The agency's performance (LCLHN Annual Report 2020-21)

Performance at a glance

In 2020-21 the Limestone Coast Local Health Network (LCLHN) continued its strong reputation for achieving key performance areas including:

  • The LCLHN effectively recovered from COVID-19 elective surgery shut downs to achieve 100% timely admissions and zero overdue patients by May 2021
  • Continued achievement of Emergency Department (ED) ‘Seen on time’ targets for triage categories 1, 2 and 5 presentations
  • Achievement of the interim National Emergency Admissions Target (NEAT) set at 70% in quarter 4
  • Introduction of LCLHN Monthly Dashboard Reporting for Acute, Aged Care, Aboriginal Health, Mental Health, Infection Control, Country Health Connect and the National Disability Insurance Scheme (NDIS)
  • Introduction of clinical governance reform and establishment of the Safety and Quality Clinical Effectiveness Council (SQCEC), the Clinical Governance and Leadership Committee (CGLC), and the formation of a General Practitioner (GP) Advisory Group
  • Reduction of Relative Stay Index from 1.09 in July 2020 to 1.07 in June 2021
  • Significant hospital avoidance and saved bed days achieved through the Better Care in the Community (BCIC) and Virtual Clinical Care (VCC) programs
  • Increased stability of ED Medical Officer staffing and decreased use of locums at the Mount Gambier and Districts Health Service (MGDHS) from 13.86 FTE in July 2021 to 10.41 FTE in June 2021, with troughs as low as 7.79 FTE
  • Increased use of Health Roundtable data to guide performance and quality improvement activities

Agency response to COVID-19

To reduce the spread of COVID-19 within South Australia, on 22 March 2020 the State Coordinator made a Declaration of a Major Emergency under the Emergency Management Act 2004 and was ongoing at the time of this report.

The LCLHN activated an all-region response through the Incident Management Team (IMT), with the Operations Room located at the MGDHS. The team consisted of: Incident Controller, Clinical and Technical Advisory, Communications, Planning and Intelligence, Logistics and Operations.

In March 2020, the LCLHN IMT made the decision to close the Penola War Memorial Hospital Emergency Department (ED) to protect Aged Care residents, as the risk to those residents was considered to be significant due to the proximity of the ED to the Aged Care facilities. The Penola War Memorial Hospital ED remained closed from July 2020 until February 2021.

On 29 July 2020, Victorian travellers returning to South Australia were directed to quarantine for 14 days in accordance with the Emergency Management (Cross Border Travel No. 10) (COVID-19) Direction 2020, and the LCLHN IMT opened a Medi-Hotel in Mount Gambier on 21 August 2020 to facilitate directed quarantine requirements for returned travellers, which had approximately 201 guests stay until the closure of the facility in November 2020.

In March 2021, COVID-19 vaccination clinics were activated at all sites across the LCLHN as the LHN commenced its COVID-19 vaccination program. The Mount Gambier clinic was transferred offsite to Mount Gambier Central Shopping Centre in May 2021. Up to 30 June 2021, LCLHN clinics had administered 9,714 doses of vaccine as a part of the program.

Agency contribution to whole of Government objectives

Key Objective Agency's contribution
More jobs

Roles created in LCLHN within Governance and Planning, Finance, Corporate Services and clinical roles including the Hospital Bed Manager at the MGDHS.

Surge workforce recruited to support the Medi Hotel and COVID-19 Vaccination program.

Creation of a Medical Administration Registrar role to support the Executive Director of Medical Services (EDMS) and further strengthen clinical governance.

