2015-16 annual report · 1978 stage 1 of cooinda lodge nursing home built, accommodating 28...

COOINDA LODGEA G E D C A R E R E S I D E N C E

R E S I D E N T I A L A G E D C A R E S E R V I C E S

R E S I D E N T I A L A G E D C A R E

We s t G i p p s l a n d H e a l t h c a r e G r o u p

W E S T G I P P S L A N D

C a r i n g f o r o u r C o m m u n i t y


H E A L T H C A R E G R O U PW E S T G I P P S L A N D



H E A L T H C A R E G R O U PRAWSON COMMUNITY

West Gippsland Healthcare Group

H E A L T H C E N T R E

H E A L T H C A R E G R O U P

W E S T G I P P S L A N DH E A L T H C A R E G R O U P

WEST GIPPSLAND HEALTHCARE GROUP


W E S T G I P P S L A N D H E A L T H C A R E G R O U P R AW S O N C O M M U N I T Y H E A L T H C E N T R E

R AW S O N C O M M U N I T Y H E A L T H C E N T R E

W E S T G I P P S L A N D H E A L T H C A R E G R O U P


2015-16Annual Report

Improving the healthand wellbeing

of our community

Acknowledgements:

Photography by Kel Dodge

Design and Print - Kage Design & Photography

Thank you to the staff, volunteers and patients of the West Gippsland Healthcare Group

ABN: 39 261 883 406

H

BERWICK

WARRAGUL

TRARALGON

West Gippsland Baw Baw Strategic Services Plan - UpdateOne of the major achievements for 2015-16 was working with the Department of Health and Human Services (DHHS), Latrobe Regional Hospital and Monash Health to develop the West Gippsland Baw Baw Strategic Services Plan.

The Plan identifies the future health care needs of the West Gippsland population in the context of the developments planned for neighbouring services, Latrobe Regional Hospital and Monash Casey.

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ContentsChair & Chief Executive Officer Report ......................2

Our Hospital ...................................................................3 History Services

Our Performance ...........................................................6 Strategic Priorities Performance Priorities Activity and Funding Environmental Report Key Performance Indicators

Our Achievements .......................................................18 Financial Report Nursing & Midwifery Report Medical Services Report Allied & Community Health Report Corporate Services Report Warragul Linen Service Report

Corporate Governance ...............................................25 Ministers & Governance Board of Directors Organisation Chart

Our People ...................................................................31 Resources Occupational Health & Safety Service Awards

Our Community ...........................................................33 Donations & Fundraising

Reporting Requirements ............................................34 Attestations & Declarations Financial Declaration Auditor General’s Report

Financial Statements .................................................40 Financial Index Financial Notes & Reports

Disclosure Index ........................................................110

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Stage One of the Building Better Healthcare

- Accommodation Project was completed in

December 2015, providing five new units funded by

donations.

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Chair and Chief Executive Officer Report

On behalf of the Board and staff of West Gippsland Healthcare Group and in accordance with the Financial Management Act 1994, it is our pleasure to provide this report of operations for the period ended 30th June 2016.

It has been another busy year at West Gippsland Healthcare Group, with the demand for our services continuing to increase year on year. During 2015-16 we treated almost 12,000 patients, an increase of 5% from the previous year. As a result, we must keep evolving to meet this demand and continue to deliver quality care to the people of West Gippsland.

One of the major achievements for the year was working with the Department of Health and Human Services (DHHS), Latrobe Regional Hospital and Monash Health to develop the West Gippsland Baw Baw Strategic Services Plan. Funded by the State Government, the plan identifies the future health care needs of the West Gippsland population in the context of the developments planned for neighbouring services, Latrobe Regional Hospital and Monash Casey.

The plan concluded that the current role of West Gippsland Healthcare Group as a sub-regional hospital will remain appropriate into the future. However it is also apparent that future demand will exceed current capacity. This blueprint document also identified a range of options and suggestions for increasing capacity in the short and longer term. We look forward to working with the DHHS and our partners in implementing key aspects of the plan.

We were pleased with the announcement in the State budget for $1 million to continue the planning work towards a long-term solution. A new hospital on the land in Lardners Track

remains the preferred option for the Board but there are planning processes that must first be followed.

The Board also released its Strategic Plan 2015-2018 identifying four key priorities that provide the direction for the organisation:

• to understand and plan for the future healthcare needs of our community

• to manage increasing patient demands within our current infrastructure until a longer term solution is achieved

• to clarify the future direction for Warragul Linen Service

• achieve financial sustainability.

Following a difficult financial year in 2014-15, it is pleasing to report that the financial result has returned to an operating surplus. There has been much focus on ensuring that the growth in revenue exceeds the growth in expenditure as we continue to achieve record levels of service.

During the year, nearly 1,000 babies were born at WGHG; the highest rate for the Gippsland region. Whilst one thousand babies has become the norm, this is at the upper limit of our capacity to safely accommodate and care for new mothers and babies. With continuing high demand, particularly from women outside the Baw Baw region, we are working with neighbouring hospitals to provide options closer to where they live.

The Emergency Department presentations increased by 5% to over 21,400. Community based programs have also been effective in helping avoid hospital based care wherever

Dan Weeks RN BBus(Acc) MHA GAICD ACHSM

Chief Executive OfficerJane Leslie BBus

Board Chair

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possible, something that will become increasingly important as the population continues to increase.

Throughout the year, we have invested in a number of infrastructure upgrades to improve patient experience and capacity.

• Aged care remains an important service and Cooinda Lodge residents benefited from a significant refurbishment program

• Stage One of the Building Better Healthcare - Accommodation Project was completed, providing five new units funded by donations

• Approximately $6 million of energy and efficiency works were completed, funded by a Government loan, to be re-paid from the savings achieved.

We continue to be humbled by the generous support of our auxiliaries, donors, volunteers, individuals, and groups from our community. Our community has made significant contributions that enhance care at WGHG and this is both special and highly valued.

Finally, we would also like to acknowledge the contribution of the Board, staff and our many community partners, including our local members of parliament at both the state and commonwealth levels, the Department of Health and Human Services and the Committee for Gippsland. Your support is greatly appreciated and we look forward to working with you over the coming year as we continue to serve our community.

Our Hospital

West Gippsland Healthcare Group (WGHG) is a customer focused health organisation providing acute care, residential care and community health services to over 45,000 people in the rural, urban residential, agricultural and industrial areas located within the Baw Baw Shire and beyond.

Our Vision:To improve the health and wellbeing of our community.

Our Mission:West Gippsland Healthcare Group is committed to the provision of high quality, integrated health care that meets the changing needs of individuals and our community.

We Value:Our customers be committed to continuity of care for

individuals whilst recognising rights, responsibilities and participation

Our community be a responsible corporate citizen and neighbour in caring for our community and environment

Our staff we are committed to our staff’s wellbeing and ongoing development

Leadership be a role model in the planning and delivery of health services

Improving ensure continuous quality performance improvement.

A new hospital on the land in Lardners Track remains the preferred option for the Board

but there are planning processes that must

first be followed.

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Our History

1888 The community established a Hospital on land donated by Mary Sargeant to service the area between Melbourne and Sale

1895 Warragul District Hospital completed

1908 Warragul District Hospital officially opened

1924 Name change to West Gippsland Hospital (WGH) in recognition of the wider area serviced

1936 The original wooden Hospital building redeveloped

1939 The foundation stone of the new brick Hospital laid by Mr Dunstan

1940 The new Hospital opened by Sir Winston Duggan

1970 Eastern extensions to the Hospital opened. The Hospital expanded to 144 beds

1978 Stage 1 of Cooinda Lodge nursing home built, accommodating 28 residents

1986 Stage 2 of Cooinda Lodge added, accommodating 56 residents

The Warragul Linen Service moved into purpose-built premises in Ley Street

1996 A Community Services Centre was established in Warragul

Stage 1 Redevelopment of Hospital completed

1997 The various health services provided across the community were brought together under the umbrella name of West Gippsland Healthcare Group (WGHG). Rawson Community Health Centre incorporated into WGHG. Andrews House opened, accommodating 30 residents

1998 Baw Baw Health and Community Care Centre opened in Drouin, a joint venture with the Baw Baw Shire

Stage 2 Redevelopment of the Hospital officially opened

2005 Extensions to Andrews House in Trafalgar completed, accommodating 50 residents. Queen Street Community Services building redeveloped

