Service Quality Care Report 2013-2014 · Risk Management & compliance systems increased...

Casterton Memorial Hospital

Service and Quality of Care Report

2013-2014

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TStrategic Plan

Casterton Memorial Hospital Service & Quality of Care Report 2013-2014 |

Service & Quality of Care Report | 1

ContentsStrategic Plan Inside front cover

President’s Report 2

Hospital Officers 4

Board of Management 5

Finance & Activity Overview 6

Statement of Priorities 8

Accreditation 11

Our Model of Care 12

Demographics of our Service Area 12

Service Model 13

Services to our Community 14

Clinical Governance 15

Consumer, Carer & Community Participation 17

Cultural Responsiveness 17

Participation Standards and Indicators 18

Quality & Safety 21

Videoconferencing 21

Pressure Injuries 22

Weight Maintenance and the Dining Experience 23

Traffic Lights Help Falls Prevention 24

“Having the Conversation” - Advance Care Planning 26

Medication Management 27

Infection Control 28

Consumer Satisfaction 29

Health Promotion 30

Volunteers 33

Our Supportive Community 34

Life Governors 34

Human Resources 35

Workforce Data 35

2013-2014 Employee Recognition 35

Staff List 36

Functional Organisational Chart Inside back cover

Committee Composition Chart Inside back cover

2 | Service & Quality of Care Report

| Casterton Memorial Hospital Service & Quality of Care Report 2013-2014

President’s Report On behalf of the Board of Management, staff and community I am pleased to present to you the Service and Quality of Care Report incorporating results from our 106th Annual Report of the Casterton Memorial

Hospital for the financial year ended 30 June 2014.

Presentation of this Service and Quality of Care Report to the community is an important document to provide you, our stakeholders, information on our services, quality and risk management and benchmarking against state-wide indicators.

In what has been once again a difficult budgetary year we are pleased to report a marginal operating surplus of $16,191 before the application of depreciation expense and capital grant inflows.

This small surplus has been achieved through maximisation of revenue with bonus funding for over-activity to targets achieved and optimum expense containment.

Our revenue for the year was a 1.17% increase on 2012/13 year at $9.15M and expenditure was managed to under a 1% increase on the previous year with a total expenditure for 2013/14 of $8.767M.

In spite of budgetary constraints and efficiency measures, this year Casterton Memorial Hospital has been able to maintain and increase activity across its acute, aged residential care, primary care and home based support services. Acute service separations were 669 compared to 591 in 2012/13 and Glenelg House, our 30 bed high-care residential care facility, occupancy for the year has been maintained at 99.92%. District nursing, home support and community transport services have all remained steady and have increased in some sectors.

Specialist visiting services have increased including physicians, surgeons and psychologists.

This year Casterton Memorial Hospital has also seen an increase to service up-take for Tele-health episodes to 44 compared to 15 last year and client satisfaction of this service has been well recorded.

Casterton Memorial Hospital has also achieved the majority of its’ Statement of Priority commitments with the State Government toward improved health service capacity and service deliverables to its community.

Our own Casterton Memorial Hospital two (2) year 2013 - 2015 Strategic Plan has seen significant achievement and work towards our 22 Strategic objectives and outcomes.

Facilities & Assets, Corporate & Clinical Governance, Quality Improvement & Risk Management, Human Resources and Services Development all form part of our ongoing strategic directions.

Statement of Priorities and Casterton Memorial Hospital Strategic Plan KPI details are listed in detail in the body of this report.

Some of our achievements in 2013/14 have included:

• Person Centred Care organisation wide training & philosophy implementation.

• Successful preparation towards Accreditation under the new National Standards;

• Capital development planning submission for $2.3M Primary Care Centre at the Hospital;

• Preparation and readiness for new aged care residential care reforms;

• Car Park expansion and redevelopment planning completed;

• Community Advisory Group appointed and operational;

• Submission lodged for 15 Aged Home Care Packages; and

• Top 3 Benchmark leader under Victorian Patient Service Satisfaction Monitor report.



These achievements, together with our Statement of Priority achieved deliverables, have kept your Board of Management working hard in 2013/14.

Casterton Memorial Hospital continues to collaborate with its regional health service partners from the South West Alliance of Rural Health, South West Sustainable Hospitals Project, Southern Grampians / Glenelg Sub-Regional Corporate Services Group, Deakin Medical School, Adelaide University Medical Intern Program, Wimmera Healthcare nurse graduate program and of course our local GP Medical Practice, Casterton Coleraine Medical Clinic.

These relationships and collaborations will develop Casterton Memorial Hospital and our access to world class healthcare services within the Barwon South-Western Region benefit the community we serve.

On behalf of the Board of Management I wish to acknowledge our dedicated staff, Medical Officers of Coleraine Casterton Medical Clinic, our visiting Specialists, Allied health teams, Ambulance Service Paramedics and all personnel who delivered excellent service and care for, or, on behalf of our organisation, thank you.

Of course our support groups and volunteers are recognised throughout this report. Casterton Memorial Hospital is fortunate to have an amazing community of volunteers and support groups, from Meals on Wheels to fundraisers on wheels, Murray to Moyne relay team, Ladies Auxiliary and Social Club all your efforts are duly recognised and applauded by our Board and your community.

The 2013/14 year has been a year of hard work by all in the provision of quality, relevant and safe healthcare to our community. We look forward

to the year ahead in 2014/2015 and can assure our community we will seek to improve on a continuous basis and provide to you what is required under our capacity as a Small Rural Health Service.

Finally I wish to thank and commend the work of my fellow Board of Management colleagues and Executive in Mary-Anne and Owen in managing and keeping the directions of Casterton Memorial Hospital efficient and relevant for the community that we serve.

Mr Graham SheppardPresident Board of Management

CASTERTON MEMORIAL HOSPITAL Board of Management Members. Back row: Mr. Terry Baker (OAM), Dr .Tim Halloran, Mr. Roger Dalby, Fr. Andrew Hayes, Mr. Gerald Smith, Mr. Peter Green Front row: Mrs. Karen Black, Mr. Geoff Cain, Manager of Nursing Services Ms. Mary-Anne Betson, Mr. Graham Sheppard and CEO Mr. Owen Stephens.



Hospital OfficersCasterton Memorial HospitalABN 62 051 291 134

Responsible MinistersCommonwealth Government AustraliaThe Hon Tanya Plibersek MP, Minister for Health & Ageing 01/07/2013 – 18/09/2013The Hon Peter Dutton MP, Minister for Health 19/09/2013 – 30/06/2014

State Government VictoriaThe Hon David Davis, MLC, Minister for Health & Ageing

Hospital Board of Management

PresidentMr. G. Sheppard

Vice PresidentFr. A. Hayes

MembersMr. T. Baker (OAM)Mrs. K. BlackMr. G. CainMr. R. DalbyMr. P. GreenDr. T. HalloranMr. G. Smith

Audit CommitteeMr. O. Stephens – CEOMrs. K. Black – ChairMr. G. Sheppard – Independent MemberMrs. B. Toma – Finance OfficerMr. R. Dalby – Independent MemberFr. A. Hayes – Independent Member

Visiting Medical StaffDr. B. S. Coulson: M.B.B.S., D.R.O.G., F.A.C.R.R.M.

Dr. M. Prozesky: M.B., ChB, (South Africa)

Dr. R. Taheri: M.B. (Mashad Uni Iran) G.P. Registrar

Dr. S. Ansari: M.B.B.S. (Army Medical College – Pakistan)

Dr. Yao Zhang: M.B. (Uni of Med Sciences – Guangzhou)

Dr. L. Thompson: BMBS FRACGP (Flinders University)

Dr. T. N. Halloran: B.D., B.Sc. (Hons)

Mr. P. H. Tung: M.B., B.S., F.R.A.C.S.

Mr. S. Clifforth: M.B., B.S., F.R.A.C.S.

Dr. G. Coggins: M.B., B.S., F.R.A.C.P.

Dr. C. de Kievit: M.B., B.S., D.R.A.N.Z.C.O.G.,F.A.C.R.R.M.

Dr. K. Fielke: M.B., B.S., D.R.A.N.Z.C.O.G., F.A.C.R.R.M.

Dr. J. D. Muir: M.B., ChB, D.A., F.R.C.A.

Dr. T. J. Hodson: M.B., M.B.S., F.R.A.N.Z.C.O.

Dr. S. Perry: G.P. Anaesthesia F.R.A.C.G.P., B.M.B.S. (Flinders), B.S.C., D.C.H.

Dr. B. Gavankar: M.D., D.G.O., D.A., M.B.B.S.

EmeritusDr.A. F. Floyd: M.B., B.S., D.Obst, R.C.O.G.

Principal OfficersChief Executive OfficerMr. O. P. Stephens: B.Bus., A.C.H.S.E.