Under the Rural Health Workforce Strategy, the LCLHN has:

  • Worked with the Rural Generalist Coordination Unit to profile the LCLHN Rural generalist pathway. The pathway has been incorporated at Naracoorte Health Service with two Medical Practitioner Trainees in a Local GP practice.
  • Engaged an Orthopaedic Surgeon, providing services across the LCLHN.
  • Commenced the Allied Health Rural Trainee Program support allied health professionals to work towards aa Graduate Diploma in Rural Generalist Practice.
  • Employed an additional 2.7 FTE Nurse Practitioner/Nurse Practitioner Candidate roles to support the MGDHS ED.
Lower costs

Costs for consumers were reduced through delivering programs such as:

  • the Patient Assistance Transport Scheme (PATS)
  • timely elective surgery in rural communities
  • increasing access to telehealth services
  • access to Virtual Clinical Care (VCC)
Better Services

Introduction of key roles of MGDHS Hospital Bed Manager to facilitate patient flow through the service.

Increased Nurse Practitioner roles in MGDHS ED to assist with patient flow through the ED and timely access to treatment.

Service Planning at the Millicent and Districts Hospital and Health Service (MDHHS) was completed and is currently undertaking the implementation stage.

Service Planning at the MGDHS is underway to enable the service to meet the current and future needs of the community.

Three (3) key quality improvement projects were undertaken over an eight (8) week period, including; a review of the General Medicine service at MGDHS, education in relation to Inpatient Diabetes Management at all acute and aged care sites, and an emphasis on Coding and Documentation.

Continued work of the LCLHN Incident Management Team (IMT) to successfully manage the COVID-19 pandemic.

The rollout of the LCLHN regional COVID-19 vaccination program commenced and continues to deliver vaccinations to the community.

A Memorandum of Understanding (MoU) between the LCLHN and the Pangula Mannamurna Aboriginal Corporation was signed, which will allow for better continuous service between the two organisations for our consumers, and two way support with education, staff and strategic decisions.

A business case has been developed for a proposed Ambulatory Care service located at the MGDHS, utilising a hub and spoke model, with services extending to sites across the region. This has been endorsed by the Governing Board to advance to the next stage.

A business proposal was completed, in collaboration with the Department for Health and Wellbeing (DHW), for an interdisciplinary approach for the utilisation of Commonwealth funding for radiotherapy services.

Agency specific objectives and performance

Agency Objectives Indicators Performance
Clinical Services Reform
Integrated Cardiovascular Clinical Network (iCCnet) Cardiology Service average response time.
The average response time was 4.24 minutes, including 415 calls made by LCLHN General Practitioners and nurses.

Stroke neurologist support for country hospitals
98 patients accessed the SA Telestroke service and 72 transfers were potentially avoided in 2020/21.

Chemotherapy and Cancer care
There were 558 more cancer specialist medical consultations, including Telehealth, delivered across the two chemotherapy units within the LCLHN in 2020/21 compared to the previous financial year.

There were 166 less chemotherapy treatments and 203 less cancer-related nurse activities than 2019/20.
Improving access to services
Care in the community
Approximately 209,380 occasions of service were delivered by Country Health Connect to 9135 individual clients in 2020/21.

Hospital avoidance program activity:
Better Care in the Community (BCIC)
The BCIC program serviced 611 clients with chronic conditions who received community-based support, which has avoided 740 hospital admissions, avoided 70 ED presentations, and saved 12 occupied bed days.

There has been an increase of 209 referrals from 2019/20 to 2020/21.

Rapid Intensive Brokerage Service (RIBS)
The RIBS assisted 61 clients, which has avoided 147 hospital admissions, avoided 25 ED presentations and saved 532 occupied bed days.

Virtual Clinical Care (VCC)
Use of VCC has resulted in the avoidance of 21 hospital admissions and the avoidance of 6 ED presentations. There were 10 clients in the VCC program.

Overall, there were 7192 occasions of service in 2020/21 in LCLHN hospital avoidance programs.

Country Access to Cardiac Health (CATCH) telephone cardiac rehabilitation program referrals and completion rates
The CATCH program had 263 referrals with 177 completed to give a completion rate of 67% in 2020/21.

National Disability Insurance Scheme (NDIS) program activity
The NDIS program delivered , 4914 occasions of services to 152 children under 12 and 12,970 occasions of service to 159 clients over the age of 12 in 2020/21.