Extensions to Warragul Linen Service completed to accommodate new continuous batch washing system

2006 Community Rehabilitation Centre relocation project commenced. Stage 3 Redevelopment of the Hospital, incorporating the High Dependency and Midwifery Units completed

2007 Community Health and Community Mental Health project completed

2008 Community Rehabilitation Centre redevelopment underneath Cooinda Lodge completed. Centenary of opening of first Warragul District Hospital celebrated. Centenary history book ‘Of the People...For the People’ and Centenary quilt launched

2009 WGHG awarded Premier’s Award for Regional Health Service of the Year

2010 WGH Drouin Auxiliary 50th anniversary celebrated. Permanent home purchased for Trafalgar Community Health Services

Extensions to Drouin Opportunity Shop completed

2011 Feasibility study for redevelopment of West Gippsland Hospital site commenced

2012 Building extension works commenced to the emergency department

New physicians consulting rooms, education facilities, teleconferencing facilities and a new home for the District Nursing Service completed

Feasibility Study identifies Lardners Track as preferred site for a new Hospital

2013 Emergency department redevelopment completed and officially opened by The Hon. David Davis MP 17th May

A record breaking 1020 babies born at WGH

2014 The first self-funded research program announced, with $100,000 made available to support clinical staff to undertake research programs

2015 Relocated High Dependency Unit within Medical Ward to expand the number of post-natal and medical ward beds

2016 Constructed five units in Sargeant Street Warragul, to provide on-site accommodation for visiting clinicians. Completed $5.8m Energy Performance Contract (EPC) asset refresh and major refurbishment of Cooinda Lodge

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Our Services

Hospital (acute)AnaesthesiaBreast SurgeryCardiologyDay SurgeryDental SurgeryDiabetes EducationEar Nose and Throat SurgeryEmergency MedicineGastroenterologyGeneral MedicineGeneral PracticeGeneral SurgeryGynaecologyHaemodialysisHigh Dependency CareInfectious Diseases MedicineMidwiferyObstetricsOncologyOpthamologyOrthopaedic Surgery Paediatric MedicinePaediatric SurgeryPain ManagementNeonatologyPre-AdmissionStomal TherapyUrology and UrodynamicsRenal Medicine

Continuing and Complex CareCommunity Rehabilitation CentreContinenceGeriatric Evaluation and Management (GEM)Hospital Admission Risk Program (HARP)McGrath Breast Care NursePalliative CarePost-Acute CareResidential In ReachTransitional Care Packages

Aged CareAged Care AssessmentAndrews House Aged Care FacilityCooinda Lodge Aged Care FacilityHome & Community Care ServicesRespite Care

Community Health ServicesAboriginal Support ServicesCognitive Dementia and Memory Service (CDAMS)ContinenceDiabetes Education, Self Help and Support GroupFamily Counselling and Case ManagementFamily Violence Counselling and Case ManagementFirst Call – Central Intake ServiceGeneralist CounsellingHealth PromotionRural and Community Allied Health Service - Occupational Therapy - Physiotherapy - Podiatry - Speech Pathology - CounsellingWomen’s HealthYoung Mums

Allied HealthCardiac RehabilitationChronic Obstructive AirwaysDisease (COAD) ProgramDieteticsOccupational TherapyPhysiotherapyPodiatrySocial WorkSpeech Pathology

Home Nursing ServiceDistrict Nursing ServiceHospital in the HomePalliative Care Nursing/Volunteers

Support ServicesAdministrationBusiness Support ServicesEducationEngineeringEnvironmental ServicesFinanceFood ServicesHealth InformationHuman ResourcesInfection ControlInformation TechnologyLibraryOccupational Health and SafetyPayrollPerformance Improvement UnitPublic RelationsSupplyWorkCover

Business UnitsConsulting SuitesSalary PackagingWarragul Linen Service

Diagnostic Services(Contract Services)BreastScreenEndoscopyMedical ImagingPathologyPharmacyStress Electro Cardiographs

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Part A: Strategic Priorities

Domain Action Deliverables Outcomes

Patient experience and outcomes

Drive improved health outcomes through a strong focus on patient-centred care in the planning, delivery and evaluation of services, and the development of new models for putting patients first.

Strengthen the response of health services to family violence. This includes implementing interventions, processes and systems to prevent; identify and respond appropriately to family violence at an individual and community level.

Improve the health outcomes of Aboriginal and Torres Strait Islanders by increasing accessibility and cultural responsiveness of the Victorian health system.

• Complete review of the models of care within maternity services and implement agreed recommendation.

• Identify new models of care for acute health services arising from the West Gippsland Baw Baw Strategic Health Services Plan.

• In partnership with St John of God establish counselling services to antenatal and post-natal women at WGHG.

• Implement an education training program across the organisation for vulnerable children as an early intervention strategy.

• Install security access door to the entrance of the birthing and nursery area.

• Collaborate with other agencies as part of the Child First Partnership and the Gippsland Family Violence Steering Committee.

• Complete roll out of cultural awareness training program by Aboriginal Health Liaison Officer.

• Actively participate in the 6 Generations of Yarning Baw Baw Action Plan.

• Deliver the Be Deadly Be Healthy allied health program.

• Provide Yarning Over Lunch program in support of Aboriginal employees at WGHG.

• Maternity review completed. Working parties established and recommendations allocated. Maternity Project Officer appointed.

• West Gippsland Baw Baw Strategic Health Services Plan completed but not yet released. Draft transition plan developed identifying priorities for action when plan endorsed.

• Site visit to St John of God held in December to further explore implementation plan.

• Further action deferred until the WGHG maternity model is determined.

• Education package developed and information session presented to senior staff and within the maternity unit. Organisation wide education to be completed in 2016-17.

• Completed in September 2015 as part of maternity unit redevelopment.

• Partnerships are ongoing and WGHG represented at governance and operational meetings.

• Roll out complete. Approximately 25% of WGHG staff have completed training including Board and Community Advisory Council.

• WGHG have actively participated at 6 Generations of Yarning meetings and reported on progress.

• Program delivered with good uptake by clients.

• The program featured in a presentation by the Coordinator at the Gippsland Allied Health Symposium. Funding secured to continue the program in 2016/17.

• Sessions delivered and will continue in the next financial year.

Our PerformanceSTATEMENT OF PRIORITIES AND HEALTH SERVICE AGREEMENT

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Governance, leadership and culture

Demonstrate an organisational commitment to Occupational Health and Safety, including mental health and wellbeing in the workplace. Ensure accessible and affordable support services are available for employees experiencing mental ill health. Work collaboratively with the Department of Health and Human Services and professional bodies to identify and address systemic issues of mental ill health amongst the medical professions.

Monitor and publically report incidents of occupational violence. Work collaboratively with the Department of Health and Human Services to develop systems to prevent the occurrence of occupational violence.

Promote a positive workplace culture and implement strategies to prevent bullying and harassment in the workplace. Monitor trends of complaints of bullying and harassment, identify, and address organisational units exhibiting poor workplace culture and morale.

Apply existing capability frameworks and clinical guidelines to inform service system planning, giving consideration to the capability of neighbouring services and how best to allocate available resources so as to deliver the maximum benefit to the local community.

Implement strategies to support health service workers to respond to the needs of people affected by ICE.

Adopt the Healthy Choices: Food and Drink Guidelines for Victorian public hospitals, to increase the availability of healthy food and drinks for purchase by staff, visitors and the general public.

• Develop a program to support junior medical staff through the provision of information and prompt confidential access to a local GP practice to seek assistance for any health concerns.

• Achieve Recognition Point 2 of the Healthy Together Achievement Program by June 2016.

• Develop and implement streamlined Occupational Violence reporting mechanism and report prevalence in Quality of Care report.

• Draft and implement new Human Resources Strategic Plan by June 2016.

• Promote acceptable behaviour through signage, and other materials across all staff areas.

• Roll out anti-bullying and harassment training for all staff on annual basis.

• In partnership with Latrobe

Regional Hospital to complete a review of specialist medical workforce in Gippsland region.

• Contribute to the completion of the West Gippsland Baw Baw Strategic Health Services Plan to determine the future health needs of the Baw Baw community.

• Host ICE seminar in conjunction with Ambulance Victoria to support training of frontline clinical staff.