Manager Nursing ServicesMs. M. Betson: N.P.,R.N., R.M., Cert. Critical Care, Nurse Immuniser, MNsg, MNP FACN

Nurse Unit Manager Acute Ward/AHS/Education OfficerMrs. J. Coulter: R.N., R.M., Cert IV Training& Assessment

Nurse Unit Manager Night Nurse in Charge /Quality ImprovementMrs. H. Dillon: R.N., R.M., Grad Cert Ad Nsg Practice (Rural Remote)

Nurse Unit Manager Acute Ward/AHSMr. S. Gill: R.N., Cert Aged Care

Nurse Unit Manager OR/Emergency / Infection Control OfficerMrs. H. Gill: R.N.Cert Infection Control & Sterilisation MACN

Nurse Unit Manager Residential CareMrs. K. Sealey: R.N., MACN, Cert IV Frontline Management

Nurse Unit Manager Community HealthMs. S. Bramall: R.N., Grad Dip CH

Nurse Unit Manager Primary & Community CareMs. A. Pekin: R.N., Nurse Immuniser, Grad Cert Diabetes Ed., BA., Grad Dip Ed (Psychology)

Programmed Activity Group Co-ordinator*Mrs. J. Annett: EN, Diversional Therapist

Mrs. S. Neill: Cert II Financial Svs., Cert III Disability

After Hours SupervisorsMrs. S. Dehnert: R.N., R.M., IBCLC , Nurse Immuniser, Grad Dip Child Maternal Health

Mrs. H. Dillon: R.N., R.M.Grad Cert Ad Nsg Practice (Rural Remote)

Mrs. A. Jenkins: R.N., Grad Dip Palliative Care, Grad Cert Ad Nsg Practice (Rural Remote), Grad Cert Gerentology

Mr. S. Bryan: R.N. B.N. Grad Cert Ad Nsg (Emergency Nursing)

Mr. S. Makore: R.N.

Administrative & Finance OfficerMrs. B. Toma

Health Information / Quality ImprovementMrs. H. Rees: Clinical Coder

Catering Services SupervisorMr. M. Nolte

Environmental Services SupervisorMrs. E. Harvey

Maintenance Coordinator / Safety*Mr. R. TomkinsMr. S. Zippel

Meals on Wheels CoordinatorMs. V. Ross

*Resigned during year


Service & Quality of Care Report | 5Service & Quality of Care Report | 5

Board of Management

Mr Graham SheppardPresident

Expertise: Management, Finance / Audit

Current Term of Appointment: 01/07/2012 – 30/06/2015

Fr Andrew HayesVice President

Expertise: IT, Community Service, User Perspective


Mr Roger Dalby

Expertise: Capital Management, Community Service, User Perspective


Dr Timothy HalloranBDS, Bsc (Hons)

Expertise: Clinical Governance, Health Issues / Planning, Finance / Audit


Mr Gerald Smith

Expertise: Management, Industrial Relations, Risk Management


Mrs Karen BlackBoard Audit Officer

Expertise: Management, Finance / Audit, IT, Community Service


Mr Terry Baker (OAM)

Expertise: Clinical Governance, Health Issues / Planning, Risk Management, Community Service, User Perspective


Mr Peter Green

Expertise: Management, Finance / Audit, Risk Management


Mr Geoffrey Cain

Expertise: Capital Management, Industrial Relations, Community Service, User Perspective


The Board of Management is appointed by the Governor-in-Council, from nominations received by the Hospital. The Hospital is an incorporated body under, and regulated by, the Health Services Act 1988.

The role of the Board of Management is to oversee and monitor the operations of the Hospital and to develop, in accordance with its mission and strategy objectives, the future directions for the Hospital.



Finance & Activity Overview The financial statements of account for the year ended 30 June, 2014 have been completed in accordance with the Australian Audit and Accounting Standards and the Financial Management Act 1994.

We have completed the year with a net surplus result, before capital and specific items, of $16,191. This positive result is on budget and is comparable to our 2012/13 result of $22,878. This is a pleasing result given the constraints of a tight and less flexible budget as compared to prior years. Contributing items to our positve 2013/14 Operating result include well managed overall expenditure, under budget salaries & wages position, consistent private patient revenue and our over target position for Department of Health funded patient activity.

Entity Comprehensive Result of ($476,508) is a $167,236 improvement on the prior year result. The improved result is a combination of $93,705 of increased capital revenue and $80,218 reduced depreciation expense.

The $9,179,661 Comprehensive Result for the year includes a $9,656,169 increase in the net fair value of the facility’s fixed assets as a result of a revaluation by the Valuer-General Victoria (VGV) Valuers as at 30 June 2014.

Our current asset ratio of 1.5 is an improvement on the 1.39 reported in 2012/13. Casterton Memorial Hospital has consistently over the past 5 years recorded an asset ratio well above the .7 Department benchmark.

Cash has been well managed with cash on hand as at 30 June 2014 totalling $2,593,340 (excluding

Joint Venture). This years’ cashflow was subject to a $263,300 recall for prior year under achieved activity, nevertheless we have still managed an increase on our 2012/13 holdings by $25,924. Current year interest earned on Term Deposit was $97,326 compared to prior year $109,862, a result of the falling interest rate.

Cash holdings combined with current assets remaining in excess of current liabilities by $1,053,853 confirms a stable liquidy position for Casterton Memorial Hospital as at 30 June 2014.

Entity operating expenditure for 2013/14 year totalled $8.767M, less than a 1% increase on the prior year. Salary, employee benefits and other labour costs accounted for $6.324M or 72% of 2013/14 total which is consistent with the prior year.

The $2.443M balance, non salary related costs, includes major items of $1.009M Joint Venture in leasing/expenditure, $0.441M supplies & consumables, $0.293M IT costs and $0.195M fuel, light & power expenses.

Total revenues for the current year totalled $9.150M, a 1.17% increase on prior year with Operating revenue of $8.784M and $0.366M being Capital Purpose income. Current year revenues include $105,137 for over target inpatient activity and $150,220 Commonwealth Aged Care funding. Total cash grants of $4,331,909 received from the Department in 2013/14 recorded a shortfall of $384,759 from the previous year. The offset of this shortfall was the recall of $263,300 and reduced activity funding of $137,121. Capital grants received in 2013/14 totalled $42,877 compared to $141,326 in the prior year.

59%

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Government Grants

Commonwealth Subsidies

G'ment Indirect Contributions

Patient Fees

Residential Care & AccommFeesCommercial Activities & OtherRevenueInterest

Capital

Donations/Bequests/Other 68%

2%

7%

1%

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Total Operating Expense % - 2013/14(Excluding Joint Venture expenses)

S&W

LSL

Superannuation

Work Cover

Non Salary Labour Costs

Supplies & Consumables

Other Expenses



The Hospital exceeded set targets with DVA inpatients, Nursing Home Type inpatients, Dialysis treatments and met target for TAC. The net result achieved additional revenue earned of $105,137. Our 30 bed high care residential activity remained consistent with a full year occupancy rate of 99.92%. Our extensive primary care, aged and community based services have benefited from extended services providing an additional $27,317 in fees and charges.Overall the 2013/14 finanical year for Casterton Memorial Hospital has been very pleasing. We have managed our expenditure within less than a 1% increase on prior year,

maintained a bottom line revenue above budget, increased capital equipment to the value of $200,026, increased our cash on hand and retained our positive asset ratio. We have increased our

clinical training program with the placement of two Nurse Graduates in 2014, retained our level of staff resources and provided a consistent and balanced range of services to our community.

Casterton Memorial Hospital achieved its financial targets for the 2013/14 financial year and plans to sustain this positive performance in 2014/15.

Five Year Financial Comparative Statement 2009/10 2010/11 2011/12 2012/13 2013/14

Total Revenue 7,067,052 8,233,277 8,746,241 9,044,597 9,149,983

Total Expenditure 7,560,397 8,600,682 9,177,363 9,688,341 9,626,491

Net Result for the Year -493,345 -367,405 -431,122 -643,744 -476,508

Venture 37,717 - - - -

Asset Revaluation (Increments / Decrements) - - - 1,405,506 9,656,169

Retained Surplus / Accumulated Deficit 7,334,072 6,966,667 6,535,545 5,891,801 5,415,293

Total Assets 17,853,140 17,710,333 17,435,253 18,409,321 27,525,008

Total Liabilities 1,783,873 2,008,471 2,164,513 2,376,819 2,312,845

Net Assets 16,069,267 15,701,862 15,270,740 16,032,502 25,212,163

Total Equity 16,069,267 15,701,862 15,270,740 16,032,502 25,212,163

Administrator Officer General – Finance, Mrs. Barb Toma, presents the 2012-13 Finance Report at the 2013 AGM.

Finance & Activity Overview continued



Statement of Priorities

Statement of Priorities Agreement

The Board of Management Casterton Memorial Hospital entered an agreement with the Victorian Department of Health in 2013-2014 year to achieve a number of priority actions in line with the State-side Victorian Health Priorities Framework for 2012 to 2022.

This agreement between the Department and Casterton Memorial Hospital details funding levels for the Hospital in line with agreed service and

activity levels to be achieved and a requirement for us to achieve a number of deliverables associated with the Victorian Health Priorities Strategic directions for the State.

The Strategic Priorities and the deliverables agreed to by Casterton Memorial Hospital are herein listed for your review of our attainment or progress with the deliverables set for 2013-2014.

PRIORITY: DEVELOPING A SYSTEM THAT IS RESPONSIVE TO PEOPLE’S NEEDS

ACTION DELIVERABLE OUTCOME

Implement formal advanced care planning structures and processes that proved patients with opportunities to develop, review, and have their expressed preferences for future treatment and care enacted.

Review advanced care planning processes across acute and aged residential care and ensure patients/residents have the opportunity to consider and enact as required.

Review of hospital policy in line with best practice guidelines.

Advanced Care Plans added to TRAK as an alert for Acute Care and record folders labelled in Glenelg House.

Register implemented.

Community awareness.

