Torres Strait-Northern Peninsula Hospital and Health ... · The State of Queensland (Torres Strait-Northern Peninsula Hospital and Health Service) annual report 2012–13 ISSN : 2202–7874

Torres Strait-Northern Peninsula Hospital and Health Service

2012–13 Annual Report

© State of Queensland (Torres Strait-Northern Peninsula Hospital and Health Service) 2013. Licence The annual report is licensed by the State of Queensland (Torres Strait-Northern Peninsula Hospital and Health Service) under a Creative Commons Attribution (CC BY) 3.0 Australia license.

CC BY Licence summary statement In essence, you are free to copy, communicate and adapt this annual report, as long as you attribute the work to the State of Queensland (Torres Strait-Northern Peninsula Hospital and Health Service). To view a copy of this licence, visit http://creativecommons.org/licenses/by/3.0/au/deed.en Public Availability Agency’s Website and the specific website address for the annual report: http://www.torres-north.health.qld.gov.au/ Agency’s website will be available from Monday, 7 October 2013. Attribution Content from this annual report should be attributed as: The State of Queensland (Torres Strait-Northern Peninsula Hospital and Health Service) annual report 2012–13 ISSN : 2202–7874 For more information Contact Ben Jesser, Director, Governance and Policy, Torres Strait-Northern Peninsula Hospital and Health Service, Po Box 2454, Cairns Qld 4870, email [email protected], phone (07) 4226 3081

Interpreter service statement The Queensland Government is committed to providing accessible services to Queenslanders from all culturally and linguistically diverse backgrounds. If you have difficulty in understanding the annual report, you can contact us on (07) 4226 3081 and we will arrange an interpreter to effectively communicate the report to you.

Torres Strait-Northern Peninsula Hospital and Health Service Annual Report 2012-2013 i

http://creativecommons.org/licenses/by/3.0/au/deed.en

http://www.torres-north.health.qld.gov.au/

mailto:[email protected]

Letter of compliance

27 September 2013 The Honourable Lawrence Springborg MP Minister for Health Member for Southern Downs Level 19, 147–163 Charlotte Street Brisbane Qld 4000 Dear Minister I am very pleased to present the Annual report 2012–13 and financial statements for the Torres Strait-Northern Peninsula Hospital and Health Service. I certify that this annual report complies with: • the prescribed requirements of the Financial Accountability Act 2009 and the

Financial and Performance Management Standard 2009 • the detailed requirements set out in the Annual report requirements for

Queensland Government agencies. A checklist outlining the annual reporting requirements can be found on page 24 of this report or accessed at www.premiers.qld.gov.au/publications/categories/guides/annual-report-guidelines.aspx. Yours sincerely Ian Maynard Director-General

Torres Strait-Northern Peninsula Hospital and Health Service Annual Report 2012-13 ii

Contents Letter of compliance___________________________________________________________ ii Message from the Health Service Chief Executive __________________________________ 1 1. Agency role and main functions ____________________________________________ 22. Operating environment ___________________________________________________ 33. Machinery of government changes _________________________________________ 44. The Queensland Government’s objectives for the community ___________________ 45. Other whole-of-government plans and specific initiatives ______________________ 56. Agency objectives and performance indicators _______________________________ 5

6.1. Revitalise services for patients__________________________________________ 56.2. Improve health outcomes ______________________________________________ 66.3. Improve consumer confidence __________________________________________ 66.4. Enhance community engagement _______________________________________ 6

7. Agency service areas, service standards and other measures __________________ 78. Summary of financial performance _________________________________________ 89. Executive management ___________________________________________________ 810. Related entities (statutory bodies and other entities) _________________________ 1011. Public Sector Ethics Act 1994 _____________________________________________ 1112. Risk Management and Audit Committee ____________________________________ 11

12.1. Audit and Risk Committee 2012–13 ____________________________________ 1113. External scrutiny _______________________________________________________ 1414. Internal audit ___________________________________________________________ 1415. Public Sector Renewal Program ___________________________________________ 1516. Carers (Recognition) Act 2008 ____________________________________________ 1517. Information systems and recordkeeping ____________________________________ 1618. Workforce planning, attraction and retention and performance _________________ 16

18.1. Induction __________________________________________________________ 1719. Employee development __________________________________________________ 17

19.1. Management and leadership development _______________________________ 1719.2. Workforce profile ___________________________________________________ 18

20. Early retirement, redundancy and retrenchment _____________________________ 1921. Voluntary Separation Program ____________________________________________ 2022. Open data _____________________________________________________________ 2023. General information _____________________________________________________ 2124. Remuneration disclosures _______________________________________________ 2325. Compliance checklist ____________________________________________________ 2426. Glossary of terms _______________________________________________________ 26APPENDIX 1. Chief Finance Officer statement _________________________________ 27 APPENDIX 2. Certification of financial statements ______________________________ 31 APPENDIX 3. Independent auditors report _____________________________________ 61

Torres Strait-Northern Peninsula Hospital and Health Service Annual Report 2012-13 iii

Message from the Health Service Chief Executive

The Torres Strait-Northern Peninsula Hospital and Health Service (TS–NP HHS) is responsible for providing health services to a population of approximately 11,000 people living in the geographical area of the Torres Strait and five communities in the Northern Peninsula area. The TS–NP HHS provides health services, as defined in the service agreement with the Department of Health.

The TS–NP HHS is an independent statutory body and was established on 1 July 2012, which will be overseen by a Hospital and Health Board (HHB), once appointed. Currently the Director-General acts as the administrator, holding the full powers of the board.

Across two hospitals and 21 primary healthcare centres, the TS–NP HHS offers the delivery of a consistent, quality, accessible and culturally effective health service to the communities in the Torres Strait and Northern Peninsula area.

The services include

• specialist clinics

• allied health

• mental health

• social and economic wellbeing

• home and community care

• primary healthcare (includes health promotion, quality lifestyle, chronic disease, maternal and child health, and men’s and women’s health).

During 2012–13, the TS–NP HHS has gone through a period of significant change. Focusing on building the ongoing sustainability of the organisation and ensuring a strong governance structure under the Hospital and Health Boards Act 2011, a turnaround plan was developed and implemented.

The huge amount of work and unerring commitment shown by the staff of the TS–NP HHS has ensured that we finished the year in a healthy position. There is still a way to go, but the foundations have been set.

Simone Kolaric Health Service Chief Executive Torres Strait-Northern Peninsula Hospital and Health Service

Torres Strait-Northern Peninsula Hospital and Health Service Annual Report 2012-13

1

1. Agency role and main functions

The TS–NP HHS was established under the Hospital and Health Boards Act 2011 on 1 July 2012. The objective of the Act is to deliver high-quality hospital and health services to persons in Queensland.

The TS–NP HHS is a statutory body and the principal provider of public healthcare sector services in the Torres-Strait and Northern Peninsula area. It exercises significant responsibilities at a local level, including the:

• control of the financial management of the organisation

• management of the service’s land and buildings

• day to day management of the staff.

The main function is to deliver acute health services, primary healthcare, health promotion and other health services required by the community.

By working in collaboration with the Far North Queensland Medicare Local, the Australian Government, other local not-for-profit organisations and the community, the TS–NP HHS delivered an accessible health service that provided a strong foundation for all generations to live a healthy and full life.

The TS–NP HHS actively supported Closing the Gap in Indigenous health and worked closely with the community to address health issues through culturally-appropriate, focused initiatives.

TS–NP HHS has engaged with community and welcomed feedback on services provided to ensure that the community has access to the health services they require. This principle, as well as commitment to ensuring quality and safety, and coordinated integrated health service delivery, guided the achievement of the TS–NP HHS in meeting its objectives to deliver high-quality hospital and health services.