• Achieve compliance with Healthy Choices guidelines.

• Promote healthy eating choices and recipes on the West Gippsland Healthcare Group website.

• Agreement in place with Gladstone Street Medical Clinic to address any health concerns of junior medical staff.

• Recognition Point 2 achieved in March 2016.

• New ‘simpler’ incident forms used in ED to encourage reporting.

• OHS Safety Management plan and KPI’s endorsed at Audit & Risk.

• Prevalence to be reported in the Quality of Care Report.

• People and Culture Strategy 2016-2019 completed and endorsed by Board.

• Strategy and two page flyer printed and readily available to staff.

• Posters developed by staff detailing acceptable and unacceptable behaviour printed and widely displayed across organisation.

• Training has been developed and currently provided as required. Annual training to commence in 2016 when Human Resources Department is expected to be fully staffed.

• Project completed and waiting final report from Aspex Consulting Service.

• WGHG actively participated in project, including Chairing the Steering Committee and facilitating the consultation phase. Plan endorsed by Steering Committee and now waiting endorsement and release by DHHS.

• Ambulance Victoria (AV) has been unable to coordinate dates and source speakers. WGHG continuing to work with AV.

• Victorian Government on-line ICE training package for frontline workers has been disseminated to clinical staff.

• Compliance with Healthy Choice Guidelines has been achieved.

• Healthy eating choices and recipes promoted via newsletters and flyers at community events and available on intranet page.

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Safety and quality

Financial sustainability

Ensure management plans are in place to prevent, detect and contain Carbapenem Resistant Enterobacteriaceae (CRE) as outlined in Hospital Circular 02/15 (issued 16 June 2015).

Implement effective antimicrobial stewardship practices and increase awareness of antimicrobial resistance, its implications and actions to combat it, through effective communication, education, and training.

Develop perinatal mortality and morbidity review processes in alignment with the Clinical Practice Guideline for Perinatal Mortality.

Improve cash management processes to ensure that financial obligations are met as they are due.

Work with Health Purchasing Victoria (HPV) to implement procurement savings initiatives.

• Implement surveillance program for Carbapenem Resistant Enterobacteriaceae (CRE).

• Complete research project on antimicrobial stewardship program and evolve existing program based on research findings.

• Revise format for the reporting and reviewing outcomes at perinatal morbidity and mortality review.

• Enhance the use of and presentation of standardised datasets to improve engagement with clinical staff.

• Audit and Risk Committee to review cash management processes to ensure creditor and debtor key performance indicators are met.

• Achieve savings of $100,000 through implementation of procurement reforms.

• CRE policies and surveillance program developed and implemented. Compliance with CRE screening and guideline requirements submitted to DHHS. CRE is monitored by the Infection Control Committee with no documented cases reported to date.

• Base line data collected. Intervention strategies have been rolled out to clinical areas. Ongoing auditing and feedback is reported to Infection Control Committee and is part of revised Terms of Reference.

• The format for reporting and reviewing of perinatal outcomes has been revised and WGHG is an active participant in the newly established Gippsland Perinatal Morbidity & Mortality Committee.

• Data and its use continues to evolve within WGHG and in conjunction with DHHS.

• Cash Management processes and reporting was reviewed. KPI’s are monitored quarterly by the Audit & Risk Committee. KPI results are within target.

• Implemented business changes to meet the HPV reform requirements within the approved timeframe. HPV remain confident this will result in improvements in expenditure visibility, good procurement governance and sourcing outcomes, with benefits sustainable in the long term.

• Procurement savings being achieved - Telstra phone charges, desktop PC purchases through Dell, legal services appended to State Purchase Contract.

Our PerformanceSTATEMENT OF PRIORITIES AND HEALTH SERVICE AGREEMENT CONTINUED

Part A: Strategic Priorities CONTINUED

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Financial sustainability(continued)

Access

Invest in revenue optimisation initiatives to ensure maximisation of revenue from both public and private sources.

Implement integrated care approaches across health and community support services to improve access and responses for disadvantaged Victorians.

Progress partnerships with other health services to ensure patients can access treatments as close to where they live when it is safe and effective to do so, making the most efficient use of available resources across the system.

Optimise system capacity by ensuring that allocated points of care are implemented as per the Travis review recommendations.

Optimise alternatives to hospital admission.

Develop Tele-health service models to facilitate the delivery of high quality and equitable specialist services to patients across regional Victoria.

• Complete a six-month trial of Medicare Benefits Scheme allied health clinic in partnership with Latrobe Community Health Service.

• Secure long-term Warragul Linen Service contracts within the public healthcare network, whilst continuing to seek private business opportunities.

• Re-engineer production processes within Warragul Linen Service to improve efficiency.

• Expand First Call centralised intake across community health programs.

• Complete Reconnect project to establish culturally sensitive cancer and palliative care pathways for Aboriginal clients.

• Formalise relationships with Bass Coast and South Gippsland hospitals in relation to support for paediatric and maternity services.

• Partner with Ramahyuck District Aboriginal Corporation to improve access to and utilisation of collocated allied health services.

• Redesign post-natal care delivery in redeveloped dedicated and secure postnatal area.

• Expand role of Hospital-in-the-Home (HITH) by developing obstetric clinical pathways.

• Implement a Palliative care telehealth project in partnership with Monash Health.

• Six-month review shows demand significantly below provided projections. WGHG continues to support LCHS with allied health services in Baw Baw Shire.

• Successfully acquiring and re-acquiring health care and aged care contracts in the Gippsland and metropolitan Melbourne area.

• Significant efficiencies made through team upskilling, production flow and strategy projects. Savings in excess of $100,000 per annum achieved.

• First Call program has expanded and utilised by all programs excluding family violence and integrated family services counselling where referral is via the Child First Partnership.

• Reconnect Phase 1 completed. Pathways and referral guidelines into WGHG developed to ensure all Aboriginal clients are followed up by the Aboriginal Health Liaison Officer.

• Gippsland Maternity Services working group is managing the relationships between services for maternity and newborn services.

• Ongoing work with Ramahyuck to improve access and provision of allied health services at Ramahyuck site.

• Redevelopment of post-natal area completed and capacity increased. Security to post-natal unit improved with swipe card access.

• Hospital in the Home (HITH) program expanded to support the early discharge of mothers and babies from Maternity Unit.

• HITH also expanded to support iron infusions day cases.

• Project launched in November in partnership with Monash Health and progressing as expected. 12 clients from the trial target of 50 clients enrolled this year.

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Part B: Performance priorities

Safety and quality performance Key performance indicator Target Actual

Compliance with NSQHS Standards accreditation Full compliance Full complianceCompliance with the Commonwealth’s Aged Care Accreditation Standards Full compliance Full complianceCleaning standards Full compliance Full complianceCompliance with the Hand Hygiene Australia program 80% 83.7%Percentage of healthcare workers immunized for influenza 75% 79%Submission of infection surveillance data to VICNISS 1 Full compliance Full compliance

Patient experience and outcomes performance Key performance indicator Target Actual

Victorian Healthcare Experience Survey - data submission Full compliance Not achievedVictorian Healthcare Experience Survey - patient experience - Qtr 1 95% positive experience 96%Victorian Healthcare Experience Survey - patient experience - Qtr 2 95% positive experience 95%Victorian Healthcare Experience Survey - patient experience - Qtr 3 95% positive experience n/aMaternity- Percentage of women with prearranged postnatal home care 100% 100%

Governance, leadership and culture performance Key performance indicator Target Actual

People Matter Survey - percentage of staff with a positive response to safety culture questions 80% 88%

Financial sustainability performance Key performance indicator Target Actual

FINANCE Operating result ($m) 0.150 0.331Trade creditors < 60 days 55 daysPatient fee debtors < 60 days 22 daysPublic & private WIES2 performance to target 100% 102.1%

ASSET MANAGEMENT Asset management plan Full compliance Full complianceAdjusted current asset ratio 0.7 0.76 Days of available cash 14 days 35.2 days

1 VICNISS is the Victorian Hospital Acquired Infection Surveillance System.2 WIES is a Weighted Inlier Equivalent Separation.