Work and plan with key partners and service providers to respond to issues of distance and travel time experienced by some rural and regional Victorians.

To work in partnership with the Glenelg Shire and other sub-regional Government agencies to gain support of Casterton Airstrip to allow for 24/7 Air Ambulance access and retrieval.

Glenelg Shire planning amendments approved. DEPI invested in air field upgrade as part of South West fire bomber base. Government approval for planning amendment near approval.

PRIORITY: INCREASING THE SYSTEM’S FINANCIAL SYSTEM’S FINANCIAL SUSTAINABILITY AND PRODUCTIVITY


Reduce variation in health service administrative costs.

Review and benchmark administrative overhead costs across all departments against similar sized health services, with a view to maximising administrative efficiency.

Developing data base and cost management process. Specific Aged Care Services costing work being conducted.

Identify opportunities for efficiency and better value service delivery.

Measure the impact on energy costs and environmental foot print of actions taken by the Casterton Memorial Hospital Group over the past 12 months.

Meetings held and costing comparative templates in place. New EMP endorsed with targets for 2014/15 ~ 2016/17.



PRIORITY: IMPROVING EVERY VICTORIAN’S HEALTH STATUS AND EXPERIENCES


To improve thirty-day unplanned readmission rates.

Review and Measure thirty day readmission rates and develop strategies to address any issues.

Unplanned Re-admissions in 28 days part of the Hospital Clinical Indicator suite – Rate has dropped from 1.7 in Jul-Dec 12 to 1.4 in Jul-Dec 13.

Use Consumer feedback to improve person and family centred care and patient experience.

Evaluate and document the effectiveness of the Person Centred Care training program delivered across the organisation in 2012.

Further develop feedback options to assist in articulation of response to PCC.

Evaluate specific PCC factors and indices of overall service. Evaluation tools in place and good feedback received.

PRIORITY: EXPANDING SERVICE, WORKFORCE AND SYSTEM CAPACITY


Build workforce capacity and sustainability by supporting formal and informal clinical education and training for staff and health students, in particular inter-professional learning.

Facilitate the employment of two nurse graduate placements in 2014.

Two graduates in place, collaborative program with Wimmera Health.

Increased relationships with education providers, ie: commenced IRON students.

2014 Graduate Nurse recruits Mrs. Grace Makore (left) and Ms. Brittnee Tait (right) talk with Glenelg House resident Mrs. Bonnie Humphries.

Statement of Priorities continued



PRIORITY: IMPLEMENTING CONTINUOUS IMPROVEMENTS AND INNOVATIONS


Support change and innovation in practice where it is proven to deliver more effective and efficient healthcare.

Endorse the training of two additional Remote Isolated Practice Endorsed Nurse Program nurses to consolidate the enhanced service already provided through the program.

Endorsed and all policies in place to support positions.

Encouraged from an organisational level to support more staff to undertake the extended scope of practice.

Review proven e-Medication Management program for implementation at Casterton Memorial Hospital in order to reduce medication errors.

Awaiting Portland District Health trial with SWARH E-Medication system evaluation. Review of PDH outcomes underway. Webinar set for product demonstration 18th June.

PRIORITY: INCREASING ACCOUNTABILITY AND TRANSPARENCY


Prepare for the National Safety and Quality Health Service Standards, as applicable.

Develop consumer consultative group, including terms of reference, in preparation for agency accreditation in July, 2014.

Group advertised, terms of reference in place and three meetings held.

Continuing to define the role and purpose with initial projects having now been provided to Advisory Group.

PRIORITY: IMPROVING UTILISATION OF E-HEALTH AND COMMUNICATION TECHNOLOGY


Maximise the use of health ICT infrastructure.

Implement patient admissions system (TRAK) and electronic health record for inpatient care delivery.

TRAK PAS implemented 1st March 2013 with TRAK clinical notes implemented on 1st July2013.

Platinum 5 upgrade also in 2013 – currently evaluating both.

Progress notes in place, and evaluated ~ successful.

Trial, implement and evaluate strategies that use e-health as an enabler of better patient care.

Pilot a tele-health project with Western District Health Service for pre-operative anaesthetist consultations.

Urgent care transitioning planned in the future. Medication Management program being reviewed for implementation, demonstration 18th June.

Statement of Priorities continued



Accreditation The National Safety and Quality Health Care Standards were developed by the Australian Commission on Safety and Quality in Health Care to improve the overall quality of healthcare in Australia. These 10 Standards were implemented nationally from 1st January 2013 and are compulsory for the majority of public and private healthcare organisations throughout Australia. They set a national uniform level of care consumers can expect from healthcare organisations and from this time all healthcare organisations will be “Accredited” to the new National Standards.

The 10 National Standards include Governance, Consumer Participation, Infection Control, Medication Management, Identification, Clinical Handover, Blood & Blood Products, Pressure Injuries, Recognising and Responding to Clinical Deterioration and Falls Prevention.

During 2013/14 Casterton Memorial Hospital undertook a wide-ranging self-assessment and improvement process using the 10 National Standards along with other specific EquIp National and Home and Community Care Common Standards. This activity included reflecting further improvement opportunities in clinical and primary care treatment and services, identifying where new structures were required and implementing these using a sustainable change management process. This method allowed the construction

and improvement of organisational systems and processes to effectively meet the requirements of each Standard. Throughout this publication reference is made to many improvements put into place in response to this self-reflection/improvement process.

The next “Accreditation/re-Accreditation” phase is due in July 2014 where Accreditation will be undertaken against the National Safety & Quality Standards, as well as the Primary Care Community Care Common Standards.

Casterton Memorial Hospital was visited by the Australian Aged Care Quality Agency in April 2014 with an “Unannounced Visit/Assessment Contact” to check ongoing compliance to the Aged Care Standards for Glenelg House. During this visit surveyors visited residents and families, viewed governance, medication management, physical environment, safety and quality improvement systems. Glenelg House successfully demonstrated an ongoing commitment to quality and safe aged care services.

Congratulations to all staff involved in both Accreditation and Assessment contacts for hospital, primary care and aged care services. The Hospital Board and management are particularly proud of the commitment to quality and individual care shown by all staff groups involved.

Mrs. Heather Rees, Quality Assurance Officer, holds the National Safety and Quality Health Care Standards chart the implementation for which she has been responsible.



Our Model of Care Casterton Memorial Hospital is classified as a Small Rural Health Service (SRHS) under the Department of Health Policy and Guidelines. This classification allows the Hospital to direct service delivery within our budget to best meet the needs of the community.

This service and planning decentralisation of the Hospital is important for flexibility from year to year or as circumstances may alter, but also allows at the local level to identify and target community needs.

It is the role of the Board of Management to utilise information available on the local area to maximise the health gains for the community.

Casterton Memorial Hospital fulfils its mission through provision of acute, residential high care and community health/primary care services from its modern facility, as well as services into the home.

Demographics of our Service Area Casterton Memorial Hospital was established in 1908 and is situated in the northern sector of the Glenelg Shire within the township of Casterton. Nestled amongst rolling hills and river red gums of the Glenelg River valley, Casterton is located on the Glenelg Highway, 359 kilometres west of Melbourne and 42 kilometres east of the South Australian border.

The Shire has a total population base of 19,520 and Casterton rural north has a catchment population of 3,500. Our catchment area includes the townships of Digby, Merino and Sandford and the surrounding rural localities. Casterton Memorial Hospital provides services to all within its population base as well as neighbouring shires.

As a Small Rural Health Service, the Hospital is flexible in its funding base to ensure services provided directly to the community within budget, best meet their needs. The Board utilises local area information available to plan for and provide the

most appropriate care and intervention options for the local catchment area to maximise health gains and status for the community.

The Hospital provides a range of acute health, aged residential care and primary healthcare services incorporating 15 medical/surgical inpatient beds, an operating theatre, two bay urgent care centre, two dialysis chairs and 30 bed high-care residential care facility, ‘Glenelg House’. The Hospital also provides an extensive range of allied and primary healthcare personnel and programs along with visiting consultant services. All of these services are provided from our facility ensuring effective triaging and access of best care in best possible time for patients and clients.

The Board of Management and staff at the Casterton Memorial Hospital are committed to providing strong and efficient health and community services to meet the needs and expectations of the community it serves.

