2016/17 Annual report | Sunshine Coast Hospital and Health ... · In particular, the report...

Sunshine Coast Hospital and Health Service Annual Report 2016-2017

Sunshine Coast Hospital and Health Service

Page 2 Sunshine Coast Hospital and Health Service 2016 –2017 Annual Report Page 2

The Sunshine Coast Hospital and Health Service is committed to providing accessible services to Queenslanders from all culturally and linguistically diverse backgrounds. If you have difficulty in understanding the annual report, you can contact us on (07) 5470 6600 and we will arrange an interpreter to effectively communicate the report to you.

© (Sunshine Coast Hospital and Health Service) 2017

This annual report fulfils Sunshine Coast Hospital and Health Service’s reporting requirement to the community and to the Minister for Health and Minister for Ambulance Services. It summarises the Hospital and Health Service’s results, performance, outlook and financial position for 2016-2017.

In particular, the report outlines Sunshine Coast Hospital and Health Service’s performance against objectives identified in the Sunshine Coast Hospital and Health Service Strategic Plan 2016-2020, as well as the Queensland Government’s objectives for the community.

Open data:

We are committed to the Queensland Government’s open data strategy and have published additional information to form part of our 2016-2017 annual report. This information is published at: www.qld.gov. au/data

Sunshine Coast Hospital and Health Service has published the following data on the government’s Open Data website:

• consultancy expenditure

• overseas travel expenditure

• Queensland Language Services Policy.

Licence:

This annual report is licensed by the State of Queensland (Sunshine Coast Hospital and Health Service) under a Creative Commons Attribution (CC BY) 3.0 Australia licence.

CC BY Licence Summary Statement:In essence, you are free to copy, communicate and adapt this annual report, as long as you attribute the work to the State of Queensland (Sunshine Coast Hospital and Health Service).

To view a copy of the licence, visit: http://creativecommons.org/licenses/by/3.0/au/ deed.en

Attribution:

Content from this annual report should be attributed as: Sunshine Coast Hospital and Health Service Annual Report 2016–2017.

ISSN: 2202-5200

Public availability statement:

Copies of this publication can be obtained by:

• visiting www.health.qld.gov.au/sunshinecoast/ annual-reports

• phoning the Communications and Corporate Affairs Unit on (07) 5202 0085

• emailing [email protected]

For enquiries or further information please visit our website at www.health.qld.gov.au/sunshinecoast

Feedback can be provided through the Department of Premier and Cabinet’s website Get Involved at www.qld/gov.au/annualreportfeedback

Page 3Page 2

Commitment to Reconciliation

Collaboration

The Sunshine Coast Hospital and Health Service acknowledges and pays respect to the Traditional Custodians, the Gubbi Gubbi people, their elders, past, present and future on whose lands and waters we provide health services.

Achieving sustainable health gains for Aboriginal and Torres Strait Islander people on the Sunshine Coast and Gympie regions is a core responsibility and high priority for our ealth ervice and is a guiding principle of Making Tracks towards closing the gap in health outcomes for Indigenous Queenslanders by 2033.

VisionWe will:• Keep reconciliation and Closing the Gap as a reference for planning and

decision making.

• Promote the service’s commitment as everyone’s commitment.

We will: • Walk alongside each other• Value family and community• Together build capacity that puts Aboriginal and Torres Strait Islander people

at the centre of decision making• Assist people to make decisions regarding their own health and wellbeing.

IntegrityWe will: • Promote a culturally safe and sensitive approach to service delivery• Recognise and value diversity and how it can enrich our work and community.

We will:• Be a source of inspiration for ourselves and others• Bring our practice wisdom and lifelong learnings to our actions• Be creative, innovative and forever evolving in our wellness and holistic healing• Allow an inclusive environment for people to thrive• Celebrate success.

ResilienceWe will:• Respect Aboriginal and Torres Strait Islander culture and heritage.• Ensure the next footprints are ours for a better future.• Acknowledge that connection to culture and spirituality are key components

through which healing takes place.• Acknowledge the diversity of Aboriginal and Torres Strait Islander cultures

and circumstances.

Statement of

Page 4 Sunshine Coast Hospital and Health Service 2016 –2017 Annual Report

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Page 5

5 September 2017

The Honourable Cameron Dick MPMinister for Health and Minister for Ambulance ServicesGPO Box 48Brisbane QLD 4000

Dear Minister

I am pleased to present the Annual Report 2016-2017 and financial statements for Sunshine Coast Hospital and Health Service.

I certify that this Annual Report complies with:

• the prescribed requirements of the Financial Accountability Act 2009 and the Financial and Performance Management Standard 2009; and

• the detailed requirements set out in the Annual Report Requirements for Queensland Government agencies.

A checklist outlining the annual reporting requirements can be found at page 118 of this annual report or accessed at http://www.health.qld.gov.au/sunshinecoast/annual-reports/default.asp.

Yours sincerely

Dr Lorraine Ferguson AM

Chair, Sunshine Coast Hospital and Health Board

Letter of compliance


Contents

Letter of compliance ........................................................................5

Table of contents .............................................................................6

Board Chair’s overview ....................................................................7

Sunshine Coast Hospital and Health Service Chief Executive’s overview ............................................................8-9

Year in review ................................................................................10

Timeline of events .........................................................................11

Financial highlights ..................................................................12-13

1 Our organisation ..........................14Our biggest achievement this year..................................................16

SCUH staged opening sequence .....................................................17

SCUH patient activity from opening ................................................18

Accreditation for SCUH ...................................................................18

Our role and functions ...................................................................19

Vision, purpose and values ............................................................19

Our objectives, services and facilities .............................................20

Commitment to the government’s objectives...................................20

Growing population .......................................................................20

Aboriginal and Torres Strait Islander people ....................................21

Health service plan ........................................................................21

Strategic challenges and opportunities ...........................................21

Interpreter services .......................................................................21

Machinery of government ..............................................................21

Sunshine Coast Health Institute .....................................................22

Consumer engagement 2016-2017 ...........................................23-24

2 Our people ...................................25SCUH, a drawcard for specialist talent ............................................25

Clinician involvement in SCUH ........................................................26

Jean Haimes biography ..................................................................27

Leadership development ...............................................................28

Workforce profile ...........................................................................29

Employee recruitment, engagement and retention ..........................35

Work Health Safety and Wellbeing ..................................................36

3 Our performance ..........................37Service Delivery Statement .......................................................37-38

Performance against strategic objectives ........................................39

Spot ON ........................................................................................40

4 Our governance ............................41Hospital and Health Board .............................................................41

Organisational Structure ................................................................42

Board member profiles .............................................................43-46

Board committees .........................................................................47

Executive committees ....................................................................47

Audit and risk committee ...............................................................47

Finance and performance committee ..............................................47

Safety and quality committee .........................................................47

Hospital and Health Service Executive .......................................49-53

Strategic committees .....................................................................54

Ethics and code of conduct ............................................................54

Ethics awareness and fraud control ................................................54

Audit and risk management ...........................................................55

Right to information .......................................................................56

Administrative and functional records management ........................56

5 Our future ....................................57Continued growth for the health service .........................................57

New treatment targets cancer more closely .....................................58

Technology leads to more efficient care ..........................................58

6 Financial statements ....................59Statement of comprehensive income ..............................................61

Statement of financial position ......................................................62

Statement of changes in equity ......................................................63

Statement of cash flows ................................................................64

Notes to the financial statements ..................................................65

Management certificate ..............................................................108

Independent auditor’s report .......................................................109

Glossary .....................................................................................113

Compliance checklist ...................................................................120

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Sunshine Coast Hospital and Health Board Chair’s overview

It is with an immense sense of pride that I present the Sunshine Coast Hospital and Health Service (the health service) annual report for 2016/17, my second as Chair of the Hospital and Health Board (the Board).

Firstly, I wish to acknowledge the former Health Service Chief Executive Mr Kevin Hegarty, who following a commitment made to his family in 2012, chose not to renew his contract past 30 June 2017. I take this opportunity on behalf of the Board to sincerely thank Kevin for his significant contribution to the health service and the community of the Sunshine Coast over the past 13 and half years. His dedication, commitment and passion for improving the health and wellbeing of the entire community will long be remembered.

Without doubt, the greatest achievement for the health service this year was the successful and safe opening of the Sunshine Coast University Hospital in March 2017. The opening of a tertiary level healthcare facility will have far reaching benefits for the community we serve for decades to come and will ensure our patients receive the highest quality healthcare closer to home.

With the opening of Sunshine Coast University Hospital and subsequent relocation of services, redevelopment activities have commenced at Caloundra Health Service and Nambour General Hospital to ensure the health service is equipped to meet the future health needs of our community. I thank the community for their support during these important changes to the way we deliver health services on the Sunshine Coast. The Board will continue to monitor all governance aspects within the health service to ensure the most efficient and effective use of resources in an environment of increasing demand for public health services.

The Board’s Committees continue to provide high level strategic guidance and support across their domains of Audit and Risk, Finance and Performance and Safety and Quality ensuring transparent and robust governance. I would like to thank the Chairs of the respective committees for their diligence in discharging their responsibilities and providing the Board with the necessary assurance and advice to facilitate sound decision making.

I would also like to acknowledge Professor Karen Woolley whose term expired in May 2017 for her service as a Board member and to welcome Ms Anita Phillips as the new member of the Board. I would like to commend the Executive Leadership Team for their unwavering commitment, diligence and strong leadership over the past year. Their guidance and support enabled staff to meet the many challenges faced and contributed significantly to the successful safe opening of Sunshine Coast University Hospital.

Finally, on behalf of the Board, I take this opportunity to thank all staff across the organisation for their professionalism and dedication to providing our community with high quality healthcare during what has been an exciting but challenging year and look forward to continuing the journey that will see the health service continue to transform and grow into the future.


Sunshine Coast Hospital and Health Service Acting Chief Executive’s overview

2016-2017 has been a year of extraordinary achievement and change.

After years of preparation and planning, the Sunshine Coast University Hospital opened safely and successfully over a six-week period commencing in March 2017. This followed months of testing the equipment and services in the new building, recruiting more than 1000 people, training our teams, running scenarios, and planning the move of equipment, numerous staff and most importantly patients from our hospitals at Nambour and Caloundra.

Demonstrating the health service’s absolute commitment to the safety of patients and staff, the readiness for moving to the new hospital was tested with greater rigour than any other major hospital project. This included assessment of more than 1800 ‘go/no go’ indicators, covering all departments and units across the health service, and the oversight of the independent Clinical Readiness Advisory Group. This group of senior clinicians reviewed the ‘go/no go’ reports and the views of Service Group Directors to ultimately advise the Health Service Chief Executive of the health service’s readiness to move, independent to the project team. This process gave us a great deal of confidence that we were all ready for the major changes across the whole health service. This included the planned changing roles of Nambour and Caloundra hospitals, underpinned by the support provided by Maleny and Gympie hospitals, and our community health services.

Finally, to emphasise the success of the commissioning, the Australian Council on Healthcare Standards awarded interim accreditation to Sunshine Coast University Hospital on 9 May 2017 against the Australian Commission on Safety and Quality in Healthcare standards. Sunshine Coast University Hospital is the first new hospital to be accredited so close to service commencement.

Before patient care commenced at Sunshine Coast University Hospital, the Sunshine Coast Health Institute (the institute) opened on 9 January 2017, with approximately 1000 TAFE Queensland East Coast, University of Sunshine Coast and The University of Queensland staff and students commencing teaching and studying on the campus. This was the culmination

of many years of collaboration by all parties and the health service to establish this facility and partnership. The partnership will only improve now that the institute is operational, and the focus can turn to developing the health education and research capability on the Sunshine Coast. Disappointingly, despite announcements by the Federal Government during the year, engagement of the new medical school partner remains uncertain due to the need to allocate 15 extra Commonwealth-funded student places. It is hoped that this issue will be resolved through formal advice to the medical school partner early in 2017-2018 so that year one students can commence in time for the 2019 academic year. Along with our Sunshine Coast Health Institute partners, we are fortunate to have strong relationships with a number of other organisations without which we would not be able to provide excellent care. These include long-term partnerships with North Coast Aboriginal Corporation for Community Health, the Primary Health Network, the Sunshine Coast Local Medical Association, Ramsay Health Care and Exemplar Health. Added this year is the Florey Institute, which has come on board with the University of the Sunshine Coast and the health service to enhance our collective research capabilities, especially in neurosciences and mental health.

Our patients and staff also benefit from the substantial support received from Wishlist, our health service foundation, the extraordinary assistance of three auxiliaries at Nambour, Caloundra and Maleny hospitals, and hundreds of volunteers.

The 2016-2017 Annual Report provides evidence that, in addition to completing the most significant transformation of health services on the Sunshine Coast and Gympie, the health service continued to perform, meeting greater demand for services and improving many aspects of our performance. In the last three months of the year activity was higher than expected, with 11 per cent more patients admitted and presenting to emergency departments than the prior period. In addition, despite receiving around 1600 more referrals per month, the waiting list for outpatients has reduced by nine per cent since the start of the year, with a 19 per cent reduction in patients waiting over the recommended times since Sunshine Coast University Hospital opened. Despite a planned reduction

Page 9

Scott Lisle - Acting Health Service Chief Executive

in elective surgery during the Sunshine Coast University Hospital move period, the health service ended the year with 23 patients waiting outside the recommended period for elective surgery. Due to greater demand, emergency access performance deteriorated in the last few months of the year. Many changes are being implemented and this aspect of our performance is expected to improve during the next year.

I would like to thank all staff across the organisation for their professionalism, enthusiasm, commitment and resilience during the busiest year in the history of the health service. Special thanks also go to my colleagues on the Executive Leadership Team and the senior clinicians and other staff who all ensure that this health service continues to deliver for our communities.

I also take this opportunity to acknowledge the strategic direction and governance provided by the Hospital and Health Board, under the leadership of Dr Lorraine Ferguson AM.

Finally it is appropriate to acknowledge the contribution of our former chief executive, Kevin Hegarty, who led us through almost 14 years, finishing in what was one of our most successful. Kevin put this health service on very strong foundations that will help us continue our journey to provide more complex care and continue to deliver health and wellbeing through exceptional care.


Year in review

++

Infographic 1: Sunshine Coast Hospital and Health Service year in review 2016 - 2017.

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Infographic 1: Sunshine Coast Hospital and Health Service year in review 2016 - 2017.

June

July

Nov

Aug

Feb

Jan

Dec

Mar

April

May

June

2016

2017

Nurse navigator roles were implemented in Gympie and Maleny hospitals

Our Mental Health and Addiction Services lead the way developing a Mental Health Resources 4 Carers website

Gympie Hospital Director of Nursing Nicole White awarded the Dr HH (Barny) Moy Memorial Medal. The health service also recognised a collective length of service by staff of more than 8700 years Paediatric Audiologist Tania Sargent was nominated by medical students for the 2016 Teaching Award for Allied Health/Nursing education. The Geriatric Emergency Department Innovation (GEDI) team at Nambour General Hospital won the 2016 Premier’s Awards for Excellence in Customer Service.Three nurses awarded Outstanding Achievement in Nursing and Emerging Nurse Leader Awards at the 2016 Association of Queensland Nurse Leaders conference.

