mercy health - mphi report 2015

Report of Operations 2014/15

AttestAtion

Statutory Authority and other relevant agency – Mercy Public Hospitals Inc

I, Julien O’Connell, certify that Mercy Public Hospitals Inc has procedures in place to ensure, as far as is practicable, that data collected for the management of public hospital services is accurate. Audit and other review processes are used to review data accuracy. Where issues are identified, action plans are put in place to improve compliance.”

Mr Julien O’Connell AMChairman, Mercy Health4 August 2015

Mercy Public Hospitals Inc

Contents3 Introduction: Chief Executive Health Services

3 Summary of financial results

4 How we govern ourselves

5 Our services

6 Organisation structure

8 Our governance structure

9 Executive group

11 Mercy Health Strategic Plan 2013/17

12 2014/15 Statement of Priorities

21 Highlights for 2014/15

23 Performance priorities

25 Activity and funding

26 Our workforce

27 Reporting procedures

29 Freedom of information

30 Research

Report of operations 2014/15

Mercy Public Hospitals Inc gratefully acknowledges the funding support provided by the Victorian Government for services, programs and research over the 2014/15 financial year.

3Report of Operations 2014/15

We are pleased to present the Mercy Public Hospitals Inc Report of Operations 2014/15.

In line with our 2013/17 strategic objectives our organisational focus has remained firmly on responding to the changing needs of our community with sustainable, accessible and high-quality care.

Mercy Public Hospitals Inc is proud to honour the vision of our Foundress Catherine McAuley in offering services built on compassion, hospitality, respect, innovation, stewardship, teamwork and a commitment to ‘care first’.

Dr Linda MellorsChief Executive – Health Services

Compassionate and responsive care is central to our ethos as a denominational healthcare provider. Delivering care in the most effective manner is key to fulfilling our mission and ensures the best use of our funds to serve the greatest need.

Introduction

2014/15 finance and performance report

Mercy Public Hospitals Inc has continued to experience increased demand for services throughout 2014/15.

Our results this year are a credit to the hard work and commitment of our people, ensuring we can grow as a sustainable and viable ministry, while managing funding and cost pressures, within the resources allocated.

Our operating result

The financial result for 2014/15 was a net loss before capital and specific items of $231,000, compared to a surplus of $4.122M in the preceding year.

The net result for the year of $1.988M included $9.177M of capital purpose income, partially offset by depreciation costs of $6.958M.

The trend of results over the past five years is shown below.

Summary of financial results

2015 2014 2013 2012 2011$000 $000 $000 $000 $000

Total revenue 281,911 273,383 257,757 234,811 217,444

Total expense 279,923 261,942 240,903 231,445 214,455

Operating surplus/(deficit) 1,988 11,441 16,854 3,366 2,989

Retained surplus (accumulated deficit) 37,993 36,069 23,906 7,258 4,244

Total assets 101,336 95,424 83,844 58,283 50,445

Total liabilities 61,350 57,426 57,287 48,580 44,108

Net assets 39,986 37,998 26,557 9,703 6,337

Total equity 39,986 37,998 26,557 9,703 6,337

4 Compassion | Hospitality | Respect | Innovation | Stewardship | Teamwork

How we govern ourselves

Mercy Public Hospitals Inc was established in 1986 under the Associations Incorporation Act 1981 (Vic). Mercy Public Hospitals Inc is a Denominational Hospital as per Schedule 2 of the Health Services Act 1988 (Vic).

Mercy Public Hospitals Inc forms part of Mercy Health, a Catholic not-for-profit organisation which provides a range of health, aged and community care services to Victoria, the Australian Capital Territory, New South Wales, Queensland and Western Australia.

The board of Mercy Health operates as the concurrent board of:

• Mercy Public Hospitals Inc

• Mercy Health & Aged Care Inc

• Mercy Hospice Inc

• Mercy Private Hospital Inc (a dormant entity)

• Bethlehem Home for the Aged Inc

• Mercy Health Service Albury Ltd

• Marianella Nursing Home Ltd

• Mercy Care Centre Young Ltd

• Rice Village Ltd.

Mercy Health works closely with government to identify and respond to current and emerging health needs in our community. We acknowledge the generous support offered by the Victorian Government over the past 12 months.

The relevant ministers for the reporting period were:

• The Honourable Dr Denis Napthine MLA, Premier of Victoria (to December 2014)

• The Honourable Daniel Andrews MP, Premier of Victoria (from December 2014)

• The Honourable Jill Hennessy MP, Minister for Health and Minister for Ambulance Services (from December 2014)

• The Honourable Martin Foley MP, Minister for Mental Health and Minister for Housing, Disability & Ageing (from December 2014)

• The Honourable David Davis MP, Minister for Health and Minister for Ageing (to December 2014)

• The Honourable Mary Wooldridge MP, Minister for Mental Health (to December 2014).

Mercy Public Hospitals Inc was established for the following purposes:

1. to carry on or assist in the carrying on of the charitable activities of the Sisters of Mercy in connection with hospital, health care and related services

2. to operate:

2.1 Mercy Hospital for Women, Heidelberg; and

2.2 Werribee Mercy Hospital; and

2.3 other hospitals, health and related services, as determined by the Association

3. to educate and train:

3.1 medical, nursing, social welfare and pastoral care students at undergraduate, intern and post-graduate level; and

3.2 others engaged in hospital, health care and related services on a paid or voluntary basis; and

4. to ensure that all activities of the Association are carried out in keeping with the vision, mission, philosophy and values of the Sisters of Mercy and the teachings of the Roman Catholic Church.


Our services

Mercy Public Hospitals Inc provides acute and subacute hospital care, mental health programs, specialist women’s health, early parenting education and support and palliative care services.

Mercy Hospital for Women

Based in Heidelberg, Victoria the hospital offers obstetric, gynaecological and neonatal services and has one of only four neonatal intensive care units in metropolitan Melbourne. The 58 bed unit is made up of neonatal intensive care and special care nurseries.

Mercy Hospital for Women provides both public and private patient care through maternity services, neonatology and paediatrics, perioperative services, women’s health and associated health and support services and diagnostic services. It is a major teaching hospital and specialist referral centre with the medical, nursing, midwifery and allied health expertise to treat the most complex obstetric, neonatal and gynaecological cases.

Werribee Mercy Hospital

Werribee Mercy Hospital is a community general hospital providing surgical, medical, maternity, newborn, renal dialysis, emergency, mental health, rehabilitation, aged and palliative care services in the south western region of Melbourne. The hospital also provides a range of home-based support services including Hospital in the Home and Midwifery in the Home.

The Catherine McAuley Centre offers subacute care to the Wyndham and surrounding regions. It includes the Continuing Care Centre, combining the Health Independence Program, Residential In-Reach and two subacute ambulatory specialist clinics, Falls and Balance and Continence. It also offers 30 geriatric evaluation and management and rehabilitation inpatient beds and therapy spaces.

Mercy Health O’Connell Family Centre

Mercy Health O’Connell Family Centre is focused on the needs of vulnerable families and young children. The residential, day and community programs provide child-focused parenting skills to promote safe child development. The centre is increasing its support for vulnerable families including families with mental health issues.

Services include:

• residential, day and community programs

• Cradle to Kinder program (home-based education and support)

• Playsteps program.