Dergholm

Balmoral

Cavendish

Ararat

Ballarat

Glenthompson

Hamilton

Dunkeld

ColeraineCasterton

Merino

Penshurst

Heywood

Dartmoor

Nelson

PortlandWarrnambool

Geelong

MelbourneMt. Gambier SA

Hamilton



Service ModelAcute Service• Acute Beds 15 (Gen. Medical and Surgical• Theatre with two bed recovery• Urgent Care – two bay (24/7)• Satellite Dialysis (Royal Melbourne)• Domiciliary / Midwifery• Nursing Home Type• Palliative Care• Infection Control / CSSD• Ambulance Service

Visiting Consultants / Practitioners• General Practitioners (Private Practice)• Obstetric / Gynaecology• Physicians General Medicine• Surgeons• Ophthalmologist• Specialist Anaesthetist• Digital Radiology Services – Bendigo Radiology• Community Rehabilitation• Infection Control Officer• Chiropractic Service• District Nursing (7 days)• Physiotherapy• Psychologist• Speech Therapy• Occupational Therapy• Dietetics• Audiology• Mental Health Team

Aged and Residential Care• 30 Bed High Care Residential Facility• Support Groups / Resident’s Committee• Diversional Therapy

Education and Workforce Development• Clinical Nursing Student Placements

- Flinders University - Deakin University- Latrobe University- Uni SA- South West TAFE- TAFE South Australia

• Medical Clinical Placements- Deakin University Medical School- Royal Adelaide Hospital Intern Rotations

• Work Experience Placements• In-House Education and Competencies

Primary Care• Planned Activity Group (3 days)• Community Health Programs

- Diabetes Education, Monitoring and Support Group

- Women’s / Men’s Health Programs- Drug Awareness and Education- Osteoporosis / Falls Risk Prevention- Alcohol and Drug Information- Asthma Education and Mentoring- Primary Mental Health Team Counsellor- Better Health Self-Management Program- Strength and Balance Programs- Walking Group- Cardiovascular Disease Circuit Program

• Meals on Wheels• Home Maintenance Services• Community Bus and Car Transport Service• Community Room Facilities• Advanced Care Planning

Infrastructure Services• Administration / Financial / Secretarial• Maintenance Personnel• Catering Services (Functions)• In-House Laundry• Meeting and Function Facilities• Consulting Rooms• Short Term Accommodation• Video Conferencing Facilities• Community Transport• SWARH IT Alliance Network• Ambulance Victoria Fixed Wing• Helicopter Emergency Service (HEMS)• Medical Specialists Video Conferencing• Medicare Consultation Facilitation

Volunteer, Ms. Kym Leonard preparing Easter activities for Glenelg House residents.



Services to our Community

Hospital 2013/14 2012/13

Total Multi-stay Inpatient Separations* 250 319

Total Same Day Separations* 419 272

Bed Days* 2,969 2,915

Total WIES 337.37 384.43

% Occupancy Rate Staffed Beds 54% 53%

Average Length of Stay ** 2.8 3.2

% Public Bed Days 70% 83%

% Private Bed Days 30% 17%

Obstetrics / Gynaecology 10 19

Operations / Procedures 126 131

Urgent Care Presentations 1,325 1,570

Glenelg House Residential Care

Residents Accommodated 37 39

Bed Days 10,941 10,912

Average Daily Occupancy 29.97 29.89

% Occupancy Rate Full Year 99.92% 99.65%

Planned Activity Group

Attendances 1,463 1,050

District Nurse

Home Visits 4,298 4,133

Kilometres Travelled 17,733 17,653

Community Health

Attendance (contacts) 506 637

Allied Health

Physiotherapy Attendance *** 2,274 1,931

Speech Therapy Attendance *** 7 25

Dietetics *** 129 72

Occupational Therapist *** 87 100

Meals Produced

Hospital / Residential Care / Other 69,625 71,178

Meals on Wheels (HACC Assessed) 4,234 4,892

Home Maintenance Program (HACC Service)

Number of Clients 98 107

Number of Visits 1,051 1,119

Number of Hours 1,115 1,209

* Does not include Newborn transfers *** Includes inpatients

** Excludes Nursing Home Type

Meals on Wheels volunteers Mrs. Heather Futerieal and Mrs. Carol McKinnon-Ward load meals with the assistance of co-ordinator Ms. Valinda Ross.

Mr. Jake Green serves supper at the 2013 AGM.

Mr. Smart Makore R.N., makes preparations in the Dialysis Unit.



Clinical Governance Clinical governance is the system by which the Board of Management, executive, managers, clinicians and staff all share responsibility and accountability for the safety and quality of care at Casterton Memorial Hospital.

Consumer experience and health outcomes are at the centre of the Hospital clinical governance framework and clinical teams have a fundamental role in the delivery of safe, high quality care. Robust organisational systems are paramount in supporting the provision of safe and quality care. Examples of organisational improvements to the four main domains of Casterton Memorial Hospital’s Clinical Governance policy framework for 2013/14 are;

1. Consumer Participation

• Implementation of an organisational wide new menu and meal delivery system for Glenelg House. Fresh meals are delivered to Glenelg House for breakfast, lunch and dinner and served to residents in each dining room.

This has led to a better dining experience for residents, improved social connection, encouraged participation in meal selection and decreased food wastage. The organisational menu was also updated for Aged Care, Hospital and Primary Care recipients. This has been a major improvement which will continue to be evaluated throughout the coming months.

• Implementation of Goal Directed Care Plans for the Planned Activity Group in early 2014 is resulting in greater satisfaction and participation for clients. Setting goals and working together to achieve them is providing clients with the opportunity to accomplish new creative activities for the individual.

Glenelg House resident, Mrs. Valda Marshall, shares some time with William James and Easter Bunny, as part of Casterton Playgroup’s visit.



Clinical Governance continued

2. Clinical Effectiveness

• Implementation of bedside handover for the Hospital during 2013 has seen nursing handover on the afternoon shift being conducted at the patient’s bedside with the participation of the patient. Patients and nursing staff have all commented on how this has resulted in improved communication and an enhanced clinical information exchange between patients and clinicians.

• Expansion of the clinical record review system is supporting a comprehensive clinical review process.

• An extended audit program is putting in place a varied surveillance program to measure clinical compliance and effectiveness.

• Reviewing and combining policies and procedures is improving effective access for clinical staff to important clinical guidelines. This in turn supports safe clinical care.

• Updating and reviewing internal clinical referral protocols based on best practice is ensuring that the right care is provided to the right patient at the right time, by the right clinician in the right way.

• Implementing new treatment / management protocols to manage safe provision of care within each of the 10 National Safety and Quality Standards.

3. Risk Management

• Organisations need to have a broad-based risk management system which integrates management of organisational risk, for example, financial, OH&S, plant, equipment & clinical risk. Ensuring correct follow up of incidents, complaints and comments, as well as ensuring staff understand organisational structures, go towards supporting a proactive approach to identifying and managing risk.

4. Effective Workforce

• Updating position descriptions ensures staff understand their roles and responsibilities for safety and quality within the organisation.

• Enhanced training and competency testing programs ensures staff skills and knowledge to undertake their roles.

• Comprehensive performance appraisal for clinical and non-clinical staff ensures staff can continue to grow and develop within their roles and responsibilities.

• Credentialing and scope of practice guidelines ensure that clinical staff continue to have the necessary qualifications to undertake their roles.

This is a snapshot of the organisational improvements put into place this year that continue to sustain our Clinical Governance systems.

Mr Damein Bell, Acting CEO of Gundjitj Mirring Traditional Owners Aboriginal Corporation, presented an interesting and informative address at our 2013 Annual Meeting.



Consumer, Carer & Community Participation

Cultural Responsiveness

Casterton Memorial Hospital’s Cultural Diversity Plan was developed using the Department of Health’s, ‘Cultural Responsiveness Framework’ as outlined below:

• Standard 1: A whole-of-organisation approach to cultural responsiveness is demonstrated.

• Standard 2: Leadership for cultural responsiveness is demonstrated by the health service.

• Standard 3: Accredited interpreters are provided to patients who require one.

• Standard 4: Inclusive practice in care planning is demonstrated, including but not limited to dietary, spiritual, family, attitudinal, and other cultural practices.

• Standard 5: CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis.

• Standard 6: Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness.

The Australian Bureau of Statistic’s data continues to reflect very low numbers of persons from non-English speaking backgrounds in the Casterton area (5.8% ABS 2011 Census). Casterton Memorial Hospital continues to develop and work on enhancing Person Centred Care for all consumers. This year the organisation focused on Aboriginal Cultural training conducted by the Dhauwurd Wurrung Elderly and Community. The Aboriginal Cultural Safety Training was run organisation wide with a full day of professional development offered and taken up by 30% of the staff, board members and volunteers. This informative session provided attendees with greater awareness of the lives of the traditional owners of the local land from before colonisation to present day. Sessions on the day included the retelling of experiences from the Stolen Generations and learning about life on Condah Mission Health Service.

Casterton Memorial Hospital continues to support and celebrate new cultures to the workforce and community. The Planned Activity Group focuses on a different culture every two months learning about life in other countries, traditional food and dances practiced and the clients also view photos and videos pertinent to these cultures. Glenelg House also participates in celebrating diversity by rotating visual displays of different cultures and practices.

This display of a ceremonial sari in Glenelg House created interest regarding Indian wedding customs.



Consumer, Carer & Community Participation continued

Participation Standards and Indicators

The five standards for consumer, carer and community participation in Victorian public health services have been incorporated into the everyday functioning of Casterton Memorial Hospital.

1. The organisation demonstrates a commitment to consumer, carer and community participation appropriate to its diverse communities.

Casterton Memorial Hospital recognises the importance community members play in the development and planning of services provided by the organisation. Upon evaluating recent community surveys and in recognition of community feedback, the Board of Management established a Community Advisory Group. The working party includes community members, Board of Management members, Chief Executive Officer, Manager Nursing Services and key staff members. This group provides a forum for consumers, carers and community members to meet quarterly, enabling them to participate and ‘have a say’ in planning for the facility. The Hospital is now able to provide a more enhanced and richer level of care as a result of the new initiative.

2. Consumers, and, where appropriate, carers are involved in informed decision-making

about their treatment, care and wellbeing at all stages and with appropriate support.

Consumers and carers have been involved in the development of goal-directed care plans in District Nursing for a number of years. These plans are reviewed quarterly and assist all people involved to ‘have a voice’ in the process of determining care options, reviewing services delivered and developing short and long term plans for the future.