Gympie Hospital received six medical students for 12 months under the Griffith University Rural Longlook program.

2000 community members were given a sneak peek of Sunshine Coast University Hospital prior to its opening.

Four operational support service staff at Nambour General Hospital were recognised in the State Strategic Operational Services 2016 Excellence Awards.

Caloundra Health Service celebrated 50 years of caring for the community.

Gympie Hospital CT service commences.

The Sunshine Coast Health Institute hosted its first conference – the Queensland Critical Care Research Forum.

About 60 staff walked, jogged or ran the first SCUH2SCHI fun run.

Perioperative nurses Kim Armstrong and Julie-Ann Nicholls were awarded the Excellence in Perioperative Nursing and Novice awards at the Perioperative Nurses Association Queensland conference.

Dietitian Catherine Mc Farlane was awarded the Nutrition and Dietetics Emerging Researcher Award at the Dietitian’s Association of Australia’s National Conference.

Gympie hospital began a pilot for a diabetes education home service.

Sunshine Coast University Hospital opens to patients.

Child Health Access service celebrates 3rd birthday

Radiation oncology service begins at Sunshine Coast University Hospital.

Sunshine Coast University Hospital receives accreditation.

Technical completion awarded for Sunshine Coast University Hospital

Commercial acceptance awarded for Sunshine Coast University Hospital.

Sunshine Coast Health Institute opened successfully.

Official opening of Sunshine Coast University Hospital.

Infographic 2: Sunshine Coast Hospital and Health Service timeline of events 2016 - 2017.


Financial highlights

The Sunshine Coast Hospital and Health Service (”the health service”) reported total comprehensive income of $18.9M for the year incorporating a net revaluation increment of $11.6M

on land and buildings and an underlying operating surplus of $7.3M (from continuing operations).

The operating surplus result is an improvement of $6.3M from FY16 ($1.0M surplus) achieved from an operating revenue base of $997.4M. Key contributing factors include a combination of prudent fiscal management and non-cash revenue gains (predominantly land and building revaluations). The result

reflects the underlying delivery of agreed major services and is considered a good result for the health service, particularly given the complexities involved in the commissioning and opening of the Sunshine Coast University Hospital during the 2016-17 financial year.

Total operating income for 2016-17 was $997.4M, up 21% from 2015-16 ($826.6M), with the majority of this increase relating to additional activity purchased by the Department of Health associated with the opening of the Sunshine Coast University Hospital.

The following chart shows the major sources of total operating income by percentage, with the Queensland State Government (predominately the Department of Health) contributing the majority of the total source of funds.

Total operating expenditure for 2016-17 was $990.1M (averaging $2.7M a day), up $164.4M or 19% from 2015-16 ($825.7M). Major drivers of the increase include an 11% increase in delivered activity, combined with additional operating requirements of the Public, Private Partnership (PPP)

arrangement with Exemplar Health for the Sunshine Coast University Hospital. Chart 2 shows the breakdown of operating expenditure with labour and employment related expenses being the largest component.

High level operating result for the year ended 30 June 2017 $’000’s

Operating income 997,408

Operating expenditure (990,138)

Net surplus from operations 7,270

Operating income

Operating expenditure

Ope

ra

ting income

Commonwealth funding 27%

User charges 6%

Grants and contributions 2%

Other contributions 1%

Queensland State funding 64%

Total operating income = $997,408,000

Table 1: High level operating result for the year ended 30 June 2017

Chart 1: Operating income 2016 - 2017

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Total assets increased by $1.6B in 2016-17 to just over $2.0B ($407.5M in 2015-16) following the opening of the new Sunshine Coast University Hospital in March 2017 which saw approximately this value of assets being transferred to the HHS, including the main hospital building, car parks, major medical equipment, and fixtures and fittings.

Cash and InvestmentsAt balance date, the health service had $120.5 million in cash and investments. This balance includes the unspent portion of Stage 2 funding received for the information and communications technology assets for the Sunshine Coast University Hospital and the timing of payables including payroll. Depreciation expenditure is not cash funded however investment in non-current assets is.

Financial Sustainability RatiosCurrent ratio: At 30 June 2017, the health service had a current ratio of 1.40. This means for every $1.00 of current liabilities payable the health service held $1.40 in cash and receivables.

Average number of day’s cash available: At 30 June 2017, the SCHHS has cash available to cover 46.4 days of operating expenditure. The current target adopted by the health service is to have cash holdings equivalent to at least 14 days of operating cash outflows.

Operating surplus ratio —Net surplus/total revenue: As at 30 June 2017, the operating ratio was a positive 0.73 (extent to which operating revenue covers operating expenditure)

Future Financial OutlookThe health service is committed to providing better health outcomes for its community through redesign and innovation across the health service but also investment in its people and infrastructure. Financial year 2017-18 will be fiscally challenging for the health service with a strong focus on efficiency, particularly with the specific operational requirements of the new Sunshine Coast University Hospital and managing a larger cost base.

High level balance sheet as at 30 June 2017 $’000’s

Current assets 146,272

Non-current assets 1,892,032

Current liabilities (104,252)

Non-current liabilities (615,674)

Net assets (equity) 1,318,378

Total operating expenditure = $990,138,000

Chart 2: Operating expenditure 2016 - 2017

Table 2: High level balance sheet as at 30 June 2017

Ope

ratin

g expenditure

Supplies and services - 31%

Depreciation and amortisation - 4%

Interest expense - 2%

Other expenses - 1%

Labour and other employment related costs - 62%


Gympie

Birtinya

Caloundra

NambourMaroochydore

Noosa

Maleny

HOSPITAL

H

Sunshine Coast University Hospital

Sunshine Coast Health Institute

Maleny Soldiers Memorial Hospital

Caloundra Health Service

Nambour General Hospital

Gympie Hospital

HOSPITAL

H

HOSPITAL

H

H

H

Glenbrook Residential Aged Care Facility

Emergency Department, Surgical and Medical Services, Maternity, Palliative Care, Rehabilitation, Renal Dialysis,Specialist Stroke Unit, a range of community-based adult and child services.

45 bed purpose built facility, providing aged care in a home-like environment.

Purpose built facility for clinical research, training and teaching,in partnership with University of the Sunshine Coast,TAFE Queensland East Coast, and a medical school university.

Community FacilitiesHealth facilities based in Caloundra, Gympie,Maroochydore, Nambour and Noosa

Palliative Care, Community Services including Oral Health and Child Health,Renal Dialysis, Ophthalmology, Minor Injury and Illness Clinic.

Services are also provided for Sunshine Coast Hospital and Health Service patientsat Noosa Private Hospital and Sunshine Coast University Private Hospital, in Birtinya

Emergency Department, Cancer Care including radiation therapy and chemotherapy,Specialised Medical and Surgical Services, Trauma Service, Paediatric Service,Maternity Services, Special Care Nursery, Rehabilitation, Renal Dialysis,Mental Health, Interventional and Diagnostic Clinical Support Services,Specialist Ambulatory Care Services, Allied Health Services.

Emergency Department, Surgical and Medical Services, Chemotherapy, Renal Dialysis, Mental Health Services,Rehabilitation, Subacute Services, Specialist Ambulatory Care Services,Community Health Services.

Emergency Department, Medical Services, Palliative Care,Ambulatory Clinics, Essential Diagnostic and Clinical Support Services,Community Based Services.

Our organisation

Sunshine Coast Hospital and Health Service covers approximately 10,020 square kilometres. It encompasses the local government areas of Sunshine Coast, Gympie and Noosa; stretching to Gympie at its northern boundary, south to Caloundra and out to Kilkivan in the west.

Page 15

Gympie

Birtinya

Caloundra

NambourMaroochydore

Noosa

Maleny

HOSPITAL

H

Sunshine Coast University Hospital

Sunshine Coast Health Institute

Maleny Soldiers Memorial Hospital

Caloundra Health Service

Nambour General Hospital

Gympie Hospital

HOSPITAL

H

HOSPITAL

H

H

H

Glenbrook Residential Aged Care Facility

Emergency Department, Surgical and Medical Services, Maternity, Palliative Care, Rehabilitation, Renal Dialysis,Specialist Stroke Unit, a range of community-based adult and child services.

45 bed purpose built facility, providing aged care in a home-like environment.

Purpose built facility for clinical research, training and teaching,in partnership with University of the Sunshine Coast,TAFE Queensland East Coast, and a medical school university.

Community FacilitiesHealth facilities based in Caloundra, Gympie,Maroochydore, Nambour and Noosa

Palliative Care, Community Services including Oral Health and Child Health,Renal Dialysis, Ophthalmology, Minor Injury and Illness Clinic.

Services are also provided for Sunshine Coast Hospital and Health Service patientsat Noosa Private Hospital and Sunshine Coast University Private Hospital, in Birtinya

Emergency Department, Cancer Care including radiation therapy and chemotherapy,Specialised Medical and Surgical Services, Trauma Service, Paediatric Service,Maternity Services, Special Care Nursery, Rehabilitation, Renal Dialysis,Mental Health, Interventional and Diagnostic Clinical Support Services,Specialist Ambulatory Care Services, Allied Health Services.

Emergency Department, Surgical and Medical Services, Chemotherapy, Renal Dialysis, Mental Health Services,Rehabilitation, Subacute Services, Specialist Ambulatory Care Services,Community Health Services.

Emergency Department, Medical Services, Palliative Care,Ambulatory Clinics, Essential Diagnostic and Clinical Support Services,Community Based Services.


Undoubtedly the most significant achievement made by our organisation this year was the opening of Sunshine Coast University Hospital. This is the first new, not replacement, tertiary level hospital in Australia in more than 20 years.

After four years of construction, the new hospital was ready for Hospital Operational Commissioning in January 2017. Hospital Operational Commissioning is the process of transforming a building into a hospital, and was

an intensive period involving staff from across the health service. Service commencement and delivery was also supported by a wonderful team of more than 250 volunteers.

This period comprised activities to ensure that staff and volunteers were ready to transition, systems were operational and equipment was safe and in place. This included a number of real-life scenario tests, from the simulation of everyday situations to major events.

The Hospital Operational Commissioning period was signed off after a comprehensive process of readiness assessments covering all clinical and support services, and reports from external advisors. Sunshine Coast University

Hospital then began its staged opening sequence,also designed to ensure a successful and safe commencement of services.

Sunshine Coast University Hospital: our biggest achievement this year

66,000

ICT tests executed

20,000

Staff inductions delivered

5200

User acceptance tests conducted on new

biomedical equipment

420

Equipment and infrastructuretraining activities delivered

370

FF&E (fixtures, fittings and equipment) items delivered, installed and commissioned

Infographic 3: Sunshine Coast University Hospital - Hospital Operational Commissioning, January-March 2017

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Infographic 3: Sunshine Coast University Hospital - Hospital Operational Commissioning, January-March 2017

Sunshine Coast University Hospital was officially opened by the Premier of Queensland and the Minister for Health and Minister for Ambulance Services on 19 April 2017. From service commencement to the end of June 2017, the new hospital has already cared for more than 16,000 patients presenting to the emergency department, had more than 700 babies born, assessed and treated more

than 50,000 patients in outpatients and discharged almost 18,000 admitted patients.

New services will commence in stage 2 when Sunshine Coast University Hospital will expand to more than 600 beds from July 2018.

07

21

28

29

04

pathology, radiology, pharmacy and operational services staff began moving in

07 March 2017

first outpatient appoint-ments commenced

21 March 2017

first inpatients, and opening of the Emergency Department

28 March 2017

maternity services began

29 March 2017

elective surgery commenced

04 April 2017

March

April

Infographic 4: Sunshine Coast University Hospital staged opening sequence, March to April 2017


Emergency Department presentations

16,845

50,638Outpatients visits

Births

724

Elective surgeries

1042

On 9 May 2017, Sunshine Coast University Hospital received interim accreditation from the Australian Council on Healthcare Standards.

Accreditation is recognition of the achievement of 10 National Safety and Quality Health Service Standards, demonstrated through an independent external assessment of performance.

Accreditation is an essential independent assurance of the quality of care provided and the systems and procedures that underpin consistent provision of safe care.

The systems, standards and processes at Sunshine Coast University Hospital are those that apply across our organisation. They are underpinned by the commitment of all our staff to deliver care to the highest standard and to do so in a caring and professional way.

The achievement of interim accreditation can directly be attributed to clinicians maintaining a focus on patient safety during the transition and opening of the hospital. Clinicians were involved in the planning and facilitation of the accreditation processes in many ways including maintaining evidence, sharing knowledge and experience, assisting with the designing and implementation of new models of care, quality improvement activities and meeting with surveyors.

The enthusiasm of our clinicians to continuously improve our service was evident throughout the accreditation process and was recognised by the surveyors.

Sunshine Coast University Hospital was the first new hospital to receive accreditation under the full suite of national standards within such a short time after opening. This outcome, while expected, demonstrates the absolute commitment of staff across the entire health service to patient safety in the preparation and execution of the changes the new hospital has brought to health service delivery across the Sunshine Coast and Gympie regions.

Accreditation for the Sunshine Coast University Hospital

Infographic 5: Sunshine Coast University Hospital patient activity from opening (21 March 2017) to end of FY17

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Our role and function

Sunshine Coast Hospital and Health Service (the health service) is the major provider of public health services, health education and research in the Sunshine Coast, Gympie and Noosa local government areas.

Established in 2012, the health service is an independent statutory body governed by the Sunshine Coast Hospital and Health Board.

We operate according to the service agreement with the Department of Health which identifies the services to be provided, funding arrangements, performance indicators and targets to ensure the expected health outcomes for our communities are achieved.

Our Strategic Plan 2016-2020 outlines our vision, purpose, values, objectives and future direction as well as how we work with our community to improve people’s health and wellbeing.

Our visionHealth and wellbeing through exceptional care.

Our purposeTo achieve our vision by delivering better care and experience for individuals, better health outcomes for our population and better use of resources for healthcare.

Our valuesThe values of the health service underpin the culture of our organisation. We have adopted the Queensland Public Service values of:

Customers first

• know your customers• deliver what matters• make decisions with empathy

Ideas into action• challenge the norm and suggest

solutions• encourage and embrace new

ideas• work across boundaries

Unleash potential

• expect greatness• lead and set clear expectations• seek, provide and act on

feedback

Empower people

• lead, empower and trust• play to everyone’s strengths• develop yourself and those

around you

Be courageous

• own your actions, successes and mistakes

• take calculated risks• act with transparency


Our objectives• better care and experience for individuals• better use of resources for healthcare• better outcomes for our local population.

These objectives are supported by improving capability across our organisation and shared communities of practice. Our objectives reflect our commitment to working closely with the Queensland Government to implement:

• the Queensland Government’s objectives for the community

• the Queensland Health Strategic Plan 2016-2020• Queensland Health’s Health and Wellbeing Strategic

Framework 2016-2020• Queensland Health’s My health, Queensland’s future:

Advancing health 2026.

