

DrMNerlekar,MBBS,DA,MD(Anaesthesia),FANZCA

DrDNoble,MBBS,FANZCA(AppointedJun2009)

DrAPurcell,MBBS,DA(UK),DipObsRACOG,FANZCA

DrMShapiro,MBBCh,DA(SA),FANZCA

Dental SurgeonsDrJJefferies,BDSc(Melb)

DrJKinnersley,BDSc,LDS

DrSMLeow,BDSC(Melb)(AppointedJun2009)

DrELiew,BDSc(Melb)

DrGParentich,BDSc(WA)

ENT SurgeonMrNHavea,MBBS,FRACS

Consultant Emeritus General PractitionerDrGGeroe,MBBS

General PractitionersDrABabovic,MBBS,FRACGP(ResignedMar2009)

DrLBettiol,MBBS,DRANZOG,FRACGP

DrGCourtis,MBBS,DipRACOG

DrRDale,MBBS,DRANZCOG,FRACGP

DrHDewhurst,MBBS,FACRRM

DrCFoley,MB,BS

DrCFowler,MBBS

DrEGriffin,MBChB,FRACGP,DipofGeriatricMedicine,DipofPaed,DipofAnaes

DrMHolland,MBBS

DrLHope,MBBS(UK),DRCOG(UK),DCH(UK),FRACGP,Dip PalliativeMedicine

DrIJonesMBBS,DipRACOG,FACRRM

DrCKerr,MBBS(Mon),DRCOG(Lond),DipRACOG,FRACGP

DrTLuscombe,MBBS,Dip(Obs)RACOG

DrRMayes,MBBS,DRANZCOG(ResignedJan2009)

DrPMacCallum,MBBS

DrJMcKern,MBBS,MRACOG,FACRRM,FACoHM

DrGMoller,MBBS,DA(UK),RCA

DrVMoule,MBBS,DRACOG,FRACGP

DrGRowland,MBBS,DRANZCOG,FRACGP

DrDSilver,MBBS,BMedSc,DRACOG,FRACGP

DrSTraill,MBBS,DRANZCOG,FRACGP

DrFXia,MBBS(China)

General SurgeonsDrABarclay,MBBS,FRACS(Melb)

MrGCampbell,MBBS,FRACS,FRCS(Eng)

MrRFerguson,MBBS(Melb),DipAnat(Mon),FRACS

GynaecologistDrMJalland,MBBS,FRANZCOG

Ophthalmic SurgeonsMrAAtkins,MBBS,BMedSc,FRACO

MrPBurt,MBBS,FRACO,FRACS

Orthopaedic SurgeonsMrKMcCullough,MBBS,FRACS, FAOrthA

MrTPerera,MBBS,FRCS(Edin),MChOrth(UK),FRACS

PhysicianDrGHarris,MBBS,FRACP

Plastic & Reconstructive SurgeonMrRDickinson,MBBS,FRACS(GenSurg),FRACS

PsychiatristDrGD’Ortenzio,MBBS,FRANZCP

DrBHyland,MB,BS(MON) (ResignedJan2009)

UrologistDrRForsyth,BMeds(Hons)(AppointedJul2008)

VISITINGMEDICALOFFICERSThere has been increased input between the VMO’s and the service this year with increased quality assurance and peer review activities conducted. This will be further extended next year.

Mt Alexander Hospital Operating Suite



20 YearsVirginiaHarkinDebbieMcKellarMaryanneMurdochShirleyProctorJoanneStubbingsDiannTurnbullHelenWatts

25 YearsGeoffreyAdamsonAllanComteRebeccaDale(Dr)GlendaJefferiesIanJones(Dr)TerryLuscombe(Dr)PeggyOdgersDannySilver(Dr)JenniferVerlinCarolWeston

30 YearsDonnaBrookGeoffCourtis(Dr)GailCrossPatriciaOliver

35 YearsKerrynBlairGregoryHughes

TheClubmaintainsitscommitmenttoourclientsbydonatingagifttoallresidentsandinpatientsatChristmas.Expenditurebreakdownforthisyearis:

ResidentsChristmasGifts $1,746.58

ActivitiesforResidents–Games $106.20

DonationfortheAnimalThemeDay$50.00

TheSocialClubacknowledgedtheretirementofBrendaHall,ValWillett,JudySpraggandfarewelledPaulineBertuchandKrisConnor.EachmemberwaspresentedwithagiftandCertificateofAppreciationinrecognitionoftheirserviceasmembersoftheSocialClub.