An intake process begins when a person comes into the Planned Activity Group. This initial interviewing process is a collaborative session between the consumer, and, where appropriate, carer and hospital staff.

The information obtained informs the Planned Activity Co-ordinator and volunteers working in Day Centre of the likes, dislikes and aspirations of those attending sessions. A review of this process identified it could be improved upon and after review Planned Activity Goal-Directed Care Plans have been developed and introduced into Day Centre. Initial audits have been positive and feedback from clients, carers and staff is assessed continuously.

Takudzwa Makore with Mrs. Audrey Milsteed during a Planned Activity Group outing to the Kathleen Millikan Centre.




3. Consumers and, where appropriate, carers are provided with evidence-based, accessible information to support key decision-making along the continuum of care.

Casterton Memorial Hospital has the benefit of being a stand-alone, independent hospital with the capacity of ‘knowing its community and being able to respond to their needs’. This is achieved via collaborations and partnerships with other health facilities in our area which enables the provision of ‘best practice’ care to the community.

One such approach, used by the Hospital clinical staff, is the collaboration and consultation processes that occurs regularly with the Barwon South Western Region Wound Consultant. This initiative aims to improve outcomes for clients by strengthening the wound assessment and management skills of hospital staff under the tutelage of a specialist. Collaboration occurs at the Hospital when the Wound Consultant attends and reviews clients from the community, whilst educating the District Nursing team as the wound is assessed and dressed. Consultation can also occur digitally, with photos and detailed descriptions provided to the Wound Consultant. This process has increased the skill level of the nurses working in the community.

4. Consumers, carers and community members are active participants in the planning, improvement, and evaluation of services and programs on an ongoing basis.

Casterton Memorial Hospital is fortunate in having the capacity to run sustainable community health programs as well as community members who are cognisant for the need to maintain their health and actively participate to enable this to occur.

A wonderful example of this process in action is a new role created for a client attending programs at the Hospital. This person has become emancipated due to the promotion of ‘wellness’ or ‘active ageing’ approach to their care that emphasises optimal physical and mental health. This client’s association with the Hospital has evolved from a person attending programs to one who supports staff with administration tasks and assists in the day-to-day care of Day Centre clients. This person’s health and sense of self have markedly increased and the staff look forward to receiving assistance.

‘Planned Activity Group’ in action.




5. The organisation actively contributes to building the capacity of consumers, carers and community members to participate fully and effectively.

Casterton Memorial Hospital Primary and Community Care has reviewed policies, procedures and documentation used when delivering care to our consumers, carers and community. The measures used to ensure the safety of all concerned has been paramount as evidenced by the development and implementation of a number of assessment tools and action plans. These include: Vulnerable Persons’ Register, Carers Support plan, Active Service Model action plan and Diversity plan. The use of these applications will be monitored and reported back to the community in the future. Primary and Community Care is committed to supporting and caring for community members in their own homes, whilst putting safety measure in place that enable people to feel independent and secure in their own environment.

The Men’s Day is an example of capacity building at a grass roots level. Initially designed to enable local men, caring for their wives, to meet and socialise once a month, this event has become a luncheon where men of all walks of life gather once a month, in the local pub, for a bar meal and a chat. The formation of the event, the process that occurs and the activities taking place during the lunch are a result of feedback received from the participants through written evaluations and verbal responses.

The event is now growing in attendees each month and is a typical ‘blokey’ event held without fuss or fanfare. Men have now started inviting their own friends to attend so the scope and range of men attending is growing. This, in turn, is enabling the men to participate more fully and effectively by letting them take some ownership in the conduct of the event.

Men’s Day participants Mr. James Widdicombe, Mr. Ray Coulson, Mr. Harry Cottier and Mr. Bryan Denton enjoy a catch up at the Glenelg Inn Hotel.



Quality & Safety

Videoconferencing

Ms. Anne Pekin, Primary and Community Care Manager, sits with Ms. Sheryl Paton during a videoconferencing consultation.

Case Study

Recently, an elderly client residing in Casterton, required a minor surgical procedure at WDHS in Hamilton. His initial consultation with the visiting surgeon had taken place in Casterton some months ago and a follow up consultation took place with his surgeon via video conference.

“It was good to be able to chat with the surgeon via video without the long trip to Hamilton and back,” said a family member of the client.

Consultation with the anaesthetist pre-procedure was also offered via video link, with a potential three trips to Hamilton turned into one, which was a positive outcome for all involved.

Casterton Memorial Hospital has introduced a video conferencing service to the Casterton community.

The use of video conferencing is fast becoming more relevant in the health field. There are many examples of clients travelling to regional centre to access specialists, when they could just as easily liaise with various health bodies without leaving their place of residence.

In the past, rural clients requiring minor surgery at a regional hospital faced the prospect of multiple trips to consult with their surgeon, anaesthetist and pre-operative clinics, as well as the trip for the actual procedure. There is overwhelming evidence the use of video conferencing not only alleviates financial costs to clients, their families and the health budget, but also lessens the inconvenience of multiple trips to regional centres.

Clients wishing to use this service firstly need to discuss it with their healthcare provider. If they are happy to consult via video conference, the client contacts the Hospital to book the video session, once they have an appointment time.

Hospital staff will liaise with the service provider about their ICT requirements. In most instances,

the client needs to arrive 15 minutes prior to the actual appointment time.

Clients can be assured their privacy throughout the process is upheld at all times.



Quality & Safety continued

Pressure Injuries

Immobility, such as that associated with extended bed rest in hospital, can cause pressure injuries. Pressure injuries are a major contributor to the care needs of patients within the health industry. In the majority of cases, pressure injuries are preventable. Pressure injuries can occur in any patient with any or all of the associated risk factors. Risk factors are not restricted to decreased mobility, but also include factors such as nutritional status, skin integrity, age and the level of oxygenated blood supply to pressure points. A pressure injury can commence in any setting, including acute areas such as operating theatres and intensive care units, and in children or adults of any age.

Strategies to prevent pressure injuries have been identified and multiple evidence-based resources are available. Management of established pressure injuries has advanced with the increasing specialisation in wound management, research and technology.1

A number of staff members attended a Skin Integrity Symposium during 2014 and they returned with new best practice standards which have been trialled in Glenelg House Residential Care. These new practices involve the use of new skin products which have shown good results. An evaluation of the data collected through the trial is being conducted and changes to practice across the facility introduced.

The Skin Integrity Policy has been re-written to reflect evidence-based practice, new skin moisturising protocol and skin inspections have begun, with the aim of seeing decreases in pressure injuries and skin tears.

Along with the skin integrity practice changes, Casterton Memorial Hospital has purchased

four new air mattresses and two pumps. These mattresses are used with at-risk residents/patients to relieve pressure on bony prominences. The circulation of air throughout the mattress surface continuously changes the contact pressure points, reducing the risk of pressure injury.

As with all changes to clinical practice, some elements have been easier to achieve than others, but the willingness of staff to provide continuous quality improvement and bring forward new ideas provides the best outcomes for patients and residents.

1 http://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard8_Oct_2012_WEB.pdf

Mr. Stewart Bryan, R.N., displays some of the new skin integrity products in use throughout Casterton Memorial Hospital.

Number of Pressure Injures developed whilst an Inpatient during 2013-14

4

8

6

4

2

0

Glenelg House RateStatewide High Care Rate

Stage 1 Pressure Injury Rate per 1000 Bedays

0

0.40.44

0.490.45

0.63

0.8

Jul-Sep 13 Oct-Dec 13 Jan-Mar 14 Apr-Jun 14

0 0

0.360.36




Weight Maintenance and the Dining Experience

Evidence has shown the elderly are more prone to malnourishment and weight loss than the average healthy person. This arises from a number of factors, which include: change in lifestyle, decreased appetite, increasing illness or injury, decreased mental function and the reduced capacity or ability to buy and prepare nutritious foods.

Casterton Memorial Hospital is committed to ensure patients and residents maintain their weight and their nutritional needs are met with processes in place to identify and manage those at risk of weight loss. A nutritional screening, assessment and care tool has been developed to ensure weights are maintained and managed, according to best practice. All staff attended an in-house study day promoting the benefits of a “person-centred” approach to care. Through this working party and the Hospital resident’s quality feedback and questionnaires, the catering service, delivery system and menus were identified as areas which could better meet resident’s needs.

With ongoing feedback and input from residents and their families, a new catering and menu system has been designed and implemented. This process has highlighted resident’s individual food preferences, meal schedules and delivery, as well as recognising nutrition and hydration as an important part of care. At this stage, anecdotal evidence has noted positive comments from residents, families and staff regarding the new meal service, from meal selection, quality, variety, service and the dining experience. Staff noted an

increase in residents attending the dining areas, an increase in food volumes consumed, and enhanced social interaction another positive of the new dining experience.

1

0

0.5

Glenelg House Rate

Statewide High Care Rate

Rate of Weight Loss each month per 1000 bed days

0.720.69

0.3

0.73 0.740.81

0.640.37

Jul-Sep13

Oct-Dec13

Jan-Mar14

Apr-Jun14

Residents also receive regular nutritional assessments with the visiting dietician as well as regular reviews by the nursing staff to ensure their nutritional needs are being met and the resident is within their ideal age-appropriate healthy weight range.

Casterton Memorial Hospital will continue to provide high quality nutritious meals, an avenue for social interaction and inclusion, and embrace the dining room meal time experience whilst working to maintain residents’ weight by meeting their hydration and nutritional needs.