Commitment to the government’s objectivesIn keeping with the Queensland Government’s objectives, the health service has in 2016-2017:

• ensured National Safety and Quality Healthcare Standards are met or exceeded

• enhanced patient access, safety and quality care• ensured our services are connected to improve access to

health and care for our population• optimised the use of our resources• supported and expanded our workforce to ensure it

is engaged, competent and valued.

Our servicesSunshine Coast Hospital and Health Service delivers a range of hospital-based specialty and sub specialty services in surgery, medicine, mental health, women’s and families. It also provides community integrated and sub-acute services.

Our facilitiesAt the core of our health service are five main hospital facilities, providing a range of acute and sub-acute services:

• Sunshine Coast University Hospital—tertiary hospital that services all parts of the Sunshine Coast and Gympie regions

• Nambour General Hospital—acute regional facility that services the Nambour and hinterland region

• Gympie Hospital—provides acute regional services to residents in the Gympie, Cooloola and Kilkivan areas

• Caloundra Health Service—is the hub for the health service’s palliative care and ophthalmology services and provides a range of outpatient, ambulatory and community-based services

• Maleny Soldiers Memorial Hospital—rural facility providing services to the Maleny region

• Glenbrook Residential Aged Care Facility—high care residential aged care facility in Nambour

• Community and other health centres—25 centres located across the health service.

Sunshine Coast Hospital and Health Service also funds public patient services at Noosa Private Hospital and Sunshine Coast University Private Hospital.

Growing populationWith an estimated resident population of 389,663 in 2015, the region is one of the fastest growing population areas in Queensland. Annual growth is expected to be approximately two per cent per year, with the population reaching more than 434,000 by 2021 and 527,309 by 2031.(Data source: InfoBank population projections 2015 edition - previous figures from the 2013 edition).

We have an ageing population. In 2015, it is estimated that 20 per cent of the population was aged over 65 years. This is projected to increase to approximately 35 per cent by 2031. (Data source: InfoBank population projections 2015 edition - previous figures from the 2013 edition).

Page 21

Compared to the whole of Queensland, our region has:

• similar low Socio-Economic Indexes For Areas (SEIFA)• higher per cent of residents aged over 65 years• lower per cent of Aboriginal and Torres Strait Islander

people• similar age and health risk factors• lower avoidable hospital deaths• higher per cent born in Australia• lower per cent of people aged 15 to 24 years• lower diabetes mellitus per 100 population.

Aboriginal and Torres Strait Islander people Aboriginal and Torres Strait Islander people account for 2.1 per cent of the health service’s population compared to 4.5 per cent for Queensland. We have a higher percentage of Aboriginal and Torres Strait Islander people under 19 years than the Queensland average. This age group represents 50 per cent of the total Aboriginal and Torres Strait Islander population in the Sunshine Coast Hospital and Health Service region.

Work on the Sunshine Coast Hospital and Health Service Diversity Plan is ongoing. Three action plans are included within the Diversity Plan including Aboriginal and Torres Strait Islander Health Action Plan (Closing the Gap), Disability Action Plan and the Multicultural Action Plan.

The health service currently employs 89 staff who have identified as Aboriginal and Torres Strait Islander people, which represents 1.34 per cent of the workforce. As our regional Aboriginal and Torres Strait Island population represents 2.1 per cent of the total population, we continue to focus on closing the gap.

Health service planThe Sunshine Coast Hospital and Health Service’s Health Service Plan 2012–2022 was developed through consultation and engagement with consumers, our staff and the wider community. It provides essential direction to ensure our transition toward the health service organisation we aim to be in 2016-2017 and beyond is achieved. The plan provides information on:

• how our communities’ health needs will change over the next five years

• the health service’s responses to meeting these needs• service priorities to 2022.

Strategic challenges and opportunitiesLike other health services in Australia and internationally, Sunshine Coast Hospital and Health Service operates in a complex and challenging environment balancing efficient service delivery with high quality health outcomes to meet the government’s expectation of ensuring that healthcare expenditure achieves value for society. Our main challenges are:

• workforce – capacity and capability of the workforce

• health technology – ability to introduce new and advanced technologies

• financial – ability to maintain budget integrity

• patient safety and quality – meeting already established regulatory, industry and community expectations

• demand – increased consumer, community and government expectations.

Interpreter servicesThe Queensland Health Interpreter Service provides interpreters in Queensland Health public facilities for patients from non-English speaking backgrounds. Interpreters are provided on-site (face-to-face), via video conference or over the phone. Interpreters are available 24 hours a day, seven days a week and are provided at no charge to the client. Our interpreter service expenditure during 2016-2017 can be found on the Queensland Government’s Open Data website www.qld.gov.au/data.

Machinery of government changesThere were no machinery of government changes which impacted Sunshine Coast Hospital and Health Service’s operations.


Sunshine Coast Health InstituteThe Sunshine Coast Health Institute (the institute) is a training, education and research facility at the Sunshine Coast University Hospital. It is a unique joint operation partnership between the Sunshine Coast Hospital and Health Service, the University of the Sunshine Coast, TAFE Queensland East Coast and a university that will deliver medical education.

The institute is expected to play an integral role in the delivery of the vision for the Sunshine Coast University Hospital, “to provide excellent care through collaboration”.

The objectives of SCHI are the:

• development of an integrated, collaborative and comprehensive education, skills training and research facility for health professionals

• provision of tools and training to improve the skills of doctors, nurses allied health professionals and other health staff

• enhancement of the quality of patient care • fostering of connectivity and collaboration across the

domains of education, patient care and research.

Sunshine Coast Health Institute commenced activities in January 2017, with more than 900 students on campus in Semester 1 studying nursing, midwifery, nutrition and dietetics. Training and education for health service staff also increased significantly since the opening of Sunshine Coast University Hospital in March 2017.

Unique collaboration strengthens research and education

The three research labs, designed for the handling of chemicals or other materials in liquid form, have achieved compliance. Lab activity will begin operations when University of the Sunshine Coast researchers take up occupancy in the third quarter of 2017.

Partnerships have been established with key stakeholders within the Sunshine Coast Health Campus and wider Sunshine Coast Health Precinct, with the Institute’s vision of collaboration at the forefront of the stakeholder engagement. A dedicated website for the Institute provides greater detail of the education, research and partnerships

offered at the facility—www.schealthinstitute.com.au

Page 23

Consumer engagement 2016–2017

Consumers engaged

Consumer and Community Engagement

137 Consumers signed up to the consumer engagement register.

End of LifeCare CommitteePatient Safety andQuality CommitteesIntegrated care alliance

Consumers have been engaged through focus groups and workshops in the development of models of care, including:

Maternity and neonatal servicesRehabilitation Major trauma

Rehabilitation Assessment Unit Consumer GroupRenal Consumer GroupMaternity Consumer Group

Issue-specific consumer groups have been developedto empower consumers, including:

Renal services

Cancer care

Diabetes

Midwifery group practice working group.

Medication safety committeeInfection control committeeMental Health Services Committees.

Patient

2400 Patient Experience Tracker (PET) surveys were completed in 2016/17, enabling consumers to provide anonymous feedback conveniently. A postcard feedback system introduced to SCUH allows consumers to

rate the facility, acknowledge staff and alert us to any problems. By the end of June 2017 over 1200 cards had been collected, with 79% of cards rating SCUH positively and over 100 staff

members acknowledged by consumers.

In 2016/17 27 patient experience surveys were commissioned by clinicians across a range of services, seeking feedback from their consumers. In

early 2016 the benchmark phase of a three phase patient experience survey to assess the impact of the opening of

SCUH on health service consumers was undertaken.

PET

Good governance

The health service governance processes for inclusion and engagement of

consumers have been developed and implemented; including a procedure, and an intranet page containing tools and staff

resources.

experience

Paediatric Consumer GroupACAT Consumer GroupPublication Review Group.

Sunshine Coast Hospital and Health Service’s consumer engagement program is overseen by the Consumer Advisory Group which was established in 2013 to foster meaningful, two way dialogue between the health service and the wider community. The purpose of the committee is to improve the health outcomes and experiences for consumers of our health services by ensuring that decision making has a patient focus.

Membership is comprised of 11 individuals who are consumers of the health service, carers of consumers, or

members of the health service community. Members are appointed on a volunteer basis and membership is based on experience of local healthcare service delivery and understanding of local and regional issues. Our current Consumer Advisory Group members are from diverse community and health experience backgrounds including university lecturers, retired engineers, health managers, teachers and patients/carers. Membership includes consumers from all parts of the region.


As in previous years, the health service continues to receive a significantly higher proportion of compliments (1532 or 63 per cent of total feedback ) than complaints (890 or 36 per cent of total feedback). Compliments and complaints provide valuable information to improve our services. 91 per cent of complaints were resolved within 35 days in 2016-2017 (target is 80 per cent).

In addition to the many consumer engagement activities undertaken this year, two significant community engagement events were held at Sunshine Coast

University Hospital, strengthening the connection and communication between health service staff, the new facility, and the wider community. These were two Sunshine Coast University Hospital open days, which provided facility tours prior to the new hospital’s staged opening. The first, held on 11 February 2017, was dedicated to staff and their families and a community open day was held on 25 February 2017. A combined total of more than 4000 people toured the hospital over the two days.

Page 25

Our people

Sunshine Coast University Hospital, a drawcard for specialist talent

The quality and profile of the new Sunshine Coast University Hospital is attracting specialists from far and wide, further strengthening our patient services.

One of those specialists is Professor James O’Beirne.

Prof O’Beirne is a hepatologist, a specialist in liver medicine, caring for patients with conditions such as viral infections of the liver, liver cancer and cirrhosis. He joined the health service from the Royal Free Hospital in London, one of the six liver transplant centres in England. Prof O’Beirne developed the UK’s first multidisciplinary liver cancer clinic and has conducted clinical research with colleagues leading to the publication of over 60 articles. He brings a wealth of tertiary experience to the Sunshine Coast Hospital and Health Service.

“The appointment of additional specialists extends the existing strengths of the Hepatology Department. It means we are now able to treat patients with serious or complex liver disease right here on the coast, which is a huge benefit to our patients and their carers. I am also developing a clinical research portfolio, which I hope will bring additional cutting edge treatments to the population of the coast.” Prof O’Beirne said.

“There was an attraction in building something world class from the ground up, like we are doing at Sunshine Coast University Hospital. The environment and facilities

at Sunshine Coast University Hospital are superb and bang up to date. This must contribute to the feeling of optimism all the staff seem to have. People seem genuinely happy to be at work and this makes it a wonderful environment.”

“It was quite a gamble to relocate a family with two teenagers to the other side of the world. But I am delighted to say we are all very happy with the change, and my sons are thriving at their new school. The Sunshine Coast is a wonderful place to live. It is a stimulating environment and the lifestyle is incredible.”

Hepatologist, Prof James O’Beirne


High quality and safe patient care is always the first priority of our health service. This was the focus of every aspect of the planning, design and commissioning of Sunshine Coast University Hospital. To ensure we deliver safe services, staff engagement is essential and our absolute commitment to consulting with staff is key to our success. This is why the health service involved senior clinicians from initial scoping right up to the decision of when to open.

Dr Ratna Aseervatham, Director of Surgical Services, provided essential clinical input throughout Sunshine Coast University Hospital’s planning and development process.

“Our Chief Executive approached me and other senior clinical colleagues when the funding commitment for Sunshine Coast University Hospital was first announced. Clinical input went right back to selecting the parcel of land on which we would build,” he said.

This group of clinicians, known as the G8, provided early input into the design of the new hospital.

The G8 considered multiple real-life scenarios to ensure the design would make the delivery of care as safe, efficient and comfortable as possible. As well as general input, the clinicians also had specific input into theirareas of expertise. For example the respiratory ward was designed by respiratory specialists.

Senior clinicians continued to play a key role in the later stages of Sunshine Coast University Hospital’s development. A Clinical Readiness Advisory Group was established to provide a direct clinical voice during theHospital Operational Commissioning period. Chaired by Dr Aseervatham, this committee ensured a rigorous patient safety approach and provided a formal expert

clinician sign-off on the health service’s readiness to move into the new hospital and also reconfigure services at Nambour and Caloundra hospitals. The group also assessed the preparation of Maleny and Gympie hospitals and community health services for the significant changes to services across the whole region. The Clinical Readiness Advisory Group’s advice was taken unedited to the Sunshine Coast Hospital and Health Board. This level of clinician involvement has set a new benchmark for major hospital commissioning.

“The high level of clinical involvement in the development of Sunshine Coast University Hospital reflected learnings and recommendations from previous hospital openings. It also reflects the general culture of the health service: committed to patient safety, rigorous in our planning and engaged with clinical staff,” he said.

Clinician involvement in the development of Sunshine Coast University Hospital

Dr Ratna Aseervatham, Director of Surgical Services,

Page 27

In 1976, Jean became a nurse in the 40-bed medical ward (2A) in Block 1 at Nambour General Hospital. Today, Jean is a nurse manager at Nambour and is located in the very room she attended her job interview in 1976—the ‘Matron’s Office’.

I worked as a registered nurse in the medical ward for 12 months then moved to the surgical ward (where the Surgical Care Unit is now situated). This ward consisted of 30 surgical beds and 10 paediatric beds. In those days there were no staff in the Emergency Department and the registered nurse in the surgical ward had to answer the Emergency Department buzzer, leave the ward and process the patient or patients in the Emergency Department.

In the 1970s, patients had a much longer stay in hospital compared to now. Of course the techniques and equipment used in procedures are now much more sophisticated, providing a much faster recovery time for patients.

Over the years I’ve seen many changes in nursing. The training of registered nurses has changed from being hospital-based to university-based and when I first began my career, nurses used to stay in the Nurse’s Quarters, although this was gradually phased out.

The nurses at Nambour General Hospital have always been excellent and very patient-focused. The rapid growth of the Sunshine Coast region has meant we have had to grow to keep up with this demand. Medical science has also gone ahead in leaps and bounds. We now have greater ability

to prolong the life of our patients, but this is also bringing the challenge of caring for an ageing population.

I have loved every minute of my time as a nurse. I always loved the clinical aspect and the patient contact and now in my present role, I feel I am looking after the nurses who are looking after the patients and helping to provide the skill mix and nursing ratios needed to achieve the best outcomes.

The transition to Sunshine Coast University Hospital has been amazing for our health service. I have remained at Nambour General Hospital but see Sunshine Coast University Hospital as a great move for the future of healthcare on the Sunshine Coast.

I have loved every minute of my time as a nurse. I always loved the clinical aspect and the patient contact.

Jean HaimesWhen Jean Haimes first joined Nambour General Hospital, she was just 17 years of age.