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Access performance Key performance indicator Target Actual

EMERGENCY CARE Percentage of ambulance patients transferred within 40 minutes 90% 96%Percentage of Triage Category 1 emergency patients seen immediately 100% 100%Percentage of Triage Category 1 to 5 emergency patients seen within clinically recommended times 80% 83%Percentage of emergency patients with a length of stay less than four hours 81% 73%Number of patients with a length of stay in the emergency department greater than 24 hours 0 39

ELECTIVE SURGERY Percentage of elective patients removed within clinically recommended timeframes 94% 75%Percentage of Urgency Category 1 elective patients removed within 30 days 100% 100%10% longest waiting Category 2 and 3 removals from the elective surgery waiting list 100% 96.9%Number of patients on the elective surgery waiting list3 600 446Number of hospital initiated postponements per 100 scheduled admissions 8 7.4Number of patients admitted from the elective surgery waiting list - annual total4 2,450 2,554

3 The target shown is the number of patients on the elective surgery waiting list as at 30 June 2016. 4 The annual total target increased from 2,450 to 2,640 (190 extra) due to additional WIES allocation in April 2016.

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Part C: Activity and funding

Funding type Target Actual Variance

ACUTE ADMITTED WIES Public1 7,444 8,116 672WIES Private 1,018 722 (296)WIES (Public and Private) 8,462 8,838 376WIES DVA 160 145 (15)WIES TAC 12 14 2WIES TOTAL 8,634 8,997 363

SUBACUTE ADMITTED GEM & Palliative Care Public 3,128 2,313 (815)GEM & Palliative Care Private 85 380 295GEM & Palliative Care DVA 0 257 257

SUBACUTE NON-ADMITTED Health Independence Program 16,421 17,420 999

AGED CARE

Residential Aged Care 38,691 33,694 4,997HACC 25,898 25,807 91

PRIMARY HEALTH Community Health / Primary Care Programs 6,401 6,407 6

1 WIES Public target increased from original Statement of Priorities, due to 190 additional WIES allocated in April 2016.


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Cooinda Lodge Aged Care Residents enjoying activities.

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Environment Report2015-16 ENVIRONMENTAL PERFORMANCE SUMMARY

Energy consumption

Total energy consumption by energy type (GJ) 2013-14 2014-15 2015-16

Electricity 14,610 14,438 12,397Natural gas and LPG 78,198 82,865 73,763Other energy types (e.g. steam, diesel) Total 92,808 97,303 92,160

Energy consumption relates to the main hospital site only and includes the Warragul Linen Service and Cooinda Lodge.

Total energy consumption has decreased 6.8% for the 2015-16 financial year. This blended rate comprises a 14.1% reduction in electricity consumption and a 5.1% reduction in gas for the year. The reduction in consumption follows the $5.8m completion of major energy and infrastructure asset replacements under the Energy Performance Contract. Gas usage is low in 2014-15 due to an issue with July 2013 billing data.

Normalised energy consumption 2013-14 2014-15 2015-16

Energy per unit of floor space (GJ/m2) 4.77 5.00 4.74Energy per unit of activity (GJ/activity) 2.07 2.26 2.24

Activity measure denominator is acute inpatient bed days plus Cooinda Lodge bed days.

Energy Intensity has decreased due to new energy efficient assets commissioined under the EPC Project.

Greenhouse gas emissions

Total greenhouse gas emissions (tonnes CO2e) 2013-14 2014-15 2015-16

Scope 1 - Direct Emissions n/a n/a n/aScope 2 - Indirect Emissions 8,923 9,104 8,259Total 8,923 9,104 8,259

Normalised greenhouse gas emissions 2013-14 2014-15 2015-16

Emissions per unit of floor space (kgCO2e/m2) 0.46 0.47 0.42Emissions per unit of activity (kgCO2e/activity) 0.20 0.21 0.20

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Water consumption

Total water consumption by type (kL) 2013-14 2014-15 2015-16

Potable water 31,665 30,899 31,420Re-used / recycled water n/a n/a n/aTotal 31,665 30,899 31,420

Water usage has increased 1.4% year on year due to increased activity within haemodialysis and theatre/CSSD (large users). Warragul Linen Service usage is excluded.

Normalised water consumption 2013-14 2014-15 2015-16

Water per unit of floor space (kL/m2) 1.69 1.59 1.62Water per unit of activity (kL/activity) 0.73 0.72 0.76

Activity measure denominator is acute inpatient bed days plus Cooinda Lodge bed days.

Water consumption per bed day has increased 5.7% due to reduced occupancy levels at Cooinda Lodge (down 2,997 bed days on 2014-15).

Water re-use and cycling 2013-14 2014-15 2015-16

Re-use / recycling rate (percentage) n/a n/a n/a

Waste generation

Total waste generation by type (Tonnes) 2013-14 2014-15 2015-16

Clinical waste 16 16 16General waste 116 150 192Recycled waste 52 69 42Total 185 235 251

Waste data is as provided by the respective contractor and refers to all sites for general and recycled and the main hospital for clincial waste. A new contractor was appointed for general and recycable waste from Jan 2015. The increase in general waste is due to a number of capital projects occurring during 2015-16, including the EPC project, Level 3 renovations and refurbishment of Cooinda Lodge.

Normalised waste generation 2013-14 2014-15 2015-16

Waste per activity (kg/activity) 4.47 5.47 6.09

Activity measure denominator is acute inpatient bed days plus Cooinda Lodge (Aged Care) bed days.

Waste recycling 2013-14 2014-15 2015-16

Waste recycling rate (percentage) 31.8% 34.9% 25.0%

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Key Performance Indicators

9000

8750

8500

8250

8000

7750

7500

7250

7000

6750

6500

2011-12 2012-13 2013-14 2014-15 2015-16

7,220

7,572

7,072

7,282

7,9918,172

8,824

8,147

8,397

8,997

Target Actual

5 Year WIES Comparison

5 Year Financial Comparison

2016 2015 2014 2013 2012 $000 $000 $000 $000 $000

Total Revenue 94,102 90,008 86,749 81,109 77,079 Total Expenditure 93,771 91,293 86,687 81,528 78,392

Operating Surplus (Deficit) 331 (1,285) 62 (419) (1,313)

Net Capital & Specific Items (4,500) (4,743) (3,634) (1,950) (3,321)Net Result for the Year

Surplus / (Deficit) (4,169) (6,028) (3,572) (2,369) (4,634)Total Assets 94,571 95,929 98,118 81,714 82,944 Total Liabilities 30,354 28,033 24,253 22,707 21,568

Net Assets 64,217 67,896 73,865 59,007 61,376

Total Equity 64,217 67,896 73,865 59,007 61,376

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Key Performance Indicators (continued)

Separations by Top 10 Diagnostic Related Group 2015-16

A Renal Dialysis 2,057B Neonatal 800C Vaginal Delivery 642D Chemotherapy 518E Diagnostic Curettage or Hysteroscopy 164F OR Procedures for Diabetic Complications 151G Red Blood Cell Disorders 147H Other Skin, Subcutaneous Tissue Procedures 146I Hernia Procedures 146J Cystourethroscopy for Urinary Disorder 136

A

BC

DEFGHIJ

Patient Debtors (Aged) Outstanding as at 30 June 2016

Under 31-60 61-90 Over Total Total 30 Days Days Days 90 Days 2016 2015

Private Inpatient Fees 69,080 13,541 13,376 35,523 131,520 95,886 Ineligible 1,502 - - 1,268 2,770 8,699 Workcover - 6,424 8,839 - 15,263 16,974 TOTAL INPATIENT FEES 70,583 19,966 22,214 36,791 149,553 121,559

17Nursing Home 48,073 9,703 4,503 10,551 72,830 4,121 Hostel 46,324 8,532 10,150 44,451 109,458 1,386 TOTAL AGED CARE 94,397 18,235 14,653 55,002 182,288 5,507

17Total 164,980 38,201 36,868 91,793 331,841 127,065

18

Our AchievementsFINANCIAL REPORT

Following a disappointing 2014-15 financial result, the West Gippsland Healthcare Group embarked on a three year financial recovery plan (2016-2018) that aimed to return the Group back into a small operating profit for 2015-16.

The Group succeeded in year one of this plan, turning around its financial performance by $1.46m to report an operating profit of $0.331m in 2015-16 against a budget operating profit of $0.150m.