Ms. Sally Goodwin and Ms. Meg Clode serve dinner from the new portable bain-marie in Glenelg House as part of the new dining experience.




Traffic Lights Help Falls Prevention

Reducing the incidence and impact of falls in a healthcare setting and the wider community is an important of part of Casterton Memorial Hospital’s care planning.

The introduction of clearly visible “traffic light” labelled mobility aids this year has raised awareness of residents’ and patients’ needs when moving about the facility.

The mobility aides have a clearly visible coloured tag indicating the level of assistance required when mobile, whilst maintaining dignity.

Casterton Memorial Hospital Traffic Light System

Hands on Assistance Required

No Assistance Required

Supervision Required – Verbal Cues Only

A fall can be defined as a sudden, unintended change in position causing an individual to land at a lower level on an object, the floor or another surface.

Falls account for the majority of injury-related admissions and injury-related death in people 65 years or older. Falls can be a burden for the residents, their families and the health care organisation and are a significant cause of mortality and injury in hospital and residential settings.

The use of a Falls Risk Assessment Tool (FRAT) in the Hospital and formation of a Falls Group, representing many areas of the organisation, has worked to enhance and encourage a person centred care approach.

The group has also developed new and individualised strategies to help prevent falls and minimise harm from falls, with a particular focus on dementia residents, as memory impairment can be a major falls risk factor.

In addition to the “traffic light” mobility aid assessment, the group uses a number of tools to carry out falls risk assessments, including:

• Continued assessment of individual bed heights;

• Cognitive assessment using mini mental test; and

• Improved documentation regarding discussion of FRAT with patient/residents and their families, so all are fully informed of risks and strategies to prevent falls.

Mrs. Jean McIntosh is supervised by Mrs. Karen Perry as she uses her mobility aid around Glenelg House.




Traffic Lights Help Falls Prevention

Additionally, sensor mats and pad alarms are used for falls risk patients who have memory loss and forget to ring for assistance, or attempt to mobilise without their mobility aid/escort.

The traffic light system and falls risk symbols are well recognised by staff hospital wide.

The Hospital’s District Nursing Service has included the falls risk assessment process for new and existing clients.

The four page tool is used annually, or when a fall or deterioration in mental or physical health is detected. District Nursing clients are advised of programs and strategies that can be implemented appropriate to the general circumstances of the client in the areas identified as potentially being a falls risk.

Referrals may include Allied Health – physiotherapy, occupational therapy, dietetics or continence nurse- or other community programs, including strength and balance class, walking group and the local gymnasium.

Casterton Memorial Hospital is committed to the implementation of systems and strategies to reduce the incidence of falls and follow best practice management when falls do occur.

The extension of falls prevention and management programs into the community also support clients to manage in their own homes.

Acute Hospital Falls Comparisons 2013/14

Falls

05

101520253035404550

Glenelg House Falls Injury Rates as a Percentage of Total Falls Reported

Minor Injury (2-3)

Major Injury

51%

2013/14

100%

% o

f Tot

al F

alls

50%47%

3%

50%

0%

Falls

10

0

5

Glenelg House Rate

Glenelg House Falls per 1000 bed days

Statewide High Care Rate

6.52 7.2 7.04


7.26

3.3

6.93 7.47 7.23

46

2012/13

34

2013/14




“Having the Conversation” - Advance Care Planning

ACP Consultants Mrs. Karen Sealey, Mrs. Di McKinnon and Mrs. Cecily Condon discuss Advance Care Planning.

Advance Care Planning is the process of planning for future health and personal care whereby a person’s values, beliefs and preferences are made known so they can guide clinical decision making at a future time when that person cannot make or communicate their decisions due to lack of capacity.

Casterton Memorial Hospital established an Advance Care Planning Working Party in 2004, developed a policy and trained staff members as facilitators to enable patients, residents or clients access to this valuable service.

The Hospital continues to be proactive in embedding advance care planning into usual clinical practice. Patients in the Acute Ward are asked if they have an Advance Care Plan (ACP) and, if they do, there is a clearly defined process to receive the ACP and to incorporate it into the patients’ medical records. If the patient does not have an ACP, information is provided and the patient is encouraged to discuss this process further with their family and one of the 10 consultants on staff at the Hospital.

Glenelg House residents have the conversation on admission to their new home. This conversation forms part of the admission guidelines which,

in turn, supports the resident and their family or authorised representative, to plan for future health care. Residents and their family or authorised representative are able to choose to have an ACP. This conversation is revisited every twelve months.

ACP facilitators meet regularly, through a working party, to ensure regular community forums and to promote and maintain community awareness about ACP and publicise the concept of ‘having a conversation’. Casterton Memorial Hospital supports the Victorian Health Priorities Framework 2012-2022 which identifies the expansion of advance care planning as an important action to improve every Victorian’s health experience. As a result, Primary and Community Care promote ACP within the District Nursing service and Community Health assist with the co-ordination of public forums on ACP.

The Hospital held a community forum about Advance Care Planning in April, 2014 to develop, review and raise awareness about ‘having the conversation’. Twenty-one people attended the forum with Dr Greta Prozesky, local doctor, and Erika Fisher, Palliative Care Nurse, facilitating. The forum was well received and raised awareness in the community.




Medication Management

Casterton Memorial Hospital’s proactive approach to the improvement of medication safety has seen the formation of an advisory committee to oversee medication management and a review of policies in line with best practice.

During the course of the year, the following medication management strategies have been implemented.

• The introduction of a Webster pack system – a dose administration aid – has improved compliance with medical administration and increased Glenelg House staff’s ability to monitor medication dispensing.

• A new medication management plan in the Acute ward has improved assessment, documentation and communication with the pharmacy and medical clinic. The plan includes a comprehensive history and risk assessment, medication reconciliation on admission and discharge and referral for a home medicines

review if required. These are communicated to the medical clinic, who work in conjunction with the pharmacy to complete reviews.

• Use of Consumer Medicine Information sheets has improved the education of patients in regard to the prescription of new medications. This printed information allows staff to provide accurate consistent information in a standardised format.

• The storage of Schedule 4 drugs of dependency has been enhanced with a daily audit of pharmacy supplies and two staff required to authorise removal from the locked storage drawer via a register. Patients who are on high-risk medication receive appropriate education from nursing staff upon discharge.

• Hospital medication policy is continuously reinforced and annual competency reviews are completed by all nurses.

Glenelg House has a high number of residents with very complex healthcare needs. Staff continues to work closely with medical and pharmacist healthcare professionals to reduce the number of medications where possible.

Incidence of Residents with 9 or more medications per 1000 beddays

02468

10


Glenelg House Rate Statewide High Care Rate

6.88

4.19 4.43

6.8 7.8

4.3

6.9

4.47

2011/12 2012/13 2013/14

20

15

10

5

0

18

9 10

Total Total Adverse Outcomes

Hospital - Patient Related Medication Incidents




Infection Control

Infection control continues to be a central focus within Casterton Memorial Hospital. The Australian Commission on Safety and Quality in Healthcare sees infection control as one of the most important aspects of healthcare and this has just been proven whilst undergoing periodic review for accreditation when Infection Control was one of the three areas of focus.

The Hospital reports to the Department of Health on certain Healthcare Acquired infections, occupational exposures, hand hygiene, influenza vaccination rates and cleanliness of the facility.

During 2013-2014, the Hospital had no Healthcare Acquired infections to report, minimal occupational exposures and has done well in hand hygiene and influenza vaccination rate data.

There has been a pleasing upward trend in compliance with the five moments of hand hygiene during all three audit periods this year. Staff have proved their dedication to protecting patients by improving on every audit since mid 2013, with the latest audit showing 79.2% compliance.

Casterton Memorial Hospital has again performed extremely well with influenza vaccination rates,

with a 95.4% uptake clearly one of the highest performers.

Cleaning audits are undertaken in-house on a monthly basis by Infection Control and Environmental Services and these always show cleanliness to be above 90% in all areas. The external audit undertaken in July returned an excellent rate of 98.4%.

Antimicrobial stewardship is a concept being strongly encouraged by the Department as resistance to antibiotics increases. The Hospital undertakes an audit of all antimicrobial prescription in the facility, with the results provided to the Medical Officers. The audit is based on best practice guidelines for antimicrobial prescription. The correct prescription of antimicrobials is essential to reduce or slow the incidence of antibiotic resistance.

Infection Control at CMH is well supported by the regional Infection Control officer, based at WDHS, and has all the policies and guidelines in place to be able to stay at the forefront in the fight against infections.

CMH External Cleaning Audit Results

100908070605040302010

0V High Risk High Risk Moderate

Risk

Jul-13

Jul-14Acceptable Level

96 99 97 100 99

85

98

CMH Hand Hygiene - Total Compliance Rates

80%

78%

76%

74%

72%

70%

68%

66%

64%

62%

60%

64%

2013 (2) 2013 (3) 2014 (1) 2014 (2)

75%

77%

79%

Total Hand Hygiene Compliance Results CMH

Acceptable Level



Consumer SatisfactionThe Victorian Department of Health have introduced a new state-wide based patient experience survey called the Victorian Health Experience Survey which commenced in April 2014.