Mercy Mental Health

Mercy Mental Health supports people in south west metropolitan Melbourne with severe and complex mental illnesses by providing acute and community-based care. Services are available to adults through acute inpatient programs, residential rehabilitation programs and crisis and community recovery-focused treatment programs. We also offer inpatient and community specialist perinatal mental health services to women and infants in western Victoria.

Mercy Palliative Care

While not officially part of Mercy Public Hospitals Inc, Mercy Palliative Care is integrated into Mercy Health’s service delivery through inpatient palliative care services at Werribee Mercy Hospital.

Mercy Palliative Care and the Royal District Nursing Service work together to provide a professional home-based palliative care service that is free to patients, families and carers in the western region of Melbourne.

Counselling, nursing and medical services, allied therapies, grief counselling and pastoral care services provide continuity of care to patients, their families and carers. Referrals to the program can come from patients, doctors or hospitals, a patient’s family or friends, or community agencies.


Organisation structure

Board of Directors

Group Chief Executive

Officer

General Counsel

Group Executive Director

Leadership & Mission

Internal Audit and Risk Assurance

Executive Assistant

Executive Officer

Group Executive Director Quality, Risk & Service

Improvement

Group Executive Director People, Learning

& Culture

Chief Executive Health Services

Chief Executive Aged &

Community Care

Chief Medical OfficerExecutive Director

Nursing & Midwifery

Surgical & Specialist Services Program

Director and Clinical Services Director

Women’s & Children’s Services Program

Director and Clinical Services Director

Executive Officer

Executive Assistant


Organisation structure

Group Executive Director Finance & Support

Services

Medical, Subacute & Palliative Care Services

Program Director and Clinical Services Director

Ambulatory, Allied Health & Community

Services Program Director

Mental Health Services Program Director and

Clinical Services Director


Our governance structureMercy Public Hospitals Inc Board

Mr Julien O’Connell AM (Chairman)

Ms Jo Barker (commenced term of office March 2015)

Ms Margaret Bounader

Ms Virginia Bourke (concluded term of office November 2014)

Ms Polly Caldow (concluded term of office November 2014)

Associate Professor Michael Coote

Mr John Corcoran

Mr Gerard Dalbosco (concluded term of office November 2014)

Mr Julian Leeser (commenced term of office March 2015)

Mr John Moore

Ms Agnes Sheehan

Sr Joan Wilson RSM

The Board is supported by five committees.

Finance and Audit Committee

Mr John Moore (Chair)

Ms Jo Barker (commenced term of office March 2015)

Ms Jay Bonnington (commenced term of office February 2015)

Mr Gerard Dalbosco (concluded term of office November 2014)

Mr John Corcoran

Mr Ray Jacobson

Mr Bruno Secatore (commenced term of office October 2014)

Ethics Committee

Sr Helen Monkivitch RSM AO (Chair)

Dr Frances Baker RSM

Adjunct Professor Stephen Cornelissen

Reverend Dr Hoa Dinh SJ (commenced term of office September 2014)

Ms Gillian Evans (commenced term of office November 2014)

Dr Genevieve Green

Ms Kate Hewett (concluded term of office November 2014)

Ms Mary Klasen

Dr Linda Mellors

Reverend Associate Professor Cormac Nagle OFM

Dr Carol Ong RSM

Associate Professor Dean Stevenson

Mr Michael Taylor (commenced term of office March 2015)

Dr Adrian Thomas

Quality Committee

Associate Professor Michael Coote (Chair)

Associate Professor Kate Birrell (commenced term of office February 2015)

Ms Polly Caldow

Dr Michelle Goh RSM (commenced term of office August 2014)

Ms Sally Moore (commenced term of office June 2015)

Professor Emeritus Margaret O’Connor AM

Adjunct Associate Professor David Parsons

Human Research Ethics Committee

Professor Janis T. Ozoli nš (Chair)

Ms Virginia Bourke (commenced term of office January 2015)

Ms Wendy Brooks (concluded term of office July 2014)

Ms Christine Childs

Mr Diarmid Davine (commenced term of office January 2015)

Mr James Dwyer (commenced term of office August 2014)

Mr Kevin Fell (concluded term of office December 2014)

Ms Geraldine Gray (concluded term of office December 2014)

Professor Susan McDonald

Associate Professor Michael McKay (concluded term of office December 2014)

Dr Linda Mellors

Sr Helen Monkivitch RSM AO

Reverend Associate Professor Cormac Nagle OFM

Associate Professor David O’Neal

Professor Michael Permezel

Ms Susan Phillips

Professor Peter Rendell (commenced term of office January 2015)

Professor Stephen Tong

Professor Susan Walker

Dr Andrew Watkins

Corporate Governance Remuneration and Nomination Committee

Mr Julien O’Connell AM (Chair)

Ms Virginia Bourke

Mr John Moore


Executive group

Adjunct Professor Stephen Cornelissen BN, MHA, Grad Cert CCL

Group Chief Executive Officer

Stephen assumed the role of Group Chief Executive Officer, Mercy Health on 1 July 2011. During his tenure Mercy Health has grown to one of Australia’s top 100 private companies, providing health, aged and home & community care services in Victoria, New South Wales, Queensland, Western Australia and Australian Capital Territory. Before taking on this role he was with Mercy Health for eight years, developing a thorough understanding of the organisation’s operational performance and strategic objectives in health services, aged care, home and community care, and support services.

Before joining Mercy Health, Stephen has held several health administration roles in New Zealand and South Australia, having worked at operations and state policy and funding levels.

Stephen is a member of the Catholic Health Australia (CHA) Stewardship Board and a member of the Aged and Community Services Australia (ACSA) Board of Directors. He is also Public Officer for the Committee for Wyndham.

Ms Julia Trimboli MA (Th), M Sc (Bioethics)

Group Executive Director, Leadership & Mission

Julia was appointed to the position of Executive Director Leadership & Mission in June 2015 and is responsible for guiding Mercy Health’s leadership team in supporting our mission. Julia holds a Master of Bioethics, Master of Arts (Theology), Graduate Certificate in Interfaith Relations, Postgraduate Certificate in Human Rights & Social Justice, and Graduate Diploma in Secondary Education and Bachelor of Arts. Julia also brings extensive experience in mission leadership roles, which includes Catholic Health Australia and most recently, Cabrini Health. Julia has a deep commitment to, and sound knowledge of, Catholic health provision and what that means for mission from community, public and private health perspectives.

Dr Linda Mellors BA, BSc (Hons), PhD (Med) GAICD, Grad Cert HSM

Chief Executive, Health Services

Linda was appointed Chief Executive (formerly Executive Director) of Health Services in August 2013. She is responsible for the oversight of Mercy Hospital for Women, Werribee Mercy Hospital, Mercy Mental Health, Mercy Palliative Care and Mercy Health O’Connell Family Centre as well as hospital services in New South Wales. Linda joined Mercy Health in 2009 as Director Performance, Planning and Strategy for Health Services and has also held titles including Executive Director Mercy Hospital for Women and Mercy Health O’Connell Family Centre, and Executive Director Mercy Public Hospitals Inc. She is a Board Director of the South Western Melbourne Medicare Local, Chair of the Productive Series Steering Group for the Department of Health and Member of the Catholic Health Australia Health Policy Committee. Linda has held executive roles in the Victorian public health sector for more than a decade and is passionate about providing improved access to state-of-the-art health services. Linda completed the Williamson Community Leadership Program in 2012 and was named Catholic Health Australia Emerging Leader in 2013.

