Limestone Coast Local Health Network Annual Report 2019-2020

Limestone Coast Local Health Network
276-300 Wehl Street North, Mount Gambier SA 5290
www.sahealth.sa.gov.au/LimestoneCoastLHN

ISSN: 2652-6662

Date presented to Minister: 25 September 2020

To:

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

Nil

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

Agency specific objectives and performance

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

Agency performance management and development systems

Work health, safety and return to work programs

*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)

**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

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.

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 with a contract value above $10,000 each

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 with a contract value above $10,000 each

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

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

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

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