Limestone Coast Local Health Network Annual Report 2019-2020

Limestone Coast Local Health Network
276-300 Wehl Street North, Mount Gambier SA 5290

Contact phone number: (08) 8721 1200
Contact email:

ISSN: 2652-6662

Date presented to Minister: 25 September 2020


Hon Stephen Wade MLC
Minister for Health and Wellbeing

This annual report will be presented to Parliament to meet the statutory reporting requirements of Public Sector Act 2009, the Public Finance and Audit Act 1987 and the Health Care Act 2008, and the requirements of Premier and Cabinet Circular PC013 Annual Reporting.

This report is verified to be accurate for the purposes of annual reporting to the Parliament of South Australia.

Submitted on behalf of the Limestone Coast Local Health Network by:

Grant King
Governing Board Chair
Limestone Coast Local Health Network

Ngaire Buchanan
Chief Executive Officer
Limestone Coast Local Health Network
Date     25/09/2020

Acknowledgement to Traditional Custodians

Limestone Coast Local Health Network acknowledges Traditional Custodians of Country throughout the region and recognises the continuing connection to lands, waters and communities. We pay our respects to Aboriginal and Torres Strait Islander cultures; and Elders past and present.

From the Governing Board Chair  

It is a great privilege to present the first annual report for the Limestone Coast Local Health Network (LCLHN).

The LCLHN commenced operations on 1 July 2019 as part of the SA Health governance reforms, which saw the establishment of 10 Local Health Networks (LHNs), each with its own Governing Board charged with the overall governance and oversight of local service delivery, including governance of performance and budget achievement, clinical governance, safety and quality, and risk management.

Six new regional LHNs replaced Country Health SA LHN (CHSALHN), with the LCLHN established to represent the region formerly known as the South East.

We could not have predicted the period that would follow these governance reforms ­ a global pandemic, the magnitude of which has not been seen for generations.

In this annual report, we reflect on our achievements over our first year as a regional local health network. The annual report outlines our contribution towards whole of government objectives of more jobs, lower costs and better services, and provides information on our corporate and financial performance, safety and quality, risk management and agency-specific objectives.

The last year has seen considerable focus on the regulatory and legislative requirements arising from the establishment of the LCLHN, its Governing Board and Committees. We are confident in the strength of our governance and risk management framework and the ability of our people to adapt to the diverse and changing healthcare needs of the Limestone Coast community.

Our goal is to be an effective and forward-thinking health network that looks for opportunities to drive innovation and translate evidence into practice in how we deliver services. Central to this is also strengthening our relationships with our partner organisations, GPs and other clinicians in our region, local government, private providers and other community representatives. Improving our engagement with consumers and our community, as well as clinicians and staff, is now an approach embedded in the Health Care Act 2008 and a key area of work the LCLHN will focus on in the coming year. The Governing Board’s Engagement Strategy Working Group has been busily working on the development of our engagement strategies, and although implementation has been delayed due to the pandemic, we are excited about rolling them out during 2021.

Our accomplishments and determination in a challenging year is a credit to each of our nearly 1,400 staff who continually go above and beyond for those in their care. I commend and thank all staff members for their contribution to the Limestone Coast community and that contribution cannot be overstated.

I would like to thank my fellow Board members, as well as all LCLHN employees, whose commitment to our core values remains essential as we strive towards our vision of being a high performing regional health service.

Grant King
Governing Board Chair
Limestone Coast Local Health Network

From the Chief Executive  

This year we have continued to deliver high quality and person­ centred health services that meet the needs of our community, despite the immense challenges presented to our local health network due to the COVID-19 pandemic.

The unique needs of those accessing healthcare across the Limestone Coast remains central to our service planning and the care we provide. We continue to monitor key population trends in our region, including an ageing population, areas of socio-economic disadvantage and complex chronic healthcare needs.

Our performance highlights include our work to improve, achieve and maintain our emergency department ‘seen on time’ triage categories, and elective surgery ‘timely admission’ and ‘overdue patient’ categories.

We continue work to provide services as close to home as safely possible, with the COVID-19 pandemic seeing an increased uptake of telehealth usage across the region. The introduction of a thrombolysis service at Naracoorte Health Service and expanded Renal Dialysis Unit at Mount Gambier and Districts Health Service again underpins our commitment to growing services within the region wherever we are able.

We have also implemented the Aboriginal Health Strategic and Operational Plan 2019-2020 and Aboriginal Experts by Experience program, which demonstrates our commitment to ensuring our services meet the needs of our local Aboriginal populations.