Ms Kate McCormack FAHRI, MBA (IRHR)

Group Executive Director, People, Learning & Culture

Kate has more than 20 years’ experience in human resources and holds a Masters of Business in Industrial Relations and Human Resource Management from RMIT University/Grenoble Ecole de Management France. Kate has also studied at the London Business School and at Harvard University.

Kate provides strategic advice to the Group Chief Executive Officer and Executive Group and is responsible for developing and implementing the overall Group Human Resources Long-term Plan. Kate is also responsible for communications, marketing and events management, and the Mercy Health Training Institute.

Kate has been instrumental in developing Mercy Health’s Employer of Choice Strategy and was the recipient of the HR Partners Award for Best HR Leader, HR Leaders Compass Awards in 2010, and the Diversity Leader for the Advancement of Women, EOWA Business Awards in 2010.

In addition to her role, Kate is a member of the Australian Human Resources Institute Presidents Forum and the Equal Employment Opportunity Network, a board member of Diversity Council Australia, and a People and Culture Board Committee member of the Environmental Protection Authority Victoria.


Mr Tony Goad BBus (Accountancy)

Group Executive Director, Finance & Support Services

Tony was appointed Executive Director Finance and Support Services for Mercy Health in June 2011 after serving as the Acting Chief Financial Officer. He assumed the role of Group Executive Director Finance & Support Services in April 2015. He has 20 years’ experience in the health industry through executive positions including Chief Financial Officer and Chief Information Officer of the Southern Health Care Network and Associate Director of a healthcare consultancy firm. Before working in health Tony undertook various executive and consulting roles in banking and merchant banking for more than 12 years. In addition to his role with Mercy Health Tony is a Director of the Mental Health Legal Centre, part of a network of Community Legal Centres providing free and confidential legal services to anyone who has experienced mental illness in Victoria.

Ms Clare Grieveson BSc (Hons) (Lond), MHSM, MACHSM

Group Executive Director Quality, Risk & Service Improvement

Clare assumed the role of Executive Director Risk Management & Quality in February 2014, before her appointment as Group Executive Director Quality, Risk & Service Improvement in April 2015. She is responsible for the overall leadership and direction of risk management and quality improvement for Mercy Health. Clare has a clinical background in speech pathology and almost two decades’ experience in the health industry, including senior management roles at Monash Health and service planning and performance roles at the Victorian Department of Health. She achieved her Honours in Speech Sciences from University College London and a Masters of Health Service Management from Monash University.

Simon Cooke BA (Hons), LLB, PhD

General Counsel

Simon is an experienced health lawyer who has oversight of all legal matters at Mercy Health. He provides legal advice to support Mercy Health’s commercial and operational activities and its governance processes.

Mr Stephen Tiley CIA, BCompt

Internal Audit and Risk Assurance

Stephen was appointed Head of Internal Audit and Risk Assurance for Mercy Health in November 2013. He has more than 20 years’ risk management and internal audit experience, as both an executive and business advisor. Previous roles included Global Vice President Assurance at BHP Billiton and the Head of Internal Audit for South African Breweries. Stephen remains an active contributor to the business community through long serving volunteer activities with the Institute of Internal Auditors (IIA), which included a Directorship and membership of the IIA ethics committee. Stephen is a past Chairperson of the Victorian Council of the IIA and was recently appointed as a publications reviewer for the IIA Global Headquarters, based in Orlando USA.


Mercy Health strategic plan 2013/17Our key focus remains on responding to the current and emerging needs of the communities we serve. Our strategic emphasis is on partnering with individuals and their carers to provide compassionate and responsive care and on improving health outcomes for the vulnerable and disadvantaged.

The objectives of this strategic plan reflect Mercy Health’s commitment to building on our position as a quality provider of health, aged and community services, through stewardship of the resources entrusted to us by the Sisters of Mercy, federal and state governments and other stakeholders.

Our strategic themes

Our strategic themes bring together our mission, vision and values and set the broad parameters for the organisation’s development into the future.

• Respond to the current and emerging needs in health, aged and community care.

• Build on our faith base as a Catholic provider in the tradition of the Sisters of Mercy.

• Nurture our culture and passion for serving and partnering with those in need.

• Develop and manage our resources to support the sustainable delivery of our mission.

Strategic objectives

Our strategic objectives have been developed to guide Mercy Health in achieving its strategic themes. The associated key directions outline the main priorities Mercy Health will focus on between 2015 and 2017.

• Strengthen our position as an efficient, effective and responsive provider of public health services.

• Expand our residential aged care and community services through targeted growth.

• Build our organisational capability with particular focus on innovation in organisational culture, quality and safety, attraction and retention of our workforce, and efficient resource use.

• Advocate for the disadvantaged and influence policy in the areas of health, aged and community care.

• Support research, teaching, training and employee development that will translate into improved outcomes for those in our care.

• Improve consistency and coordination of services within Mercy Health and develop collaborative partnerships which benefit those we serve.


2014/15 Statement of PrioritiesPriority Action Deliverable OutcomesDeveloping a system that is responsive to people’s needs

Develop an organisational policy for the provision of safe, high-quality end of life care in acute and subacute settings, with clear guidance about the role of, and access to, specialist palliative care.

•Develop and implement policy for end of life care.

•Achieved.

Implement formal advance care planning structures and processes, including putting into place a system for preparing and/or receiving, and documenting advance care plans in partnership with patients, carers and substitute decision makers.

• Implement approved advance care planning procedure, with education package.

•Measure and increase the number of palliative care patients who die in their place of choice.

•Achieved. Advance care planning procedure and education package developed. Education rollout in progress.

•Achieved. Monthly data collection introduced. 58% patients currently die in their place of choice, compared to the estimated national average of 14%.

Optimise timely access to specialist care through the implementation of the Access Policy for Specialist Clinics in Victorian Public Hospitals.

•Complete implementation of policy across Mercy Public Hospitals Inc.

•Achieved. Referral processes to be standardised across sites and programs.


Priority Action Deliverable OutcomesDeveloping a system that is responsive to people’s needs (continued)

Configure and distribute services to address the health needs of the local population.

• Increase the number of births at Werribee Mercy Hospital by 20% and increase special care nursery occupancy as required.

•Further develop gynaecology services at Werribee Mercy Hospital.

•Separate public outpatient services from private consulting suites at Werribee Mercy Hospital.

• Implement an interim strategy to increase critical care capacity at Werribee Mercy Hospital.

•Achieved. Target for births increased by 20% in 2014/15 to 3216 births per year; 96% of target met (3085 births) due to low demand in February and June 2015. Special care nursery capacity increased as required.

•Achieved. Outpatient gynaecology clinic established. Gynaecologic oncology service available. Planning in progress for urogynaecology services.

•Senior medical staffing for Obstetrics and Gynaecology increased by 1.4EFT.

•Achieved.

•Achieved. Advanced skills training for clinical staff and implementation of new devices to support higher acuity and deteriorating patients in the medical ward monitored area.

•State Budget announcement of $85 million to fund Stage 1c will provide 8 critical care beds as part of the Werribee Mercy Hospital Master Plan.


Priority Action Deliverable OutcomesImproving every Victorian’s health status and experiences

Use consumer feedback to improve person and family centred care, health service practice and patient experience.

•Establish a Consumer Engagement Framework.