The TS–NP HHS remains committed to providing the community with information that is open and transparent. This includes responding timely to concerns and complaints made about services, focussing on dealing with these matters in a concise and transparent process and providing feedback to community.

The Hospital and Health Service provided a workplace that was free from bullying, harassment and discrimination. The respect for our employees and their diversity drove a positive workplace culture. The TS–NP HHS remains committed to engagement with clinicians, consumers and community members in the planning, developing and delivering of various services. Opportunities for research, development, training and education are pillars in the TS–NP HHS guiding principles.

The TS–NP HHS did not administer any legislation during the reporting period.

Principal place of business

Thursday Island Hospital

163 Douglas Street

Thursday Island Qld 4875

Regional offices

Level 14, 147–163 Charlotte St

Queensland Health Building

Brisbane Qld 4000

Level 6, 5B Sheridan Street

William McCormack Building II

Cairns Qld 4870


2

2. Operating environment

The following were identified by the organisation as being the primary risks for the delivery of services in the Torres Strait and Northern Peninsula area. The TS–NP HHS worked to mitigate these risks through the work undertaken during 2012–13.

Strategic risk Mitigating strategies

Siloed and ‘one size fits all’ approach to health service delivery negatively affects health service delivery.

The TS–NP HHS works collaboratively with key stakeholders to develop services and models of care specific to the changing needs of individuals and the broader community.

Health gaps experienced by Indigenous people within the TS–NP HHS area are further exacerbated.

Health promotion programs are developed and implemented that focus on reducing the impact of key risk factors that contribute to the gap in health outcomes for Indigenous people.

The TS–NP HHS fails to attract, and retain, qualified and committed staff.

Preliminary workforce planning and development opportunities focus on building a sustainable workforce for the region.

Clinical risks increase and are not responded to.

The TS–NP HHS Clinical Governance Framework is implemented and monitored.

The TS–NP HHS fails to comply with statutory and legislative requirements.

Statutory and legislative requirements are documented and strong processes for monitoring compliance are implemented across the TS–NP HHS.

Infrastructure continues to degrade and health service delivery is negatively affected by non-compliant buildings

Infrastructure requirements are identified and funding is secured for back-log maintenance and future needs.

Approximately 85 per cent of TS–NP HHS consumers are identified as Aboriginal and/or Torres Strait Islander. Aboriginal and Torres Strait Islander Queenslanders experience significant gaps in health status and outcomes compared to other Queenslanders and other Australians. The TS–NP HHS recognises, and is committed, to closing the health gap for Indigenous Australians. The gap is defined as the difference between the Aboriginal and Torres Strait Islander burden of disease estimates and those for the general population. In Queensland, the life expectancy gap is currently estimated at 10.4 years for males and 8.9 years for females.

There are six leading drivers of the health gap between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander Queenslanders, which together explain 80 per cent of the health gap:

• cardiovascular disease—an estimated 28 per cent of the health gap • diabetes—an estimated 16 per cent of the health gap • chronic respiratory disease—an estimated 11 per cent of the health gap • cancers—an estimated 9 per cent of the health gap • injuries—an estimated 8 per cent of the health gap


3

• mental disorders—an estimated 8 per cent of the health gap.

Cardiovascular disease, diabetes and chronic respiratory diseases are the leading contributors to the health gap in major cities, regional centres and remote areas, together accounting for 55 per cent of the health gap in Queensland. There are considerable risk factors which contribute to approximately 37.4 per cent of the total burden of disease including:

• smoking, alcohol and other drugs • obesity, low rates of physical activity and poor nutrition • high blood pressure and high cholesterol • unsafe sex • child sexual abuse and intimate partner violence.

Of these, smoking was the largest cause of health loss, contributing 17 per cent to the health gap and one-fifth of all Aboriginal and Torres Strait Islander deaths nationally.

Our challenge has been to embrace new partnerships with local service providers, both Australian and state funded programs, to deliver health promotion and primary healthcare services effectively to Indigenous Australians in the Torres-Strait and Northern Peninsula area.

To meet these challenges, the governance structure of the TS–NP HHS needed significant strengthening. In July 2012, the Minister for Health appointed the Director-General as Administrator of the TS–NP HHS in order to strengthen governance and financial systems, prior to the appointment of a board. The TS–NP HHS held monthly meetings with the Director General and his senior management team throughout the year. During 2012–13, 12 meetings were held between the Administrator and the Health Service Chief Executive (HSCE), Ms Simone Kolaric, and members of her senior management team.

3. Machinery of government changes

The TS–NP HHS was established as a statutory body on 1 July 2012. No other machinery-of-government changes have occurred during 2012–13.

4. The Queensland Government’s objectives for the community

The TS–NP HHS supports and is committed to the Queensland Government’s Statement of objectives for the community and Getting Queensland back on track.

The TS–NP HHS supports this through its TS–NP HHS Strategic Plan 2013–2017:

Our purpose

To deliver a consistent, quality, accessible and culturally effective health service to the communities in the Torres Strait and Northern Peninsula area.

Our vision

By working in collaboration with the community, we deliver an accessible health service that provides a strong foundation for all generations to live a healthy and full life.

Our values

The TS–NP HHS acknowledges and supports The Blueprint for better healthcare in Queensland by adopting and applying its six key values:

1. Better service for patients. 2. Better healthcare in the community. 3. Valuing our employees and empowering frontline staff.


4

4. Empowering local communities with a greater say over their hospital and local health services.

5. Value for money for tax payers. 6. Openness.

5. Other whole-of-government plans and specific initiatives

The TS–NP HHS contributes to the Statement of government health priorities, and to achieving the Queensland Government’s Statement of objectives for the community, to revitalise frontline services for families and deliver better infrastructure. We add value to healthcare in the TS–NP HHS area through our three tier value framework—capability, courtesy and compassion.

6. Agency objectives and performance indicators

The TS–NP HHS is responsible for providing health services to a population of just under 11,000 living in the geographical area of the Torres Strait and five communities in the Northern Peninsula area. The TS–NP HHS provides health services, as defined in the service agreement with the Department of Health

The TS–NP HHS is responsible for the direct management of the following facilities within the HHS geographical boundaries:

• Thursday Island Hospital • Bamaga Hospital • 21 multi-function primary health care centres.

Our purpose is to deliver a consistent, quality, accessible and culturally effective health service to the communities in the Torres Strait and Northern Peninsula area.

By working in collaboration with the community, we deliver an accessible health service that provides a strong foundation for all generations to live a healthy and full life.

6.1. Revitalise services for patients

The TS–NP HHS seeks to streamline and improve frontline clinical services through an extended application of appropriate and responsive care, with a particular focus on culturally-appropriate service delivery. The key performance indicator is the development and implementation of the integrated health service delivery model by February 2014 that has a specific focus on wellness through a primary healthcare model focussing on Indigenous peoples’ health needs.

During 2012–13, the TS–NP HHS worked with neighbouring HHSs, the Far North Queensland Medicare Local and other external providers, including Australian Government agencies and not-for-profit provides, to improve collaboration and bilateral agreements for shared healthcare delivery.

The TS–NP HHS focussed on building sustainability through increased compliance and development of systems to assist in the management of the TS-NP HSS.

This work included investing in improvements in key infrastructure, including the construction of the Chronic Disease Centre (CDC) at the Thursday Island Hospital. The CDC provides increased number of consulting rooms for visiting specialists, in addition to office accommodation for primary healthcare program staff.