ThesuccessofthepastyearwouldnothavebeenpossiblewithoutthesupportofSocialClubCommittee,Members,Management,theBoardofManagement,theLocalBusinessCommunity,FoodServiceDepartment,CafeteriaStaffandallotherstaffwhohaveassistedtheCluboverthepastyear.TheClubextendsitsappreciationfortheirassistance.

Board of Management LeeBower 10YrsLesFitzgerald 15YrsBillO’Donnell 15Yrs

Resigned Staff 10yrs+ ServiceLynetteBakerPeterGrantGwendaGrowcottMauriceHoldenWayneMurphyLisaHewittLeonieStevensJudithSpraggValdaWillettPaulineBertuchBrendaHall

10 YearsMareeBagleyAlisonClarkCarmenElshaughLeonieForestKerryHoltGrantHuntlyKerrynJamesCharlesKerr(Dr)DianneMurrayTraceyOakesChristynPassalaquaChristineRidallLindySmith

15 YearsSandraChapmanJohnDaviesNarelleHamiltonLouisaHope(Dr)SuzanneIbbsHelenJohnstoneSallyLevershaJoanMcCookeGaryMoller(Dr)

Our Social Club

TheSocialClubCommitteehasagainexperiencedanotherbusyyearprovidingadiverserangeofactivitiesforSocialClubmembersaswellasassistingwiththewelfareofourresidents.

Overthepasttwelvemonths136members,outofatotalmembershipof203,havebeenluckyenoughtowinanindividualprizeinthe“SpecialEffort”draw.The“SpecialEffort”isstillextremelypopularwithmembersandthisyeartheprizepoolwas$5,438.00.Sinceitsinception,inexcessof$48,000.00hasbeenreturnedtomembersasprizesintheformofvouchersthatareredeemableatthoselocalbusinesseswhosupporttheSocialClubDiscountScheme.ThisisadditionaltothenormaloperatingexpenditurefortheClubandthese“SpecialEffort”prizesaresupplementarytothefreelunches,specialprizedraws,bustripsandtheChildren’sandStaffChristmasPartiesthatwereenjoyedbymembers.

“If the knitter is weary, the baby will have no new bonnet” Connie Perkins-Reflections Project

STAFFYEARSOF SERVICE

Eileen Thomas - Reflections Project

Inconclusion,IwouldliketoextendmythankstoahardworkingCommittee,consistingofHeatherStuchbree,DiannTurnbull,LisaPollard,MargPatton,CindyStreeter,LynneBoyce,CarmelAitchison,PeterGrant,GregHughes,CherylBridglandandCarolWestonfortheirexcellentwork.

Frank Carroll

President MtAlexanderHospitalSocialClub.



Life Governors since July 1,19861987

MrJAndersonMissChapmanMrsFCroweMrsLDavisMrsCDoughMrsRHarwoodMrsJHinksMrsIJuliusMrsLJuryMrSGLevershaMrsMLovelaceMrsGMorrisonMrsEPalmerMrsHPryorMrsDRichmondMrs E TreloarMrsVTreloarMrsMVirtue