•Build capacity to engage and use consumer experience to plan, implement and evaluate care through establishment of a Community Advisory Group for Mercy Hospital for Women.

•Appoint consumers to key organisational committees.

•Consumer advisors to review our patient information brochures to ensure they are clear, effective and easily understood by patients.

• Include both formal and informal consumer feedback in improvement strategies and monitor through quality improvement system.

•Achieved.

•Achieved.

•Achieved. Consumers are now attending the Clinical Governance Committee, Clinical Safety Quality and Risk Committee and the Advanced Care Planning Project working party. Work in progress to engage a consumer for the Care of the Older Person Committee.

•Achieved and ongoing. Process for consumer review of patient information completed.

•Achieved. Consumer feedback dashboard developed.

•Department quality improvement plans include action based on feedback from consumers.

Reduce unplanned readmissions.

•Establish baseline, monitor and improve 30 day unplanned readmission rates.

•Achieved. Clinical indicators dashboard completed.

•Readmission rates have fallen from 6.8% (June 2014) to 4.9% (June 2015).

•Reported to the Performance meeting on a monthly basis and bimonthly to Board Quality Committee.

Identify service users who are marginalised or vulnerable to poor health, and develop interventions that improve their outcomes relative to other groups, for example, Aboriginal people, people affected by mental illness, people at risk of elder abuse, people with disability, homeless people, refugees and asylum seekers.

• Improve rates of Aboriginal identification at Mercy Hospital for Women and Werribee Mercy Hospital and improve cultural safety of the workplace at both sites through ongoing cultural safety training.

• Implement prevention of elder abuse policy.

•Achieved. Process well embedded to ask patients if they identify as Aboriginal and/or Torres Strait Islander.

•Ongoing cultural awareness training implemented for staff.

•Ongoing development of the Reconciliation Action Plan.

•Achieved.

2014/15 Statement of Priorities cont’d


Priority Action Deliverable OutcomesImproving every Victorian’s health status and experiences (continued)

Improve health literacy and support informed choice and shared decision-making by responding to the health information needs of service users.

•Develop and implement health literacy policy and procedures, and build capacity for the development of accessible consumer information by staff training and the application of the consumer review process.

• Increase uptake of interpreter usage at Werribee Mercy Hospital for people identifying preferred language other than English from 30% to 80%.

•Achieved. Health literacy procedure implemented. Resources adapted to support staff to improve health information. Ongoing education and health literacy skills development for staff. Inclusion of health literacy in cultural diversity training.

•Partially achieved. Inpatient utilisation has increased to 32% (from 23%) and outpatient utilisation has increased to 63% (from 48%) with further education planned for 2015/16.

Expanding service, workforce and system capacity

Develop and implement a workforce immunisation plan that includes preemployment screening and immunisation assessment for existing staff that work in high risk areas in order to align with Australian infection control and immunisation guidelines.

•Recruit dedicated staff immunisation nurse and meet Australian infection control and immunisation guidelines.

•Achieved. Staff immunisation nurse recruited.

•Staff influenza immunisation rates >75%.

•Staff health plan completed including pre-employment screening and immunisation assessment.

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

•Seek Board approval and implement Mercy Perinatal plan to improve clinical service, training and education.

•Continue to implement Allied Health Assistant positions in appropriate areas across MPHI where positions become funded or where substitution is possible.

•Achieved. Mercy Health Board endorsed Mercy Perinatal business plan in May 2015.

•Mercy Perinatal launch scheduled for 2015/16. Global Obstetrics Update (international conference) scheduled for November 2015.

•Achieved. Existing Allied Health Assistant positions are ongoing.

•Allied health position descriptions are reviewed whenever positions are vacated to consider opportunities for staff substitution models.


Priority Action Deliverable OutcomesExpanding service, workforce and system capacity (continued)

Optimise workforce productivity through identification and implementation of workforce models that enhance individual and team capacity and support flexibility.

• Implement staff specialist anaesthesia model at Werribee Mercy Hospital.

•Produce and implement plan for transition from fee for service to staff specialist model for surgical services at Werribee Mercy Hospital.

• Increase obstetrics and gynaecology staff specialists at Werribee Mercy Hospital.

• Identify opportunities and implement nurse led and allied health led outpatient clinics and discharge processes.

•Achieved.

•Achieved. Contracts provided and appointments offered from 1/7/15. Grant funding for junior medical staffing obtained to support transition to staff medical model this financial year and next.

•Achieved. Senior medical staffing for obstetrics and gynaecology increased by 1.4EFT at Werribee Mercy Hospital.

•Achieved. Criteria-led discharge plans being developed for Short Stay Unit at Werribee Mercy Hospital.

•Advanced Physiotherapy Scope of Practice funding secured to develop advanced practice roles in Urogynaecology and the Emergency Department (WMH).

Increase employment of Aboriginal people in mainstream health services in line with the strategic objectives of Koolin Balit: Victorian Government strategic directions for Aboriginal Health 2012–2022 and Karreeta Yirramboi workforce participation targets.

• Increase the number of Aboriginal people working in our services using our Aboriginal Employment Plan.

•Achieved.

•Aboriginal Employment Plan Project Officer appointed.

•New process implemented for existing staff to update their own records confidentially if they identify as Aboriginal and/or Torres Strait Islander.

•Number of Aboriginal and/or Torres Strait Islander staff increased by 25% in 2014/15.



Priority Action Deliverable OutcomesIncreasing the system’s financial sustainability and productivity

Identify and implement practice change to enhance asset management.

•Ensure all preventative maintenance contracts are in place, the performance of the contracts is being managed and the asset management system is tracking asset activity.

•Achieved.

•Maintenance contracts are reviewed on a regular basis with current status and planned actions documented.

•Asset management plan in place to track assets.

Reduce health service administrative costs.

•Undertake agreed projects where appropriate and share learnings across system.

•Review mental health resources and operations ensuring optimal services within allocated funding.

•Achieved. Mercy Health has begun implementation of an Enterprise Resource Platform. This project is expected to be 18 months in duration. The implementation of this system will result in the streamlining of “back-office” processes resulting in improved efficiencies and cost reductions.

•Achieved. Review completed and redesign plan developed, to be implemented in 2015/16.

Implementing continuous improvements and innovation

Develop a focus on ‘systems thinking’ to drive improved integration and networking across health care settings.

•Finalise regional service plan between Werribee Mercy Hospital, Western Health and Djerriwarrh Health, with key focus areas being elective surgery, maternity and paediatric planning.

• Increase the number of Werribee Mercy Hospital Shared Maternity Care bookings from 40 to 100 per month.

•Achieved. Progress report provided to DHHS in December 2014 (Strengthening Hospitals in Melbourne’s West). Priority areas agreed: emergency department and urgent care centres.

•Achieved. 20% increase in shared care bookings following targeted communications to primary care providers.

•Shared care bookings for Q1, 2015/16 have increased to an average of 104 per month.


Priority Action Deliverable OutcomesImplementing continuous improvements and innovation (continued)

Develop a focus on ‘systems thinking’ to drive improved integration and networking across health care settings. (continued)

•Build partnerships with primary, secondary and tertiary care providers to ensure patient experience is coordinated and safe.

•Develop and systematise approaches to the collection and use of quality and safety data to inform health service improvements e.g. data driven decision making.

•Build capacity for the analysis of systems thinking through staff training in adverse event analysis.