The turnaround in performance was largely driven by rostering efficiencies within the medical division and an additional 190 elective surgery Weighted Inlier Equivalent Separation (WIES) revenue awarded in April 2016. Whilst Public/Private WIES activity for the year didn’t reach the budgeted level of 104% of full year target, the actual level of 102.6% still provided profitable margins to the Group.

Total operating revenue for the year was $92.14m, up $3.7m or 4.2%. Government grant revenue represented an increase of $3.6m and included additional WIES funding plus higher Commonwealth revenue at Andrew’s House Aged Care Residence.

Total operating expenditure on the other hand was contained to an increase of 2.5% to $93.77m, even after allowing for the unbudgeted extra resources in delivering additional ESIS WIES awarded in April 2016. Employee expenses increased in line with Government wage policy of 2.4%.

The net result for the year after capital items and depreciation was a loss of $4.17m, compared to a loss of $5.5m in 2014-15. Capital donations were notably down on last year.

Cash reserves for the year declined by $5.2m from $12.6m to $7.4m. This expected decline in cash was largely due to cash outflows for capital works projects including the Energy Performance Contract (EPC) and Doctors Accommodation, plus the transfer of $1.5m into a term deposit > 3 months.

Cash flows from operating activities increased by $4.16m, inflated due to outstanding payments of salaries under unsettled Enterprise Bargaining Agreements (EBAs) as at 30 June 2016.

The liquidity ratio for the Group deteriorated during the year as a result of cash outflows to 0.73:1, still above the Department of Health and Human Services benchmark of 0.7:1.

Net assets for the Group fell by $4.17m to $64.2m, attributed mostly to the unfunded depreciation charge of $6.4m for 2015-16.

Overall the financial performance was an excellent result and we now look forward to the second year of the three year financial recovery plan and building on the 2015-16 operating profit.

Baby Dustin with Special Care Nursery staff at the launch of 'Victor' (Trackand Trigger observations charts).

19

20

Our AchievementsDIRECTOR OF NURSING & MIDWIFERY

Report by Kathy Kinrade RN GradDipCCareN DipMgt MNurs

• Undertook major review of maternity services to help manage demand

• Introduced a new education platform to record education for all staff at WGHG

• Improved security and installation of security doors with swipe card access into the labour/special care nursery area

• Active participation in the Gippsland Regional Perinatal Morbidity & Mortality Committee

• Commenced single point of access for elective surgical cases through day surgery to ensure timely access for patients

The Director of Nursing & Midwifery is an extensive role, overseeing a diverse range of services. Responsible for all units in the hospital, same day services such as dialysis and oncology, home based sub-acute services as well as two aged care residential facilities.

Key achievements during 2015-16 include:

• Commenced an infusion clinic within surgical unit to provide a separate treatment space for patients requiring ongoing infusion management

• Introduced Safe & Timely Care for patients being admitted through the emergency department

• Implemented an electronic medication management system within both aged care facilities to improve medication safety

• Improvement in hand hygiene audit results. Overall increase this year from 80% to 83% compliance to the ‘5 steps of hand hygiene’.

21

Our AchievementsDIRECTOR OF MEDICAL SERVICESDIRECTOR OF EMERGENCY MEDICINE

Report by Dr Gary Campain MBBS, FACEM, GradCertMgt

• Increased General Medicine Registrar numbers from 4 to 5 providing 24 hour coverage seven days per week

• Increased General Medicine Intern numbers from 3 to 4 to meet increased workload

• Successfully recruited emergency department staff reducing the reliance on locum doctor coverage

• Achieved significant savings in medical salary and wages expenses ($1.6M) despite the increase in medical staff EFT, by efficient rostering and leave management practices

The Director of Medical Services and Emergency Medicine provides oversight of the junior and senior medical staff; provides oversight of safety and quality processes and outcomes; provides high level advice on medical matters; assists in fostering optimal working relationships between medical staff and the Executive in achieving the common goal of high quality patient care within a responsible financial reality.


In November 2015, Dr Liz Mullins departed WGHG as the Director of Medical Services. WGHG wishes Liz all the best for her next endeavours and thanks her for her contribution.

• Reviewed credentialing and appointments process and transitioning to electronic credentialing platform

• Enrolled the first Emergency Medicine Certificate (EMC) candidate who since continued with the Emergency Medicine Diploma (EMD). A further six EMC candidates have enrolled for the 2016 medical year

• Emergency Department attendances up 5.0% to a record 21,414. Acute inpatient separations up 5.3% to 11,989 including 2,572 elective surgical cases.

22

Our AchievementsDIRECTOR OF ALLIED AND COMMUNITY HEALTH

Report by Audra Fenton RN, GradDip MN, Grad Dip Bus Man, CMHN, MNurs (Mental health)

• Established a high risk foot clinic to provide a specialist wound care service staffed by a podiatrist and wound consultant

• Continued the Workplace Achievement program to embed health and wellbeing into the organisations culture, with positive impact on morale, safety and productivity

• Introduced The Reconnect project to explore how Aboriginal people in Baw Baw Shire access health services. Findings presented at the Gippsland Innovation Health Forum in July 2016

• Continued the Be Deadly Be Healthy – aboriginal outreach exercise program

• Winner of the Outstanding Innovation at Health Round Table conference for Positive Pregnancy Program (dietetic intervention for obese pregnant women)

• Developed an education package to be rolled out to staff to better identify children at risk in our organisation

The Director of Allied and Community Health has a pivotal role in the delivery of community and hospital based services for West Gippsland, advising on issues related to primary, allied and community care services. The role also requires a continuing development and involvement in strategic alliances and partnerships, and community based networks both within Baw Baw Shire and on a regional and statewide basis.


In February 2016, Linda McCoy departed WGHG as the Director of Community Health & Allied Services. WGHG wishes Linda all the best for her next endeavours and thanks her for her contribution.

• Expanded the family violence counselling and case management program

• Accreditation for Integrated Family Services and Children with disability programs maintained

• Conducted continence carers day providing an opportunity for carers to come together with experts in a social and fun environment

• Delivered the Young Mums Group to assist younger mums in the community with social support and linkages into main stream services

• Implemented cultural awareness program to educate staff about local aboriginal culture

• Delivery of the diabetes schools program to offer staff in the education sector the opportunity to expand their knowledge in supporting and facilitating the day to day experience of young people with type 1 diabetes.

23

Our AchievementsDIRECTOR OF CORPORATE SERVICES

Report by Justin Walsh CPA BBus (Acct) BBus (Bank&Fin)

• Developed and implemented a new Procurement Policy Framework that provides for greater strategic direction and planning of major procurement activities. This enables transitioning to the new Victorian Procurement Policy Framework and Health Purchasing Victoria (HPV) requirements from 1 July 2016

• Developed the 2016-2019 People and Culture Strategy which provides the vision and direction for our workforce in achieving the 2015-2018 WGHG Strategic Plan

• Implemented electronic payslips for all employees

• Completed $5.8m Energy Performance Contract (EPC) program to address critical and inefficient energy plant and equipment across the Group including WLS resulting in energy savings of over $300k

• Completion of Stage One accommodation project to provide five new units for clinical staff


• Completed a $600k ‘significant refurbishment’ of Cooinda Lodge including upgraded air conditioning and refurbishment of interior common areas

• Implemented Emergency Code Grey to respond to and de-escalate aggressive behaviour directed towards staff. Received $52.8k under the Department of Health & Human Services Violence Prevention Fund to provide personal duress alarms for staff in maternity and paediatrics and improve security in the paediatrics unit

• Embraced lean thinking techniques under the 2015 Vative lean program that identified 12 projects delivering over $200k in savings through improved process efficiencies

• Maintained full compliance with cleaning standards, food safety standards and fire risk management standards for Victorian Health Services.

24

Our AchievementsGENERAL MANAGER - WARRAGUL LINEN SERVICES

Report by Alan Hollensen BEng(Hons) DipPracMgt

• Awarded contracts for all MECWA aged care sites, opening delivery run to Melbourne’s west and allowing expansion of truck fleet

• Awarded contracts for several Gippsland health and aged care businesses and successfully extended contract for Regis Aged Care

• Three employee teams engaged in LEAN manufacturing training and delivered projects to increase factory capacity by 5%, reduce linen re-wash by nearly 50% and improve overall on-time delivery by 5%

• Commissioned new state of the art ironer line and upgraded dryers to deliver energy efficiency savings and throughput improvement

• Achieved audit compliance with ISO 9001. Quality certification maintained

The General Manager of Warragul Linen Service (WLS) oversees all functions and operations. WLS operates as a business unit of WGHG and is one of the largest linen services in Victoria.