Registered Nurse, Jean Haimes


Leadership development

The 2016-2017 financial year saw the continued delivery of a number of leadership development programs. These were designed to empower and enable a strong and positive leadership culture for the health service. The two priority programs were the Step Up Leadership Program and the Process Communication Model® (PCM). • Step Up Leadership Program is a two-month program

designed to meet the complex leadership needs of the health service. The program focuses on developing and strengthening the skills staff need to supervise, motivate and provide effective leadership within a healthcare team. Normally offered as a state-wide, Queensland Health program to clinical staff only, Sunshine Coast Hospital and Health Service has adopted it and delivered this program in-house. There have been four programs with a total 87 attendees in 2016-2017.

• Process Communication Model® (PCM) is a course that has had international success and is supported by the Royal Australasian College of Surgeons for advanced training positions. It aims to teach participants how to observe and analyse verbal and non-verbal behaviours to ensure they communicate effectively, specifically in high pressured situations. There have been four programs with a total of 46 attendees in 2016-2017.

A number of health service staff also accessed leadership development workshops and initiatives offered by Human Resources, Corporate Services Division, Department of Health. In addition a range of other courses are provided to staff as summarised in Table 5 below.

Table 3: Other significant development and awareness training delivered by the health service includes:

MCP Attendance 2016-2017 No. of sessions

No. of staff attendance

MCP1(A) - Recruiting for Success: Selecting the right candidate 45 313

MCP1(B) - Recruiting for Success: Policy and obligations 37 112

MCP2 - Effective performance discussions 11 24

MCP3 - Work health and safety for managers and supervisors 3 40

MCP4 - Working together: supporting ill or injured employees 10 31

MCP5(A) - Payroll Management Foundations: Payroll Assurance 48 212

MCP5(B) - Payroll Management Foundations: Workbrain Assurance 49 205

MCP6 - Team Socialisation 18 18*

LEADS Management Capability Program (MCP) – Line Manager Essentials

*Note: For MCP6 Team Socialisation the number of staff attending is the number of teams

Page 29

Workforce profile

Sunshine Coast Hospital and Health Service is working to ensure we have a sustainable and highly-qualified workforce to meet our future needs. There are a number of challenges facing the future growth of our organisation, including:

• further commissioning of new services and growth in demand

• an ageing workforce

• significant population growth on the Sunshine Coast

• a multi-generational workforce. In order to meet these challenges and other emerging needs of the health service environment, it is critical we continue to invest in our people.

The opening of Sunshine Coast University Hospital was supported by a dedicated human resource function, which supported the health service’s readiness for the expansion of services through initiatives including comprehensive workforce planning, transition, establishment, recruitment, onboarding and change management activities. As at 30 June 2017, we employed 5378 Full Time Equivalent (FTE) people, representing a Minimum Obligatory Human Resource Information (MOHRI) Headcount of 6613 employees.

Table 4: Our workforce profile - Minimum Obligatory Human Resource Information (MOHRI) Occupied FTE (full time equivalent)

Employment category FY2016(note 1)

FY2017(note 2)

Health practitioners 502.16 655.15

Managerial and clerical 906.24 1097.74

Medical including Visiting Medical Officers (VMOs) 583.57 712.15

Nursing 1763.72 2082.21

Operational 499.58 778.21

Professional and technical 39.80 40.10

Trade and artisans 14.00 12.00

Total 4309.07 5377.56

Notes:1. Includes all full time, part time and casual health service employees at the end of June 20162. Includes all full time, part time and casual health service employees at the end of June 2017


Employment category FY2016 FY2017

Health practitioners 488.90 554.20

Managerial and clerical 840.50 990.44

Medical including Visiting Medical Officers (VMOs) 557.04 633.99

Nursing 1689.65 1850.84

Operational 500.56 610.93

Professional and technical 37.59 41.17

Trade and artisans 12.42 12.73

All paypoints 4126.66 4694.29

Table 5: Year-to-date MOHRI average FTE

Over the past financial year:

• the workforce (MOHRI Occupied FTE) increased by 1068 FTE or 24.8 per cent. Clinical streams accounted for 56.2 per cent and non-clinical for 43.8 per cent of the growth. The increase was mainly associated with the opening of Sunshine Coast University Hospital

• clinical streams make up 64.9 per cent of the workforce

• the headcount (MOHRI Occupied Headcount) increased by 1122 or 20.4 per cent

• the headcount to Occupied FTE ratio increased from 1:0.78 to 1:0.81.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%2013 2014 2015 2016 2017

Permanent Temporary Casual

2.9%

18.4%

78.7% 78.0% 76.1% 72.7% 75.3%

19.3% 20.7% 24.4% 20.6%

2.7% 3.2% 2.9% 4.0%

Employee status - 5 years to FY2017

The majority of our employees are employed permanently - reaching a peak of 78.7 per cent in the 2013 financial year. In the 2017 financial year, the proportion of permanent employees was 75.3 per cent, casual staff increased from 2.9 per cent to 4.0 per cent, and temporary

employees dropped from 24.4 per cent to 20.6 per cent. These changes were largely due to the winding up of the Sunshine Coast University Hospital project following the opening of the new hospital.

Chart 3: Five-year workforce type comparison: based on MOHRI Occupied FTE

Page 31

Chart 4: Five-year workforce type comparison: based on MOHRI Occupied FTE

Employee status - 5 years to FY2017

The proportion of part time employees remained steady at nearly 40 per cent of MOHRI Occupied FTE from 2012-2013 to 2015-2016, but has dropped to 35.7 per cent in 2016-

2017. Full time employees increased from 57.6 per cent in 2015-2016 to 60.3 per cent in 2016-2017.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%20172013 2014 2015 2016

Permanent Temporary Casual

35.7%

60.3%57.7% 57.6% 56.9% 57.6%

39.4% 39.7% 39.9% 39.5%

2.9% 2.7% 3.2% 2.9% 4.0%

Over the period 2012-2013 to 2014-2015 there was a steady increase in the proportion of employees aged over 55 years, with an increase from 21.6 per cent in 2012-2013 to 23.4 per cent in 2014-2015. However, the over 55 rate dropped slightly to 23.3 per cent in 2015-2016, and has dropped to 22.0 per cent in 2016-2017. The proportion of employees aged less than 25 years has averaged 3.6 per cent over the last five years, but has

increased to 4.7 per cent in 2016-2017. Supporting our ageing workforce is a key focus in our Strategic Workforce Plan.

The average age of our workforce reduced from 45.36 years in 2015-2016 to 44.65 years in 2016-2017, mostly due to the influx of new staff to Sunshine Coast University Hospital.

Age distribution comparison over the last five years

Chart 5: Age distribution comparison over five years (MOHRI Occupied FTE)

4.7%

Under 25 yrs 25 yrs to 54 yrs 55 yrs and over

20172013 2014 2015 2016

80%

70%

60%

50%

40%

30%

20%

10%

0%

73.3%75.6% 74.0% 73.2%

23.4% 23.3%

72.9%

2.8% 3.4% 3.4% 3.8%

22.0%21.6% 22.5%


Length of service

The average length of service has dropped from 9.05 years in 2015-2016 to 8.21 years in 2016-2017.

At 10.09 years, the trades and artisans stream has the longest average length of service. This is followed by nursing at 9.56, health practitioners at 8.37 and operational at 7.28 years. Medical and Visiting Medical Officers have the shortest average length of service due to the rotation of junior medical staff.

Table 6: Permanent retention rate per cent (MOHRI Occupied Headcount)

Permanent Retention Rate 2013 2014 2015 2016 2017

Sunshine Coast Hospital and Health Service permanent retention rate

92.96 93.73 94.85 95.68 95.02

Queensland Health retention rate 89.58 93.07 94.38 94.60 93.78

Chart 6: Permanent retention rate per cent (MOHRI Occupied Headcount)

The health service has maintained a permanent employee retention rate of more than 92 per cent from 2013 to 2017. While the rate dropped slightly in 2016-2017, the overall trend has been upward and for the past two years has exceeded 95 per cent. Retaining the right people is a key element in the Sunshine Coast Hospital and Health Service Employee Retention Plan 2012-2017 as we undergo significant workforce growth.

SCHHS Permanent Retention Rate QH Retention Rate

20172013 2014 2015 201680%

85%

90%

95%

100%

Health service vs QH permanent retention rate

Chart 7: Per cent of People with Disabilities (PWD) in our workforce (June 2017)

The health service supports the As One Public Service Disability Employment Strategy. As at June 2017 1.47 per cent of the workforce (97 employees) had identified as having a disability.

PWD Surveyed

Medical inc. VMOs

Nursing HP. Professionaland technical

Managerialand clerical

Operational Trades Health service total

Empl

oyee

s su

rvey

ed

Per c

ent

100%20.0%

18.0%

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

2.0%

4.0%

0.0%

80%

60%

40%

20%

0%

1.47%

Page 33

Chart 8: Diversity in the workforce (2016-2017)

Increasing Aboriginal and Torres Strait Islander representation in employment and reducing the overall level of disadvantage among Indigenous Australians, is an integral part of the health service’s commitment to closing the gap between Indigenous and non-Indigenous Australians.

The health service currently employs 89 staff who have identified as Aboriginal and Torres Strait Islander people, which represents 1.34 per cent of the workforce.

Aboriginal and Torres Strait Islander Target Surveyed

Medical inc. VMOs

Nursing HP, Professionaland technical



Empl

oyee

s su

rvey

ed

Per c

ent

100%4.0%

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%

80%

60%

40%

20%

0%

1.34%

Chart 9: Per cent of Non-English Speaking Background (NESB) in our workforce (June 2016)

The health service encourages and supports linguistically diverse backgrounds across all occupational streams. As at 30 June 2017 7.1 per cent (470 employees) have identified themselves as having a non-English speaking background.

NESB SurveyedPSC Target

Medical inc. VMOs

Nursing HP. Professionaland technical



Empl

oyee

s su

rvey

ed

Per c

ent

100%20.0%

18.0%

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

2.0%

4.0%

0.0%

80%

60%

40%

20%

0%

7.10%


Table 7: Per cent of women in our workforce (2016-2017)

Per cent female by stream 2013 2014 2015 2016 2017

Health practitioners 77.8 76.6 76.7 76.8 76.9

Managerial and clerical 89.2 87.1 86.8 84.9 85.4

Medical incl Visiting Medical Officers (VMOs) 36.4 39.8 38.9 39.2 40.1

Nursing 86.7 86.7 86.7 86.5 86.1

Operational 58.7 59.3 58.2 58.1 52.5

Professional 64.1 62.8 62.8 68.1 72.9

Technical 100.0 - 100.0 100.0

Trade and artisans 0.0 0.0 0.0 0.0 0.0

All paypoints 75.7 75.8 75.9 75.7 74.3

According to the Australian Government Gender Equality Agency report July 2013, the highest representation of women working in any industry was in healthcare. The health service workforce has consistently been composed of nearly 76 per cent women from FY2013 to FY2016, but has dropped to 74.3 per cent in FY2017.

In FY2017 the highest representation of women is in the Nursing stream at 86.1 per cent, with Managerial and Clerical at 85.4 per cent and Health Practitioners at 76.9 per cent. The lowest is in the Trades and Artisans stream with no women. The female representation in Medical and Visiting Medical Officers has increased from 36.4 per cent in FY2013 to 40.1 per cent in FY2017.

Page 35

Employee recruitment, engagement and retention strategies

The provision of public health services in Sunshine Coast Hospital and Health Service has undergone a significant change in the past year with the transition of services from Nambour General Hospital and Caloundra Health Service, and the opening of Sunshine Coast University Hospital.

Our workforce has experienced significant change, including employees transitioning to new work locations, temporary employees securing permanent roles, and existing employees undertaking career progression.

The health service will continue to expand the services it provides to the community over the next four years. The attraction, recruitment, development and retention of the workforce is paramount.

The Sunshine Coast Hospital and Health Service Strategic Workforce Plan 2011-2021 ensures workforce planning and development is effectively addressed.

The health service continues to align with the Public Service Commission’s Conduct and Performance Excellence (CaPE) framework in the management of employee conduct and performance. The focus remains on early identification of issues, implementing good practice and developing line manager capability.

Matters relating to allegations of suspected corrupt conduct are reported to the Crime and Corruption Commission. During 2016-2017, Sunshine Coast Hospital and Health Service had carriage of 123 new matters; of which 30 matters were assessed as suspected corrupt conduct and 93 relating to other ethical and employment related matters. Of the 30 new matters assessed as suspected corrupt conduct; three matters were substantiated, two matters had partial substantiation, five were not substantiated and 20 matters continue to be managed. A Health Service Consultative Forum, along with local consultative forums representative of our workforce disciplines, continues to operate in line with the Public Service Commission Guidelines for Consultative Forums. These forums enable a strong focus and commitment to local resolution and provide a robust framework for consultation between management and unions on matters arising out of industrial instruments, workforce change or other workforce matters.

Organisational and workforce service change activitiesThe impacts of reforms across the health service as a result of workforce transition, service reconfiguration and the opening of the Sunshine Coast University Hospital in March 2017 resulted in the establishment of a dedicated human resource project team. This team supported the workforce service change processes required for the opening of Sunshine Coast University Hospital and the settling of services across all facilities.

These changes included realignment of clinical and corporate support services, role changes, roster changes, hours of operation and reporting line changes.

A range of human resource workforce change and roster change processes, templates and documents were piloted and modified to support ongoing human resource workforce change initiatives.

The health service also implemented roster working parties reporting to the Consultative Forum as an employee and union consultative strategy to oversee trial roster changes prior to formal agreement and implementation.

Nineteen Business Cases for Change were released during the period November 2016 to June 2017. These communication, consultation and engagement processes required for working arrangements and roster changes for employees have resulted in improvements to the efficiency and effectiveness of our staff and services and are consistent with the models of care developed over previous years.

Early retirement, retrenchment and redundancy

The health service continued to identify efficiencies through organisational change throughout 2016-2017, focussing on suitable employment placements for affected employees. Despite the significant changes to the workforce as a result of Sunshine Coast University Hospital service commencement, only one employee was offered and accepted a voluntary redundancy package ($137,586).


People are the focus of the Sunshine Coast Hospital and Health Service, and our commitment to ensuring the safety, health and wellbeing of all workers including volunteers, students, contractors and other persons is a key underpinning factor supporting the provision of safe and quality public healthcare services.

The health service undertakes safety assurance activities to monitor the effectiveness of the safety management system and identify areas for improvement these include: • Work Health and Safety Legislative Compliance Check • Safety Management System Executive Review• external audit of the safety management system against

Australian Standard 4801—Safety management systems • Australian Council for Healthcare Standards

accreditation • internal WHS Audit and Inspection program. The opening of the Sunshine Coast University Hospital created an opportunity to embed critical, proactive Work Health and Safety activity early on in the Sunshine Coast University Hospital journey. A proactive Work Health and Safety assurance and validation framework was coordinated to:

• integrate with the final stages of Sunshine Coast University Hospital commissioning

• support the official opening sequence • embed a series Work Health and Safety lead indicators

in the first calendar year of Sunshine Coast University Hospital.