•Achieved. MPHI is participating in the Strengthening Hospitals in the West plan to develop a coordinated approach to common services. Benefits include: · Referral pathways streamlined · Collaborative regional planning · Enhanced consistency of care provision and standardised assessment and referral tools · Interagency relationships enhanced . Information sharing and enhanced transparency

•GP Liaison Officers have coordinated education sessions for local GPs and working to improve the service coordination between our hospitals and the community.

•Participation in North Eastern Metropolitan Integrated Cancer Service (NEMICS) and the Western Central Metropolitan Integrated Cancer Service to improve coordination of services, including attendance at service planning workshops.

•Achieved. Decision Point dashboard developed to include a Clinical Indicators dashboard. This has provided additional quality and safety information to the monthly Performance meeting and bimonthly Board Quality committee.

•Achieved. Clinical Safety Quality and Risk Committee attended DHHS training on root cause analysis.

•Human factors presentation to Board Quality Committee.




Develop a focus on ‘systems thinking’ to drive improved integration and networking across health care settings. (continued)

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

• Implement Mercy Perinatal initiative to improve clinical service, training and education.

•Launch Institute for Maternal and Family Wellbeing (perinatal mental health), in keeping with Mercy Health’s commitment to advancing coordinated improvements in ante and postnatal services to women and families experiencing low prevalence mental health disorders.

• Improve outcomes for patients presenting with alcohol and other drug related conditions through expansion of alcohol and drug support services.

•Adopt a co-design (with patients) approach in the development of the inpatient mental health unit at Werribee Mercy Hospital.

•Appoint consumer representatives to key quality and safety committees to ensure consumer voice informs improvements.

•Achieved. Business case approved by Health Services Leadership Team and Executive Operations Committee. Mercy Health Board endorsed Mercy Perinatal business plan in May 2015.

•Global Obstetrics Update (international conference) scheduled for November 2015.

•Achieved. Incorporated into Mercy Perinatal initiative.

•Achieved. Alcohol and Other Drug (AOD) Project has improved coordination of care for at risk clients presenting to WMH Emergency Department (ED).

•Direct referral process with external specialist services established. 57% increase in AOD presentations to ED in 2014/15

•Average 40 new referrals per month - 31% are referred to specialist AOD services - 23% are referred for longer-term mental health follow up.

•Achieved. Consumers participated in design working party.

•Achieved. Consumers are now attending the Clinical Governance Committee, Clinical Safety Quality and Risk Committee and the Advanced Care Planning Project working party. Work in progress to engage a consumer for the Care of the Older Person Committee.



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

•Review and refine model of care for patients undergoing perinatal loss through consumer participation.

•Review and relaunch support groups for families of babies in neonatal intensive and special care.

•Achieved. Bereaved families focus groups held.

•Learnings documented and presented to Grand Round. Provided additional information for Perinatal Bereavement working party.

•Partially achieved. Review completed. Relaunch to be implemented in 2015/16.

Increasing accountability & transparency

Undertake an annual board assessment to identify and develop board capability to ensure all board members are well equipped to effectively discharge their responsibilities.

•Undertake Board assessment and use to build Board capacity and capability.

•Achieved.

Ensure that gender sensitivity and women’s safety are key principles in the delivery of mental health and alcohol and drug services.

•Design new Werribee Mercy Hospital inpatient mental health facility with gender sensitivity and women’s safety principles incorporated.

•Achieved. Building works commenced; phase one scheduled for 2015/16.

Improving utilisation of e-health and communications technology.

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

•Provide midwives in Maternity in the Home (MITH) with mobile electronic access to Mercy Health data systems.

•Provide palliative care staff with mobile electronic access to Mercy Health data systems.

•Finalise terms of reference for electronic medical record study and commence study.

•Move to integrated information technology solution through the implementation of Enterprise Resource Planning.

•Achieved. iPads used to access clinical systems.

•Trial of upgraded clinical system in progress. Final implementation due end of 2016.

•Achieved.

•Achieved. Electronic Medical Record design authority established and current state report produced.

•Future state and recommended solution report due December 2015.

•Achieved.

•First stage commenced to implement Enterprise Resource Platform. This project is expected to be 18 months in duration.

Ensure local ICT strategic plans are in place.

•Secure Board approval for ICT strategic plan.

•Achieved.



Accreditation

MPHI underwent our first accreditation survey as one organisation in November 2014. The survey covered Mercy Hospital for Women, Werribee Mercy Hospital, Mercy Mental Health and Mercy Palliative Care, with satellite sites also visited by members of the survey team. The National Safety and Quality Health Service Standards (NSQHSS) and National Standards for Mental Health Services (NSMHS) were assessed.

MPHI met all 209 core actions required under the NSQHSS and the 68 unmapped NSMHS. Surveyor feedback was extremely positive and recognised MPHI’s commitment to “improve quality and safety, and put patients first”. Elements of the audit system, reporting, consumer participation and blood management were recognised by the survey team as excellent. The result represented an outstanding team effort and commitment to our motto ‘Care First’ by everyone who took part.

The O’Connell Family Centre (OFC) underwent an organisation-wide survey under EQuIP and the Department of Health and Human Services Standards in December 2014. OFC met all criteria as well as recommendations from the previous ACHS accreditation survey. The survey team acknowledged the dedication and commitment of the team and complimented OFC’s high-quality care and robust systems and processes.

Community engagement

With the newly created role of Senior Manager Consumer Participation and Experience commencing in June 2014, Mercy Health has cemented our commitment to improving the experience of the people in our care.

The Mercy Health Consumer Engagement Framework, policy and supporting documentation were released in August 2014. To support the launch of the framework more than 1,200 Mercy Health employees attended training sessions on person-centred care. We now have community advisors sitting on many of our clinical and subject matter governance committees. In addition, we have applied health literacy principles to all our written patient information which is reviewed and receives a ‘community review tick’ from a panel of Community Information Advisors before publication.

Mercy Health’s Community Advisory Committee has now entered its second term under the leadership of our first Consumer Chair. Under the direction of this committee

the Werribee Mercy Hospital Community Advisory Group has implemented its action plan, and a Mercy Hospital for Women Community Advisory Group has been established and has implemented its action plan.

Organisational development A number of initiatives were implemented throughout the past year to support the growth and development of our people and to foster an ethos-driven culture, allowing Mercy Public Hospitals Inc to carry out its mission to serve those in need.

Diploma of Management (formerly Middle Managers Program)

Facilitated by our Registered Training Organisation the Mercy Health Training Institute, this program gives managers a valuable opportunity to receive a formal qualification while collaborating on strategic workplace initiatives. Five participants graduated in 2014 and 29 participants commenced the new program in May 2015.

Living Our Values Awards

The Living Our Values Awards are instrumental in allowing employees to acknowledge each other for bringing Mercy Health’s values to life. 2014 recipients were formally recognised at the annual Mercy Health Leadership Day for their contribution to fostering our values driven culture.

Learning Precinct, Werribee Mercy Hospital

The Learning Precinct has become an invaluable asset in supporting the continued learning and development of local Mercy Health staff.

The facilities have been used throughout the year to support ongoing professional development of clinical staff in line with the learning calendar, and events such as the Grand Rounds.

It has also become a venue for the education of our potential future workforce, with local school students using the classrooms and skills rooms to support their VET in Schools programs.