These and other achievements listed throughout this report have only been possible through the hard work and commitment of our people, who are undoubtedly our greatest asset.

I would like to take this opportunity to thank our dedicated employees across our acute, residential, aged care, community health and mental health services. I remain ever confident that the Limestone Coast community is in safe hands.

Ngaire Buchanan
Chief Executive Officer
Limestone Coast Local Health Network

Overview: about the agency

Our strategic focus

Our Purpose

Limestone Coast Local Health Network (LCLHN) delivers a comprehensive range of public acute, residential aged care, community health and mental health services, throughout 10 public hospitals/health services in regional South Australia, according to population needs, focusing on integrating its service delivery with metropolitan hospitals and other service providers in regional locations.

    Our Vision

    To be the best rural health service.

    Our Values

    • Customer Focus
    • Collaboration
    • Caring
    • Creativity
    • Courage

    Our functions, objectives and deliverables

    Limestone Coast Local Health Network provided a wide range of public acute, residential aged care, community health and mental health services to country communities.

    Limestone Coast Local Health Network’s key objectives were to:

    • build innovative and high-performing health service models that deliver outstanding consumer experience and health outcomes
    • pursue excellence in all that we do
    • create a vibrant, values-based place to work and learn
    • harness the power of partnerships to improve the effectiveness of services
    • elevate and enhance the level of health in country communities.

    LCLHN’s key deliverables were to:

    • Provide safe, high-quality health and aged care services.
    • Engage with the local community and local clinicians.
    • Ensure patient care respects the ethnic, cultural and religious rights, views, values and expectations of all peoples.
    • Ensure the health needs of Aboriginal people are considered in all health plans, programs and models of care.
    • Meet all legislation, regulations, Department for Health and Wellbeing policies, and agreements.

    Our organisational structure

    Limestone Coast LHN Governing Board

    • Grant King, Board Chair
    • Glenn Brown
    • Lindy Cook
    • John Irving
    • Dr Anne Johnson
    • Dr Andrew Saies


    • Chief Executive Officer


    • Director Governance & Planning
    • Executive Director, Medical Services
    • Executive Director, Nursing & Midwifery
    • Executive Director, Community & Allied Health
    • Director, Aboriginal Health
    • Director, Mental Health
    • Chief Finance Officer
    • Director Corporate Services
    • Director People & Culture
    • Quality, Risk & Safety Manager


    The Regional LHN leadership structure

    • Acute hospital care – inpatient, emergency and outpatient
    • Aged care – residential, multi-purpose services and community
    • Allied health care
    • Community health care
    • Mental health care

    Acute and Aged Care facilities are managed by a dedicated Executive Officer/Director of Nursing & Midwifery, who report to the Executive Director, Community & Allied Health.

    Each Acute facility has a Health Advisory Council (HAC) who link with the leadership of their associated site.

    Some sites have Consumer Advisory Committees or health related advisory groups, who share discussion with the relevant HAC and are linked with the leadership of their associated site.

    Changes to the agency

    During 2019-20 there were the following changes to the agency’s structure and objectives as a result of internal reviews or machinery of government changes.

    • The State Government established the Limestone Coast Local Health Network Incorporated, and its Governing Board, on 1 July 2019. From this date Country Health SA was dissolved and its assets, rights and liabilities were transferred to six new regional LHNs, including the Limestone Coast Local Health Network.

    Our Minister

    Hon Stephen Wade MLC is the Minister for Health and Wellbeing in South Australia.

    The Minister oversees health, wellbeing, mental health, ageing well, substance abuse and suicide prevention.

    Our Executive team

    As at the 30 June 2020, the LCLHN Executive team consisted of:

    • Chief Executive Officer – Ngaire Buchanan
    • Executive Director of Medical Services – Dr Elaine Pretorius
    • Executive Director of Nursing and Midwifery – Paul Bullen
    • Executive Director of Community and Allied Health – Marcy Lopriore
    • Director of Aboriginal Health – Kathryn Edwards
    • Director of Mental Health – Pauline Beach
    • Chief Finance Officer – Kristen Capewell
    • Director of Corporate Services – Ravinder Singh
    • Director of People and Culture – Peta-Maree France
    • Regional Quality, Risk and Safety Manager – Hannah Morrison
    • Director of Governance and Planning – Angela Miller

    Legislation administered by the agency


    Other related agencies (within the Minister’s area/s of responsibility)