A comprehensive four-year infrastructure plan for the TS–NP HHS will be finalised by December 2013—the plan will seek to revitalise structures and facilities across the TS–NP HHS.


5

6.2. Improve health outcomes

In 2012–13, the TS–NP HHS continued to provide high-level healthcare to a diverse community—focussing on culturally-appropriate health service provision. The TS–NP HHS sought to create a healthier and more resilient community by changing the focus of healthcare from illness to wellness by increasing the participation of patients in maintaining and managing their own health.

6.3. Improve consumer confidence

The TS–NP HHS improved and strengthened their financial and performance management. This has been demonstrated by making cost savings throughout the service, implementing streamlined processes and delivering a surplus budget for the 2012-13 financial year. In addition to creating a more robust financial system and delivering a surplus budget position, the TS–NP HHS increased own source revenue, including Medicare payments and federal funding for Indigenous health programs by 10 per cent (based on the 2012–13 revenue).

Across 2012–13, the TS–NP HHS reorganised the workforce to ensure sustainability and increase quality of health service delivery. A workforce plan, focussing on increased workforce capacity and integrated health service delivery, will be finalised by December 2013.

6.4. Enhance community engagement

Through the development of the interim Consumer and Community Engagement Strategy1, the TS–NP HHS identified strategies to enhance community engagement and active participation in the planning, design and delivery of healthcare services for the region.

The document acts as the ‘big picture guide’ to ensure the TS–NP HHS works with the local community about what they want, and need, in healthcare. The purpose of the strategy is to provide the foundations to develop a plan, which will be developed by the TS-NP community, for the community.

The strategy aims to: • develop and implement community engagement actions • ensure comprehensive community involvement • identify what issues, projects and focus areas need consultation • ensure the methods for consultation are culturally appropriate • identify and consult with members of the community who are, or are at risk of,

experiencing poor health outcomes or who may have difficulty accessing health services

• follow the principles of consultation.

Founded on the requirements of the Hospital and Health Boards Act 2011, the strategy aligns with, and where appropriate, complies with:

• relevant national and state strategies, policies, agreements and standards on providing health services, including Close the Gap

• the TS–NP HHS Strategic Plan to deliver a culturally effective and accessible health service that provides a foundation for all generations to live a full and healthy life

• the TS–NP HHS clinical engagement strategy and the protocols in place with local primary healthcare organisations, to ensure a holistic approach to engagement.

1 Please see generally: http://www.health.qld.gov.au/publications/torres/commengagframe.pdf


6

http://www.health.qld.gov.au/publications/torres/commengagframe.pdf

Although attempts were made, the Consumer and Community Advisory Committee was not established due to low levels of engagement from the community, however it is hoped that this committee will be established in 2013–14.

7. Agency service areas, service standards and other measures

Reporting on service areas—service performance2

The TS–NP HHS reports service delivery under six service areas that reflect our planning priorities and support investment decision-making across the public healthcare sector.

Our service areas are:

1. Prevention promotion and protection

Aims to prevent illness and injury, actively promote and protect the good health and wellbeing of Queenslanders and reduce the health status gap between the most and least advantaged in the community. This service area is directed at the entire well population or specific sub-populations rather than individual treatment and care, using a range of strategies, such as disease control, regulation, social marketing, community development and screening.

2. Primary healthcare

The TS–NP HHS, through multidisciplinary teams of healthcare professionals, provides a range of primary healthcare services, including early detection and intervention, and risk factor management programs through community health facilities, child health centres and dental clinics.

3. Ambulatory care

Provides equitable access to emergency medical services in public hospital emergency departments and services provided through outpatient departments, including a range of pre-admission, post-acute and other specialists medical, allied health nursing and ancillary services.

4. Acute care

Aims to increase equity of access to high quality acute hospital services on a statewide basis and includes the provision of medical, surgical and obstetric services to people treated as acute admitted patients in Queensland’s public acute hospital.

5. Rehabilitation and extended care

This service area includes rehabilitation, palliative care, respite, psychogeriatric evaluation and management, residential aged care services for young people with physical and intellectual disabilities, and extended care services.

6. Integrated mental health services

Spanning the health continuum through the provision of mental health promotion and prevention activities (including suicide prevention strategies), community-based services, acute inpatient services and extended treatment services. The aim of mental health services is to promote the mental health of the community, prevent the development of mental health problems where possible, and to provide timely access to assessment and treatment services.

2 2013-2014 Queensland State Budget- Service Delivery Statements – Queensland Health


7

Service standard data 2012–13

TS–NP HHS service standards

Notes 2012–13 2012–13 2012–13 Target/estimated Estimated/actual Actual

Total weighted activity units:

Acute inpatients 2,453 1,977 2,081

Outpatients 207 894 2,050

Sub-acute 75 394 159

Emergency department 320 499 689

Mental health 58 22 21

Interventions and procedures 23 30 27

Number of in-home visits, families with newborns

New measure 100 No data

Ambulatory mental health service contact duration

New measure 1,801 No data

8. Summary of financial performance

The TS–NP HHS is committed to delivering appropriate, safe and efficient acute and primary healthcare services as well as improving financial management and restructuring the workforce The TS–NP HHS achieved an operating surplus of $1.23 million while still delivering all services within the service agreement with the Department of Health. The surplus is mainly attributed to improved financial management procedures, the implementation of a TS–NP HHS Financial Turn-Around Plan and increased own source revenue. Through its financial management policies and turn-around framework, the TS–NP HHS is committed to minimising operational expense through the introduction of contestability, implementing an integrated health service and delivering the best possible healthcare to the community. The TS–NP HHS will re-invest the surplus in building staff capacity across all disciplines, better infrastructure and increased services available at local centres for the community.

9. Executive management

During 2012–13, the TS–NP HHS had an administrator and Executive Management team that had authority and the responsibility for the planning, directing and controlling TS–NP HHS activities.

Administrator

The Director-General was appointed the administrator of the TS–NP HHS, by the Queensland Governor in Council, to act in place of a HHB, until established. The administrator has unilateral authority to make decisions in respect of the usual functions of a HHB.


8

Torres Strait-Northern Peninsula Hospital and Health Service organisational structure

Executive Management team

The Executive Management team comprise of:

Name and position Responsibilities

Simone Kolaric

Health Service Chief Executive

Responsible for the overall management of the TS–NP HHS to ensure the delivery of key government objectives in improving the health and wellbeing of Queenslanders. She provides strategic leadership and direction for the delivery of healthcare services, promotes the effective and efficient use of resources, and improvements in the quality of health services delivered by the TS–NP HHS.

Ben Jesser

Acting Director, Governance and Policy*

Provides high-level and confidential support services and advice to coordinate the governance, decision-making and both State and Commonwealth reporting requirements of the TS–NP HHS. Provide strategic leadership, direction and coordination of the Service.

Oscar Whitehead

Executive Director, Medical Services

Is the single point of accountability for the professional leadership and direction of medical services within the TS–NP HHS. He maximises the potential of medical practice to enhance health outcomes.

Charlotte Tamwoy

Director, Primary Healthcare

Is responsible for the leadership and delivery of high-quality, efficient and effective primary healthcare services.

Allison Wilkinson

Acting District Director, Nursing, Midwifery and Integrated Health Service Delivery

Is the single point of accountability for the professional leadership and direction of nursing services within the TS–NP HHS. She maximises the potential of nursing practice to enhance health outcomes.