Outpatient Activity
There were 55,529 outpatient service events in 2020/21, an increase from 42,632 in 2019/20.
Hospital Services
ED Activity
LCLHN EDs 32,495 in 2020/21, an increase from 30,941 in 2019/20.
Please note Penola ED was closed July 2020 to February 2021 due to COVID-19 as it is co-located with an aged care facility.

Elective Surgery Timely Admissions
The LCLHN was impacted by the COVID-19 pandemic, however recovered to meet Elective Surgery Timely Admission targets from May 2021.

Inpatient Activity
There were 17,641 inpatient separations, of which 9317 were overnight and 8324 were same day separations.
Safety and Quality
SAC 1 and SAC2
There were 19 SAC 1 and 2 incidents in 2020/21, compared to 21 last year, which is a decrease of 9.5%.

Overall, there was a 1.3% increase in reported patient incidents, with SAC 1 and 2 incidents accounting for 0.72% of all incidents reported in 2020/21.
Aboriginal Health
The number of people attending ED identifying as Aboriginal and/or Torres Strait Islander
Steady upward trend in the number of Aboriginal people identifying in EDs from 80 in July, peaking at 127 in May 2021.

Progression of targets under Reconciliation
Implementation of LCLHN Innovate Reconciliation Action Plan (RAP).

Strengthening health partnerships
Signing of Memorandum of Understanding (MoU) with Pangula Mannamurna Aboriginal Corporation.

Aboriginal and/or Torres Strait Islander access to Country Health Connect services
There were 4541 service events provided to 277 individual Aboriginal and/or Torres Strait Islander consumers.
Aged Care Commonwealth Mandatory Aged Care Reporting
Use of Moving on Audits as a tool to capture results and report Mandatory Quality Indicators to the Commonwealth.

Monitoring of KPI data
Reform of LCLHN Aged Care Governance Committee.

LCLHN Operational and Board Reporting compliance.

Aged Care Dashboard implemented in 2020/21.

Aged Care Diversity Action Plan for the LHN implemented.

Access to community based aged care services
There were 603 Aged Care Assessment Program (ACAP) assessments undertaken in 2020/21.

There has been an increase in the number of active Home Care Packages (HCP) from 208 in July 2020 to 237 in June 2021.
Mental Health
Service Activity
There has been an increase in Mental Health ED Presentations in the LCLHN from 962 in 2019/20 to 1138 in 2020/21.

There has been an increase in Mental Health admissions to hospital with 381 in 2020/21 compared to 324 in 2019/20. Of these, there were 278 Integrated Mental Health Inpatient Unit (IMHIU) admissions and 103 Mental Health outliers in general wards in 2020/21 compared to 250 IMHIU admissions and 74 outliers in general wards in 2019/20.

The number of admissions to the Intensive Community Program (ICP) has increased from 123 in 2019/20 to 138 in 2020/21.

There was a reduction in Community Mental Health Team admissions, with 627 in 2019/20 and 477 in 2020/21.

Corporate performance summary

  • 30 Employees completed the LCLHN Growing Leaders Program and two (2) employees commenced the TIER (Transform, Inspire, Engage & Redesign) Leadership Program.
  • Health Roundtable membership for Mount Gambier and Districts Health Service (MGDHS), Millicent and District Hospital and Health Service (MDHHS) and Naracoorte Health Service (NHS) to drive performance improvement.
  • The LCLHN Diversity and Inclusion Plan 2020-2023 was endorsed.
  • The LCLHN Disability Action and Inclusion Plan 2020-2023 was endorsed and published.
  • Several Major and Minor Capital Projects were completed across the LCLHN, including:
    • Bathrooms upgraded at Bordertown Memorial Hospital (BMH)
    • Corporate WIFI installation at Penola Multi-Purpose Service (MPS)
    • Fire system upgrades at Kingston MPS and at NHS
    • Free public WIFI access at the MGDHS
    • Front entrance upgrade at NHS
    • Roof repairs at MDHHS
    • Staff car park expansion at the MGDHS
  • A variety of dashboard and scorecard style reports were created and implemented, providing a comprehensive summary of performance and activity across the LCLHN on a monthly basis.
  • MGDHS Service Planning activities continued in 2020/21 and will shape future service delivery.
  • The LCLHN Risk Management Procedure and flowchart were implemented.
  • New electronic Risk Management software ‘Risk Console’ was implemented.
  • ‘Moving on Audits’, a consistent electronic web-based auditing software was implemented across the LCLHN.
  • Improvements were made to the LCLHN Intranet hosted by Microsoft 365 application SharePoint, to increase the ease of access to LCLHN specific information for all staff.
  • LCLHN corporate branding was introduced and the LCLHN website presence was improved.
  • The LCLHN Consumer, Carer & Community Engagement Strategy 2021-2024 was endorsed.
  • The LCLHN Strategic Plan 2021-2025 was developed.