1988

MrsMWhaley

1989

MrJStuart

1990

MrsLDaweMrWEberyMrASamsonMrJVerlin

1991

RevHHallettDrSPilbeam

1992

DrJKinnersley

1993

DrELevecke

1994

MrMFyffe

1995

MrsJBuntine

2005

MrsMHeagney

Certificates of AppreciationCollier Charitable Fund

MrsMFlegg Elliott Midland Express TopEndServo

ThompsonsFoundryBand

Murray to Moyne Riders

Alex MactierChris WattsMelissa WadeGordon DonaldsonBrett StruhsCheryl NeilsonDianne McCoombeRachel FryRhonda ChapmanNeil BlakeleyTony BatemanTerry LuscombeGuy PetersMark BestBrett CornishDavid MayoRob ScottTim FordTim CaldwellKevin SharkeyGrant ThomasSteve HaslamKen O’BrienHowie HallGary BunnCarl HarrisPeter MahlstedtPhil PriestBryan MaddernPeter GrantGlen LorenzAlan Chapman

COMMUNITY SUPPORT

Herb Rasmussen (Resident at Ellery House) & daughter Rhonda

Caitlyn Hardy (little girl) and Lorna Howe - Reflections Project



Duringtheyear,anumberofspecialeventsinvolvingstaffandthelocalcommunityraisedfundsforourredevelopmentappeal.InApril2009,34ridersconsistingofstaffandmembersofthecommunityrode520kilometresintheMurraytoMoyneCycleRelay.WewerewellsupportedbytheRotaryClubofCastlemaine,NationalAustraliaBank,LionsClubofCastlemaine,TopEndServoalongwithmanybusinessesinthecommunity.Anumberofadditionalactivitieswereheldtosupporttheriderswiththeirfundraisingefforts.

Thisyear’srelayraisedarecord$48,693,afantasticeffortfromallridersandeveryoneinvolvedin thisevent.

Since2002AlanHarrishasbeenamajorsponsoroftheMurraytoMoyne,donatingpetrol,iceandwatereachyearfortheride.

Hospitalstaffandvisitingmedicalofficersraisedatotalof$24,122totheRedevelopmentAppealthroughpayrolldeductions(MAHRAClub).Since1994staffhasdirectlyraised$291,656throughtheircontributionstotheMAHRAClub.

InappreciationoftheHospital’scareandsupport,anumberoffamilieschosetomakedonationsinlieuofflowersatfuneralsduringtheyear. Atotalof$3905wasdonatedthisyear.Thisisaverydirectandpracticalwayofexpressingtheirgratitudeandbenefitsforthosereceivingcarein thefuture.

TheGoldenBundleClubalsocontinuestopromoteourmaternityservicesthroughthepresentationofaBabyBundleeachmonth.TheHospitalsincerelythanksWallerRealtyfortheirgenerousongoingsponsorship.

Bequests&Legacies TotalDonationsreceiptedYearended30/06/2009$147,000.

SincetheRedevelopmentAppealwaslaunchedinSeptember1994atotalof$2,963,283hasbeenreceipted.

FUNDRAISING

Bequests & Legacies $27,882

CollierCharitableFund $20,000

EstateofWMcBeath $4402

EstateofWSGodfree $1780

WilliamAnglissCharitableFund $1000

TheWalter&ElizaHallTrust $700

(L to R) Alan Chapman (Murray to Moyne Rider) with Alan Harris

(L to R) Rob Waller from Waller Realty Pty Ltd who sponsor the Golden bundle with proud parents Tony and Catherine, baby Colin and Graeme Hill

(L to R) “Originals”