• Introduction of modernised stocktake model and system to improve count and financial accuracy

• Commenced multiple project program to add capacity to plant by removing bottlenecks that have become apparent with growth

• Collaborated with customers to develop and deliver on-line and web portal reporting processes, auditing tools and linen tracking systems

• Improved systems for recovery of customer owned goods, on site linen management and other service offerings to maintain position as market leader in customer service

• Introduced additional tools and systems for internal development, mentoring and training of linen service staff.

25

CorporateGovernance

Ministers and Governance

The Hon. Jill Hennessy MP

Minister for Health Minister for Ambulance Services

The Hon. Martin Foley MP

Minister for Housing, Disability and Ageing Minister for Mental Health

The Hon. Jenny Mikakos MP

Minister for Families and Children Minister for Youth Affairs

The functions of the Board of Directors as determined by the Health Services Act 1988 are:

• to oversee and manage the Group; and

• to ensure the services provided by the Group comply with the requirements of the Act and aims of the Group.

Governance by the Board is achieved through:

• strategic planning

• effective management of the Chief Executive Officer

• funding of service agreements

• local policy setting

• regular reviews of the Group’s by-laws and strategic plans.

The Board Directors met eleven times throughout the year and were active members of various Board Sub-Committees, set up to assist in monitoring the Groups various operations.

These Sub-Committees include:

• Appointments Committee

• Audit & Risk Committee

• Clinical Governance Committee

• Community Advisory Council

• Credentialing Committee

• Human Research Ethics Committee

• Remuneration & Board Performance Committee Performance Committee

The Board establishes Working Groups for appropriate projects on an 'as needs' basis.

25

26

Board of Directors

Jane Leslie BBus GAICD

Company Director and Business Consultant

Position: Chair

Commenced as a Board Director in July 2012.

Member of the Appointments Committee, Remuneration & Board Performance Committee, Accommodation Fundraising Working Group and the Project Control Group (Strategic Services Plan).

Board Meetings attended 11 of 11.

Peter Kingwill BEng FGCLP FAICD

Company Director

Position: Vice Chair

Commenced as a Board Director in 2002.

Member of the Clinical Governance Committee, Project Control (Accommodation) Working Group, Project Control (Energy Performance Contracting) Working Group.

Board meetings attended 9 of 11.

Duncan Smith DipBus (ACCT) FCPA CTA AIMM CFP

Accountant/Certified Financial Planner

Position: Treasurer

Commenced as a Board Director in June 1998.

Member of the Audit & Risk Committee, Remuneration & Board Performance Committee and the Accommodation Fundraising Working Group.


Brian Davey BA DipEd GAICD

Management Consultant

Position: Director

Commenced as a Board Director in November 2005.

Member of the Audit & Risk Committee, Remuneration & Board Performance Committee and Project Control Group (Strategic Services Plan) Working Group.


27

John Davine BComm LLB

Solicitor

Position: Director

Commenced as a Board Director in 1998.

Member of the Appointments Committee, Credentialing Committee, Community Advisory Council and Critical Priorities Review Working Group.


Joanne Campbell BEd GradDipBuss GradCertInstrDesign, MEd (Research), GAICD

Instructional Design/Knowledge Management Consultant

Position: Director


Member of the Human Research Ethics Committee, Clinical Governance Committee and Critical Priorities Review Working Group.


Christine Holland FAICD MCareerDev GradCertCarCounsel

Career and Transition Consultant

Position: Director


Member of the Community Advisory Council and Clinical Governance Committee.


Peter Marx AssocDipSurveying Assoc DipCartography

Licensed Land Surveyor

Position: Director

Commenced as a Board Director in November 1996.

Member of the Appointments Committee, Audit & Risk Committee, and the Project Control (Accommodation) Working Group and Project Control (Energy Performance Contracting) Working Group.


28

Board of Directors

John Monagle MB BS MSc FANZC FCHSM

Anaesthetist. Director Medical Services

Position: Director

Commenced as a Board Director in August 2015.

Member of the Credentialing Committee, Human Research Ethics Committee and Clinical Governance Committee.

Board Meetings attended 10 of 11.

Nathan Voll BComm GradCertBusMgt MBA FCPA FAICD

Corporate Services Manager/Company Director

Position: Director

Commenced as Board Director in July 2010.

Member of the Audit & Risk Committee and Clinical Governance Committee.

Board Meetings attended 6 of 11 (Leave of absence effective March 2016).

Heather Stacy Dip App Sci (Ag) MBA GAICD ARLP

Company Director and Agribusiness Executive

Position: Director

Commenced as a Board Director in August 2015.

Member of the Audit & Risk Committee, Board Performance & Remuneration Committee and the Project Control Group (Strategic Services Plan) Working Group.


Margaret Jackson AC BEc, MBA, Hon LLD (Monash), FCA, FAICD

Board Director July 2015 – February 2016.

29

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30

Our People

West Gippsland Healthcare Group is committed to providing a safe & healthy workplace. In achieving this we acknowledge our legal obligation under OHS and Dangerous Goods legislation to ensure the health & safety of each of our staff, contractors & visitors. We aim to ensure that all hazards are properly managed to ensure any risk posed is controlled so far as is reasonably practicable.

In 2015-16 the focus of OH&S has been on implementing the review of our emergency management procedures and the development and implementation of Code Grey to afford greater protection to our staff, clients and visitors. In addition substantial upgrades are underway to security in our surgical, paediatric, maternity and medical units.

Our OH&S Committee has updated its Safety Management Plan (OHSMS) which focusses on further integrating OH&S into our culture and targeting areas of greatest risks of injury and injury management.

The key features of the OHSMS are the training of employees to improve their safety capability; auditing our systems and facilities; hazard management and the management of legislative requirements.

The three areas of greatest risk that we are taking action to reduce are: exposure to occupational violence and aggression, musculoskeletal injuries and slips, trips and falls. A closer alignment between prevention and injury management programs is also identifying and overcoming barriers to achieving effective, timely and meaningful return to work. Our return to work priorities are early intervention and support to optimize the care of injured workers to ensure their safe return to work.

Continuous improvement is still a key driver within WorkCover. New performance indicators have been established to assist WGHG in returning staff back to work in a safe and timely manner.

This process incorporates:

• engaging external consultants with specialist knowledge and expertise in early intervention

• WGHG engaging with staff through increased consultation

• staff play a more active role in their return to work.

These measures have helped WGHG in reducing potential long-term injuries and assisted injured staff back into the workforce quicker, safer and with improved outcomes in their rehabilitation. While there has been an initial spike in claims, claims have had reduced lost time with staff returning to work earlier and with better support.

OH&S Statistics 2013-14 2014-15 2015-16No. of reported hazards/ incidents for the year per 100 full-time equivalent staff members 26.8 23.6 24.3No. of ‘lost time’ standard claims for the year per 100 full-time equivalent staff members 0.09 0.09 0.13Average cost per claim for the year (including payments to date and an estimate of outstanding claim costs as advised by WorkSafe) $79,495 $48,561 $18,273

Occupational Health & Safety (OH&S)

31

Our People

Occupational Violence Statistics 2015-16

Workcover accepted claims with an occupational violence cause per 100 FTE 0.14

Number of accepted Workcover claims with lost time injury with an occupational violence cause per 1,000,000 hours worked 0.7

Number of occupational violence incidents reported 61

Number of occupational violence incidents reported per 100 FTE 0.08

Percentage of occupational violence incidents resulting in a staff injury, illness or condition 1.6%

Definitions:

For the purposes of the above statistics the following definitions apply.

Occupational violence any incident where an employee is abused, threatened or assaulted in circumstances arising out of, or in the course of their employment.

Incident occupational health and safety incidents reported in the health service incident reporting system. Code Grey reporting is not included.

Accepted WorkCover claims Accepted WorkCover claims that were lodged in 2015-16.

Lost time is defined as greater than one day.