Hospital & Health Service Administrator (Board)


Committees & Sub-Committees

Governance & Policy

Office of the Chief Executive

Medicine, Allied Health and Mental

Health

Nursing, Midwifery & Integrated

Health Service Delivery

Finance Corporate Services


9

Scott Bryant

Acting Chief Financial Officer**

Provides strategic and operational leadership for the financial management function of the TS–NP HHS. Scott develops and maintains the reporting systems, policies and guidelines to facilitate effective budgetary and financial management.

Danielle Hoins

Acting Director, Corporate Services

Is responsible for the leadership of the TS–NP HHS’s Corporate Services Branch. The branch includes human resources, supply services, travel, accommodation (staff and patients), assets, administration, operational and engineering support, workplace health and safety, and rehabilitation for both hospital and community health services.

* This position was established on 2 May 2013. ** This position was established on 13 November 2012.

10. Related entities (statutory bodies and other entities)

Far North Queensland Medicare Local

The TS–NP HHS and Far North Queensland Medicare Local (FNQ ML) recognise the important role that general practice, primary care and acute care play in the delivery of health services. Both agree to:

• promote cooperation with one another in the planning and delivery of health services.

• collaborate wherever possible and practical on matters and issues of common concern and interest.

Both parties will work together in order to achieve joint objectives in line with state and national strategies, policies, agreements and healthcare standards.

Torres Strait-Northern Peninsula Hospital and Health Service committee structure 2012–13


10

11. Public Sector Ethics Act 1994

Members of staff, including contractors, of the TS–NP HHS are bound by the Queensland Government Code of Conduct. All new staff are required to undertake the online training — approximately 60 staff completed the training within 2012–13.

12. Risk Management and Audit Committee

12.1. Audit and Risk Committee 2012–13

During 2012–13, an Audit and Risk Committee was established and functions under the authority of the administrator in accordance with the Hospital and Health Boards Act 2011 and is a prescribed under the Hospital and Health Board Regulation 2012. The committee is responsible for directly providing independent assurance and assistance to the administrator on the following:

• examine any matter in relation to its objectives as it sees fit or as requested by the administrator

• engage external resources if necessary to obtain independent advice in relation to committee matters with the approval of the administrator

• have access to all levels of management in accordance with agreed protocols in order to seek information from any employee to assist in carrying out the committee’s responsibilities

• TS–NP HHS’ risk, control and compliance frameworks • TS–NP HHS’ external accountability responsibilities, as prescribed in the

Financial Accountability Act 2009, the Auditor-General Act 2009, the Financial Accountability Regulation 2009 and the Financial and Performance Management Standard 2009.

During 2012–13, the committee met on five occasions, including one meeting to review and endorse the financial statements. The first meeting of the new committee, comprising the new members, took place on 4 February 2013.

Hospital & Health Service Administrator (Board)


Audit and Risk Committee

Executive Management

Team

Medicines and Therapeutic

Safety and Quality Lead Clinicians Group

Accommodation Committee


11

Membership of the Audit and Risk Committee

Name Membership Dates

Susan Middleditch Department of Health member 4/02/13, 1/05/13, 4/06/13, 7/08/13, 29/08/13

John Slaven Chief Finance Officer, Cairns and Hinterland Hospital and Health Service

4/02/13, 1/05/13, 4/06/13, 7/08/13, 29/08/13

Greg Edwards External member 4/02/13, 1/05/13, 4/06/13, 7/08/13, 29/08/13

Oscar Whitehead Executive Director, Medical Services

4/02/13, 29/08/13

Danielle Hoins Acting Director, Corporate Services 4/02/13, 1/05/13, 4/06/13, 29/08/13

James Sherry Acting Director, Corporate Services 4/02/13

Note: External members on the committee are not remunerated for their time.

The Terms of Reference provides the guidance and direction for the operation of the committee, with specific responsibilities across nine key business functions:

Financial statements

• Review the appropriateness of accounting policies. • Review the appropriateness of significant management assumptions in

preparing financial statements. • Review financial statements for compliance with prescribed accounting and

other requirements. • Review, with management and the internal and external auditors, results of the

external audit and any significant issues identified. • Ensure proper explanations exist for any unusual transactions, trends or

material variations from budget. • Ensure management provide appropriate assurances on the accuracy and

completeness of the financial statements.

Fraud, misconduct and corruption oversight

• Ensure arrangements are in place for the proportionate and independent investigation of fraud and corruption referrals, including follow-up action.

• Consider the major findings of relevant internal investigations regarding control weaknesses, fraud or misconduct and management’s responses.

• Oversee and review processes for staff to confidentially raise concern over possible fraud or corruption.

• Consider policies for preventing or detecting fraud and ensure compliance with relevant standards.

• Ensure the department complies with relevant integrity legislation and whole-of-government principles, policies and guidelines.

• Provide advice and recommendations as required on relevant integrity issues to the HSCE and Executive Management team


12

Risk management

• Review whether management has an appropriate enterprise risk management framework for the effective identification and management of all departmental risks.

• Review the adequacy and effectiveness of the TS–NP HHS enterprise risk management strategy, policy and procedures, including management’s implementation of internal risk controls and risk recommendations.

• Where appropriate, assess sufficiency of insurance arrangements with regard to the enterprise risk management framework

• Assess and contribute to the audit planning process relating to relevant risks and threats to the TS–NP HHS.

Internal control

• Review of the internal and external audit functions, the adequacy of the internal control structure and systems, including information technology security and control.

• Review of the internal and external audit functions, whether relevant policies and procedures are in place and up-to-date, including those for the management and exercise of delegations and if they are being complied with in all material matters.

• Review, by the chief finance officer, of financial internal controls to see if they’re operating efficiently, effectively and economically.

Performance management

• Review whether management has implemented a current and comprehensive framework to meet the TS–NP HHS compliance with the performance management and reporting requirements of relevant legislation and the annual report requirements for Queensland Government agencies.

• Review whether management has an appropriate reporting function in place for adequate reporting on performance.

Internal audit

• Review of the Internal Audit Charter. • Review adequacy of the budget, staffing, skills and training of the internal audit

function, having regard for the department’s risk profile. • Review and recommend the Internal Audit Strategic and Annual plans, its

scope and progress and any significant changes, including difficulties or restrictions on scope of activities or significant disagreements with management.

• Review and consider the findings and recommendations of internal audit reports and implemented actions.

• Review and assess performance of the internal audit activities against Annual and Strategic Audit plans.

• Monitor developments in the audit field and standards issued by professional bodies or other regulatory authorities to encourage use of best practice by internal audit.

External audit

• Consult with the external auditor on their proposed audit strategy and audit plan for the year.

• Review findings, recommendations and reports issued by the external auditor and corresponding responses from management, including alignment to the TS–NP HHS Risk Management Framework.


13

• Review implementation of recommendations accepted by management. • Assess whether any material overlap exists between the external and internal

audit plans. • Assess the extent of the external auditor’s reliance on internal audit work.

Compliance

• Determine whether management has considered legal and compliance risks as part of the department’s risk assessment and management arrangements.

• Review the effectiveness of systems implemented for monitoring compliance with relevant laws, regulations and government policies.

• Review findings of any examinations by regulatory agencies and any audit observations.

Reporting

• Submit reports as required to the administrator, outlining relevant matters that need to be brought to attention.

• Submit a summary report of each Audit and Risk Committee meeting to the Executive Management team.

13. External scrutiny

The TS–NP HHS was audited externally by the Queensland Audit Office (QAO).

In accordance with the Queensland Audit Office Report of the 2012–13 financial year, there were no significant findings or issues identified by the audit in the TS–NP HHS that would lead to a material misstatement as part of the financial statement.

In accordance with the Auditor-General Act 2009 the external audit presents a true and fair view and in all respects the material has been in compliance.