Highlights for 2014/15


State government funding for Werribee Mercy Hospital expansion

MPHI is grateful for the $85 million funding allocation we received in the 2015/16 State Budget. The funding will enable us to expand Werribee Mercy Hospital’s services to meet the urgent and growing demand for acute and critical care in the Wyndham region.

The expansion will give the community a critical care unit, six operating theatres, an additional 56 inpatient beds and a new central sterile supply department.

The funding is a welcome and tangible response to the concerns of the Wyndham community and our dedicated staff. and will be supplemented by the Werribee Hospital Foundation and Mercy Health raising an additional $2 million.

Mercy Perinatal

In recognition of Mercy Hospital for Women’s leadership in perinatal medicine and research, work has begun by Mercy Health Foundation to secure funds that will support ongoing research, teaching and clinical advances.

Mental health inpatient expansion

Construction has begun on the $34.7 million redevelopment of the mental health facility at Werribee Mercy Hospital.

The finished development will include a two-storey 54-bed building, located in the same area as the existing facility at Werribee Mercy Hospital. The facility will enable the hospital to meet the growing demand for acute mental health services in Melbourne’s southwest.

The two-stage project is expected to be finished in 2016.

Work is also nearing completion on our new acute mental health and psychiatric inpatient facility at Western Health’s Footscray campus. The 16-bed Ursula Frayne Centre will provide valuable extra support to the fast-growing Wyndham region.

Medical staff credentialingThe credentialing of senior medical staff is one of the most important roles performed by the Office of the Chief Medical Officer. It is part of the appointments and scope of practice process coordinated with the Medical Credentialing and Appointments Committee, which includes senior medical leaders and a human resources manager.

As of 2015 all senior medical staff across Health Services are now being credentialled by a common, consolidated process. This ensures all documentation is completed and all staff are assessed, and are qualified, to perform the work they do. Credentialing is repeated at least every five years.

AwardsWinner of Age Diversity in the Workplace award in Australian Human Resources Institute (AHRI) Inclusion and Diversity Awards 2014

Winner of AHRI R U OK? Workplace category at the AHRI Inclusion and Diversity Awards 2014

Workplace Gender Equality Agency Employer of Choice for Gender Equity citation (WGEA)

Breastfeeding Friendly Workplace accreditation

Recognised as an Employer of Choice in the Australian Business Awards 2015

Catholic Health Australia Awards: Ms Kate Hewett, winner of Excellence in Pastoral Care Award

Finalists

Australian HR Awards 2014/15:

Adjunct Professor Stephen Cornelissen for Australian HR Champion (CEO) of the Year

Mercy Health, Best Use of Technology

Mercy Health, Best Workplace Flexibility Program

Mercy Health, Employer of Choice (more than 1,000 employees)

Mercy Health, Employer of Choice (public sector and non-for-profit) Ms Sandra Cinar for Australian HR Manager of the Year

The CEO Magazine’s Executive of the Year Awards 2014/15: Mr Julien O’Connell for Chairperson of the Year

Ms Cel Gusman for Executive Assistant of the Year

AHRI Inclusion and Diversity Awards 2014: Gender Equity in the Workplace Award


Performance priorities

Attestation

I, Julien O’Connell, certify that Mercy Public Hospitals Inc (MPHI) has put in place appropriate internal controls and processes to ensure that reported data reasonably reflects actual performance. Mercy Public Hospitals Inc has critically reviewed these controls and processes during the year.

Julien O’Connell AMChairman, Mercy Public Hospitals Inc4 August 2015

Financial performance

Operating Result Target 2014/15 actuals Target 2014/15 actualsAnnual Operating result ($M) $1.4M ($0.231M)

WIES activity performance Target 2014/15 actualsPercentage of WlES (public and private) performance to target

100% 100.7%

Cash managementCreditors <60 days 48

Debtors <60 days 56

Access performance

Emergency care Target MHW actuals

WMH actuals

Percentage of ambulance transfers within 40 minutes 90 100 87

Percentage of Triage Category 1 emergency patients seen immediately

100 100 100

Percentage of Triage Category 1 to 5 emergency patients seen within clinically recommended times

80 80 55

NEAT – Percentage of emergency presentations to physically leave the emergency department for admissions to hospital, be referred to another hospital for treatment, or be discharged within four hours

81 79 60

Number of patients with length of stay in the emergency department greater than 24 hours

0 0 208


Elective surgery Target MPHI actualsNEST – Percentage of Urgency Category 1 elective patients treated within 30 days 100 100

NEST – Percentage of Urgency Category 2 elective surgery patients treated within 90 days

88 92

NEST – Percentage of Urgency Category 3 elective surgery patients treated within 365 days

97 100

Number of patients on the elective surgery waiting list 1165 1286

Number of Hospital Initiated Postponements per 100 scheduled admissions 8 6

Service performance

Elective surgery Target MPHI actualsNumber of patients admitted from the elective surgery waiting list – quarter 1 1482 1460

Number of patients admitted from the elective surgery waiting list – quarter 2 1522 1364



Number of patients admitted from the elective surgery waiting list – annual total 5853 5561

Critical care Target MPHI actualsNumber of days operating below agreed Neonatal ICU minimum operating capacity

0 22

Quality and safety Target ActualsVictorian Healthcare Experience Survey Full compliance Achieved

Health service accreditation Full compliance Achieved

Cleaning standards overall Full compliance Achieved

Cleaning standard (AQL-A) 90 97.1

Cleaning standard (AQL-B) 85 96.7

Cleaning standard (AQL-C) 85 98.2

Hospital acquired infection surveillance No outliers Achieved

Hand hygiene

– Audit 3 2014 (July-Sept) 75% 79.33%

– Audit 1 2015 Oct-Mar) 77% 82.25%

– Audit 2 2015 (April-June) 80% 77.13%

SAB rate per occupied bed days <02/10000 >01/10000

Health care worker immunisation – influenza 75 76.5%

*Based on data September 2013-June 2014.

Maternity Target MPHI actualsPercentage of women with prearranged postnatal home care 100 100

Mental health Target MPHI actuals28 day readmission rate – percentage 14 13

Post-discharge follow-up rate – percentage 75 76

Seclusion rate per occupied bed days <15/1,000 13


Activity and funding

Funding type MPHI actuals

MHW WMH

Acute admitted

WIES Public 34,077 19,514 14,563

WIES Private 4,218 3,337 881

Total WIES (Public and Private) 38,295 22,851 15,444

WIES DVA 136 15 121

WIES TAC 1 1

WIES TOTAL 38,433 22,866 15,567

Subacute admitted

GEM Public 6,854 6,854

GEM Private 0 0

Rehabilitation Public 799 799

Rehabilitation Private 0 0

Palliative Care Public 4,644 4,644

Palliative Care DVA 105 105

Transition care – Bed days 2,080 2,080

Transition care – Home days 911 911

Subacute Non-Admitted

Health Independence Program 14,292 14,292

Mental health & drug services

Mental Health Inpatient – Beddays 2011 2011

Mental Health Inpatient – WOt 9484 9484

Mental Health Ambulatory 34460 34460

Mental Health Subacute 9789 9789

Primary health

Community Health/Primary Care Program 645 645

Consultancies

Consultancies in excess $10,000

Listing Project details Approved project fees

Fees incurred Future commitment

Redluob Food Service provision review across whole of Mercy Group

$20,000 $20,000 $Nil

Loss Prevention Group of Australia

Security Audit $31,500 $31,500 $Nil

Consultancies less than $10,000

Number of consultancies Total cost1 $4,250


Our workforce

Category 2014 (June month)

2015 (June month)

2014 (YTD June)

2015 (YTD June)

Administrative and clerical 195.7 207.7 173.7 199.8

Ancillary support services 91.6 76.3 75.8 72.8

Hospital medical officers 127.7 140.3 115.1 134.7

Hotel and allied 138.7 149.5 126.0 147.1

Medical officers 22.2 22.9 19.8 22.4

Medical support services 62.4 81.0 56.0 80.3

Nurses 1,014.8 1,031.6 950.0 1,004.4

Sessional clinicians 54.2 62.6 50.6 61.9

Total 1,707.2 1,771.9 1,566.9 1,723.4

Mercy Public Hospitals Inc is committed to recruiting and selecting a highly skilled workforce through a fair, equitable and transparent process. All decisions on recruitment and selection are based on merit.