Equivalent Full Time Staff June Current Month June Year to DateLabour Category 2015 2016 2015 2016Nursing Sevices 304.11 299.61 295.11 298.49Hotel & Allied Services 100.25 96.18 98.72 96.79Administration & Clerical 80.48 80.46 80.76 78.81Medical Support Services 16.87 16.11 15.81 17.99Hospital Medical Officers 36.89 31.55 36.20 32.04Medical Officers 3.38 7.08 2.88 5.73Ancillary Support 47.67 47.65 46.48 46.40Sessional Clinicians 6.44 6.43 4.40 6.39Warragul Linen Service 131.89 127.62 137.50 125.39Total 727.98 712.69 717.86 708.03

All employees at WGHG are correctly classified in the above workforce data and are required to abide by the WGHG Code of Conduct and all WGHG policies under their employment agreement.

32

40 YearsJames White

35 YearsMary GleesonJoan KeebleMarie SmithHelen TinkAlice Wells

30 YearsJadwiga (Judy) BarczykSheree BlumAmanda CropleyMeredith HenryClaire OsterlundMaxine PeningtonYvonne RoweVicky Ballantyne

25 YearsSandra BellJenine BoweringSue ColbyDiane HaysomJulie HumeKathy KinradeMaria McMahonMandy MilesPatricia NobeliusAnne-Marie OsborneJoanna ReekieMarie WallisMargaret Winter

20 YearsLois DorlingAlison GloverMichelle GreenFiona GriffinPauline LintzenChristine MeakerSharon MildrenJulie ProctorJane SantoGina SavoryPamela SlabickiGlenda TottenhamJenny TullyCarol Van LochemSusan VickeryBeverley Widrick

15 YearsJodee BethuneAlli BrightLynette ChmielewskiBeverley ElliottFleur GloverTamara GuyDonna JonesLinda McCoyBernadette McKennaLyn WilkinsonRaelene McDonaldLouise PaulSue SchenaRosemary WestKerrie Wright

Life Governor Awards Each year, the Board of Directors consider people who are worthy recipients for a Life Governorship Award. The criterion is stringent and reflects first and foremost meritorious service, with a secondary length of service requirement.

Dr Jenny Eury was awarded the 2015-16 Life Governor Award for outstanding achievement on behalf of WGHG. Dr Jenny Eury was the site Academic co-ordinator for 10 years for Warragul and Latrobe Valley School of Rural Health until end of June 2015.

Jenny then took up the role of sessional clinical teacher for School of Rural Health Latrobe Valley and West Gippsland and remains a vibrant member of the GP community and regular contributor to the WGHG Friday medical forums.

Life Governor Award presented to Dr Jenny Eury at the AGM in November 2015.

Service Awards

Staff presented with Long Service Award Certificates and Badges at the AGM in November 2015.

33

Volunteer Recognition of Service Award

Our Community Donations

Volunteers and Auxiliary members with 10 years or more of volunteer service to WGHG are recognised under the award category of Volunteer Recognition of Service Award, presented at the Annual General Meeting.

The following volunteers received an award:

John Moran Community Rehabilitation CentreRex Baker Palliative CareRoma Rippon Palliative CareLynette Gardner Drouin Auxiliary

WGHG are fortunate to have a dedicated team of long serving volunteers who tirelessly give their time freely to assist the Group to enhance programs and services that we provide. We are grateful to the following volunteer groups for their continued support:

• Cooinda Lodge Volunteers• Drouin Auxiliary and Drouin Opp Shop• Palliative Care Service• Rawson Auxiliary• Trafalgar & District Community Opp Shop• Mobile Book Trolley Service• Past Nursing Graduates Archive Department• Andrews House Volunteers• Community Rehabilitation Centre• Community Health Services• Community Advisory Council• The Board of Directors

We acknowledge each member and group within our community who contributed financially to WGHG during the year.

WGHG received an impressive $684,680 through generous donations, fundraising activities, events and bequests.

Service Awards

34

Reporting Requirements

Statement of fees and chargesWest Gippsland Healthcare Group charges fees in accordance with the Department of Health and Human Services Victoria directives issued under Regulation 8 of the Hospital and Charities (Fees) Regulations, 1986 as amended.

Freedom of InformationThe Freedom of Information officer is the Manager, Health Information Services, with final approval by the Director of Medical Services. Consumers wishing to access documents may contact the Freedom of Information Officer on 03 5623 0611 and access details will be provided.

During 2015-16 year, 119 requests for information under the regulations of the Freedom of Information Act 1982 were received. Access was granted in full to 113 applicants.

Full Access 113 (95%)

Partial Access 0

Denied 0

Withdrawn 3

No Documents 3

Not yet finalised 0

TOTAL 119

Victorian Industry Participation Policy DisclosuresWest Gippsland Healthcare Group did not award contracts to Victorian Industry Participation Policy for the year 2015-16.

Overseas TravelThere was no overseas travel taken during the year 2015-16.

National Competitive PolicyIt is Government policy that the costing policies of publicly funded organisations should reflect any competitive advantage available to the private sector. During 2015-16 all competitive neutrality requirements were met.

Conformity & Building MaintenanceAll renovations to existing buildings conform to the Building Act 1993. All existing buildings complete with regulations in force at the time of construction. There are no orders to cease occupancy or to undertake urgent works. All sites are subject to a Fire Safety Audit and Risk Assessment according to revised standards as directed by the Department of Health and Human Services.

Buildings

Buildings certified for approval 1 – Accommodation Building

Constructions subject to mandatory inspections 1 – Accommodation Building

Certificate of final inspection 1 – Accommodation Building

Maintenance

Notice for urgent rectification, attention or major expenditure were received Nil

All renovations to existing buildings comply with Regulations and standards including the Building Code of Australia Yes

Orders to cease occupancy Nil

Carers Recognition Act 2012As a care support organisation, West Gippsland Healthcare Group takes all practicable measures to ensure that its employees and agents have an awareness and understanding of the care relationship principles. We take all practicable measures to ensure that persons who are in care relationships and who are receiving services in relation to the care relationship from West Gippsland Healthcare Group have an awareness and understanding of the care relationship principles.

West Gippsland Healthcare Group takes all practicable measures to ensure that employees and agents reflect the care relationship principles in developing, providing or evaluating support and assistance for persons in care relationships.

Protected Disclosure Act 2012West Gippsland Healthcare Group complies with the Protected Disclosure Act 2012. There were no complaints made under the Act against West Gippsland Healthcare Group or its staff for

2015-16.

35

Financial ManagementThe information requirements listed in the Financial Management Act 1994 (the Act), the Standing Directions of the Minister for Finance under the Act (Section 4 Financial Management Reporting) and Financial Reporting Directions have been prepared and are available to the relevant Minister, Members of Parliament and the public upon request.

Consultancies DisclosureOver 10k

In 2015-16, there were four consultancies where the total fees payable to the consultants were $10 000 or greater. The total expenditure incurred during 2015-16 in relation to these consultancies is $243,442 (excl. GST).

Consultant Purpose of Consultancy Start Date End Date 2015-16 Future Expenditure Expenditure

John Salmon Maternity Review Aug-15 Sep-15 $13,000 nil

JTA Corporation Workcover 2011-2015 Remuneration Review Mar-15 Sep-15 $112,000 nil

P2 Group Workcover Management Jul-15 Ongoing $103,000

AECOM Aust P/L Engineering Consultant Energy Performance Contracting Project May-15 Aug-16 $15,000 $35,000

Under 10k

In 2015-16, there were two consultancies where the total fees payable to the consultants were less than $10 000. The total expenditure incurred during 2015-16 in relation to these consultancies is $15,332 (excl. GST).

3636

Standing Direction 4.5.5 - Risk Management Framework and Processes

I, Dan Weeks certify that the West Gippsland Healthcare Group has complied with the Ministerial Standing Direction 4.5.5 - Risk Management Framework and Processes. The West Gippsland Healthcare Group Audit Committee verifies this.

Dan Weeks Chief Executive Officer

Warragul5 September, 2016

Responsible Bodies Declaration

In accordance with the Financial Management Act 1994, I am pleased to present the Report of Operations for West Gippsland Healthcare Group for the year ending 30 June 2016.

Jane LeslieBoard Chair


Attestation on Data Integrity

I, Dan Weeks, certify that the West Gippsland Healthcare Group has put in place appropriate internal controls and processes to ensure that the Department of Health and Human Services are provided with data that reflects actual performance. The West Gippsland Healthcare Group has critically reviewed these controls and processes during the year.