    • Barossa Hills Fleurieu Local Health Network
    • Central Adelaide Local Health Network
    • Commission on Excellence and Innovation in Health
    • Department for Health and Wellbeing
    • Eyre and Far North Local Health Network
    • Flinders and Upper North Local Health Network
    • Northern Adelaide Local Health Network
    • Office for Aging Well
    • Riverland Mallee Coorong Local Health Network
    • South Australian Ambulance Service
    • Southern Adelaide Local Health Network Wellbeing SA
    • Women’s and Children’s Health Network
    • Yorke and Northern Local Health Network

      The agency’s performance

      Performance at a glance

      In 2019-20 The Limestone Coast Local Health Network (LCLHN) continued its strong reputation for achieving key performance areas including:

      • Achieving and maintaining the % Emergency Department (ED) presentations ‘seen on time’ Key Performance Indicator (KPI) targets for triage 1 and 2 across the LCLHN
      • Meeting all elective surgery ‘timely admission’ and ‘overdue patient’ categories until the COVID-19 pandemic disrupted elective surgeries across the state
      • Successful implementation of the electronic medical record Sunrise EMR and PAS in September 2019 at the Mount Gambier and Districts Health Service (MGDHS) as an exemplar site. While the electronic system implementation has been successful, certain Emergency Department KPIs were impacted during the implementation stage
      • The MGDHS has seen steady improvement in the Healthcare Acquired Complication Rate for overnight admissions with a 1.5% decrease from June 2019 to May 2020
      • Average Length of Stay for obstetrics at the Naracoorte Health Service has steadily improved over the 2019/20 financial year
      • The number of clients utilising Virtual Clinical Care services has increased from 23 clients in 2018/19 to 29 clients recorded for 2019/20
      • Development of an Aboriginal Health Strategic and Operational Plan 2019­ 2020
      • Establishment of Governing Board Performance Reporting to meet Service Agreement requirements
      • The LCLHN has undertaken significant Clinical Governance Structure Reform which is currently in the process of being implemented
      • The LCLHN has experienced a decline in activity in ED, inpatient, outpatient and elective surgery as a direct impact of the COVID-19 pandemic due to hospital avoidance and the restrictions on elective surgery across the state
      • Service improvements have also been identified as a direct result of the COVID-19 pandemic which has included the increased uptake of services being provided using Telehealth platforms across the LCLHN, bringing specialist services even closer to home for our consumers

      Agency contribution to whole of Government objectives

      Key objective Agency’s contribution
      More jobs

      The commencement of the Rural Health Workforce Strategy was a critical achievement, contributing investment towards:

      • improving services for long-term, high-quality maternity care
      • providing further specialised training for allied health professionals
      • providing additional training and career opportunities for Aboriginal and Torres Strait Islander health practitioners
      • providing medical workforce support grants, supporting recruitment and retention of GPs in rural communities
      • expanding training opportunities for community support workers
      • providing mental health education for suicide prevention and patient management
      • supporting rural community nursing workforce to manage more complex clients in rural areas
      • providing rural dental workshops, promoting a rural career for dental professionals
      • expanding the Digital Telehealth Network
      • providing simulation and training equipment

      The LCLHN commenced recruitment for an Implementation Lead for the Rural Health Workforce Strategy. This role is responsible for the development and implementation of local strategies that align with the Rural Health Workforce Strategy and Local Health Network priorities.

      Awarding of a Rural Health Undergraduate Scholarship to a full-time student currently studying or about to commence studying in the areas of need and reside and intend to work in rural South Australia at the completion of their study.

      The LCLHN has been supporting efforts by local General Practitioner (GP) clinics to support an advertising campaign to attract GP Obstetricians to Mount Gambier. A one-off grant was provided as GP Obstetricians manage the majority of birthing services at the MGDHS.
      Lower costs Costs for consumers were reduced through delivering programs such as:
      • the Patient Assistance Transport Scheme (PATS)
      • timely elective surgery in rural communities
      • increasing access to telehealth services
      • increasing access to Virtual Clinical Care (VCC)
      • home-based chronic disease monitoring

      Better services

      Implementation of the Donna Project for acute settings across the LCLHN to deliver quality, timely and compassionate care to patients approaching end of life.

      Comprehensive Care of the Older Person was rolled out to the LCLHN to better identify and manage dementia and delirium patients in a considered manner.

      #endPJparalysis was launched within the LCLHN to encourage patients to ‘get up, get dressed and get moving’ and to provide support for these activities. The initiative is aimed at decreasing falls, decreasing pressure injuries and decreasing the hospital length of stay, with the additional benefit of maintaining muscle strength.