As such, recruitment and selection decisions are based on matching the applicant’s skills, experience and qualifications to the selection criteria for the position.

Mercy Public Hospitals Inc works to ensure the recruitment and selection process is applied consistently, resulting in the appointment of high-calibre employees and satisfying equal opportunity principles and obligations.


Reporting proceduresDisclosures of improper conduct or detrimental action by Mercy Public Hospitals Inc or its employees may be made to the following:

The Independent Broad-based Anti-corruption Commission

Phone: 1300 735 135 Fax: (03) 8635 6444 Post: IBAC, GPO Box 24234, Melbourne, Victoria 3000 Website: ibac.vic.gov.au

Further information

Written guidelines outlining the system for reporting disclosures of improper conduct or detrimental action by Mercy Public Hospitals Inc or its employees are available for public perusal.

National Competition Policy

Mercy Public Hospitals Inc adheres to competitive neutrality guidelines in the contracting process and reviews existing contracts where appropriate.

The Building Act 1993

Mercy Public Hospitals Inc ensures buildings, plant and equipment that it owns are maintained in accordance with the requirements of all relevant statutory authorities. All new building works performed by or on behalf of Mercy Public Hospitals Inc comply with current requirements of the Building Code of Australia and other applicable Australian standards, statutory authorities or codes of practice.

Victorian Industry Participation Policy Act 2001

During 2014/15, no contracts that required disclosure under the Victorian Industry Participation Policy Act 2003 were started or completed.

Protected Disclosure Act 2012

Mercy Public Hospitals Inc is committed to the aims and objectives of the Protected Disclosure Act 2012 (Vic). We do not tolerate improper conduct by employees or officers, nor the taking of detrimental actions or reprisal against those who come forward to disclose such conduct.

Mercy Public Hospitals Inc recognises the value of transparency and accountability in our administrative and management practices, and supports the making of disclosures that reveal corrupt conduct, conduct involving a substantial mismanagement of public resources, or conduct involving a substantial risk to public health or safety or the environment.

Mercy Public Hospitals Inc will take all reasonable steps to protect people who make such disclosures from any detrimental action by way of reprisal for making the disclosure in accordance with relevant regulatory obligations.

Disclosure Requirements (FRD 10)

Mercy Public Hospitals Inc works within the Financial Reporting Directions and statutory disclosure requirements. All disclosures applicable under Australian Accounting Standards are independently audited.

Environmental performance

As a Catholic healthcare organisation Mercy Health is committed to promoting the common good. This means we are not only concerned for the people of today but for future generations as well. We are all responsible for caring for the earth and using its resources wisely to preserve them for those who come after us.


Work health and safety

Mercy Public Hospitals Inc is committed to ensuring the health, safety and welfare of its workers, patients, residents, clients, visitors and others who may be affected by its operations.

We are two years into our four year Work Health & Safety Long Term Plan 2013/17.

Our achievements in 2014/15 include:

• manual handling (MH) WorkCover claims reduced by 17%

• MH incident reporting has increased by 29%, indicating that the reporting culture is strong, while the overall severity of injuries has reduced considerably, with fewer staff seriously injured

• a review of resources has seen the employment of a full-time MH trainer in our hospitals; this is aligned with the Long Term Plan and will have a further impact on reducing the MH injury rate

• assault and aggression reported incidents rose by 7%, reflecting the strong reporting culture and risk to staff

• assault and aggression claims have risen to 3 in 2014/15 from 2 in 2013/14

• slips, trips and falls have seen a 50% reduction in claims from 2013/14 (14 claims) to 2014/15 (7 claims); reporting of incidents remained consistent during this period

• work conducted by the Manual Handling Advisory Group has seen further work in the research, purchase and installation of products to assist in caring for all patients but particularly in addressing the challenges of bariatric care

• Mercy Public Hospitals commits to fulfilling our Work Health & Safety Long Term Plan 2013/17 and to reducing any harm to our staff.

Risk management

A revised Risk Management Framework, strategy and policy was developed and implemented across Mercy Health in 2014. This framework updated our approach and processes for managing organisational and clinical risks, and is aligned with contemporary international standards.

The Board endorsed Mercy Health’s first risk appetite statement in March 2015. The purpose of the risk appetite statement is to establish the amount of risk the organisation is willing to accept. It guides management and risk owners when deciding if a risk is acceptable or not.

Audit framework

A best in class audit framework and centrally managed audit system was developed and implemented in 2014. The Mercy Health Audit System combines both quality audit and independent internal audit resulting in a single integrated activity. This enables us to know how we are doing compared with recognised best practice and to identify points in processes where variation may exist. We can also measure the rate of improvement over time.

This approach has bridged the gap between the traditionally siloed quality and internal audit activities. In addition, this assurance process now operates as a single integrated activity into other key governance requirements of Mercy Health such as Risk Management and Board Sub Committees. Lastly this approach has enabled a direct link into contemporary organisational development and design such as the “three lines of defence modelling.”

Carers Recognition Act 2012

Mercy Public Hospitals Inc recognises, promotes and values the role of carers. We take all practical measures to comply with our obligations under the Act, including:

• promotion of the principles of the Act to people in care relationships who receive our services and to the wider community – for example, support groups and information sessions run by the Mercy Palliative Care Program (the ‘Carer’s Own Information Session’)

• ensuring our staff have an awareness and understanding of the care relationship principles set out in the Act

• consideration of the carer relationships principles set out in the Act when setting policies and providing services – for example, availability of flexible working arrangements (per our Workplace Flexibility Policy and Procedure) for employees who are carers.

Attestation

I, Julien O’Connell, certify that Mercy Public Hospitals Inc has risk management processes in place consistent with the AS/NZS ISO 31000:2009 and an internal control system is in place that enables the executive to understand, manage and satisfactorily control risk exposures. Mercy Public Hospitals Inc verifies this assurance and that the risk profile of Mercy Public Hospitals Inc has been critically reviewed within the last 12 months.

Julien O’Connell AM Chairman, Mercy Public Hospitals Inc 4 August 2015


Freedom of information

The Freedom of Information Act 1982 (Vic) allows the public a right of access to documents held by Mercy Public Hospitals Inc. For the 12 months ending 30 June 2015, Mercy Public Hospitals Inc received 407 applications.