Dan Weeks Chief Executive Officer


Attestations

4040

Financial StatementsFinancial Index

Notes Contents Page

Comprehensive Operating Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Balance Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Statement of Changes of Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Cash Flow Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Notes to the Financial Statements

1 Summary of Significant Accounting Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2 Analysis of Revenue by Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

2a Net Gain/(Loss) on Disposal of Non-Financial Assets . . . . . . . . . . . . . . . . . . . 75

2b Nett Gain/(Loss) on Disposal of Financial Assets . . . . . . . . . . . . . . . . . . . . . . . . 75

3 Analysis of Expenses by Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

3a Analysis of Expense and Revenue by Internally Managed and Restricted Specific Purpose Funds for Services Supported by Hospital and Community Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

4 Depreciation and Amortisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

5 Cash and Cash Equivalents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

6 Receivables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

7 Investments and other Financial Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

8 Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

9 Non-Financial Physical Assets Classified as Held for Sale Including Disposal Group Assets Classified as Held for Sale . . . . . . . . 80

10 Prepayments and Other Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

11 Property, Plant and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

12 Payables ...........................................................................................88

13 Borrowings .......................................................................................89

14 Provisions .........................................................................................90

15 Other Liabilities ................................................................................91

16 Superannuation ................................................................................91

17 Equity ................................................................................................92

18 Reconciliation of Net Result for the Year to Net Cash Inflow/(Outflow) from Operating ........................................93

19 Financial Instruments .......................................................................94

20 Commitments .................................................................................103

21 Contingent Assets and Contingent Liabilities .................................103

22 Operating Segments .......................................................................104

23 Jointly Controlled Operations and Assets .......................................106

24a Responsible Persons Disclosures ...................................................107

24b Executives Officers Disclosures .....................................................108

24c Payment to Other Personnel ...........................................................108

25 Remuneration of Auditors ...............................................................109

26 Events Occurring after Balance Date ..............................................109

27 Alternate Presentation of Comprehensive operating statement .....109

40

4141

Comprehensive Operating StatementFOR THE FINANCIAL YEAR ENDED 30 JUNE 2016

4242

Balance SheetFOR THE FINANCIAL YEAR ENDED 30 JUNE 2016

4343

Statement of Changes in EquityFOR THE FINANCIAL YEAR ENDED 30 JUNE 2016

4444

Cash Flow StatementFOR THE FINANCIAL YEAR ENDED 30 JUNE 2016

4545

West Gippsland Healthcare GroupNotes to the Financial Statements

30 JUNE 2016

4646

•

•

•

•

•

•

•

•

•

West Gippsland Healthcare GroupNotes to the Financial Statements30 JUNE 2016

4747


30 JUNE 2016

4848


4949

•

• o o

•

•

•

•

•

•

•

•


30 JUNE 2016

5050

•

•


5151

•

•


30 JUNE 2016

5252

•

•

•

•


5353

•

• •

•


30 JUNE 2016

5454

•

•

•


5555


30 JUNE 2016

5656

•

•


5757

• • •


30 JUNE 2016

5858


5959

• • •


30 JUNE 2016

6060

• • • • •

• •

•


6161

-

-

-

•

•


30 JUNE 2016

6262

•

•


6363

•

•


30 JUNE 2016

6464


6565


30 JUNE 2016

6666

•


6767

•


30 JUNE 2016

6868

•

•

•

•


6969

•


30 JUNE 2016

7070

•

•


7171

• •

•

•

•

•


30 JUNE 2016

7272


7373


30 JUNE 2016

7474


7575


30 JUNE 2016

7676


7777


30 JUNE 2016

7878


7979


30 JUNE 2016

8080


8181


30 JUNE 2016

8282


8383


30 JUNE 2016

8484


8585


30 JUNE 2016

8686


8787


30 JUNE 2016

8888


8989


30 JUNE 2016

9090


9191


30 JUNE 2016

9292


9393


30 JUNE 2016

9494


9595

Note:


30 JUNE 2016

9696

Note:

Note:

Note:


9797


30 JUNE 2016

9898


9999


30 JUNE 2016

100100


101101


30 JUNE 2016

102102


103103


30 JUNE 2016

104104


105105


30 JUNE 2016

106106


107107


30 JUNE 2016

90

250

Dr J Mongale works as an anaesthetist with the St John of God Hospital (Berwick)

Mr N Voll is on the board of management of Latrobe Health Services (private health

insurer). West Gippsland Healthcare Group has a commercial arrangement whereby it

receives private inpatient income from Latrobe Health Services.

108108


109109


30 JUNE 2016

110110

The annual report of the West Gippsland Healthcare Group is prepared in accordance with all relevant Victorian legislation. This index has been prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.

Legislation Requirement Page Reference

Ministerial DirectionsREPORT OF OPERATIONS CHARTER AND PURPOSEFRD 22G Manner of establishment and the relevant Ministers 25FRD 22G Purpose, functions, powers and duties 25FRD 22G Initiatives and key achievements 2, 18-24FRD 22G Nature and range of services provided 5 MANAGEMENT AND STRUCTUREFRD 22G Organisational structure 29 FINANCIAL AND OTHER INFORMATIONFRD 10A Disclosure index 110FRD 11A Disclosure of ex gratia expenses n/aFRD 21B Responsible person and executive officer disclosures 36FRD 22G Application and operation of Protected Disclosure 2012 34FRD 22G Application and operation of Carers Recognition Act 2012 34FRD 22G Application and operation of Freedom of Information Act 1982 34FRD 22G Compliance with building and maintenance provisions of Building Act 1993 34FRD 22G Details of consultancies over $10,000 35FRD 22G Details of consultancies under $10,000 35FRD 22G Employment and conduct principles 31FRD 22G Major changes or factors affecting performance 2, 18FRD 22G Occupational health and safety 31FRD 22G Operational and budgetary objectives and performance against objectives 18FRD 24C Reporting of office-based environmental impacts 14FRD 22G Significant changes in financial position during the year 18FRD 22G Statement on National Competition Policy 34FRD 22G Subsequent events n/aFRD 22G Summary of the financial results for the year 16FRD 22G Workforce Data Disclosures including a statement on the application of employment and conduct principles 31FRD 25B Victorian Industry Participation Policy disclosures 34FRD 29A Workforce Data disclosures 31SD 4.2(g) Specific information requirements 45SD 4.2(j) Sign-off requirements 36SD 3.4.13 Attestation on data integrity 36SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 36SD 4.5.5 Risk management compliance attestation 36

Financial Statements FINANCIAL STATEMENTS REQUIRED UNDER PART 7 OF THE FMASD 4.2(a) Statement of changes in equity 43SD 4.2(b) Comprehensive operating statement 41SD 4.2(b) Balance sheet 42SD 4.2(b) Cash flow statement 44OTHER REQUIREMENTS UNDER STANDING DIRECTIONS 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements 45SD 4.2(c) Accountable officer’s declaration 37SD 4.2(c) Compliance with Ministerial Directions 45SD 4.2(d) Rounding of amounts 50LEGISLATIONFreedom of Information Act 1982 34Protected Disclosure Act 2012 34Carers Recognition Act 2012 34Victorian Industry Participation Policy Act 2003 34Building Act 1993 34Financial Management Act 1994 35

Disclosure Index

111111

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112112

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COOINDA LODGEA G E D C A R E R E S I D E N C E

R E S I D E N T I A L A G E D C A R E S E R V I C E S

R E S I D E N T I A L A G E D C A R E

We s t G i p p s l a n d H e a l t h c a r e G r o u p




H E A L T H C A R E G R O U PW E S T G I P P S L A N D



H E A L T H C A R E G R O U PRAWSON COMMUNITY

West Gippsland Healthcare Group

H E A L T H C E N T R E

H E A L T H C A R E G R O U P

W E S T G I P P S L A N DH E A L T H C A R E G R O U P

WEST GIPPSLAND HEALTHCARE GROUP


W E S T G I P P S L A N D H E A L T H C A R E G R O U P R AW S O N C O M M U N I T Y H E A L T H C E N T R E

R AW S O N C O M M U N I T Y H E A L T H C E N T R E



HEAD OFFICE:West Gippsland Hospital41 Landsborough StreetWarragul Victoria 3820Phone: 03 5623 0611Fax: 03 5623 0896Email: [email protected]

www.wghg.com.au