The survey will allow a wide range of people to provide feedback on their experiences and features specialised questionnaires for different patient types including; adult and child inpatients, maternity clients, adult and child emergency department attendees, including parents/guardians. Surveys are distributed about one month after discharge from hospital by the coordinating company appointed by the Department of Health. The first reports for Casterton Memorial Hospital will be available later this year.

Casterton Memorial Hospital collects feedback from a diverse range of services from Planned Activity Group, District Nursing, inpatients, Glenelg House residents as well as Meals on Wheels and Home Maintenance Services. These surveys gather information from clients about their level of satisfaction and identify where services could be improved.

A regular review of complaints received identifies where service and/or system improvements may be made. The Hospital works with consumers to resolve complaints in a fair and respectful manner. Comment and complaint forms are widely available for clients to confidentially report concerns and/or praises.

This year there were five formal complaints which were fully resolved. There were also three informal complaints, relating mainly to food delivery. In response to this, and other general feedback, the entire hospital menu was reviewed with input from Glenelg House residents and families. This resulted in improvements also being made to the way meals are delivered in Glenelg House with all meals served individually in each dining room by catering staff. Residents are now able to choose and be served their breakfast, lunch and dinner from options provided on the day. The new system is enhancing choice and improving the overall dining experience for residents of the facility. The new menu has been widely praised by staff, residents and patients alike, especially the roast pork and crackling. Evaluation will continue in this area as the year progresses.

During early 2014 comments were made about the clarity of Theatre pre-admission information provided to clients. A review of Endoscopy information resources was conducted and further feedback sought from theatre patients. In June 2014 the Community Advisory Committee made further suggestions and all ideas were incorporated into a new format. A new information sheet was provided to Theatre patients in July, who noted the improvement in clarity. The new format has now been implemented and feedback has improved.

Feedback Sought

The 2013-2014 Quality of Care Report has been produced with the cooperation and consultation of staff and community members.

Following the distribution of last year’s Quality of Care Report there was no feedback received from the community regarding the publication, either in content and/or format.

To assist Casterton Memorial Hospital in providing the most relevant content and appropriate format, please take the opportunity to complete a Feedback Form, which is available from the main reception desk, or via our website at www.castertonmemorialhospital.com.au.



Health PromotionThe Victorian Department of Health have iHealth promotion is an important aspect of Primary and Community Care at Casterton Memorial Hospital. Health promotion functions on a number of levels, including:

• raising community awareness and engagement supporting healthy behaviours;

• community development through education, providing solutions and interventions and capacity building for various chronic diseases; and

• building partnerships with other organisations to support shared clients.

All of these health promotion activities are supported through the development of a Casterton Memorial Hospital Community Health Strategic Plan 2014-17 which reflects Glenelg Shire Health and Wellbeing Plan 2013-17 and Southern Grampians and Glenelg Primary Care Partnership (SGGPCP) Health Promotion Key Priority Areas 2014-17.

Casterton Memorial Hospital works in collaboration with other local organisations such as the Glenelg Shire Council, to provide health promotion activities within the area. One example is Youth Services. Glenelg Shire Council’s Youth Resource Officer chairs Youth Network Meetings attended by the Hospital and Casterton Secondary College staff. The focus of these meetings is to organise and promote drug, alcohol and smoke free events targeting youth (12-25 year olds).

Casterton Memorial Hospital is a partner agency of the SGGPCP. The vision of SGGPCP is ‘through capacity building for collaboration, enhance the health and wellbeing for our community’.

Therefore, the Hospital’s membership enables an increased capacity to work together with other similar agencies to enhance health promotion ability. The Hospital works with others on projects to benefit the community, replicate successful projects from other towns and areas and adapt to suit local needs and problem-solve, with other health professionals, issues that are of paramount concern to residents.

Ms. Anne Pekin, Mr. Paddy Neeson and Mr. Geoff Cain promote Casterton Memorial Hospital at the annual Kelpie Festival.



Health Promotion continued

Exercise Programs – Community Health

Casterton Memorial Hospital has a diverse range of physical activities that can be attended by any community members depending on level of fitness. These activities include: an exercise class to increase physical fitness (Cardiovascular Fitness Program), to build strength and balance to help prevent falls (Strength and Balance Exercise Program) and a Walking Group.

Cardiovascular Fitness Program

Australia is today ranked as one of the fattest nations in the developed world. The prevalence of obesity in Australia has more than doubled in the past 20 years. Cardiovascular disease (CVD), diabetes and chronic kidney disease account for approximately a quarter of the burden of disease in Australia, and just under two-thirds of all deaths. These three diseases often occur together and share risk factors, such as physical inactivity, overweight and obesity and high blood pressure.

Casterton Memorial Hospital introduced a Cardiovascular Fitness Program (CVD Fit) in response to the above alarming statistics. Whilst commenced as a short term program, CVD Fit has been further developed and expanded as the interest of participants increased and as the number of weeks passed.

Each week six to twelve people attend CVD Fit. Many attendees speak of their increased sense of wellness and the motivation to exercise more as a result of attending our interval, high intensity CVD Fit.

One such devotee has completely changed her approach to physical fitness, transformed her body and, more importantly, drastically improved her health. Here is her story:

Physiotherapist Ms. Mel Roll encourages Mrs. Fran Newbegin to greater effort in the Cardiovascular Fitness Program.

‘I was unwell, in and out of hospital and told that I didn’t have a bright future due to my weight, heart problems and sedentary lifestyle. My husband even received a sympathy card once, when I was in hospital, because the rumour circulated that I had died that is how unwell I was. I tentatively joined the CVD Fit classes and had difficulty attending to the exercises, and I was very shy and self-conscious about my body and lack of fitness. Everyone attending the classes were so supportive and I found that several were like me, new to exercise and didn’t know what to do. I began to enjoy myself, lose weight and became more confident. I have lost over 18 kgs, have the confidence to exercise outside of class time and feel the healthiest I have for years and years.’



Health Promotion continued

Strength and Balance Exercise Program

Slips, trips and falls can happen to anyone but are more common and have a more significant impact in older age, as the likelihood of injury increases. Although falls are a common problem for older people and are often the reason people are admitted to hospital or move into care, many falls are preventable. Casterton Memorial Hospital introduced a Strength and Balance Exercise Program nearly ten years ago, to help people remain steady on their feet.

Physical activity increases health and reduces the risk of falls. Exercise classes, such as Strength and Balance, increase strength and improve balance and, as a consequence, lower the risk of having a fall. Other side effects of attending Strength and Balance are: improved muscle strength and flexibility, stronger bones, increased energy levels, improved sleep patterns, improved blood pressure, blood sugar levels and weight. Exercise also helps a person to feel good about life.

A regular attendee of the Hospital’s Strength and Balance moved to Casterton for a tree change and because of the excellent health facilities available

in town. She has been an inspiration to many with her dedication to attending a variety of programs offered at the facility. She has a condition that impacts on her strength and balance and, therefore, attending this program was a natural addition to her weekly regime of care.

‘I feel l have better control when I walk and I also have more confidence in exercising because I am stronger and I can see that it benefits me. I have also changed my opinion on ageing as I now know I can remain active. I have also made a great number of new friends from joining in a participating in caring for myself through exercising.’

Casterton Memorial Hospital’s exercise programs have been designed to be inclusive, informative and fun. People are encouraged to come and ‘have a go’ in a supported, non-threatening environment. The programs are designed to accommodate all fitness levels.

Staff members get behind Pink Day and show their support for Breast Cancer Awareness.



Volunteers

Murray to Moyne

Casterton Memorial Hospital was once again represented in the annual Murray to Moyne Cycle Relay event held in April of this year. The great team of eight well-trained and enthusiastic cyclists, supported by four experienced support crew, took on the challenge. The team rode out of Mildura on Saturday and completed the 520 kilometres, arriving ahead of time in Port Fairy Sunday morning.

The Casterton Memorial Hospital’s Murray to Moyne Relay Committee has been one of the Hospital’s major fundraisers for more than 20 years now. This year the Committee raised a record sum of $16,519.40. These funds, combined with previous years’, enabled the hospital to purchase new theatre equipment to the value $46,000 and a new mobile food servery for the catering department to the value of $3,180.

Murray to Moyne Cycle Team 2014.Left to right: Mr. Michael Greenham, Mr. Stephen Mutch, Mr. Andrew Edgar, Mr. Simon Povey Victorian Premier The Hon. Dr. Denis Napthine MP, Mr. Duncan Wishart, Mrs. Barb Toma, Mr. Trevor Edwards, and Mr. Paul Beauglehole.

Device Technology Instructor with Casterton Memorial Hospital Theatre Staff Mrs. Heather Gill, Mrs. Alison Jenkins, Mrs. Debbie Gartlan and Mr. Muza Makore.

Casterton Memorial Hospital cook Ms. Sally Goodwin serves up meals from the new mobile servery unit provided by Murray to Moyne Relay Committee.



Our Supportive CommunityCasterton and district community members, businesses, service groups and fund raising committees continue to support the activities, planning and development of Casterton Memorial Hospital. This support is very much valued and reinforces the strong community spirit.

During 2013 /2014, hospital fundraising committees and the community contributed $39,264 to the facility, to assist with maintenance of the modern well-equipped hospital, aged care facility and community health development. The Hospital also acknowledges and appreciates the general donations received from families, community members, staff and estates.

Volunteers provide purposeful activities and roles, and as such are greatly appreciated by staff and the community. Their contribution extends to activities including delivery of Meals on Wheels, bus driving, visiting, entertainment and diversional and lifestyle activities. It is through volunteers that the Hospital is able to foster community connections and participation for residents and their families.