Team at Fundraising BBQ Gordon Donaldson,

Chris Watts, Neil Blakeley

and Alex Mactier



Angliss,TheWilliamCharitableANZBankingGroup Atkin,MrDavid Barker,Mr&MrsE&C Barkla,MrDavid Bateman,MrTony Baud,Mr&MrsBruce&DianaBendigoBank Bertoncini,MrFrank BishopAcounting&TaxationBodzsar,Mr&MrsJoseph&MarthaBorderlineGardenSupplies Borghesi,MsAnna Boyle,JessicaBradshaw,Mr&MrsAlanBRiTBruinier,HelenBuckman,Mr&MrsF&BButcher,MrTrevorCanning,MrsBettyeCarter,Mr&MrsWilfred&AkikoCastlemaineBusLinesCastlemaineCamerasCastlemaineCellarsCastlemaineChurchofChristCastlemaineFootball&NetballClubCastlemaineFruitSupplyCastlemaineGolfClubLadiesCastlemainePropertyGroupCastlemaineRodsCastlemaineT.O.W.N.ClubIncCastlemaineToyotaCawthan,Mr&MrsCecilChapman,MrAlanChristmas,MrDanielClark,Mr&MrsIan&JudithClark,MrsDorothyCommonwealthBankCommFundCowden,MrsMargaretCurwen-Walker,MrHalDale,DrRebeccaDalreneonMostynDarwinkel,MrBDenniston,MrsMarieDesmond,MrRichardDewey,MrDeanDunse,MrRobinEdwardson,MrsDEllery,Mr&MrsCharles&SylviaEnvall,MrDavidEstateofMrsKathleenCockramExtremityStreet&SurfWearFaulkner,MrsPatricia

Fettling,MrNormanFlegg,MrsMAForestCreekNursery& CastlemaineFloristyFurness,MrTonyGardensChemmartAlburyGarnett,MrsPenelopeGFMAccountantsGolles,Mr&MrsPeterGrainger,MrsElizabethGray,MrsEveGriffin,DrEdGuildfordHotel,Hagley,MsEdnaHamblin,Mr&MrsRobbin&MarionHarris,MrAlanHarris,MrsMaryHeagney,Mr&MrsM&MIngram,MsAmyJ&MBandJenkin,MrJohnJones,DrIanKeoghRealEstatePtyLtdKidson,MrBarrieKing,MrClintonKymJermynBuildingLang,MrsJoyLeechEarthmovingPtyLtd.Leech,MrMathewLevecke,Dr&MrsEdward&MargaretLewis,MrGaryLifehouseDesignLionsClubofCastlemaineLMSWLawyersLuscombe,DrTerryLynch,Mr.&MrsJohn&MaureenMactier,MrAlexMadderns TransportMAHRACLUBMawson,MrPhilipMayberryJnr,MrBillMcGrory,MsLucyMcKenzieDaveyPharmacyMcKenzie,MsJudyMellor,Mr&MrsHughMoore,MrLukeMuntz,MrEdwardMyers,MrsBettyNationalAustraliaBankNeighbourhoodWatchNorris,MrsEO’Brien,MrKenPadgham,Mr&MrsDouglas&

BeverleyParnaby,Mr&MrsD&SParsonsMotor&BodyShopPilcher,Mr&MrsJPiper,MrsEileensPoyserMotorsPtyLtdR.&R.McClureExcavationsPtyLtdRailwayHotelRalph,Mr&MrsGeorge&BeverleyRegionalOneRevell,MrsPatriciaRice,MrsMareeRobinsonsPtyLtdRotaryClubofCastlemaineScott,Mr&MrsRob&MarinaScutt,MsFSeedsman,MrsMargaretSharkey,Mr&MrsK&TSilver,DrDannySmark,Mr&MrsTony&NadiaSpiller,MrsLauraStewart,Mr&MrsLindsay&JoanStewart,MsVeraStraw,MrsBeverleySubwayRestaurantSutton,Mr&MrsBill&MyraSymbionPharmacyServicesTaitDecorativeIronTait,Mr&MrsJohn&JoyceTecturaPtyLtdTennant,MsCherryTheBikeVault“ThePups”TheWrongBiasClubThompson,Mr.KeithTolson,MsVeronicaTonksBrosPty.LtdVetsAllNaturalVosslohCogiferAustraliaPtyLtdWalker,Mr&MrsDonaldWallerRealtyPtyLtdWatson,Mr&MrsWes&PegWeatherall,Mr&MrsWilliam&FlorenceWednesdayLadiesTennisClubWesleyHillBakehouseWilliamson,MrMartinWilson,Mr&MrsIan&HelenWright,MrRobbie