This early integration of Work Health and Safety in the Sunshine Coast University Hospital journey will influence Work Health and Safety culture during a critical period in health service transition and transformation. The aim is to ensure safe environments are maintained and a culture of

safety and wellbeing is promoted.The health service implementation of the new Queensland Health incident and risk management software solution Riskman has commenced and is expected to be operational in November 2017. Once implemented the program will provide enhanced WHS incident management and reporting capability.

There was a decrease in Work Health and Safety incidents reported per 1000 full time equivalent for 2016—2017 in comparison to 2015—2016. Ergonomics, occupational violence and slips/trips and falls are the top three WHS risk exposures. Incidence of each causative factor has remained approximately stable in compared to last year.

WorkCover Performance Indicators

• 2016—2017 hours lost (WorkCover versus Occupied FTE) has improved 0.326 per cent (target 0.33 per cent)

• new claims 2016—2017 at 324 was below the industry average of 326.48

• average days first return to work at 31.43 was above the industry average of 21.37.

Work Health Safety and Wellbeing

Page 37

Our performance

Table 8: Service Delivery Statement

Notes 2016-2017Target/Est.

2016-2017Actual

Percentage of patients attending emergency departments seen within recommended timeframes:

• Category 1 (within 2 minutes) 100% 99.7%





• All categories - 69%

Percentage of emergency department attendances who depart within four hours of their arrival in the department

>80% 71.5%

Median wait time for treatment in emergency departments (minutes) 20 21

Median wait time for elective surgery (days) 25 28

Percentage of elective surgery patients treated within clinically recommended times:

Category 1 (30 days) >98% 96%



The Sunshine Coast Hospital and Health Board is responsible for the delivery of the organisation’s strategy and monitoring of performance.

We measure our success by our ability to achieve the objectives set out in our Strategic Plan 2016-2020. The Sunshine Coast Hospital and Health Service performance is also monitored through a Service Agreement with Department of Health.

In 2016-2017 the health service delivered increased services to our growing population. The table below provides information on the volume of services provided.

Our performance against the Service Delivery Statements is outlined below.

Delivering our services


CONT. Notes 2016-2017Target/Est.

2016-2017 Actual

Percentage of specialist outpatients waiting within clinically recommended time

Category 1 (30 days) 80% 67.39%

Category 2 (90 days) 55% 49.1%

Category 3 (365 days) 70% 87.11%

Total weighted activity units (WAUs): 1

Acute inpatient 81,628 76,876

Outpatients 19,633 13,870

Sub-acute 7411 6538

Emergency department 17,401 17,309

Mental health 8511 12,979

Prevention and primary care 2 4424 4767

Number of Telehealth outpatient occasions of serviceNew

Measure2181

Average cost per weighted activity unit for activity based funding facilities 3 $5231 $5150

Rate of healthcare associated Staphylococcus aureus activity (including MRSA) bloodstream (SAB) infections/10,000 acute public hospital patient days

4 <2.0 0.56

Rate of community follow-up within 1-7 days following discharge from an acute mental health inpatient unit

> 65 % 64.38%

Proportions of readmissions to an acute mental health inpatient unit within 28 days of discharge

< 12 % 12.82%

Ambulatory mental health service contact duration (hours) 67,780 58,034

Service delivery statement notes:

Notes:

1. A WAU is a measure of activity and provides a common unit of comparison so that all activity can be measured consistently. Service agreements between the Department of Health and HHSs and other organisations specify the activity to be provided in WAUs by service type.

2. The health service achieved a total of 144,010 WAU (including Procedures and Interventions) compared to a target of 139,008.3. The 2016-17 Estimated Actual figure reflects 1 July to 31 December 2016 activity based costs and actual activity based funded activity. The Target/

Estimate reflects the activity based funding less Clinical Education and Training and Specified Grants and activity within the finance and activity schedules of the Final Round Service Agreements Contract Offers. Target/Est. for cost per Queensland WAU includes HHS activity forecast over delivery in 2016-17, funded by the Commonwealth at a marginal rate of 45%. As a result, funding per Queensland WAU in 2017-18 is generally lower than the 2016-17 Target/Est cost per Queensland WAU. The impact of this is partially offset in some HHSs due to changes in Own Source Revenue classification between 2016-17 and non- Queensland WAU investments. 2016-17 Est Actual cost per Queensland WAU is a point in time measure which includes the first 6 months of HHS expenditure and activity. It includes the impact of one-off investments in 2016-17.

4. This is a National Performance Agreement indicator and a measure of effectiveness of infection control programs and services in hospitals. Staphylococcus aureus are bacteria commonly found on around 30 per cent of people’s skin and noses and often cause no adverse effects. Infections with this organism can be serious, particularly so when they infect the bloodstream. The data reported for this service standard are for bloodstream infections with Staphylococcus aureus (including methicillin resistant Staphylococcus aureus) and are reported as a rate of infection per 10,000 patient days. The Target/Estimate for this measure aligns with the national benchmark of 2 cases per 10,000 acute public hospital patient days for each jurisdiction. The 2016-17 Estimated Actual figures are based on actual performance from 1 July 2016 to 31 March 2017.

Page 39

In early 2016 Sunshine Coast Hospital and Health Service reviewed and updated its strategic objectives to guide the work of the health service in a period of growth and change.

We remain committed to fundamentally changing and enhancing healthcare delivery across our region. The key strategic focus during 2016-2017 has been the successful commissioning of Sunshine Coast University Hospital and the resulting reconfiguration of services across the region.

Better care and experience for individuals

We are committed to ensuring our patients receive safe and reliable care. In 2016–2017 we worked to achieve this through:

• achieving interim accreditation of Sunshine Coast University Hospital

• conducting, and implementing the recommendations from, the BEaRS (Base Excess and Renal Substitution solution) study to decrease patients’ length of stay in intensive care by designing a better, less complex system for patients on kidney support

• piloting the SPOT ON program (in collaboration with the Queensland Ambulance Service and Central Queensland, Wide Bay and Sunshine Coast Primary Health Network) to reduce the number of unnecessary admissions to emergency departments

• creating an enriched environment to provide stimulation for stroke patients, where there is access to physical, social and cognitive activity while they recover

• participating in a Queensland University of Technology led study to determine patients’ risk of developing heart disease.

Better use of resources for healthcare

We endeavour to deliver healthcare by managing our resources as efficiently as possible. In 2016-2017 we achieved this through:

• delivering a favourable budget result as well as significantly increased activity, enabling investments in 2017-2018 in initiatives like stage 2 of the Electronic Medical Record program

• implementing the Patient Flow Manager system to provide staff with a convenient digital view of patient status from admission through to discharge

• successfully opening the new Sunshine Coast University Hospital and progressing the refurbishment of Caloundra Health Service and Nambour General Hospital to better meet community needs

• implementing a Minor Injury and Illness Clinic at Caloundra Health Service to meet community needs

• continuing to expand our Telehealth service which has improved patients’ hospital access, enabling them to see clinical specialists from home.

Better outcomes for our local population

We are working to better connect our services to improve access to health and care for our population. To facilitate this, the health service has adopted a ‘one health service, many campuses’ model. In 2016–2017 achievements include:

• commencement of the nurse navigator service. Nurse navigators focus on patients with complex healthcare needs and provide end-to-end care coordination to ensure their needs are met

• implementing a nurse-led breast cancer review clinic at Gympie Hospital to complement specialist management and provide more holistic care to patients, emphasising the psychosocial and physical effects of a patient’s diagnosis and treatment

• establishing the Acute and Restorative Care service for older people at Nambour General Hospital, to provide care to older people with both acute and chronic diseases who are finding it difficult to manage in the community.

Better organisational capability

Our people are our greatest asset as we continue to grow to meet the challenges of future health needs. This year has seen record workforce expansion to support the successful opening of Sunshine Coast University Hospital, including:

• 54 medical interns

• 70 nursing and midwifery graduates

• more than 1000 new staff for Sunshine Coast University Hospital.

Performance against strategic objectives


SPOT ON with patient care

Our Supporting Patient Outcomes through Organised Networks (SPOT ON) team were finalists at the 2016 Queensland Health and Department of Health Awards for Excellence in Brisbane.

SPOT ON is an innovative collaboration between Queensland Ambulance Service (QAS), General Practitioners (GP) and the Central Queensland, Wide Bay, Sunshine Coast PHN, as well as the emergency departments, the Safety and Quality redesign team, Silverchain and the Queensland Health Improvement Unit.

The SPOT ON pilot was established to trial the adoption of integrated care pathways for patients who request ambulance transport for minor injury or illness.

The model of service delivery focuses on a greater role for primary care staff and paramedics in reducing lower acuity (category 4 and 5) presentations to health service emergency departments.

During the pilot, QAS transported 890 patients directly to Medical Centres rather than hospital.Approximately 60 per cent were transported to their own GP and 40 per cent to a Tier 2 GP practice (extended scope/hours).

An additional 500 patients were referred by QAS to a GP, and not transported, either to patient’s own GP or Tier 2 GP practice.

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Our governance

The Sunshine Coast Hospital and Health Board (the Board) is the governing body of the Sunshine Coast Hospital and Health Service. The Board is responsible for providing strategic direction and oversight of the organisation, to ensure objectives and goals meet the needs of the community and are in line with government health policies and directives.

The Board is comprised of eight members who were appointed by the Governor in Council on the recommendation of the Queensland Minister for Health and Minister for Ambulance Services (the Minister), in accordance with the provisions of the Hospital and Health Boards Act 2011. The Board reports to the Minister.

New Board members are inducted at both the local and state-wide level. Ongoing professional development and education is provided to Board members as appropriate, to ensure they have a clear understanding of their roles, responsibilities and duties as a member.

The functions of the Board, as articulated in the Board Charter, include but are not limited to:• overseeing the health service, including its control and

accountability systems• providing input into and final approval of management’s

development of organisational strategy and performance objectives, including approving the Service Agreement with the Department of Health

• monitoring the Health Service Chief Executive and other senior executives’ performance

• reviewing, approving and monitoring systems of risk management, internal control and legal compliance

• approving and monitoring the annual health service• budget and financial and performance reporting.

The Board’s major priority for 2016-2017 was ensuring the new Sunshine Coast University Hospital commenced safe patient services in March 2017. The Board was required to determine readiness based on various recommendations provided by numerous readiness assessment processes and criteria. Other key Board achievements for 2016-17 include:

• governance and oversight of the Sunshine Coast University Hospital Program and subsequent successful opening of the new hospital.

• development and approval of the 2016–2020 (updated 2017) Strategic Plan

• approval of the health service budget• approval of the Internal Audit Charter and internal audit

strategic and annual plans• approval of the health service accounting policies and

the annual financial statements• review and approval of Board and Committee Charters• completion of Board and Board Committee evaluations.

Hospital and Health Board


Organisational structure

• HR Business Partners• Complex case management• Recruitment Services (including medical (SMO)• recruitment)• Training and Development• Workforce Planning and Reform• Establishment Management

• Finance, Funding and Performance• Business Services • Asset and Infrastructure Management Services -BEMS• Contracts, Procurement and Commercial Services

Professional Leads• Executive Director Medical• Executive Director Nursing and Midwifery• Executive Director Allied Health

Service Groups • Surgical Services, Medical Services - Clinical Support Services,

Community Integrated and Sub-acute Services, Mental Health and Addiction Services, Women’s and Families Services

• Clinical Access and Operations• Facilities

• Knowledge Technology Management• Information Services• ICT Business Analysis• Clinical Information and Records• Corporate Records

• Safety, Quality and Innovation• Research• Education

Office of the CE• Director • Internal Audit• Communications and

Corporate Affairs• Legal Counsel• Risk Management• Board Operations• Ethics and Integrity

• SCUH Transformation and Transition program• Health Service Planning, Commissioning and Operational Design

Sunshine Coast Hospital and Health Board

Health Service Chief Executive

Executive Director Finance, Business and Operational Services

Executive Director Clinical Services

Chief Information Officer

Executive Director Innovation, Quality,Research and Education

ChairpersonClinical Council

Executive Director SCUH Program

Executive Director Human Resources

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Dr Lorraine Ferguson AM is a registered nurse, a respected educator, an experienced executive, board member and author of a number of published works on healthcare reform, clinical management and nursing. She was appointed a Member of the Order of Australia in 2002 for service to critical care nursing, particularly in clinical, management and education disciplines, and to professional nursing organisations.

Since 2008, Lorraine has worked as a casual academic and independent education consultant, and has been involved in research and development of online educational materials for a number of tertiary institutions. Previously she held a conjoint appointment as Associate Professor of Nursing (Clinical Leadership and Professional Development) with the University of Western Sydney and the Sydney West Area Health Service.

Lorraine has held senior nursing and management positions at The College of Nursing, Northern Sydney Area Health Service and Royal North Shore Hospital.

She has also served as a member of nursing executive teams, and as a member and chair of local, state and national committees including quality, casemix, clinical costing, healthcare funding, research ethics and curriculum development.

She also held numerous board memberships and executive positions including President and Honorary Treasurer, New South Wales College of Nursing.

Lorraine currently holds Adjunct Associate Professor positions with the University of the Sunshine Coast and the University of Western Sydney.

Board member profiles

Original appointment date 1 July 2012. Current term 18 May 2016 to 17 May 2019.

Original appointment date 6 September 2012. Current term 27 May 2016 to 17 May 2019.


Board ChairRN, BSocSc, MPH, PhD, FACN, Ass.FACHSM, ACCCN (life member), Dip Company Directors Course

Peter Sullivan

Deputy ChairBBus (Acc), FCPA

Mr Peter Sullivan is a highly-credentialed executive and has held a broad range of financial leadership and strategic planning positions in large and complex organisations.

Peter was the Pro Vice-Chancellor (Corporate Services) and Chief Financial Officer of the University of the Sunshine Coast from 2007 until his retirement in 2013 and was responsible for overseeing a range of business functions to facilitate the ongoing financial and planning viability of the university.

Peter provided advice on budget and financial management issues as well as major strategy and policy functions.

His key achievements included the establishment of a planning and reporting framework that allowed the University to undertake strategic and operational planning. He also established an audit and assurance framework to assist the university in its stewardship responsibilities, as well as establishing an open and accountable system of governance and continuous improvement processes.

Prior to that appointment Peter was appointed Executive Director — Finance and Resource Planning at the Queensland University of Technology, where he was responsible and accountable for corporate planning and resourcing policies and practices of the university.


Original appointment 6 September 2012. Current term 18 May 2016 to 17 May 2019

Edward (Ted) Weaver is a Senior Medical Officer in the Department of Obstetrics and Gynaecology within the Sunshine Coast Hospital and Health Service. He is also an Associate Professor in the Department of Obstetrics and Gynaecology and Deputy Head of the Sunshine Coast Clinical School, both within The University of Queensland.

From 1990 to 2011, he was a private specialist in obstetrics and gynaecology in Nambour and a visiting medical officer at Nambour and Selangor Private Hospitals. In 2001 he was awarded an Honorary Fellowship of the Australian College of Midwives in recognition of work developing collaborative systems of maternity care.

Ted was Vice President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) from 2006, and President from 2008, during a time of significant maternity care reform in Australia.