      Implementing Goals of Care which are the clinical and personal goals for a patient’s acute episode of care that are determined through a shared decision-making process.

      Undertaking Service Planning activities within the LCLHN at the Millicent and Districts Hospital and Health Service (MDHHS) and the Mount Gambier and Districts Health Service (MGDHS) to plan for the future health needs of the community.

      The LCLHN response to the COVID-19 pandemic and the establishment of an Incident Management Team has resulted in the safe management of patients, staff and the community during the pandemic.

      The SA Health Orthogeriatric Hip Fracture Management Model of Care was implemented within the LCLHN to ensure that all patients within the scope of the model of care, receive best practice clinical care.

      Country Stroke Thrombolysis Service has been implemented at the Naracoorte Health Service (NHS) in addition to the existing service at the MGDHS, enabling rapid stroke treatment and reducing the need for transfers.

      South Australian Virtual Emergency Service (SAVES) units have been installed at all acute sites within the LCLHN to enable face to face consultations via video conferencing equipment.

      Upgrade of the Renal Dialysis Unit at the MGDHS with increased capacity and improvements to facilities for consumers and staff.

      Increased availability and uptake of service delivery by Telehealth platforms during the COVID-19 pandemic and as an ongoing option.

      Agency specific objectives and performance

      Agency objectives Indicators Performance
      Clinical Services Reform
      • Integrated Cardiovascular Clinical Network (iCCnet) Cardiology Service average response time
      • Stroke neurologist support for country hospitals
      • Chemotherapy and cancer care activity

      • The average response time was 6:42 minutes, including 554 calls made by LCLHN General Practitioners and nurses.
      • 47 patients accessed the SA Telestroke service and 26 transfers were potentially avoided between November 2019 to June 2020
      • There were 544 more chemotherapy treatments, 144 more cancer specialist medical consultations and 705 more cancer-related nurse activities delivered across the two chemotherapy units within the LCLHN in 2019/20 compared to the previous financial year
      Improving access to health services in our communities
      • Community, nursing and allied health service activity
      • Avoidable hospital activity
      • Country Access to Cardiac Health (CATCH) telephone cardiac rehabilitation program uptake/completion rates
      • National Disability Insurance Scheme (NDIS) program activity
      • Approximately 30,850 community nursing and allied health occasions of services were delivered to 4932 individual clients in 2019/20
      • Better Care in the Community serviced 705 clients with chronic conditions who received community-based support, which has avoided 669 hospital admissions, avoided 32  emergency department presentations, and saved 59 occupied bed days
      • The Rapid Intensive Brokerage Service (RIBS) assisted 200 clients, which has avoided 83 hospital admissions, avoided 14 Emergency Department presentations and saved 383 occupied bed days
      • The CATCH program had 234 referrals, with a 69% uptake, and completion rate of 63% in 2019/20, which has helped to improve patient risk factors and morality rates The NDIS program had a total of 107 requested services, including 38 children and 69 adults
      • The NDIS program had a total of 107 requested services, including 38 children and 69 adults
      Hospital Services
      • Emergency Department (ED) activity
      • Elective surgery timely admissions
      • Telerehabilitation consultations
      • Virtual Clinical Care (VCC) home tele­ monitoring program admissions avoided
      • Acute inpatient activity

      • There were 30,936 presentations to ED’s across the LCLHN
      • Targets were met until the COVID-19 pandemic response resulted in disruption to Elective Surgery in the LCLHN
      • 541 telerehabilitation consultations were held in inpatient and ambulatory settings across the Digital Telehealth Network or other therapeutic applications in 2019/20, an increase from 458 consultations in 2018/19
      • Use of VCC has resulted in the avoidance of 29 hospital admissions and the avoidance 6 emergency department presentations and the saving of 1 occupied bed day from early discharge There were 29 clients in the VCC program and 2430 occasions of service in 2019/20
      • 7206 same-day patients and 8988 overnight patients were admitted, and 630 babies were delivered in 2019/20
      Continuous improvement of quality and safety
      • Safety assessment code (SAC) 1 and 2 incidents

      • There were 21 SAC 1 and 2 incidents in 2019/20, compared to 26 last year, which is a decrease of 19.3%
      • Overall, there was a 6.3% decrease in reporting of all patient incidents, with SAC 1 and 2 incidents accounting for 0.80% of all incidents reported in 2019/20