14. Internal audit

During 2012–13, audits from the originally approved and subsequently revised Annual Internal Audit Plan were delivered and reports issued to the TS–NP HHS’s Audit and Risk Committee and the Director General. The internal audit function has had due regard to Queensland Treasury’s Audit Committee Guidelines.

The Department of Health’s Internal Audit Unit performs the functions of internal audit as required under Section 29 of the Financial and Performance Management Standard 2009. The TS–NP HHS did not have an internal audit function during 2012–13. An internal audit function will be established during the second half of the 2013–14 year.

The Internal Audit Unit provided an independent, objective assurance and consulting activity designed to add value and enhance Queensland Health’s operations. In line with the overriding requirement of independence and objectivity, the Director of internal audit reports directly to the Director-General and the Audit and Risk Committee. The Director of the Internal Audit Unit attends all Audit and Risk Committee meetings, where reports on the unit’s activities and significant audit findings are tabled.

Internal audit’s purpose, authority and responsibility are formally defined in its Charter, which is reviewed by the Audit and Risk Committee and approved by the Director-General. The charter is consistent with the International Professional Practices Framework of the Institute of Internal Auditors. All members of the unit are bound by the principles of integrity, objectivity, confidentiality and competency under the institute’s Code of Ethics.

As a result of the Queensland Health restructure, staffing levels of the Internal Audit Unit decreased during 2012–13, with a decision being made to co-source internal audit activities. From 1 October 2012, the permanent Internal Audit team decreased to five team


14

members. A tender process was progressed for the co-sourcing of internal audit activities, with the tender being awarded to PriceWaterhouseCoopers (PwC) in December 2012.

PwC performed the internal audit for the TS–NP HHS during May 2013, providing their final report to the Audit and Risk Committee on 6 June 2013. The internal audit focussed on:

• actual expenditure against budget for the current year-to-date • effectiveness of processes and controls over budget monitoring • high-level indicators of potential financial mismanagement.

The TS–NP HHS performs monthly monitoring of expenditure against budget for labour expenses, non-labour expenses and depreciation and amortisation expenses. The TS–NP HHS also performs additional monthly analysis of actual Minimum Obligatory Human Resource Information (MOHRI) against budget, which is the key driver of total labour expenses, as well as analysis of travel expenses to date against prior year balances.

Analysis found that actual expenditure is $66.158 million as at 30 April 2013, against a budget of $70.643 million, representing a positive variance of 6.78 per cent. The TS–NP HHS chief finance officer provided a forecast analysis which projects a balanced position at year end.

Internal audit found no indication of financial mismanagement or areas of significant over or under spend.

15. Public Sector Renewal Program

The TS–NP HHS participates in all renewal activities as outlined by Queensland Health and the Public Sector Renewal Program.

16. Carers (Recognition) Act 2008

The TS–NP HHS acknowledges the important role of carers in the support of patients, particularly those experiencing chronic disease. Recognising the objectives of the Carers (Recognition) Act 2008 (Qld), the interim community engagement strategy3, specifically notes the important role of carers and ensures that the TS–NP HHS works with them as a group.

Specifically, the TS–NP HHS is committed to culturally responsive engagement with its diverse communities which will:

• demonstrate whole-of-organisation commitment • ensure patients, carers and the broader community are involved in informed

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

• provide evidence-based, accessible information to support key decision-making along the continuum of care

• ensure community members are active participants in the planning, improvement and evaluation of services on an ongoing basis

• actively contribute to building the capacity of community members to participate fully and effectively in healthcare provision and planning for the future.

3 Please see Strategy: http://www.health.qld.gov.au/publications/torres/commengagframe.pdf


15

17. Information systems and recordkeeping

Record keeping, both clinical and corporate records, were identified as a significant and potential risk to the TS–NP HHS. Due to distance and isolation of the different sites within the TS–NP HHS, along with the challenges of technology, it was difficult to provide staff with adequate training and support to ensure a standard approach to both clinical and corporate records is taken.

A senior health information manager position was created and advertised to address the opportunities for improvement within the clinical records across the TS–NP HHS. In the final months of the 2012–13 financial year, significant training of staff occurred and new streamlined processes were implemented to make improvements within the clinical records area. This included:

• providing all staff with appropriate training on how to file records within a clinical chart, tracking and maintenance of charts and appropriate administrative procedures

• chart splitting for large volumes • culling charts and reviewing secondary storage areas • destruction of charts in accordance with the legislative requirements and

guidelines, including correct records of destroyed charts being established • engaging with clinical staff and administrative staff regarding appropriate

recording of attendance and procedures within a chart • establishing a correct coding process, including providing further training for

staff.

In addition to the work done during 2012–13, the TS–NP HHS will conduct a whole-of-health information management and corporate records review during 2013–14 and further recommendations will be made to the Executive Management team on how best to address the challenges faced.

An electronic corporate records system will be implemented to compliment the paper based records. Further, the TS–NP HHS will implement a new policy and procedure for the management of clinical and corporate records.

18. Workforce planning, attraction and retention and performance

During 2012–13, Human Resources worked with business units across the TS–NP HHS to identify critical business roles and to embed workforce planning into business plans.

Business units critically reviewed workforce needs and skills, and aligned workforce planning with business priorities to ensure a flexible workforce and service delivery.

Succession strategies for critical roles included building internal talent through capability development, relieving opportunities and mobility programs.

The TS–NP HHS supports the promotion of flexible working arrangements and work-life balance, such as:

• the implementation of an explicit work and family policy

• flexible working hours and leave arrangements

• working from home and telecommuting

• part-time and job share opportunities.

These initiatives are essential components in attracting and retaining motivated and qualified staff in a geographically diverse and remote network of health services.


16

Demographic factors, such as an ageing workforce, and increasing the recruitment of Indigenous employees were addressed through the recruitment and retention of graduates in critical occupational groups. Hard-to-fill roles were identified and targeted advertising was used to attract and retain skill staff.

The TS–NP HHS will continue to align people with business priorities and focus on developing a flexible and resilient workforce able to respond efficiently to changing priorities.

The priority in 2012–13 was to build capacity and to provide internal staff development programs across the TS–NP HHS. Career entry programs resulted in:

• employment of four graduates • Indigenous administration staff enrolment and completion of:

− 5 x Certificate IV in Business − 14 x Diploma in Management − 1 x Advanced Diploma in Business

• employment of 12 health worker trainees all completing Certificate III in Aboriginal and/or Torres Strait Islanders in Primary Health Care

• professional progression for approximately 30 employees from all streams (staff who have applied and been approved Study and Research Assistance Scheme (SARAS).

18.1. Induction

To integrate new employees and to help them understand their role, responsibilities and the culture internally and externally across a complex and geographically dispersed service, all new employees were required to complete the online induction course.

The course covered:

• Queensland Health and the TS–NP HHS structure and functions • conditions of employment • behaviour at work • safety at work • keeping information safe and secure • cultural awareness training • fire and evacuation instructions • hand hygiene • clinical competencies.

Employees were required to complete the online courses:

• Code of Conduct for the Queensland Public Service

• Ethical decision making.

Business units and work divisions within the TS–NP HHS also provided information on policies and procedures, and particular needs of the business.

19. Employee development

19.1. Management and leadership development

A suite of programs was delivered in 2012–13 to develop and strengthen staff capabilities.

The focus was on building management and leadership skills, and building resilience in the workplace, including:


17

• staff enrolment in a Diploma of Management and Business through external organisations

• line manager and management forums were held throughout the year • research and sourcing of high-level management programs.

19.2. Workforce profile

As at 30 June 2013, the TS–NP HHS employed 392 full-time equivalent staff.