Ted is currently the Chair of the Queensland Training Accreditation Committee for RANZCOG, overseeing specialist Obstetrician and Gynaecologist training in Queensland hospitals. He was on the Board of Directors for the RANZCOG Research Foundation, responsible for the financial management, fundraising and overall financial viability of the foundation, and for overseeing the annual awarding of eight research scholarships. He was a member of the Recognition of Medical Specialists committee of the Australian Medical Council.

In 2011, Ted was awarded The University of Queensland Medical Society and School of Medicine Distinction in Clinical Teaching Award for the Sunshine Coast Clinical School.

Ted was awarded an Order of Australia Medal (General Division) for his service to medicine and to medical education in the 2016 Australia Day Honours.

Associate Professor Edward Weaver OAM

Board memberMBBS, FRANZCOG, FACM (Hon)

Original appointment 18 May 2013. Current term 17 May 2017

to 18 May 2020

Appointed 18 May 2013 to 17 May 2017

Cosmo Schuh

Board memberBBus, CA, CPA

Dr Karen Woolley Board memberPhD(MedSc), BSc/BEd(HonsClass)

Cosmo Schuh has worked as a Public Accountant in Gympie and South East Queensland for more than 35 years. After graduating from the University of Southern Queensland in 1976, he moved to Gympie and developed an accounting business, servicing the Gympie area and extending throughout rural Queensland.

Cosmo has been involved extensively in property development and syndication, financial management, estate planning and strategic management for small to medium businesses. He sits on a number of boards for private and public companies and is a Director of a family Charitable Foundation. He is also a Registered Company Auditor.

Dr Karen Woolley has more than 25 years’ experience in medical research and publications within tertiary hospital settings and the biotech and pharmaceutical industry in North America and the Asia Pacific region.

In 2000, Karen co-founded ProScribe Medical Communications, an internationally recognised medical writing company that won the Queensland Premier’s Regional Exporter of the Year in 2014. In December 2014 Karen sold ProScribe to the Envision Pharma group and now leads the Asia Pacific division.

Karen is the recipient of an Honorary Doctorate from the University of the Sunshine Coast, is a Fellow of the American Medical Writers Association, a Life Member of the Association of Regulatory and Clinical Scientists and has received several business awards (including the Telstra Business Woman of the Year Award). She is also a Certified Medical Publication Professional.

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Appointed 18 May 2017 to 17 May 2020

Brian Anker

Board memberMAICD

Brian Anker has held a number of senior executive roles within the Queensland Government. Until November 2010 he was the Deputy Director-General, Innovation of the former Queensland Department of Employment, Economic Development and Innovation, and worked in partnership with leaders in industry, science and technology.

In 2011, Brian established Anker Consulting Pty Ltd, to provide strategic advice and planning particularly to the research and university sectors. He has undertaken strategic reviews for the University of the Sunshine Coast, assisted the University of Queensland and Queensland University of Technology on specific funding projects, and assisted the Sunshine Coast Regional Council on project assessments. In addition he provides employee mentoring to corporations.

Brian currently is the Chair of the federally funded National Research Data Services Initiative, and Chair of the Sunshine Coast Education and Research Taskforce. He has also acted as strategic advisor to a number of Queensland-based universities.

Brian has an extensive background in the business and industry sectors. He is a current member of the Australian Institute of Company Directors, and has been a member on a number of boards and committees. Brian has also served as a government representative on review bodies for the Australian Institute of Bioengineering and Nanotechnology, Australian Tropical Forest Institute, Australian Tropical Science and Innovation Precinct, and the Institute for Molecular Bioscience.

Original appointment 18 May 2013. Current term 18 May 2017 to 17 May 2020

Anita Phillips

Board memberBA, Grad Dip Leg.Studs, MPA, Dip Soc.Studs, GAICD, AMAASW

Anita Phillips has an extensive career spanning more than thirty years as an Executive Director in the public sector at all levels of government and in social welfare and community services agencies.

Her most recent position was as the Public Advocate/Guardian in the Australian Capital Territory. Anita also brings valuable experience as a former Member of the Queensland Parliament and an adviser to Federal Ministers. After graduating as a social worker, Anita spent many years in North Queensland, predominately in hospital and health settings. She has also worked in a diverse range of health and community settings, where she enjoyed direct consultation with patients, their families and other consumers of these services, as well as managing and developing these agencies.

Anita holds a Master of Public Administration and a Graduate Diploma in Legal Studies, and is a sessional lecturer in Legal Studies and Public Policy in Social Work at the Australian Catholic University. Since 2014, Anita has conducted her own consultancy, Calm Energy Consulting, through which she provides services and is a Board Director for several not-for-profit agencies.

She has current governance experience, in that she is a Graduate of the Australian Institute of Company Directors, and has been appointed by the Commonwealth Government as a Community Member on the Aboriginal and Torres Strait Island Health Practitioners’ Board, and is an elected Director on the National Board of the Australian Association of Social Workers.


Original appointment 1 July 2012. Current term 18 May 2017 to 17 May 2020

Dr Mason Stevenson

Board member MB ChB

Professor Julie-Anne Tarr

Board member PhD, JD, LLM, BA, GAICD

Dr Mason Stevenson has 30 years’ experience as a General Practitioner (GP), the majority on the Sunshine Coast. He has held senior roles within medical associations since 1996 and owned and managed medical practices since 1990.

Mason began his medical career in Melbourne after completing his studies at Monash University in 1983. He completed his internship and Junior Resident Medical Officer training at the Queen Victoria Medical Centre. Once completed, Mason worked as a doctor for the MelbourneDoctors After Hours Cooperative for a number of years before joining the Glen Waverley Medical Centre in Melbourne as a Principal General Practitioner Assistant in 1988.

In 1990, Mason moved to the Sunshine Coast to open and work in his own private practice as a GP. Mason received his Vocational Registration — General Practitioner in 1996. This same year he became an owner in a group GP practice with three other doctors and Treasurer of the Sunshine Coast Division of General Practice for two years.

Mason has held various executive positions within medical associations including Treasurer and President of the Sunshine Coast Local Medical Association (SCLMA), Treasurer and President of the Australian Medical Association (AMA) of Queensland, and Queensland representative for the AMA Federal Council. From 2010 to mid 2014, Mason worked as a GP subcontractor while continuing in executive positions within these organisations.

Professor Julie-Anne Tarr brings a diverse background in commercial law and governance to the Board. As a Professor in the Business School of the Queensland University of Technology, her particular area of speciality is complex project management, insurance and risk.

From 2007 to 2010, Julie-Anne served as the General Manager/Chief Operational Officer of the Queensland Institute of Medical Research and was also actively engaged in the Boards of several medical research facilities and start-up companies.

Prior to returning to Australia in 2007, Julie-Anne worked at the Director of USP Solutions, the commercial arm of the University of the South Pacific and at Indiana University, where she held a professorial appointment in the Law School.

Julie-Anne has authored three books on Insurance and risk, several editions of the Laws of Australia treatise on Insurance and Insurance Contracting, and a number of articles and law reform reports.

She is a Fellow of the Australian Centre for Philanthropy and Non-profit Studies and has served on the Humanitarian Law Committee for the Red Cross (Qld) as well as a number of other community based non-profit bodies.

She holds degrees from The University of Queensland (PhD), Cornell University (JD), Monash University (LLM), and University of Wisconsin (BA).

Original appointment 18 May 2016. Current term 18 May 2017 to 17 May 2021

Page 47

The Board has legislatively prescribed committees which assist the Board to discharge its responsibilities. Each committee operates in accordance with a Charter that clearly articulates the specific purpose, role, functions and responsibilities.

The committees are:

• Executive Committee• Audit and Risk Committee• Finance and Performance Committee• Safety and Quality Committee.

Executive CommitteeThe role of the Executive Committee is to support the Board in its role of controlling our organisation by working with the Health Service Chief Executive to progress strategic priorities and ensure accountability in the delivery of services.

Committee members:• Dr Lorraine Ferguson AM (Chair)• Mr Peter Sullivan• Assoc Prof Edward Weaver.

Audit and Risk CommitteeThe purpose of the Audit and Risk Committee is to provide independent assurance and assistance to the Board on:

• the organisation’s risk, control and compliance frameworks

• the Board’s external accountability responsibilities as prescribed in the Financial Accountability Act 2009, the Hospital and Health Boards Act 2011, the Hospital and Health Boards Regulation 2012 and the Statutory Bodies Financial Arrangements Act 1982.

The Audit and Risk Committee has observed the terms of its charter and had due regard to the Treasury’s Audit Committee Guidelines.

The Audit and Risk Committee is responsible for overseeing, advising and making recommendations to the Board on the following matters, including but not limited to:

• appropriateness of the health service’s financial statements, ensuring compliance with relevant accounting policies and standards

• monitoring and advising the Board about the internal audit function

• consulting with Queensland Audit Office — the external auditor in relation to proposed audit strategies and annual audit plans

• reviewing the findings and recommendations of external

audit (including from performance audits) and the management response

• reviewing the risk management framework for identifying, monitoring and managing significant risks, including fraud

• assessing and contributing to the audit planning processes relating to the risks and threats to the health service

• reviewing, through the internal and external audit functions, whether relevant policies and procedures are in place and complied with, including those for management and exercise of delegations.

Committee members:• Mr Cosmo Schuh (Chair)• Professor Julie-Anne Tarr• Mr Peter Sullivan.

Finance and Performance CommitteeThe Finance and Performance Committee oversees the financial position, performance and resource management strategies of the health service in accordance with relevant legislation and regulations. It also provides advice and recommendations to the Board on the following matters including, but not limited to:

• assessing the budgets and ensuring they are consistent with the organisational objectives and having appropriate regard to the organisation’s funding to enable the approval of the annual budgets by the Board

• monitoring the financial and operating performance of the health service

• monitoring activity performance against prescribed indicators and targets

• monitoring the health service’s performance against relevant Service Agreement KPIs specifically related to performance and funding

• monitoring human resource indicators and compliance with the health service strategic workforce planning.

Committee members:

• Mr Peter Sullivan (Chair)• Mr Brian Anker• Mr Cosmo Schuh• Dr Mason Stevenson.

Safety and Quality CommitteeThe role of the Safety and Quality Committee is to ensure a comprehensive approach to governance of matters relevant to safety and quality of health services is developed and monitored. The Committee is also responsible for advising the Board on matters relating to safety and quality of health services provided by the health service including:

Board Committees


SCHHB meetings

Executive Committee

Finance and Performance Committee

Audit and Risk Committee

Safety and Quality

Committee

Total number of meetings 12 1 12 4 4

Dr Lorraine Ferguson AM 10 1

Assoc Prof Edward Weaver 10 1 3

Mr Peter Sullivan 12 1 12 4

Dr Mason Stevenson 11 12 4

Dr Karen Woolley 11* 3*

Mr Brian Anker 12 10 4

Mr Cosmo Schuh 10 10 4

Prof Julie-Anne Tarr^ 12 4

Ms Anita Phillips * 1

Table 9: Board member meeting attendance 2016-2017

• strategies to minimise preventable patient harm• reducing unjustified variations in clinical care• improving the experience of patients and carers of the

health service in receiving health services• monitoring the health service governance arrangements

relating to the safety and quality of health services, including monitoring compliance with health service policies and plans about safety

• promoting improvements in the safety and quality of health services being provided.

Committee membership:• Mr Brian Anker (Chair)• Dr Mason Stevenson• Dr Ted Weaver• Dr Karen Woolley (until 17 May 2017)• Ms Anita Phillips (from 6 June 2017).

*Ms Anita Phillips appointed 18 May 2017*Dr Karen Woolley’s term expired on 17 May 2017* There were no out of pocket expenses for Board members.

Page 49

Hospital and Health Service executive

Kevin Hegarty

Health Service Chief Executive (until 30/06/2017)

BBus (Acc), MAICD, MCHSM

Reporting to the Health Service Chief Executive are executives who are responsible for a portfolio within the organisation. Together they form the Executive Leadership Team.

Kerrie Hayes

Executive Director Clinical ServicesBNurs, Grad Dip Ed, Grad Cert Mgt (Health)

The Executive Director Clinical Services is accountable for the management of integrated clinical services across the health service. This role ensures that current ‘best practice’ models for safe and effective clinical care and consumer involvement are in place to deliver on our operational and strategic actions and achieve better health for our communities on the Sunshine Coast.

This leadership role focuses on continuous improvement and optimising the health service performance across these key result areas: patient safety and service quality; access and equity of services; balanced budget performance; workplace culture; partnerships; cooperation and integration; prevention and health outcomes; clinical education and research.

Kerrie joined the Sunshine Coast Hospital and Health Service team in October 2014 and has extensive Australian and New Zealand experience in health service leadership and service development at executive level. Kerrie is passionate about collaborating and working with clinicians, support staff and consumers to actively participate in making health services better for our communities.

The Health Service Chief Executive is accountable to the Board for all aspects of our performance including the overall management of human, material and financial resources, and the maintenance of health service and professional performance standards. The Health Service Chief Executive, with the Board, is also responsible for ensuring the development of our strategic direction.

Kevin served in senior positions within Queensland Health from 1995, including District Manager of the Rockhampton Health Service District. He commenced as District Manager Sunshine Coast Health Service District in December 2003, and continued as Chief Executive in a number of iterations of the health service’s structures.

Kevin was appointed inaugural Health Service Chief Executive of Sunshine Coast Hospital and Health Service on its creation as a statutory body on 1 July 2012. He was directly involved with the development and progress of the Sunshine Coast University Hospital, since its announcement in 2005.

He was the Senior Responsible Officer for all aspects of the commissioning on the new hospital

Throughout his time as Chief Executive, Kevin worked with senior clinicians to grow and expand both service capacity and capability. This saw the strategic development of services, particularly in the context of preparing for the opening of Sunshine Coast University Hospital.

After 13 years of service, Kevin left the organisation at the end of the 2016-2017 financial year. At the time of this report’s publication, Scott Lisle, Executive Director Sunshine Coast University Hospital Program, was acting in the Health Service Chief Executive role.


The Executive Director Finance, Business and Operational Services provides leadership and strategic advice on the financial performance and the financial management of our organisation to the Board, Health Service Chief Executive, Executive Leadership Team and senior management.

The Executive Director Finance, Business and Operational Services supports the Health Service Chief Executive in strategic negotiations with Department of Health, and has an overarching responsibility to enable the maximisation of our revenue streams.

John commenced with the health service in April 2015.

He began his career with 12 years working for PricewaterhouseCoopers (PwC), initially employed in business services, taxation and audit. John later moved to Senior Manager roles in audit, as an IT specialist and financial advisory. Over the following 15 years John gained valuable experience from senior roles in commercial businesses including finance, change management, business development and company restructuring.

Between 2009 and 2015 John gained a strong understanding of Queensland Health and the challenges faced in providing health services as the Chief Finance Officer for the Cairns and Hinterland Hospital and Health Service.

John is committed to maintaining the financial sustainability the Service has achieved since its establishment in 2012 while providing access to high quality care.