      Aboriginal Health
      • Aboriginal percentage of workforce
      • Aboriginal Experts by Experience
      • Memorandum of Understanding with Pangula Mannamurna
      • 1.42% in June 2020 compared to 1.15% in June 2019
      • The Aboriginal Experts by Experience program was implemented into the LCLHN on 1 July 2019, which now has grown to have 15 active people on it as at 30 June 2020
      • A Memorandum of Understanding with Pangula Mannamurna is in draft
      Improving mental health outcomes
      • 28-day readmission rate to the Integrated Mental Health Inpatient Unit (IMHIU)
      • Percentage of mental health clients seen by a community health service within 7 days of discharge
      • Physical restraint and seclusion incidents per 1,000 bed days in the IMHIU
        • 10.2% for the LCLHN for 2019/20 (target <12%)
        • 86% for the LCLHN for 2019/20 (target 80%)
        • 0% physical restraint or seclusion incidents in the IMHIU in 2019/20

        Aged Care
        • Aged Care Assessment Program (ACAP) assessments
        • Home Care Package occupancy rates
        • Commonwealth Home Support Program (CHSP) client numbers
        • 681 ACAP assessments were completed, against a baseline target of 636
        • Occupancy rates have increased from 135 active packages in July 2019 to 203 active packages in June 2020
        • There were 1795 CHSP clients and 14,650 service events in the LCLHN, enabling older people to remain independent in their own home for longer

        Corporate performance summary

        Limestone Coast Local Health Network (LCLHN) achieved key corporate performance outcomes including:

        • Adoption of the Country Health SA Local Health Network (CHSALHN) Reconciliation Action Plan in July 2019, the LCLHN is developing a localised version of the plan in 2020
        • Embedding the Management Operating System at a regional level. This is currently in the process of being rolled out to all sites within the LCLHN and focuses on risk identification, management and escalation
        • Commencing planning and implementation of significant capital investments, including investing in existing assets to address important repairs/maintenance in hospitals and health services within the region
        • Regionalising Aboriginal Health Impact Statements to support culturally respectful engagement with Aboriginal stakeholders
        • 279 employees have completed the Management of Actual or Potential Aggression (MAPA) Training
        • 12 employees have completed the Growing Leaders Program
        • 25 employees have commenced Clinical Costing Fundamentals and Analyses training
        • A total number of 1330 staff received a seasonal Influenza Vaccination during 2019-20, which is 90% of the workforce
        • Achievement of Performance Level 1 against the 2019-20 LCLHN Service Agreement
        • Establishment of the Audit & Risk, Clinical Governance and Finance & Performance Committees
        • Two scholarships have been awarded to employees to support their post graduate study (Masters of Nursing – High Dependency and Midwifery)
        • The LCLHN participated in the National Safety and Quality Health Service (NSQHS), National Disability Insurance Scheme (NDIS) & Aged Care accreditation processes

        Employment opportunity programs

        Program name Performance
        Skilling SA
        Under the Skilling SA Program, LCLHN identified three (3) existing employees for upskilling and enrolment in Certificate IV qualification.

        Agency performance management and development systems

        Performance management and development system Performance
        Performance Review and Development is a process for supporting continuous improvement of employees’ work performance to assist them to meet SA Health values and objectives 89.99% of employees had a performance review and development discussion.

        Work health, safety and return to work programs

        Program name Performance
        Prevention and Management of musculoskeletal injury (MSI)
        Ongoing manual task local facilitator model on all sites and workgroups to assist in reduction of MSI injuries resulted in a decrease of 23% in MSI claims.
        Prevention and Management of Psychological injury (PSY)
        Implemented Mental Health First Aid Officer accredited training to assist and guide their peers towards better mental health. Developed a suite of COVID-19 Wellbeing resources to support worker wellbeing and resilience during the COVID-19 pandemic and associated disruption.

        Workplace injury claims 2019-20  2018-19 % Change
        (+ / -)
        Total new workplace injury claims 30
        Fatalities 0 0 0%
        Seriously injured workers* 0
        0 0%
        Significant injuries (where lost time exceeds a working week, expressed as frequency rate per 1000 FTE) 14.1 20.5

        *number of claimants assessed during the reporting period as having a whole person impairment of 30% or more under the Return to Work Act 2014 (Part 2 Division 5)

        Work health and safety regulations 2019-20 2018-19 % Change
        (+ / -)
        Number of notifiable incidents (Work Health and Safety Act 2012, Part 3) 1
        Number of provisional improvement, improvement and prohibition notices (Work Health and Safety Act 2012 Sections 90, 191 and 195) 1
        0 +100%
        Return to work costs** 2019-20 Past year 2018-19 % Change
        (+ / -)
        Total gross workers compensation expenditure ($) $532,345
        Income support payments – gross ($) $190,161 $182,196

        **before third party recovery

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see: Data SA website

        Executive employment in the agency

        Executive classification Number of executives
        SAES1 1

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see: Data SA website

        The Office of the Commissioner for Public Sector Employment has a workforce information page that provides further information on the breakdown of executive gender, salary and tenure by agency.