MAJORDONORLISTING



STATUTORY COMPLIANCE

STATUTORY COMPLIANCE

Attestation on Compliance with Australian / New Zealand Risk Management Standard I, Graem Kelly, certify that Mt Alexander Hospital has risk management processes in place consistent with the Australian / New Zealand Risk Management Standard and an internal control system is in placed that enables the executives to understand, manage and satisfactorily control risk exposures. The audit committee verifies this assurance and that the risk profile of Mr Alexander Hospital has been critically reviewed within the last 12 months, and Attestation on Data Accuracy Certify that Mt Alexander Hospital has put in place appropriate internal controls and processes to ensure that the Department of Human Services is provided with data that reflects actual performance. Mt Alexander Hospital has critically reviewed these controls and processes during the year.

GRAEM W KELLY, PSM Chief Executive Officer Date: 6 August 2009

Ex-gratia Payments Mt Alexander made no ex-gratia payments for the year ending 30 June 2009. Freedom of Information Applications All applications were processed in accordance with the provisions of the Freedom of Information Act 1982, which provides a legally enforceable right of access of information held by Government agencies. Mt Alexander provides a report on these requests to the Department of Justice. Freedom of Information requests can be submitted to the Chief Executive Officer, Mt Alexander Hospital, PO Box 50, Castlemaine 3450. Application forms are available on our website www.castlemainehealth.org.au, or by phoning 5471 1555. Application fees and charges apply. Fifteen requests were received under Freedom of Information in 2008/09. All requests were processed within the required timeframes. Whistle Blower’s Act

The Whistle Blower’s Protection Act 2001 provides protection for any person who would like to make a disclosure of improper or corrupt conduct by an official of a public entity. Mt Alexander Hospital received no complaints under this Act during the year. Compliance with Building and Maintenance Provisions of Building Act 1993

All building works have been designed in accordance with the Department of Human Service’s Guidelines and comply with the Building Act 1993 and the Building Code of Australia 1996.

Victorian Industry Participation Policy Act 2003 There were no contracts commenced or completed at Mt Alexander Hospital under the Victorian Industry Participation Policy Act 2003 during this year.

Statement on National Competition Policy Mt Alexander Hospital complied with all Government policies regarding neutrality requirements with regards to all tender applications. Consultancies for Year ended 30 June 2008 • Consultancies in excess of $100,000 – Number of

consultants engaged one - Aspex Consulting engaged to complete a Service Needs Analysis

• Consultancies costing less than $100,000 – Number of

consultants engaged two. Total cost of engagements $28,812.50

Fees Charged for Service

All fees and charges charged by Mt Alexander Hospital are regulated by the Commonwealth Department of Health & Ageing and the Hospitals & Charities (Fees) Regulations 1986, as amended and as otherwise determined by the Department of Human Services, Victoria. Ethical Standards The Board of Management promotes the continued maintenance of corporate governance practice and ethical conduct by the Board members and employees of Mt Alexander Hospital. The Board has endorsed a code of conduct with applies to Board members, officer and all employees. Pecuniary Interests Members of the Board of Management of Mt Alexander Hospital are required to notify the President of the Board of any pecuniary interests which might give rise to a conflict of interest in accordance with Mt Alexander Hospital Board’s code of conduct. Tax Deductible Gifts Mt Alexander Hospital is endorsed by the Australian Taxation Office as a Deductible Gift Recipient. Gifts to Mt Alexander Hospital as a Public health service qualify for a tax deduction under item 1.1.1 of section 3-BA of the Income Tax Assessment Act 1997. Disability Act 2006 Mt Alexander Hospital has commenced developing a Disability Action Plan for full completion and implementation in 2010.



AUDITED FINANCIALSTATEMENTS










FINANCIALSTATEMENTS



FINANCIALSTATEMENTS

Documents

ANNUAL REPORT - Castlemaine Health · Victoria MT ALEXANDER HOSPITAL ANNUAL REPORT 2009. Our Aim To provide the most effective and efﬁcient physical, emotional and social care possible