John Slaven

Executive Director Finance, Business and Operational ServicesB Commerce CA

Dr Margaret WayExecutive Director Innovation, Quality, Research and EducationBSc, MBA, FACHSM, DrPH

The Executive Director Innovation, Quality, Research and Education is a key member of the Executive Leadership Team accountable for the effective leadership and management of safety and quality, clinical and corporate governance functions, ensuring effective consumer engagement, oversight and leading initiatives to increase organisational effectiveness and high quality patient care.

The role is responsible for leading the development of teaching, training and research activities across the health service, and establishing a central hub to support faculties and partnering academic organisations including those at Sunshine Coast Health Institute. Margaret joined the health service in March 2017 and has extensive experience in health service leadership, strategy and performance. Her previous positions at Austin Health and Alfred Health involved strategic planning, performance improvement, and implementing clinical governance systems and processes to deliver effective and safe healthcare to patients. She has a strong research and educational background underpinned by a Masters of Business Administration from Monash University, a Professional Doctorate in Public Health at LaTrobe University and she is a graduate of the Leadership Victoria Program. She is an Adjunct Associate Professor, Monash University Department Epidemiology and Preventive Medicine, where she teaches in the Masters of Public Health Program. She also holds an expert appointment with the Australian Commission on Safety and Quality in Healthcare on the Clinical Communications Advisory Group. She was recently appointed Chair of Queensland Health’s State Clinical Governance Forum.Margaret is passionate about collaborating and working with clinicians, support staff and consumers to actively participate in making health services better for our communities.

Page 51

The Executive Director Medical Services is the professional lead for all medical staff. The Executive Director Medical Services leads the strategic direction, governance and professional support for the patient safety agenda, including the functions of patient safety management, patient complaints, maintenance of clinical standards and compliance with the National Safety and Quality Health Service (NSQHS) Standards, medical administration including credentialing and recruitment, and medical education and research.

Piotr (pronounced Peter), commenced his role as Executive Director Medical Services in March 2009, after moving from the central coast of New South Wales where he worked as Director of Medical Services. His clinical background is in general practice, with continuing limited clinical practice and the Fellowship of the Royal Australian College of General Practitioners.

He has worked clinically in various settings, both in Australia and the United States of America. His particular interest is in data analysis and financial mathematics and he is pursuing a PhD in a related area.

Dr Piotr Swierkowski

Executive Director Medical ServicesBSc (Biochem), MBBS(Hons), FRACGP, FRACMA, MHA, E-MBA, GAICD

Scott Lisle

Executive Director Sunshine Coast University Hospital ProgramBPhty, MHA

The Executive Director Sunshine Coast University Hospital Program responsibilities have changed during the year to a focus on leading the planning and delivery of the Sunshine Coast University Hospital, including the Transformation and Transition Program.

Scott commenced with Queensland Health in January 2010, after almost four years as Executive Director Service Planning and Development, South Metropolitan Area Health Service in Perth. He was a senior executive on the Fiona Stanley Hospital project, a position similar to his current role in the development of Sunshine Coast University Hospital. Prior to that, he held senior executive positions in Northern Sydney Central Coast Health Service in roles such as Director of Finance and Director Population Health, Planning and Performance.

Scott is committed to ensuring we continue to deliver on community expectations and work towards providing the majority of services on the Sunshine Coast through the commissioning of Sunshine Coast University Hospital. He is also committed to delivering health services of a high quality and balancing available resources with growing demands.


The Executive Director Nursing and Midwifery is the professional lead for nursing and midwifery services. In this role, Suzanne leads the strategic direction, clinical governance and professional support for all nursing and midwifery services. The position is also accountable for enhancing research, innovation, education, the nursing and midwifery workforce, and the future development of these services.

Suzanne commenced her role as Executive Director Nursing and Midwifery in February 2017, after moving from Melbourne, Victoria where she worked as the Director of Nursing Services at a large metropolitan health service.

Suzanne’s background is in renal nursing, nursing education, safety and quality and workforce development. She has extensive nursing leadership experience in Australia and England and is passionate about working collaboratively with the Nursing and Midwifery Leadership team to support all nurses and midwives to deliver exceptional care and reach their career potential.

Suzanne Metcalf

Executive Director Nursing and Midwifery RN, DipHE, BSc (Hons) Healthcare Practice, Grad Dip Clinical Education, Grad Dip Renal Nursing

The Executive Director Human Resources is accountable for the development and implementation of human resource strategies to ensure the health service is well positioned to deliver current, emerging and future health needs. In this role the Executive Director Human Resources works at all levels in the organisation to develop, promote and maintain a culture of teamwork, personal accountability and continuous improvement.

Nick commenced with the health service in March 2015. He has an extensive background as a Human Resources executive in the private sector having worked recently for BHP Billiton and ANZ. He has also worked offshore having spent six years based in Switzerland and 18 months in the United States of America. He has a Masters in Psychology from Sydney University and a Graduate Diploma in Labour Law from the Melbourne Law School.

Nick is passionate about working with executive and management teams to create a working environment that aspires to excellence and enables all individuals to fully contribute.

Nicholas Lake

Executive Director Human Resources

BA (Econ and Psych), MA (Psych), GradDip Labour Law

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Barry Mather

Chief Information Officer

Barry commenced as the inaugural Chief Information Officer in February 2015. Prior to this he was the Chief Technology Officer at Ramsay Health Care, based in Sydney, New South Wales, where he had worked in many different technology roles since 2005.

Prior to Ramsay Health Care, Barry worked for a small private healthcare organisation where he transferred from the parent operations in the United Kingdom. Barry is a United Kingdom national and moved to Australia in 2003.

Training in electrical and mechanical engineering, Barry has a keen eye for detail which he twins with a passion for technology.

A keen desire for technology to help to increase the safe and efficient delivery of healthcare is paramount to his working ethics. He is proud of a ‘can-do’ attitude to delivering technology solutions to meet both clinical and non-clinical business requirements. Involving clinicians in solution design and delivery is often key to ensuring successful project delivery; Barry sees this as the key to a successful partnership of technology in healthcare.

Barry also has a desire to give back to the community, having devoted 10 years of volunteer service in senior rescue positions to the New South Wales State Emergency Service, and can often be found fundraising for charity events.

The Clinical Council was formed in 2015 following a revision of the Clinical Leadership Group. The Clinical Council is a forum for the strategic engagement of clinicians. This group enables the opportunity for clinicians to have formal input by providing advice and decisions that are considered part of our strategic and operational planning processes. The Clinical Council also focusses and deliberates on aspects of research, quality and education.

Jeremy, who is Oncology Director for Sunshine Coast Hospital and Health Service, was appointed as inaugural Chair of the Clinical Council in March 2014 and the first Clinical Council meeting was held in April 2015. He is included as a member of the Executive Leadership Team, to support the organisation’s decision making processes and work as a direct conduit between the Executive Leadership Team and clinicians.

Dr Jeremy Long

Chair Clinical CouncilMB BCh, FCP(SA), FRACP


Strategic committees

The Executive Leadership Team is the overarching body within our committee structure supporting the Health Service Chief Executive.

To guide the operation of the organisation, a strategic level committee system has been implemented. Each committee has terms of reference clearly describing their respective purpose, functions and authority.

These committees are all chaired by an Executive Leadership Team member who has the appropriate sub-delegation relevant to the function and purpose of the committee. The committees are a vehicle for providing essential integration and uniformity of approach to health service planning, patient safety and quality, service development, workforce, resource management, information, communication and technology, performance management and reporting.

Number of meetings held

1 Executive Leadership Team 38

2 Clinical Council 4

3 Patient Safety and Quality Committee 10

4 Health Planning and Infrastructure Committee 2

5 Safe Practice and Environment Committee 7

6 Information Service Governance Committee 2

7 Education and Training Strategic Committee 6*10 meetings, 2 did not proceed as quorum not met

Table 10: Strategic committees

Sunshine Coast Hospital and Health Service is committedto ensuring the highest level of ethical behaviour throughall aspects of our activities. We uphold our responsibilityto the community to conduct and report on our businesstransparently and honestly while maintaining processesthat ensure our staff, at all levels, understand theseresponsibilities. The health service is a prescribedpublic service agency under the Public Sector EthicsRegulation 2010 and therefore the Code of Conduct for theQueensland Public Service is applicable to all employeesof the Sunshine Coast Hospital and Health Service.The ethics principles are:

• integrity and impartiality• promoting the public good• commitment to the system of government• accountability and transparency.

All employees are expected to uphold the code bycommitting to and demonstrating the intent and spirit of

the ethics principles and values. We strongly support andencourage the reporting of Public Interest Disclosures. Allemployees have a responsibility to disclose suspectedwrongdoing and to ensure any disclosure is in accordancewith our ethical culture. This responsibility is againreinforced by the Public Sector Ethics Act 1994, as well asour Public Interest Disclosures Policy and Public InterestDisclosure Management Procedure.

Ethics awareness and fraud controlTo adhere to Department of Health mandatory trainingupdates, the Code of Conduct training module wasreplaced with the Ethics, Integrity and Accountabilitytraining. Staff must attend Code of Conduct training every two years. At the end of 2016-2017, 78 per cent of employees (5475 staff) had completed this module.

• Clinical Council• Patient Safety and Quality Committee• Health Planning and Infrastructure Committee

• Safe Practice and Environment Committee• Information Service Governance Committee• Education and Training Strategic Committee

Our strategic committees:

*

Ethics and code of conduct

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Internal auditThe Sunshine Coast, Wide Bay and Central Queensland hospital and health services have established a hub and spoke internal audit function to ensure effective, efficient and economical operation of the function. The function provides independent assurance and advice to the Board Audit and Risk Committee and executive management. It enhances the health service’s corporate governance environment through an objective, systematic approach to evaluating internal controls and risk assessment.

The role, operating environment and reporting arrangements of the function are established in the Internal Audit Charter that has been approved by the Hospital and Health Board Chairs. The Charter is consistent with the Institute of Internal Auditors Professional Practices Framework and the Audit Committee Guidelines.

The internal audit function is independent of management and the external auditors. The function has:

• discharged the responsibilities established in the Internal Audit Charter by executing the annual audit plan prepared as a result of risk assessments, materiality, contractual and statutory obligations, as well as through consultation with executive management

• provided reports on the results of audits undertaken to the Health Service Chief Executive and the Audit and Risk Committee

• monitored and reported on the status of the management’s implementation of audit recommendations to the Audit and Risk Committee

• liaised with the Queensland Audit Office to ensure there was no duplication of ‘audit effort’

• supported management by providing advice on corporate governance and related issues including fraud and corruption prevention programs and risk management

• allocated audit resources to areas on a risk basis where the work of internal audit can be valuable in providing positive assurance or identifying opportunities for positive change.

The audit team are members of professional bodies including the Institute of Internal Auditors, CPA Australia and ISACA. The health services continue to support their ongoing professional development.

External scrutinySunshine Coast Hospital and Health Service’s operations are subject to regular scrutiny from external oversight bodies. These include Queensland Audit Office, Crime and Corruption Commission, Office of the Health Ombudsman, Australian Council on Healthcare Standards, Aged Care Standards and Accreditation Agency, National Quality Management Committee of BreastScreen Australia, Postgraduate Medical Education Council of Queensland, Australian College of Accreditation, National Association of Testing Authorities, Queensland Ombudsman, the Coroner and others. Sunshine Coast Hospital and Health Service had one coronial inquest in this financial year and there were no adverse findings or recommendations.

Risk managementRisk is managed in accordance with our Enterprise Risk Management Framework 2014-2017. Aligned to Australian and international standards (ISO31000), the framework confirms the Board and Executive Leadership Teams’ commitment to appropriately identify, analyse and treat risks across the organisation.

The framework reinforces that risk management is a responsibility for all staff and designates risk accountabilities and responsibilities at appropriate levels across the organisation. Our risk management function supports the capacity and capability of the health service to effectively manage risk through the provision of risk advisory, analysis and training services.

We ensure that risk is adequately identified, thoroughly analysed and appropriately treated across all management levels and work contexts. This is achieved through integrating risk management within existing systems and processes, including strategic and operational governance functions, planning and decision making that support endeavours to achieve our strategic objectives.

Audit and risk management


We apply a standardised and structured approach for identifying, evaluating and managing our risks. Significant risks are reported to the Board, its sub-committeesand the Executive Leadership Team on a regular basis. Organisational-wide and operational risks are regularly considered at Strategic Committee, Service Group operational performance and cost-centre management meetings. Key activities and achievements for 2016-2017 include:

• Continual improvement in risk management practice and maturity through the use of the Enterprise Risk Management Framework 2014-2017 and associated risk analysis tools designed to standardise, enhance, strengthen and streamline our risk management approach.

• Revision and improvement of our strategic risks information and reporting to reflect the changing context associated with the expansion of the health service to include a tertiary university hospital.

• Articulation of key risk exposure areas for the health service through the development of work health and safety, fraud and corruption, clinical safety and quality and significant project (transformation and transition) risk profiles.

• The safe and successful opening of the Sunshine Coast University Hospital. Through build, fit out and commissioning, risk management played an integral part in the project.

• Continued networking with the Department of Health and other hospital and health services through our participation in the Health System Risk Working Group. We have actively contributed to the development of health system risks and the risk management community of practice across Queensland Health.

• Participating in external risk and governance group activities (such as those run by the Governance Institute of Australia) in order to identify and understand current best practice and trends in the domain.

Right to informationThis financial year 2016-2017, there were 262 applicationsreceived under both Right to Information and InformationPrivacy Acts (2014–2015: 320), with 36 withdrawnby the applicant and 251 finalised in the year. The totalnumber of pages processed including full and part accesswas 35,248 with 12,295 pages refused in full. Fees collected for applications under the Right to Information totalled $5148.60 (including application fees and access fees).

Administrative and functional records managementThe most significant improvements for recordkeeping and information management have addressed the aim to transition from paper to digital records as follows:

• Clinical records—the health service is undertaking a staged roll out of an Electronic Medical Record in the Sunshine Coast University Hospital and Nambour General Hospital. The Electronic Medical Record will provide enhanced support for the delivery of healthcare and clinical decision-making. It is planned to extend the use of the Electronic Medical Record in future to the entire health service.

• Administrative and functional records—the health service has partnered with eHealth to develop an electronic recordkeeping system. It will be trialled by 120 users over the next 18 months and forms a potential springboard for future administrative records management.

• Identity and Access Management solution—a new identity and access management solution (the health service Personnel Register) provides a reliable and up-to-date record of all persons (staff and non-staff) involved with delivering services at the health service. This system streamlines access and security administration to over 90 different information systems. This efficiency gain in the management of records and information was a key factor in delivering a smooth onboarding experience for the thousands of new workers required at Sunshine Coast University Hospital.

Other significant activities include regular education for staff in administrative records management, along with the continued progress in reducing significant paper repositories managed at all facilities across the health service.

Release of confidential informationIn accordance with section s160 of the Hospital and Health Boards Act 2011, the health service is required to include a statement in its Annual Report detailing the disclosure of confidential information in the public interest. There were no disclosures under this provision during 2016-2017.