Of the requests received by Mercy Public Hospitals Inc, access was granted in full for 345, in part for 7 and access was denied for 2 (under sections 33(1), 35(1)(a) and 38 of the Act). A total of 53 applications were withdrawn, not proceeded with or had not been finalised at 30 June 2015. No applications were referred to the Victorian Civil & Administrative Tribunal during this period.

Making a request

Access to documents may be obtained through written request to the Freedom of Information Manager, as detailed in section 17 of the Freedom of Information Act 1982. In summary, the requirements for making a request are:

• the application should be made in writing

• the application should identify as clearly as possible which document is being requested

• the application should be accompanied by the appropriate application fee; the fee may be waived in certain circumstances.

Freedom of Information fact sheets and an access request form are available on the Requesting Personal Health Information section of the Contact Us page of the Mercy Health website at mercyhealth.com.au. Requests for documents in possession of Mercy Public Hospitals Inc should be addressed to the relevant facility/service:

Freedom of Information Officer Mercy Hospital for Women Health Information Services 163 Studley Rd Heidelberg VIC 3084

Freedom of Information Officer Werribee Mercy Hospital Health Information Services 300 Princes Hwy Werribee VIC 3030

Freedom of Information Officer Mercy Mental Health Saltwater Clinic PO Box 2083 Footscray VIC 3011

Freedom of Information Officer Mercy Health O’Connell Family Centre 6 Mont Albert Rd Canterbury VIC 3126

Freedom of Information Officer Mercy Public Hospitals Inc Level 2, 12 Shelley St Richmond VIC 3121

Access charges may also apply once documents have been processed and a decision on access is made; for example photocopying and search and retrieval charges.

For further information on Freedom on Information visit foi.vic.gov.au and foicommissioner.vic.gov.au

Additional information (FRD 22F)

In compliance with the requirements of FRD 22F Standard Disclosures in the Report of Operations, details in respect of the items listed below have been retained by Mercy Public Hospitals Inc and are available to the relevant Ministers, Members of Parliament and the public on request (subject to the Freedom of Information requirements, if applicable):

(a) a statement of pecuniary interests of all relevant officers;

(b) details of shares held by senior officers as nominee or held beneficially or in a statutory authority or subsidiary;

(c) details of publications produced by Mercy Public Hospitals Inc about the activities of the Health Service and where they can be obtained;

(d) details of changes in prices, fees, charges, rates and levies charged by the Health Service;

(e) details of any major external reviews carried out on the Health Service;

(f) details of major research and development activities undertaken by the Health Service that are not otherwise covered either in the Report of Operations or in a document that contains the financial statements and Report of Operations;

(g) details of overseas visits undertaken including a summary of the objectives and outcomes of each visit;

(h) details of major promotional, public relations and marketing activities undertaken by the Health Service to develop community awareness of the Health Service and its services;

(i) details of assessments and measures undertaken to improve the occupational health and safety of employees;

(j) general statement on industrial relations within the Health Service and details of time lost through industrial accidents and disputes, which is not otherwise detailed in the Report of Operations;

(k) a list of major committees sponsored by the Health Service, the purposes of each committee and the extent to which those purposes have been achieved;

(l) details of all consultancies and contractors including consultants/contractors engaged, services provided, and expenditure committed for each engagement.


Research

The past 12 months have again witnessed a diverse and highly productive research output across Mercy Health. This report highlights significant advances our teams have made in many areas. These include perinatal care, with strides made towards combatting preeclampsia, fetal growth restriction, preterm labour and other life-threatening perinatal conditions; paediatric care; ovarian cancer care; prolapse and incontinence, and anaesthesia.

More detail on our research and development activity is available in the 2014 Mercy Health Research and Development Report (visit the Publications section of mercyhealth.com.au).

Below are some highlights of our 2014/15 research work.

Respiratory management and prevention of chronic lung disease

The neonatal unit at Mercy Hospital for Women is a leader in the research and development of respiratory support via high-flow nasal cannuale. The HIPSTER trial is currently investigating this mode of non-invasive support for infants under 28 weeks of gestation.

The cytokine study in collaboration with the Ritchie Centre examined the association of inflammatory markers in the blood of premature infants and the development of chronic lung disease of prematurity. Outcomes of this study are due to be published in 2015.

Improved diagnosis of fetal growth restriction

As the single biggest contributor to stillbirth, growth restriction in unborn babies is a key research focus for our Maternal Fetal Medicine Group. Current studies include examining placental transcripts released into the maternal blood stream to better detect pregnancies where the baby is likely to be growth restricted at term.

Medication based treatments to replace surgery for ectopic pregnancies

Current treatments for this life-threatening condition often entail invasive surgery. Our Translational Obstetrics Group has been developing a promising treatment to replace surgery with a single injection (methotrexate) and seven oral gefitinib tablets taken daily.

Gestational Diabetes Follow-Up Project

This project is an adjunct to the Gestational Diabetes Follow-Up Program, Australia’s longest running clinical service and epidemiological study into the development of Type 2 diabetes among women with a history of gestational diabetes mellitus.

The research group at Mercy Hospital for Women has continued to recruit and follow up thousands of women who previously experienced gestational diabetes and to evaluate blood-borne proteins and lipids that may indicate Type 2 diabetes onset.

The early detection of Type 2 diabetes would allow early intervention strategies to be implemented, preventing or delaying complications of diabetes such as cardiovascular disease, kidney disease and blindness.

Treatments for severe preeclampsia

The Translational Obstetrics Group is working to develop drugs to treat preeclampsia, one of the most serious complications of pregnancy. In 2014, the team developed a number of very promising approaches. These include the use of interventions such as proton pump inhibitors, pravastatin and sulfasalazine.

Association between maternal size and outcomes for caesarean section (The MUM SIZE study)

This large multicentre study examines the relationship between maternal body weight and anaesthetic outcomes.

MiniArc Monarc suburethral sling in women with stress urinary incontinence

This global trial evaluates the efficacy of a suburethral sling in treating a common cause of incontinence, one of the most prevalent urogynaecological conditions in women.

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Our researchers have presented at major national and international conferences including:

• Urogynecological Association and American Urogynecological Association Annual Scientific Meeting, Washington, USA, 2014

• International Gynaecologic Cancer Society Scientific meeting, Melbourne, November 2014

• Medical Disorders in Pregnancy Symposium, Melbourne, September 2014

• 24th World Congress of the International Society of Ultrasound in Obstetrics and Gynaecology pre-congress course on Prenatal Screening, Barcelona, September 2014

• Australian and New Zealand Intensive Care Society/Australian College of Critical Care Nurses Intensive Care Unit Annual Scientific Meeting, Melbourne, October 2014

• Health Literacy Community of Practice, Melbourne, Australia, December 2014.

The Human Research Ethics Committee, Mercy Health operates to ensure our research projects, studies or clinical trials are conducted within the guidelines of the 2007 National Statement on Ethical Conduct in Human Research, the Catholic Health Australia guidelines, the Victorian Managed Insurance Authority guidelines for clinical trials and the Health Privacy Principles of the Health Records Act 2001 (Victoria). The committee reports to the Mercy Health Board, National Health and Medical Research Council, and Health Services Commissioner. All research projects, studies or trials conducted within Mercy Health must first be approved by this committee.


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Mercy Health

Level 2, 12 Shelley Street

Richmond Victoria 3121

Phone +61 3 8416 7777

mercyhealth.com.au

mercy health - mphi report 2015

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