        Financial performance

        Financial performance at a glance

        The following is a brief summary of the overall financial position of the agency. The information is unaudited.

        Statement of Comprehensive Income 2019-20 Budget
        2019-20 Actual
        2018-19 Actual
        Total Income 162,428
        1,794 N/A
        Total Expenses 162,054
        Net Result 374 706
        Total Comprehensive Result 374

        Statement of Financial Position 2019-20 Budget
        2019-20 Actual
        2018-19  Actual
        Current assets N/A
        Non-current assets N/A
        128,427 128,427
        Total assets N/A
        Current liabilities N/A 36,574
        Non-current liabilities N/A 60,372 60,372 N/A
        Total liabilities N/A 96,946
        Net assets N/A 60,422
        60,422 N/A
        Equity N/A 60,422

        Consultants disclosure

        The following is a summary of external consultants that have been engaged by the agency, the nature of work undertaken, and the actual payments made for the work undertaken during the financial year.

        Consultancies with a contract value below $10,000 each

        Consultancies Purpose $ Actual payment
        All consultancies below $10,000 each - combined Various $ 0

        Consultancies with a contract value above $10,000 each

        Consultancies Purpose $ Actual payment
        AsiaAustralis Mount Gambier Private Hospital Review
        $ 35,000
        Keith & District Hospital Review
        $ 20,000
          Total $ 55,000

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see: Data SA website

        See also the Consolidated Financial Report of the Department of Treasury and Finance for total value of consultancy contracts across the South Australian Public Sector.

        Contractors disclosure

        The following is a summary of external contractors that have been engaged by the agency, the nature of work undertaken, and the actual payments made for work undertaken during the financial year.

        Contractors with a contract value below $10,000

        Contractors Purpose $ Actual payment
        All contractors below $10,000 each - combined Various $ 27,677

        Contractors with a contract value above $10,000 each

        Contractors Purpose $ Actual payment
        HCA - Healthcare Australia Pty Ltd
        Agency $1,013,628
        Your Nursing Agency Pty Ltd Agency $83,602
        Allied Employment Group Pty Ltd
        Agency $80,919
        Randstad Pty Ltd
        Medrecruit Pty Ltd Agency $40,270
        Rural Locum Scheme Pty Ltd Agency
        Homecare Plus
        Personal Care & Domestic Assistance
        Zeep Medical Pty Ltd
        Hays Specialist Recruitment (Australia) Pty Limited Agency $17,727
          Total $1,377,673

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see: Data SA website

        The details of South Australian Government-awarded contracts for goods, services, and works are displayed on the SA Tenders and Contracts website. View the agency list of contracts.

        The website also provides details of across government contracts.

        Other information

        Not applicable.

        Risk management

        Risk and audit at a glance

        On 29 July 2019, the LCLHN Governing Board endorsed the formation of the LCLHN Risk Management and Audit Committee (renamed Audit and Risk Committee on 25 May 2020 to be consistent with Committees across the State). This Committee reports directly to the LCLHN Governing Board.

        The purpose of the Audit and Risk Committee (the Committee) is to assist the LCLHN Governing Board (the Board) in fulfilling its oversight responsibilities for the:

        • Integrity of the financial statements,
        • Compliance with legal and regulatory requirements,
        • Independent auditor’s qualification and independence,
        • Performance of the internal audit function, and
        • Efficient and effective management of all aspects of risk.

        The Committee consists of at least 2 members of the Board, one of which acts as Chair, and 1 external (independent) qualified member. All Committee members are appointed by the Board. Standing Invitees include selected LCLHN Executive, the Risk Management Consultant, Rural Support Service (RSS), the Group Director, Risk and Assurance Services from the Department for Health and Wellbeing (as an independent observer); and a representative from the Auditor-General’s Department. Meetings of the Committee are held quarterly at which time a review of Risk Management, Internal Control, Financial Statements, Compliance Requirements, Internal Audit, External Audit, Audit Reporting Matters, Corruption Control and business arising are reviewed.