Permanent retention/separation rate

Permanent MOHRI

Occupied Headcount retained as at pay ending 23

June 2013

Retention %

Permanent separations (headcount) 1 July 2012

to 23 June 2013 where staff have not returned

to Queensland Health (note 1) Separation rate %

221 76.47% 76 26.30%

Minimum Obligatory Human Resource Information (MOHRI) occupied FTE per gender

Permanent status Temporary status Casual status Contract status

Female 184.82 68.55 10.91 1.00

Male 76.56 21.53 8.11

All employees 261.38 90.08 19.02 1.00

Disaggregated annual earnings per gender

Annualised average earnings

Average amount per employee

per fortnight

Average FTE hours per

employee per fortnight

Average headcount

per fortnight Fortnights

Female $88,742 $3,413 72.00 299.00 26

Male $108,519 $4,174 72.00 131.00 26

Difference $19,777 $791 0 168 0


18

Overall staff by stream – Full Time Equivalents

2009–10 2010–11 2011–12 2012–13

Medical, including visiting medical officers

12.82 13.24 14.24 14.45

Nursing 102.67 112.76 125.72 121.39

Professional and technical

11.00 15.42 23.00 21.00

Managerial and clerical 82.88 78.38 94.91 76.74

Operational 157.91 155.17 167.30 136.93

Trade and artisans 4.00 2.00 2.90 1.00

All paypoints 371.28 376.97 428.07 371.48

Workforce Diversity

• Non-English speaking background - 26.79 per cent of surveyed staff • Aboriginal and Torres Strait Island people - 32.65 per cent of surveyed staff • People with a disability - 2.55 per cent of surveyed staff

Employee performance management framework

The TS–NP HHS commenced the implementation of a performance management framework. Supervisors and employees provided input to set clear individual and business unit goals, and objectives to achieve the overall business strategy. This critical partnership between employee, supervisor and the Executive Management team ensures that each employee has a performance and development plan (PAD) that cascades from the strategic plan through the phases of performance planning, (operational plans) assessment, coaching and development. The emphasis is on monitoring of agreed measures, skills, competency requirements, and ongoing learning and development, resulting in a motivated and high performing workforce.

Industrial and employee relations framework

The TS–NP HHS actively pursued a positive relationship with its industrial partners to promote workplace harmony.

The TS–NP HHS meets all obligations under the relevant legislation, awards, agreements and public service directives.

The HHS Consultative Committee is a joint union/employer committee. It provides a regular forum to discuss a broad range of employee issues and is an avenue for consultation between the HHS and relevant unions regarding current and emerging industrial issues.

20. Early retirement, redundancy and retrenchment

With the changing government priorities, economic influences along with National Health Reforms and subsequent changes borne form the devolution of the Queensland Health departmental structure to progressively autonomous Hospital and health Services resulted in a number of employee changes.

During 2012–13, a program of redundancies was implemented—38 employees received voluntary redundancy packages at a cost of $5,823,079.94. Employees who did not accept a voluntary redundancy were offered case management for a set period of time, where reasonable attempts were made to find alternative employment placements. At the conclusion of this period, and where it is deemed that continued attempts of ongoing


19

placement were no longer appropriate, employees yet to be placed were terminated and paid a retrenchment package. During the period, no employees received retrenchment packages. Employees were supported throughout the changes by human resource programs and proactive policies.

21. Voluntary Separation Program

A Voluntary Separation Program was implemented during 2011–12. The program ceased during 2011–12 with employees receiving a voluntary separation package during 2012-13.

22. Open data

On 9 October 2012, the Premier of Queensland announced an ‘open data revolution’ for the Queensland Government with the aim of releasing as much government data as possible to encourage other sectors to develop innovative new services and solutions.

The purpose of the Department of Health Open Data Strategy 2013–2016 is to outline the plan of action for the Department of Health to achieve the Queensland Government’s commitment to this open data revolution. In keeping with the intent of the Open Data initiative, the TS–NP HHS will commence progressive publication of its data collections, where this is appropriate to do so.

The policy principles that underpin the strategy are that data published on the open data website, available from www.data.qld.gov.au will be:

• available for open use

• available for free

• available in accessible formats and easy to find

• released within set standards and accountabilities.


20

23. General information

Consultancies during 2012–13

Vendor

Financial year in which

consultancy was first reported

Consultant’s details

(organisation, vendor name)

Consultant’s details

(organisation, vendor address

Brief description of projects and reasons for consultancy

Details of officer

overseeing project

Total 2012–13 financial

year expenditure (GST excl.)

($)

398333 2013 Health Insight NSW Pty Ltd

4 Bellevue Street Kogarah NSW

2217

TS–NP HHS readiness

assessment

Mike Wallace, 0408 288 352

15,600

225441 2013 Paxton Partners

Level 2, 448 St Kilda Road

Melbourne VIC

Review of primary health

services

Julian Maiolo 100,000

228412 2013 Prominence Pty Ltd

PO Box 66 Taigum QLD 4018

Website and template

design

Leanne Ryan 144,857

308092 2013 Arkaeon Pty Ltd

Level 1 230 Lutwyche

Road Windsor QLD

4030

Review of accounts payable process

Chris Kent 61,425

151166 2012 Barbara Schmidt &

Associates P/L

PO Box 63M Manunda QLD

4870

Torres model of care

Barbara Schmidt

87,500

Total 409,382

Overseas travel

During 2012–13, one occasion of staff overseas travel was recorded. This travel was approved by the Director-General in accordance with the Queensland Health Staff Overseas Travel Standard and Procedure.

Date of Travel Staff Name Destination Reason for travel Cost

20 to 22 February 2013

Dr. Oscar Whitehead Daru, Papa New Guinea

Attend AusAID meetings

NIL (AusAID Cost)

Additionally the TS–NP HHS incurred minimal costs for the relocation of two overseas recruited clinicians. The total cost to the TS–NP HHS was $1,064.00.


21

Queensland Multicultural Action Plan 2011–2014 Whole-of-government core outcomes

Core outcome Performance indicators Measure Improved cultural competence of staff Number of staff that have participated in cultural competence

training annually.

237

Number of staff that have participated in cultural competence training as a percent of the total number of department staff for the year.

60% 237 of 392

FTE

Improved access to interpreters for clients when accessing services

Amount spent annually on interpreters engaged by department and government funded non-government organisations.

$102.52

Number of interpreters engaged annually by the department and government funded non-government organisations.

3

Improved communication and engagement with culturally and linguistically diverse (CALD) communities and/or organisations

Number of key information publications translated into languages other than English.

0

Number of languages in which publications are available. 0

Number of information sessions or workshops held for people from CALD backgrounds.

0

Number of CALD groups, peak bodies and other stakeholders consulted or engaged on the development or implementation of department projects, services, policies and programs.