Page 57

Our future

The successful transformation of the health service post transition to Sunshine Coast University Hospital is a high priority for the next 18 months.

The scale of changes proposed is significant and is driven by community need. Stage two of Sunshine Coast University Hospital includes the opening of additional beds, as well as the start of new tertiary services, such as cardiac and thoracic surgery.

Digital transformation

Supporting this will be the continued digital transformation of the health service. As part of the digital transformation, clinical solutions will continue to be enhanced. A large component is the roll out of an integrated electronic medical records (ieMR) system at Sunshine Coast University Hospital and Nambour General Hospital. The ieMR will improve clini-cians’ access to patient information, making it integrated, complete, reliable and readily available. Clinicians at our other facilities will have viewing access to the ieMR records. In addition, as experienced following implementations in other hospitals, significant improvements in the quality of care is expected with potential reductions in medication

errors and falls for example.

Nambour General Hospital and Caloundra Health Service redevelopment

In 2017-2018, work will continue to redevelop our facilities at Nambour and Caloundra. This includes early works to outpatients and inpatient areas, and the main reception, at Caloundra Health Service, and the development of future refurbishment designs for Nambour General Hospital.

Continued growth for the health service


New treatment targets cancer more closely

Radiation oncology services began in June 2017 at the $1.8 billion Sunshine Coast University Hospital.Sunshine Coast University Hospital’s Adem Crosby Centre provides comprehensive oncology, clinical haematology and for the first time in our region, radiation oncology services are now delivered publicly from the centre.

These services have never been offered in a public hospital in the Sunshine Coast Hospital and Health Service area, with patients previously being treated by a private provider.

This service will ensure the provision of a single oncology service directly controlled by the Sunshine Coast Hospital and Health Service and will remove the interface required between medical oncology (operated by the hospital and health service) and a private provider.

It is anticipated 45 to 50 patients per week will receive radiation therapy treatments at Sunshine Coast University Hospital.

Outpatient radiotherapy planning clinics began on 5 June 2017, with radiation therapy starting on 12 June 2017. The Adem Crosby Centre is home to about 30 staff including medical specialists in radiation oncology, radiation therapists, radiation oncology medical physicists, oncology nurses and allied health staff.

Technology leads to more efficient care

In 2017 Gympie Hospital began the New Year with some significant new technology to assist with smooth and efficient patient management.

The Patient Flow Manager system was rolled out to all Gympie inpatient wards, providing staff with a convenient digital view of patient status from admission through to discharge. The state-of-the-art technology replaced manual whiteboard views of patient status and current admission care details.

The Patient Flow Manager system enables staff to access a view of a patient’s journey and clinical treatment on a single screen, and it can be securely accessed on any of the hospital’s electronic devices such as computers, laptops and iPads.

For clinical handover sessions, staff view the information electronically on large screens instead of updating whiteboards. Staff can quickly see important patient information such as fall and infection risks, special dietary or other medical requirements, and referral requests.

The Patient Flow Manager system is an important innovation for healthcare. It enables efficiencies, supports a clinical focus on patient care and aligns with the health service strategy for ‘Digital Health’ solutions.

Former Health Service Chief Executive Kevin Hegarty with some members of the cancer care radiation

therapy team.

The Patient Flow Manager system in action.

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Financial statements

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61

60

62

63


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The above statement of financial position should be read in conjunction with the accompanying notes

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The above statement of financial position should be read in conjunction with the accompanying notes


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64

76

85

98

66

83

90

64

76

86

99

67

83

95

104

64

76

88

102

68

83

96

105

65

80

88

102

73

84

96

66

81

89

102

103

74

85

97


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Glossary

AccessibleAccessible healthcare is characterised by the ability of people to obtain appropriate healthcare at the right place and right time, irrespective of income, cultural background or geography.

ABF

Activity Based Funding

A management tool with the potential to enhance public accountability and drive technical efficiency in the delivery of health services by:

• capturing consistent and detailed information on hospital sector activity and accurately measuring the costs of delivery

• creating an explicit relationship between funds allocated and services provided• strengthening management’s focus on outputs, outcomes and quality• encouraging clinicians and managers to identify variations in costs and practices

so they can be managed at a local level in the context of improving efficiency and effectiveness

• providing mechanisms to reward good practice and support quality initiatives.

ACHS Australian Council on Healthcare Standards

ACP Advanced Care Planning

Acute Having a short and relatively severe course.

Acute care

Care in which the clinical intent or treatment goal is to:

• manage labour (obstetric)• cure illness or provide definitive treatment of injury• perform surgery• relieve symptoms of illness or injury (excluding palliative care)• reduce severity of an illness or injury• protect against exacerbation and/or complication of an illness and/or injury• that could threaten life or normal function• perform diagnostic or therapeutic procedures.

Q-ADDS Queensland Adult Deterioration Detection System

Admission

The process whereby a hospital accepts responsibility for a patient’s care and/or treatment. It follows a clinical decision, based on specified criteria, that a patient requires same-day or overnight care or treatment, which can occur in hospital and/or in the patient’s home (for hospital-in-the-home patients).

Admitted patientA patient who undergoes the formal admission process as an overnight-stay patient or same-day patient.

Allied health staff

Professional staff who meet mandatory qualifications and regulatory requirements in the following areas: audiology; clinical measurement sciences; dietetics and nutrition; exercise physiology; leisure therapy; medical imaging; music therapy; nuclear medicine technology; occupational therapy; orthoptics; pharmacy; physiotherapy; podiatry; prosthetics and orthotics; psychology; radiation therapy; sonography; speech pathology and social work.


Ambulatory careThe care provided to hospital patients who are not admitted to the hospital, such as patients of emergency departments and outpatient clinics. Can also be used to refer to care provided to patients of community-based (non-hospital) healthcare services.

Australian Standard 4801Australian Standard 4801 sets out all requirements for implementing an occupational health and safety management system.

Bed alternativeAn item of furniture (trolley or chair) which is used exclusively or predominantly to provide accommodation for same day admitted patients.

BenchmarkingInvolves collecting performance information to undertake comparisons of performance with similar organisations.

Best practiceCooperative way in which organisations and their employees undertake business activities in all key processes, and use benchmarking that can be expected to lead to sustainable, world class positive outcomes.

CAT Clinical Assessment Tool

Clinical governanceA framework by which health organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

Clinical practiceProfessional activity undertaken by health professionals to investigate patient symptoms and prevent and/or manage illness, together with associated professional activities for patient care.

Clinical workforce

Staff who are or who support health professionals working in clinical practice, have healthcare specific knowledge / experience, and provide clinical services to health consumers, either directly and/or indirectly, through services that have a direct impact on clinical outcomes.

CPoC Consumer Perception of Care survey

DAMA Discharge Against Medical Advice

DEM Department of Emergency Medicine

DoH Department of Health

EDPES Emergency Department Patient Experience Survey

Page 115

Elective surgery categories

The category system ensures all patients who need surgery can be treated in order of priority. There are three urgency categories, where 1 is most urgent and 3 is least urgent.

Category 1 – A condition that could worsen quickly to the point that it may become an emergency. The patient should have surgery within 30 days of being added to the waiting list.

Category 2 – A condition causing some pain, dysfunction or disability, but is not likely to worsen quickly or become an emergency. The patient should have surgery within 90 days of being added to the waiting list.

Category 3 – A condition causing minimal or no pain, dysfunction or disability, which is unlikely to worsen quickly and does not have the potential to become an emergency. The patient should have surgery within 365 days of being added to the waiting list.

ELT Executive Leadership Team

Emergency department waiting time

Time elapsed for each patient from presentation to the emergency department to the start of services by the treating clinician. It is calculated by deducting the date and time the patient presents from the date and time of the service event.

EEO

Equal Employment Opportunities

Requires that all employees have equal access to employment opportunities, employment decisions are made on the basis of the individual merit and requirements of the role, and the workplace is managed to ensure absence of harassment.

ERMF Emergency Response Management Framework

FTEFull-time equivalent

Refers to full-time equivalent employees currently working in a position. Several part-

time and casual employees may add up to one FTE.

FY Financial year

GEDI Geriatric Emergency Department Intervention

GP General Practitioner

GPLO General Practitioner Liaison Officer

Head countThe number of employees based on each data record representing an individual employee.

Health outcomeChange in the health of an individual, group of people or population attributable to an intervention or series of interventions.

Health reform

Response to the National Health and Hospitals Reform Commission Report (2009) that outlined recommendations for transforming the Australian health system, the National Health and Hospitals Network Agreement (NHHNA) signed by the Commonwealth and states and territories, other than Western Australia, in April 2010 and the National Health Reform Heads of Agreement (HoA) signed in February 2010 by the Commonwealth and all states and territories amending the NHHNA.

HSCE Health Service Chief Executive


HospitalHealthcare facility established under Commonwealth, state or territory legislation as a hospital or a free-standing day-procedure unit and authorised to provide treatment and/or care to patients.

HHB

Hospital and Health Board

Made up of a mix of members with expert skills and knowledge relevant to managing a complex healthcare organisation.

HHS

Hospital and Health Service

A separate legal entity established by Queensland Government to deliver public hospital and health services.

HITH

Hospital-in-the-home

Provision of care to hospital-admitted patients in their residence, as a substitute for hospital accommodation.

HSMR

Hospital Standardised Mortality Ratio

Is the ratio of observed in-hospital deaths in comparison with expected in-hospital deaths based on the patient’s characteristics. For our result to be favourable, the HSMR value is not to be significantly higher than the expected rate. A HSMR of 100 indicates that there is no difference.

Inpatient A patient who is admitted to hospital for treatment or care.

ISBAR

A communication tool used to rapidly communicate clinical issues:

• Identification of Patient• Situation and status• Background and history• Assessment and action• Recommendation/responsibility.

Long wait

A ‘long wait’ elective surgery patient is one who has waited longer than the clinically recommended time for their surgery, according to the clinical urgency category assigned. That is, more than 30 days for a category 1 patient, more than 90 days for a category 2 patient and more than 365 days for a category 3 patient.

KPI

Key Performance Indicator

A measure that provides an indication of progress towards achieving the organisation’s objectives. It usually has targets that define the level of performance expected against the performance indicator.

MHAIU Mental Health Acute Inpatient Unit

MHS Mental Health Service

Page 117

MOHRI

Minimum Obligatory Human Resources Information Whole-of-Government defined measures. Includes only active and paid employees. Excludes employees on extended unpaid leave, and casuals that did not work. MOHRI is used for the majority of external reporting and is based on the terms that an employee is employed to work, not the actual worked hours.

NCACCH North Coast Aboriginal Corporation for Community Health

NEAT National Emergency Admission Targets

NEST

Part 1

National Elective Surgery Target

The percentage of patients treated within the clinically recommended time frame, and the volume of patients treated.

NEST

Part 2

National Elective Surgery Target

The average days that ‘long wait’ patients waited over the clinically recommended time, and removal from the waiting list of the 10 per cent longest-waiting patients (the cohort).

Never events

The total number of events which resulted in one or more of the six never events including:1. death or neurological damage as a result of intravascular gas embolism2. retained instrument or other material after surgery, requiring re-operation or further surgical procedure3. procedures involving the wrong patient or body part resulting in death or major permanent loss of function4. death or likely permanent harm as a result of bed rail entrapment or entrapment in other bed accessories5. death or likely permanent harm as a result of haemolytic blood transfusion reaction resulting from ABO (blood type) incompatibility6. infants discharged to the wrong family.

NGO Non-government organisation

NSQHS National Safety and Quality Health Standards

Nurse Practitioner

A registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessing and managing clients using nursing knowledge and skills and may include, but is not limited to, direct referral of clients to other healthcare professionals, prescribing medications, and ordering diagnostic investigations.

Occupied FTE (MOHRI)FTE of employees currently working in a position. Excludes the FTE of employees on extended unpaid leave.

Occupied headcount (MOHRI)

Represents staff actively employed, for instance a permanent employee on recorded leave, with leave paid in advance, is included in this value.

OutpatientNon-admitted health service provided or accessed by an individual at a hospital or health service facility.


Overnight-stay patientsA patient who is admitted to, and separated from, the hospital on different dates (not same-day patients).

Patient flowOptimal patient flow means the patient’s journey through the hospital system, planned or unplanned, happens in the safest, most streamlined and timely way to deliver good patient care.

Permanent separation rateCalculated by dividing the number of permanent employees who separated during a period of time by the number of permanent employees in the organisation. The period for the annual report is 12 months.

PHN

Established by the Commonwealth to coordinate primary healthcare services across all providers in a geographic area. Works closely with HHSs to identify and address local health needs. The Central Queensland, Wide Bay, Sunshine Coast PHN covers the health service region.

PIR Partners in Recovery

Primary care

First level healthcare provided by a range of healthcare professionals in socially appropriate and accessible ways and supported by integrated referral systems. It includes health promotion, illness prevention, care of the sick, advocacy and community development.

Private hospital

A private hospital or free-standing day hospital, and either a hospital owned by a for-profit company or a non-profit organisation and privately funded through payment for medical services by patients or insurers. Patients admitted to private hospitals are treated by a doctor of their choice.

PPP Public Private Partnership

Public hospital Offers free diagnostic services, treatment, care and accommodation to eligible patients.

Q-ADDS Queensland Adult Deterioration Detection System

QAO Queensland Audit Office

QBA Queensland Bedside Audit

QFES Queensland Fire and Emergency Services

RACF Residential Aged Care Facility

REF Requisite Education Framework

health service Sunshine Coast Hospital and Health Service

SCHHB Sunshine Coast Hospital and Health Board

Page 119

SCUPH Sunshine Coast University Private Hospital

SCUH Sunshine Coast University Hospital

Separation The process by which an episode of care for an admitted patient ceases.

Statutory body A non-departmental government body, established under an Act of Parliament.

SustainableA health system that provides infrastructure, including workforce, facilities and equipment, and is innovative and responsive to emerging needs, including research and monitoring within available resources.

TelehealthDelivery of health-related services and information via telecommunication technologies and information technology.

Turnover ratePercentage of the number of workers that had to be replaced in a given time period to the average number of workers

VLAD

Variable Life Adjusted Display

A system implemented to monitor the quality of services provided. It provides graphical overview of clinical outcomes over time and provides a system for identifying trends. It plots the cumulative difference between expected and actual outcomes.

WAU

Weighted Activity Unit

A measure of the health service activity expressed as a common unit. It provides a way of comparing and valuing each public hospital service, by weighting it for its clinical complexity.

WorkCoverWorkCover provides workers compensation insurance for employers, compensating and helping workers with their work-related injuries

YTD Year to date


Compliance checklist

5

2

2

2

2

7- 9

19

20-21

3, 21

39

42

54

47, 55-56

47

55

19

N/A

37-38

12-13

20-21

6113-119

43-46, 49-53

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55

56

2

2

2

108

2, 21

35

28-36

109-112

Sunshine Coast Hospital and Health Service2016 –2017 Annual Reportwww.health.qld.gov.au/sunshinecoast

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