        The LCLHN Board formally adopted the SA Health Risk Appetite Statement on 29 July 2019.

        LCLHN have developed and implemented a local Risk Management Procedure which is consistent with the System-Wide Risk Management Policy Directive, providing staff with specific guidance on context, identification, analysis, evaluation, treatment, monitoring and communication of risk.

        A consistent Audit Charter has been developed by the RSS and implemented in the LCLHN enabling the internal audit function to be delivered by the RSS. The Charter provides guidance and authority for audit activities.

        Fraud detected in the agency

        Category/nature of fraud Number of instances

        NB: Fraud reported includes actual and reasonably suspected incidents of fraud.

        Strategies implemented to control and prevent fraud  

        The Limestone Coast Local Health Network (LCLHN) Governing Board has established an Audit and Risk Committee and a Finance and Performance Committee to ensure oversight of operational process relating to the risk of fraud. These Committees meet on a regular basis and review reports regarding financial management, breaches and risk management. The Chair of the LCLHN Audit and Risk Committee is a Board member who liaises closely with SA Health’s Group Director Risk & Assurance Services and a representative from the Auditor Generals Department. The Audit and Risk Committee additionally has an external (independent) member as part of the membership and who is a Certified Fraud Examiner.

        The SA Health Corruption Control Policy and Public Interest Disclosure Policy Directives are followed relating to risk of fraud. Any allegations of fraud, including financial delegation breaches, are reported to the Board by Management. Shared Services SA provide a report to the LCLHN Chief Finance Officer providing details of any expenditure that has occurred outside of procurement and approved delegations. These breaches are reviewed and reported to the Board. The Audit and Risk Committee’s reporting calendar ensures compliance with Fraud & Corruption policy and procedure and are reviewed on a regular basis.

        All Board members and senior management are required to declare any actual, potential or perceived conflict of interest and the register of interest is reviewed regularly.

        The Audit and Risk Committee Terms of Reference define the Scope and Function as below:

        The Committee will:

        • Advise on the adequacy of the financial statements, having regard to the following:
          • the appropriateness of the accounting practices used;
          • compliance with prescribed accounting standards under the Public Finance and Audit Act 1987;
          • external audits of the financial statements; and
          • information provided by Limestone Coast Local Health Network about the accuracy and completeness of the financial statements.
        • Monitor LCLHN’s compliance with its obligation to establish and maintain an internal control structure and systems of risk management, including whether the LCLHN has appropriate policies and procedures in place and is complying with them
        • To monitor and advise the Board on the internal audit function in line with the requirements of relevant legislation
        • Oversee LCLHN’s liaison with the South Australian Auditor-General’s Department in relation to LCLHN’s proposed audit strategies and plans including compliance to any performance management audits undertaken
        • Assess external audit reports of LCLHN and the adequacy of actions taken by LCLHN as a result of the reports
        • Monitor the adequacy of LCLHN’s management of legal and compliance risks and internal compliance systems, including the effectiveness of the systems in monitoring compliance by LCLHN with relevant laws and government policies
        • Undertake any other function given to the Committee by the Board, if the function is not inconsistent with the above

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see:
        Data SA website

        Public interest disclosure

        Number of occasions on which public interest information has been disclosed to a responsible officer of the agency under the Public Interest Disclosure Act 2018:

        One (1)

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see:: Data SA website

        Note: Disclosure of public interest information was previously reported under the Whistleblowers Protection Act 1993 and repealed by the Public Interest Disclosure Act 2018 on 1/7/2019.

        Reporting required under any other act or regulation

        Act or Regulation


        Nil  Not Applicable

        Reporting required under the Carers’ Recognition Act 2005

        Limestone Coast Local Health Network had a comprehensive  consumer engagement strategy and regularly consulted with health advisory councils, the Health Consumers Alliance of South Australia and other representative groups when developing policies and programs that affect consumers or carers when undertaking strategic or operational planning.

        Limestone Coast Local Health Network actively encouraged consumer and carer engagement in health services and actively sought feedback from consumers and carers about the services that we provided.