3

Improved recruitment and retention strategies for staff from CALD backgrounds

Percentage of staff indicating they’re from a non-English speaking background

26.79%

Number of complaints about racial discrimination within the department

1


22

24. Remuneration disclosures

The Executive Management team comprised of the following: Name

Position

Contract classification and appointment authority

Date appointed to Position (date resigned from

position) Dr Oscar Whitehead Executive Director, Medical Services

Medical Officer C2 1 July 2012

Charlotte Tamwoy Director, Primary Health Care

A08 1 July 2012

Simone Kolaric Health Service Chief Executive

s27/s70 23 July 2012

Scott Byrant Chief Financial Officer

A08 acting 13 November 2012

Nahtanha Davey Director, Corporate Services

A08 1 July 2012 (5 December 2012)

Alison Wilkinson District Director of Nursing, Midwifery and Integrated Health Service Delivery

Nurse Grade (NRG)11

10 March 2013

Beverley Hammerton District Director of Nursing, Midwifery and Integrated Health Service Delivery

NRG11 1 July 2012 (10 March 2013)

Patricia Yusia Director, Northern Peninsula Area

A08 1 July 2012 (10 March 2013)

James Sherry Director, Corporate Services

A08 acting 5 December 2012 (31 March 2013)

Danielle Hoins Director, Corporate Services

A08 acting 1 April 2013

Ben Jesser Director, Governance and Policy

A08 acting 2 May 2013

The Executive Management team remuneration for the financial year:

Personnel Base ($)

Non-monetary

benefits ($)

Long-term benefit ($)

Post- employment

benefit ($) Termination

benefit ($)

Total Remuneration

($)

Simone Kolaric 305,146 8 7,399 37,120 - 349,673

Ben Jesser 12,435 279 1,427 - 14,141

Dr Oscar Whitehead 428,978 - 3,928 27,843 - 460,749

Charlotte Tamwoy 83,547 - 2,524 12,769 - 98,840

Alison Wilkinson 35,058 798 3,766 - 39,622

Beverley Hammerton 82,983 430 2,233 9,691 115,475 210,812

Scott Byrant 71,017 - 2,395 7,221 - 80,633

Danielle Hoins 26,808 - 526 1,902 - 29,236

James Sherry 44,664 - 862 3,146 - 48,672

Nahtanha Davey 54,659 - 1,163 5,967 15,252 77,041

Patricia Yusia 98,381 9,622 1,840 8,713 193,516 312,072


23

25. Compliance checklist

Summary of requirement Basis for requirement

Annual report reference

Letter of compliance

• A letter of compliance from the accountable officer or statutory body to the relevant Minister

ARRs- section 8 ii

Accessibility • Contents ARRs- section 10.1 3 • Glossary 26 • Public availability ARRs- section 10.2 i

• Interpreter service statement

Queensland Government Language Services Policy ARRs- section 10.5

i

• Copyright notice Copy Right Act 1968 ARRs- section 10.4 i

• Information licensing

Queensland Government Enterprise Architecture- Information Licensing ARRs section 10.5

i

General information

• Introductory information ARRs- section 11.1 1 • Agency role and main function ARRs- section 11.2 2 • Operating environment ARRs- section 11.3 3 • Machinery-of-government

changes ARRs- section 11.4 4

Non-financial performance

• Government objectives for the community ARRs- section 12.1 4

• Other whole-of-government plans/specific initiatives ARRs- section 12.2 5

• Agency objectives and performance indicator ARRs- section 12.3 5

• Agency service areas, service standards and other measures ARRs- section 12.4 7

Financial performance

• Summary of financial performance ARRs- section 13.1 8

• Chief Finance Officer statement ARRs- section 13.2 Appendix 1 Governance- management and structure

• Organisational structure ARRs- section 14.1 8 • Executive management ARRs- section 14.2 8 • Related entities ARRs- section 14.3 10 • Boards and committees ARRs- section 14.4 10

• Public Sector Ethics Act 1994

Public Sector Ethics Act 1994 (section 23 and schedule) ARRs – section 14.5

11

Governance- risk management and accountability

• Risk management ARRs- section 15.1 11 • External scrutiny ARRs- section 15.2 14 • Audit committee ARRs- section 15.3 11 • Internal audit ARRs- section 15.4 14 • Public Sector Renewal Program ARRs- section 15.5 15


24

• Information systems and recordkeeping ARRs- section 15.7 16

Governance - human resources

• Workforce planning, attraction and retention and performance ARRs- section 16.1 16

• Early retirement, redundancy and retrenchment

Directive No.11/12 Early Retirement, Redundancy and Retrenchment ARRs - section 16.2

19

• Voluntary Separation Program ARRs - section 16.3 20 Open data • Open data ARRs - section 17 20 Financial statements • Certification of financial

statements

FAA - section 62 FPMS- sections 42, 43 and 50 ARRs - section 18.1

Appendix 2

• Independent auditors report FAA- section 62 FPMS- section 50 ARRs- section 18.2

Appendix 3

• Remunerations disclosures

Financial Reporting Requirements for Queensland Government Agencies ARRs- section 18.3

23


25

26. GLOSSARY OF TERMS

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

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

• manage labour (obstetric) • cure illness or provide definitive treatment of injury • perform surgery of illness or injury • relieve symptoms of illness or injury (excluding palliative care) • reduce severity of an illness or injury • protect against exacerbation and/or complication of an illness and/or

injury that could threaten life or normal function • perform diagnostic or therapeutic procedures

Allied health staff

Professional staff who meet mandatory qualifications and regulatory requirements in the following areas:

• audiology

• clinical measurement sciences

• dietetics and nutrition

• exercise physiology

• leisure therapy

• medical imaging

• music therapy

• nuclear medicine technology

• occupational therapy

• orthoptics

• pharmacy

• physiotherapy

• podiatry

• prosthetics and orthotics

• psychology

• radiation therapy

• sonography

• speech pathology

• social work.

Clinical governance

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


26

Health outcome

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

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

Hospital and Health Boards

The Hospital and Health Board is made up of members with expert skills and knowledge relevant to managing a complex healthcare organisation.

Hospital and Health Service

A Hospital and Health Service (HHS) is a separate legal entity established by the Queensland Government to deliver public hospital services. The first HHS commenced on 1 July 2012. Queensland’s 17 HHSs replaced existing health service districts.

Indigenous health worker

An Aboriginal and/or Torres Strait Islander person who holds the specified qualification and works within a primary healthcare framework to improve health outcomes for Indigenous Australians.

Medicare locals

Established by the Australian Government to coordinate primary healthcare services across all providers in a geographic area. Work closely with the HHS to identify and address local health needs.

SARAS Study and Research Assistance Scheme

Statutory bodies

A non-departmental government body, established under an Act of Parliament. Statutory bodies can include corporations, regulatory authorities and advisory committees/councils.


27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

Closing Report

Torres Strait – Northern Peninsula Hospital and Health Service 30 June 2013

Final Issued: August 2013

62

Contents

1. Purpose of the report ....................................................................................... 187

2. Scope of the audit ........................................................................................... 187

3. Audit conclusion .............................................................................................. 187

4. Key matters ..................................................................................................... 188

5. Other audit activities ........................................................................................ 190

6. Audit fee .......................................................................................................... 190

7. Other matters .................................................................................................. 190

63

187

1. Purpose of the report This report has been prepared to provide the Audit Committee with an update on the status of our audit of the financial statements for Torres Strait – Northern Peninsula Hospital and Health Service (TS-NP HHS) as at 26 August 2013. It summarises the action taken and issues identified since our interim report provided to you on 7 August 2013.

In particular, this report outlines issues impacting on the finalisation of the audit and remaining audit work to be completed prior to the certification of the financial statements.

2. Scope of the audit In accordance with the Auditor-General Act 2009 (the Act), the Auditor-General is required to undertake an audit of Torres Strait-Northern Peninsula Hospital and Health Service each financial year. This includes auditing the annual financial statements and issuing an independent auditor’s report on the annual financial statements. The Auditor-General’s mandate, however, is not limited to expressing this opinion and accordingly the audit may also include an assessment of the probity and propriety of the use of public resources and compliance with other legislative and policy requirements.