The Hospital also appreciates the input and contributions from the businesses and the broader community through community surveys, questionnaires and Hospital Card Program. This community spirit contributes to Casterton Memorial Hospital being a proud facility and also supports the continual effort to provide the best quality services to meet the changing needs of the community.

The Board of Management sincerely thanks all Casterton Memorial Hospital supporters for their generous, tireless and invaluable support during 2013/2014.

Life GovernorsCasterton Memorial Hospital Life Governors

Burston, Sir S.G.W.

Collins, Mr D.

Cowland, Mr R.

Edge, Mr E.

Flanders, Mrs E.

Floyd, Dr. A. F.

McEachern, Mrs. N. J.

McKinnon, Mrs. C.

Moffatt, Mrs M.

Nicol, Mr R.

Ross, Mrs. J. (OAM)

Sandow, Mr. P.J.

Simson, C. R. & K. L.

Squire, D.

Thompson, Mrs. R. G.

Recognised for Service and Dedication to Casterton Memorial Hospital

DonationsFundraising Committee

CMH Hospital Social Club 1,000.00

CMH Ladies Auxiliary 3,367.51

CMH Murray to Moyne 16,519.40

CMH Hospital Card Program 5,650.00

CMH Staff 1,043.05

Friends of Glenelg House 1,000.00

Staff - Exercise Group 640.15

Fundraising Committee

In Memory of Mr Gerald McArlein 170.00

In Memory of Mrs Gladys Goodwin 300.00

In Memory of Mr James Johnson 635.00

In Memory of Mr Peter Humphries 445.00

In Memory of Mr Barry Peters 275.00

Anonymous 730.00

Casterton Lions Club 500.00

Casterton Motor Enthusiast Club 2,200.00

Grace Groves Estate 152.20

Hamilton Bridge Club 400.00

Mrs Beverly Baines 50.00

Mr Hugh Delahunty, MP 200.00

Mr Paul Bell 250.00

Estates

Equity Trustees - Estate John MacPherson 1,250.00

Equity Trustees - Estate Louise Henty 2,036.43

Equity Trustees - Estate William Health 450.00

Total Donations 39,263.74

Total Donations 39,263.74



Human Resources

Workforce Data

During the 2013/14 year Casterton Memorial Hospital employed a total of 102 staff, 40 full-time, 61 part time and 11 casual across the labour

categories as detailed in the following table. Staff attended 1257 hours of training and professional development.

Employee of the Year 2013Ms. Sheila Bramall, Nurse Unit Manager Community Health, received Casterton Memorial Hospital’s Employee of the Year Award in 2013. Throughout her 19 years’ service at the Hospital, Sheila’s enthusiasm and dedication to community health enabled her to deliver outstanding programs.

Her passion was brought to the fore in particular with the Make a Move project, which was developed to enable older people to remain in their homes by keeping them physically and mentally active.

Sheila’s retirement in 2014 brought to an end an era of a highly engaged, witty and committed community worker.

Labour Category – Full Time equivalent (FTE)

Category Staffing June Current Month June Year to Date

2013 2014 2013 2014 2013 2014

Nursing 54 56 37.32 43.40 37.58 43.28

Administration & Clerical 10 12 8.24 8.91 8.42 8.94

Hotel & Allied Services 48 44 29.12 23.61 31.23 24.19

CEO Mr. Owen Stephens (left) and Board President Mr. Graham Sheppard (right) present Mrs. Cheryl Rees and Mrs. Janice Annett awards for 35 and 20 years service to Casterton Memorial Hospital, respectively.

Mrs. Sheila Bramall retired after 19 years’ service at the Casterton Memorial Hospital.

2013-2014 Years of Service5 Years

Mrs. Dot Louden

Mrs. Olivia Makwati

Mr. David Richardson

Ms. Valinda Ross

Mrs. Gayle Twardowski

10 Years

Mrs. Loren Hulm

Mrs. Leeanne Kettle

15 Years

Mrs. Susan Wombwell

20 Years

Ms. Mary-Anne Betson

25 Years

Mr. Shane Gill

Mrs. Heather Rees

Mrs. Wendy Tibbles

Mrs. Barb Toma

30 Years

Mrs. Kathy McArlein

2013-2014 Employee Recognition



Staff ListRegistered NurseBetson, M. A.Brown, D.M. *Bryan, S.Clutterbuck, M. P.Coulter, J. M.Dehnert, S. D.Dillon, H. V.Gartlan, D. A.George, A. A.Gill, H. L.Gill, S. M. D.Gunning, P. SsJenkins, A. J.Jose, C.Kettle, L. J.Mahanda-Makore, C.Makore, G.Makore, M.Makore, S.Makwati, O.Matthews, J. A.McEachern, B. M.McGrath, K. A.McKinnon, D. R.Rees, C. M.Sealey, K.Sheahan, V. J.Tait, B. L.Taylor, A.C *Young, J. L.Zippel, W. J.

Community HealthBramall, S.N. *Layley-Doyle, P. L.Pekin, A. M.

Enrolled NurseBeever, A.Benson, A. M.Bogie, R. M.Bowman, I.T.Bryan, B. H.Condon, C. A.Cunningham, C.J. *

Galpin, S. P.Johnson, C. D.Johnson, K. M. *Jones, N. M.Kirby, H. M.McArlein, K. M.Michau, R.Nesbitt, D. A.Parsons, K. L.Perri, D.Russell, M. R.Tait, P. M.Tibbles, W . K.Wombwell, S. M.

Nursing Attendant/ Personal Care WorkersBrooker, A. J. *Moyle, M. M.Reilley, R. F.Sealey, T. B.Townsend, S.Thurkle, E. R.

Healthcare AttendantKent, B. M.

Diversional TherapyPerry, K. M.Watts, A. M.E.

Planned Activity GroupAnnett, J.M. *Neill, S. M.

AdministrationBandel, G. M. *Betinsky, M. J.Carmichael, P. GDavis, S. S.Hodson, F T. *Hulm, L. S.

Rees, H.Richardson, J.F.Shone, C. M.Smith, S. J.Stephens, O. P.Toma, B. G.

Environmental ServicesBellinger, C.Bunnik, I.East, J. A.Edwards, K. D.Harvey, E. T.Hurrell, J. A.Jones, P. A.Louden, D. J.McDonald, B. A.J.Smith, C. L.

CateringClode, J. M.Craig, E. A.Goodwin, S. M.Gould, D. A.

Green, J. R.Jackson, B. J. *Jordan, J. *Kensen, M. D.McPeake, M. L.Murrell, J. A.Naylor, J. H .Nolte, M. R.Northcott, C. J.Ross, V. L.Sealey, D. J.Southern, D. L.Stanislawski, H.Talbot, P. A. *Twardowski, G. M.

MaintenanceNaylor, M. L.Richardson, D. J.Ryan, P. D.Tomkins, R. W. *Zippel, S. J.

*denotes resigned during year

Mr. Owen Stephens, CEO, farewells Mr. Ross Tomkins after 28 years of service in Casterton Memorial Hospital’s maintenance department.

Acute CareOperating Room

Planned Activity GroupCommunity Health /

Health PromotionInfection Control

Home NursingUrgent CareEducation

Visiting Medical ServicesDirector Medical Services

PharmacistAllied Health

Principal Committees• Executive• Audit• Quality Committee• Visiting Medical Officers• Credentials• Medical Appointments• Facility, Fabric & Assets• Environmental

Management

Residential Aged Care Finance ReportingIT/Information Systems

Health InformationReception

Human ResourcesPayroll

Supply ServicesRisk Management

Contracts

CateringLinen

Waste DisposalLaundry

HousekeepingMeals on Wheels

Plant & Equipment Building & Maintenance

Garden & GroundsEssential Services

Home MaintenanceFleet Management

Committee Composition

Functional Organisational ChartCasterton Memorial Hospital

Casterton Memorial Hospital

BOARD OF MANAGEMENT

DEPARTMENT OF HEALTH

BOARD OF MANAGEMENT

CHIEF EXECUTIVE OFFICERMANAGER NURSING SERVICES

SAFETY / CONTINUOUS QUALITY IMPROVEMENT / OH&S / RISK

EXECUTIVE

BOARD SUB-COMMITTES

ExecutiveAudit

QualityFacility / Fabric and Assets

Credentials Medical Appointments

Environmental Management

CLINICAL SERVICES

Clinical Services CommitteeAcute Nursing Staff

Residential Care StaffSenior Nursing Staff

Primary Care StaffMedication Advisory Committee

Minimal HandlingVisiting Medical Officers

Midwifery Staff

CLINICAL & COMMUNITY

SERVICES

RESIDENTIAL CARE

ADMINISTRATIVE SERVICES

HOTEL SERVICES

MAINTENANCE SERVICES

CORPORATE SERVICES

Department HeadsOccupational Health & Safety

ComplianceInformation, Communication &

TechnologyAdministration

Environmental ServicesCatering

OTHER

Consumer Advisory GroupResident’s CommitteePlanned Activity CarePerson Centered Care

Working Group

Functional Organisational Chart

Committee Composition Chart

Casterton Memorial Hospital63 - 69 Russell Street, Casterton, Victoria 3311

Phone: (03) 5554 2555 Fax: (03) 5581 1 051 Email: [email protected]

A Fully Accredited Healthcare Facility

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