Accreditation Status

  • National Safety and Quality Health Service (NSQHS) Standards
    The Limestone Coast Local Health Network underwent NSQHS Standards Accreditation. All sites were assessed against the 8 Standards and 6 Aboriginal Actions within this process: Clinical Governance, Partnering with Consumers, Preventing and Controlling Healthcare-associated Infection, Medication Safety, Comprehensive Care, Communicating for Safety, Blood Management and Recognising and Responding to Acute Deterioration. LCLHN were successfully awarded full accreditation status up to 4 January 2024.

    The LCLHN Attestation Statement, and the Mount Gambier Private Hospital Attestation Statement, were submitted on 24 September 2020.
  • Aged Care Quality Standards

Residential Aged Care Site Code Accreditation Expiry Date
13/1/2022 (pending accreditation outcome from survey July 2021)
Kingston MPS

In-line with NSQHS accreditation
Penola MPS

In-line with NSQHS accreditation
  • National Disability Insurance Scheme (NDIS) Practice Standards
    Limestone Coast Local Health Network underwent assessment against the NDIS Practice Standards in May 2021. LCLHN (Country Health Connect Disability Services plus Residential Care Facilities) retained status as a registered NDIS provider through to 20 January 2023.

Employment opportunity programs

Program name Performance
Skilling SA Under the Skilling SA Program six (6) existing employees have been identified for enrolment and upskilling in Certificate IV and Diploma level qualifications.
Enrolled Nurse Cadetship Program
Commencement of two (2) Aboriginal Enrolled Nurse Cadetships.

Agency performance management and development systems

Performance management and development system Performance
Performance Review and Development is a process for supporting continuous improvement of the work performance of employees to assist them to meet the organisation’s values and objectives
85.92% of employees had a performance review and development discussion.

Work health, safety and return to work programs

Program name Performance
Management of work-related injury
The following has been achieved:
5% ($32,122) reduction in cost of open claims
25% reduction in the number of long-term claims (ie > 1 year old)
LCLHN has a collaborative approach between injury management practitioners, human resources practitioners, the work health & safety practitioner and LHN Managers to support early intervention and proactive return to work. This is particularly important given the significant increase in new claims across the LHN and SA Health in general.

Workplace injury claims

Current year

Past year

% Change
(+ / -)

Total new workplace injury claims
56 30 +86.7%
Fatalities 0 0 0.0%
Seriously injured workers* 0 0 0.0%
Significant injuries (where lost time exceeds a working week, expressed as frequency rate per 1000 FTE)
30.41 9.89 +207.5%

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

Work health and safety regulations

Current year

Past year

% Change
(+ / -)

Number of notifiable incidents (Work Health and Safety Act 2012, Part 3).
0 1 -100%
Number of provisional improvement, improvement and prohibition notices (Work Health and Safety Act 2012 Sections 90, 191 and 195). 0 1 -100%

Return to work costs**

Current year

Past year

% Change
(+ / -)

Total gross workers compensation expenditure ($)
Income support payments – gross ($)

**before third party recovery
Data for the previous year is available at:

Executive employment in the agency

Executive classification Number of executives


Data for the previous year is available at: .

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.