The audit has been conducted in accordance with the Auditor-General of Queensland Auditing Standards which incorporate the Australian Auditing Standards and require compliance with relevant ethical and professional requirements. The audit approach focused on key financial reporting risks. This involved gaining an understanding of significant financial reporting processes and the performance of a combination of internal control testing and substantive audit procedures to address our assessment of the residual risk of material error.

We confirm that up to the date of this report we have maintained our independence obligations in relation to our conduct of this audit.

3. Audit conclusion We conclude that:

• audit progress to date will allow completion of the audit and audit certification of the financial statements on 29 August 2013

• conclusion of the audit process is subject to satisfactory resolution of the outstanding items outlined below

• an unmodified audit opinion is currently proposed.

The following items relating to the completion of our audit procedures are outstanding at the date of this report and need to be resolved prior to the issue of our audit opinion.

Item Action required Responsibility

Financial report certification To be signed on adoption of the accounts by the Board.

Management

Management representation letter To be signed as near as practical to, but not after, certification of the financial statements.

Management

Completion of our review QAO quality control procedures. QAO

After the issue of the audit report we are required to undertake procedures summarised in the table below. Any issues identified from this review will be reported to the chief executive officer for remedial action.

64

188

Item Action required Responsibility

Whole-of-Government (Tridata) certification

Review and certify Tridata financial statements

Audit

Annual report Review contents of annual report and confirm that correct audit report is included

Management and audit

Website Review website for correct audit report Management and audit

4. Key matters In forming an opinion on the financial report, we have considered probity and propriety of the use of public resources and compliance with other legislative and policy requirements, as well as the significant accounting and financial reporting issues. The following matters have been identified as significant for inclusion in this report and may be considered for inclusion in the final management report.

4.1 Material unusual transactions, accounting policies and disclosure issues

The following material unusual transactions and accounting policies were considered by audit.

Description of policy/disclosure issue Impact on financial report Audit conclusion

Land and buildings were transferred to TS-NP HHS under a three year lease arrangement with the intention that ownership would transfer to TS-NP HHS in the near future.

TS-NP HHS is recognising the value of land and buildings assets under the control definition of the Australian Accounting Standards, but control is not clearly achieved when based on a three year lease arrangement and an intention around future ownership.

QAO has obtained written confirmation from the Minister for Health that legal title and ownership will transfer during the current lease term or the lease will be extended. Based on the Minister’s confirmation, QAO concluded that recognition of the value of land and buildings assets by TS-NP HHS is appropriate.

4.2 Management judgements and estimates The Audit Committee and Board should be made aware of the process used to formulate material accounting estimates and the judgements made by management underlying these estimates.

The following items have been assessed by QAO as being subject to material accounting estimates. We have reviewed the underlying assumptions by management for reasonableness.

Component Basis of estimate and underlying assumption Audit conclusion

Property, plant and equipment The valuation methodology for buildings is based on

depreciated replacement cost, a model used in place of market value as these assets cannot be bought or sold on the open market. Estimates of remaining life are based on the assumption that the asset remains in its current function and will be maintained. Buildings have been valued on the basis that there is no residual value.

We are satisfied that the valuation methodology achieved fair value for land and buildings.

65

189

Component Basis of estimate and underlying assumption Audit conclusion

Receivables Provision for impairment of receivables is based on an assessment of the credit risk associated with receivables balances and is determined based on consideration of objective evidence of impairment, past experience and management judgement. Factors considered include financial difficulties of the debtor, changes in debtor credit ratings and current outstanding accounts over 30 days.

We are satisfied that the provision for impairment is based on a robust assessment of the collectability of receivables.

4.3 Written representations As part of our evidence gathering, we obtain formal management written representations in relation to a number of matters. A management representation letter will be requested from management and will be required to be signed on the same date as the certification of the financial report.

The following key representations to be included in the management representation letter will be relied upon in forming our audit opinion.

4.3.1 Management specific representations relied upon

Representation Made by

Component affected and implications for financial

reports

Valuation of land and buildings – Management review and Administrator endorsement of the results of valuation to ensure that the results are in line with management understanding of the valuation methodology, that robust assessment was conducted over valuation results and increment or decrement arising from the revaluation of assets is materially correct.

Signatories to the Financial Report

Property, plant and equipment

Internal control environment - Management has obtained and assessed the formal representation from the Department of Health confirming that no significant internal control or governance issues have been identified within their overall control environment and application systems that could affect the integrity of our financial transactions and balances for the period 1 July 2012 to 30 June 2013.

Signatories to the Financial Report

Material expense items including Health Service employee costs

4.4 Adjustments and unadjusted differences identified by audit In the course of our audit we identified financial amounts and disclosure matters that we believe should be recorded differently in the financial statements. Where these are material, we request that management adjust the financial report.

66

190

In assessing these differences we have used the following materiality levels in accordance with the guidelines prescribed in Australian Accounting Standard AASB 1031 Materiality and Australian Auditing Standard ASA 320 Materiality and Audit Adjustments.

Financial statement line item

Balance as at 30 June 2013

($’000) Materiality %

Materiality ($’000)

Scoresheet Threshold

($’000)

Revenue/Expense 80 000 1% 800 8 Assets/Liabilities, excluding Property, plant & equipment

10 000 5% 500 5

Property, plant & equipment 118 000 5% 5 900 59

We consider all matters identified during the audit in terms of paragraph 9 of AASB 1031 in relation to the omission, misstatement or non-disclosure of information. There are no material unadjusted differences or disclosure matters.

4.4.1 Adjusted material financial audit differences and disclosure matters

Component(s) affected

Amount of adjustment/disclosure

matters

Underlying cause of difference

Status

Key Management Personnel disclosure.

Adjustments to the Key Management Personnel note resulted in an increase of $309 145 or 22% in the total remuneration disclosed.

Recognition and classification of termination payments for three key executives.

All significant disclosure issues have been resolved.

4.5 Irregularities, fraud or regulatory non-compliance We have not identified any further areas of material fraud risk or exposure.

5. Other audit activities

5.1 Audit of whole-of-Government information Whole-of-Government (Tridata) financial package and notes questionnaire are to be provided to us for review, so that certification can be completed by 30 August 2013.

6. Audit fee The estimated audit fee of $140,000 as communicated in the Client Strategy was based on an estimate of the hours required to undertake the audit in accordance with the client strategy and the hourly charge out rates approved by the Treasurer. It is expected that the final fee for the audit will not exceed the estimated fee and the final fee will be advised in the final management letter.

7. Other matters

7.1 Planning issues for 2013-14 The following matters identified during the 2012-13 audits will be considered in planning the 2013-14 financial year audits.

67

191

• Transfer of legal title to land and buildings from the Department of Health. • Useful life of medical equipment.

7.2 Reports to Parliament A Hospital and Health Service sector specific Report to Parliament is being prepared for tabling in November/December 2013. This report will comment on the HHS sector in its first year and the following topics are being considered for reporting.

• Financial performance measures and sustainability assessments • Planning and management of asset maintenance backlog • Effectiveness of audit committees and internal audit functions • Monitoring of key financial transactions and internal controls • Internal control findings • Financial Reporting findings • Effectiveness of governance arrangements including CFO assurance processes • Timeliness and quality of financial statements • Financial performance linked to activity data.

HHSs will be provided an opportunity to review and comment on the final draft of this Report to Parliament.

John Adams, Team Leader Bryan Steel, Director 23 August 2013

68

Torres Strait-Northern Peninsula Hospital and Health Service2012–13 Annual Report www.torres-north.health.qld.gov.au

Documents

Torres Strait-Northern Peninsula Hospital and Health ... · The State of Queensland (Torres Strait-Northern Peninsula Hospital and Health Service) annual report 2012–13 ISSN : 2202–7874