        Public complaints

        Number of public complaints reported

        Complaint categories Sub-categories Example Number of Complaints
        Professional behaviour Staff attitude Failure to demonstrate values such as empathy, respect, fairness, courtesy, extra mile; cultural competency 33
        Professional behaviour Staff competency Failure to action service request; poorly informed decisions; incorrect or incomplete service provided 0
        Professional behaviour Staff knowledge Lack of service specific knowledge; incomplete or out-of-date knowledge 0
        Communication Communication quality Inadequate, delayed or absent communication with customer 28
        Communication Confidentiality Customer’s confidentiality or privacy not respected; information shared incorrectly 2
        Service delivery Systems/technology System offline; inaccessible to customer; incorrect result/information provided; poor system design 6
        Service delivery Access to services Service difficult to find; location poor; facilities/ environment poor standard; not accessible to customers with disabilities 23
        Service delivery Process Processing error; incorrect process used; delay in processing application; process not customer responsive 0
        Policy Policy application Incorrect policy interpretation; incorrect policy applied; conflicting policy advice given 0
        Policy Policy content Policy content difficult to understand; policy unreasonable or disadvantages customer 0
        Service quality Information Incorrect, incomplete, out dated or inadequate information; not fit for purpose 1
        Service quality Access to information Information difficult to understand, hard to find or difficult to use; not plain English 0
        Service quality Timeliness Lack of staff punctuality; excessive waiting times (outside of service standard); timelines not met 11
        Service quality Safety Maintenance; personal or family safety; duty of care not shown; poor security service/ premises; poor cleanliness 27
        Service quality Service responsiveness Service design doesn’t meet customer needs; poor service fit with customer expectations 43
        No case to answer No case to answer Third party; customer misunderstanding; redirected to another agency; insufficient information to investigate 0
        Treatment Treatment
        Inadequate treatment; Coordination of treatment; Wrong/inappropriate treatment; Withdrawal/denial of treatment; Adverse outcome; Diagnosis; Negligent treatment
        Costs Costs Billing practices; Government subsidies
        Administrative services; Lost property
            Total 219

        Additional Metrics Total
        Number of positive feedback comments 395
        Number of negative feedback comments 219
        Total number of feedback comments 618
        % complaints resolved within policy timeframes 92%

        With effect from 1 July 2019, six new Regional LHNs replaced Country Health SA Local Health Network.

        To access data published for reporting periods prior to 2019-20, please see: Data SA website

        Service Improvements resulting from complaints or consumer suggestions over 2019-20

        • End of Life care in Acute - The Donna Project (refer Agency contribution to whole of Government objectives)
        • Car Parking - The secure carpark expansion at MGDHS was driven by ongoing negative consumer experience around car parking at the site
        • Culturally welcoming spaces and services - We are committed to ongoing enhancement of culturally welcoming spaces and services across the LHN. Across 2019-2020 we have commissioned and displayed Aboriginal artwork, printed local Aboriginal Elders CORKA Mob artwork on our volunteer t-shirts and the volunteer guide welcoming station at the entrance of MGDHS, implemented Aboriginal Health Impact Statements for all new or changed programs, developed and implemented the LCLHN Aboriginal Health Strategic Operational Plan, LCLHN Aboriginal Workforce Plan, and the LCLHN Reconciliation Action Plan. The LCLHN Aboriginal Experts by Experience register is in place, with members consulted for varying projects. Sites in LCLHN are actively involved in Reconciliation week, NAIDOC and other ceremonies, whether by holding events or participating in events. Aboriginal flags flying at all sites, and smaller flags including Aboriginal and Torres Strait on display. Aboriginal Health Impact Statements are considered and developed for all projects. ‘Are you of Aboriginal and/or Torres Strait Islander origin’ posters have been developed specifically for our region, utilised in conjunction with programs to promote self-identification
        • Patient Centred Care in Acute – the implementation of consumer driven Goals of Care (refer Agency contribution to whole of Government objectives)
        • Expansion of Dialysis Services - Renal Dialysis Unit upgrade at MGDHS (refer Agency contribution to whole of Government objectives)
        • Paediatric Ward upgrade at MGDHS – guided by consumer feedback and suggestion, the Paediatric Ward has upgraded the play area, outside spaces and is in development of a ‘treatment room’ to ensure that any painful treatment is undertaken away from the child’s bedside, ensuring that their bed remains a safe place
        • Naracoorte Health Service (NHS) Maternity upgrade – the upgrade to the Maternity area has been informed and guided by consumer feedback and input
        • Millicent Aged Care Hair Salon – the upgrade and beautification of the Hairdressing Salon in the Sheoak Lodge Residential Aged Care facility was driven and guided by the residents and families
        • Family support and involvement – development of the LCLHN Family Are Not Visitors initiative