C.1 Internal Accountability

Senior executive and responsibilities

The organisational chart on page 6 shows the structure of ACT Health at 30 June 2014. This chart includes the names of the senior executives responsible for each of the organisation's output areas.

Executives in the ACT Public Service are engaged under contract for periods not exceeding five years. Their remuneration is determined by the Australian Capital Territory Remuneration Tribunal.

Senior executive and organisational changes

In 2014 ACT Health contracted Governance Plus to undertake a gap analysis against the National Safety and Quality Health Service Standards to assess its preparedness for accreditation.

The report recommended that, to ensure effective oversight of the organisation's progress towards meeting the requirements for accreditation and patient safety, resources associated with safety and quality be realigned to sit within a single clinical governance structure.

To this end, a proposal was put forward to move resources from the Quality and Safety Branch (with the exception of the Workplace Safety section) and Quality and Safety Officers (QSOs) within Canberra Hospital and Health Services (CHHS) to HealthCARE Improvement in CHHS. The consultation period for the proposal commenced on 31 March 2014 and ceased on 28 April 2014.

There was general support for the opportunities the restructure could create, including coordinated oversight and progression of accreditation and patient safety requirements, minimisation of duplication, improved efficiencies, enhanced and open communication, creation of a culture of quality and service improvement, and provision of a clear, well-articulated quality and safety system that holds all staff to account.

From 1 July 2014, positions from the Quality and Safety Branch will be realigned to the Healthcare Improvement Branch, CHHS. Staff from Workplace Safety will remain as part of the Strategy and Corporate Divisions.

Senior executive

ACT Health is organised into groups and operational areas which report directly to the Director-General.

The four groups - Canberra Hospital and Health Services, Strategy and Corporate, Health Infrastructure and Planning, and Population Health - are led by Deputy Directors-General. Canberra Hospital and Health Services employs the majority of staff working in ACT Health.

Senior executive positions across the organisation are as follows:

  • Dr Peggy Brown Director-General (DG)
  • Stephen Goggs Deputy Director-General (DDG), Strategy and Corporate
  • Ian Thompson Deputy Director-General (DDG), Canberra Hospital and Health Services
  • Dr Paul Kelly Chief Health Officer, Population Health Division
  • Jacinta George Acting Deputy Director-General, Health Infrastructure and Planning
  • Dr Frank Van Haren Director, DonateLife ACT
  • Elizabeth Trickett Executive Director, Quality and Safety Branch
  • Ron Foster Chief Finance Officer
  • Judy Redmond Chief Information Officer, E-health and Clinical Records Branch
  • Phil Ghirardello Director, Performance Information
  • Rosemary Kennedy Executive Director, Business and Infrastructure Branch
  • Ross O'Donoughue Executive Director, Policy and Government Relations Branch
  • Judi Childs Director, People, Strategy and Services
  • Veronica Croome ACT Chief Nurse
  • Karen Murphy Chief Allied Health Advisor
  • Prof Frank Bowden Chief Medical Administrator
  • Dr Marianne Bookallil GP Advisor
  • Professor Charles Guest Director of Research
  • Barbara Reid Executive Director, Division of Surgery, Oral Health and Imaging
  • Elizabeth Chatham Executive Director, Division of Women, Youth and Children
  • Denise Lamb Executive Director, Division of Cancer, Ambulatory and Community Health Support
  • Linda Kohlhagen Executive Director, Division of Rehabilitation, Aged and Community Care
  • Katrina Bracher Executive Director, Division of Mental Health, Justice Health and Alcohol and Drug Services
  • Prof Peter Collignon Executive Director, Division of Pathology
  • Rosemary O'Donnell Executive Director, Division of Medicine
  • Adrian Scott Executive Director, Clinical Support Services
  • John Woollard Director, Health Protection Service
  • Joanne Greenfield Director, Health Improvement Branch
  • Barbara Reid Acting Executive Director, Division of Critical Care

Senior management committees, roles and membership

ACT Health committees are established at the following levels:

  • Tier 1 - directorate level
  • Tier 2 - division/branch level and Tier 1 subcommittees
  • Tier 3 - unit/team level.

Information within the organisation is cascaded down from Tier 1 committees, and similarly information and issues can be raised at the Tier 3 level and reported and managed up through the higher committee tiers.

The overarching governance committee for ACT Health is the Executive Council.

 

ACT Health Executive Council

 

 

Name of committee Role of committee Membership
Executive Council At the centre of ACT Health's governance model is the Executive Council. Its role is to:
  • support the Director-General to meet responsibilities outlined in the Health Act 1993 and other relevant legislation
  • make recommendations on the strategic direction, priorities and objectives of the organisation and endorse plans and actions to achieve the objectives
  • oversee finance, performance and human resources
  • set an example for the corporate culture throughout the organisation.
  • The Executive Council is chaired by the Director-General and meets twice monthly; one of these meetings each month is focused on finance, performance and other matters, and the other is focused on other business. A number of subcommittees report to the Executive Council, each dealing with different areas of accountability across the directorate.

Director-General (Chair)

Deputy Director-General, Canberra Hospital and Health Services

Deputy Director-General, Strategy and Corporate

Chief Health Officer, Population Health

Chief Finance Officer

Chief Allied Health Advisor

ACT Chief Nurse

Chief Medical Administrator

Consumer Representative

Academic Representative

Executive Directors Council

This council provides an opportunity for all executive members to communicate and collaboratively work in partnership with other areas of ACT Health to deliver patient-focused, high-quality care by influencing policy and strategic direction, managing policy governance and risk, and maximising operational effectiveness.

The Executive Directors Council meets monthly and reports to the Executive Council on strategic operational matters and risk management.

Director-General (Chair)

Deputy Director-General, Canberra Hospital and Health Services

Deputy Director-General, Strategy and Corporate

Acting Deputy Director-General, Health Infrastructure and Planning

Chief Health Officer, Population Health

Senior Manager, Executive Coordination Unit

GP Advisor

Chief Medical Administrator

Executive Director, Mental Health, Justice Health and Alcohol and Drug Services

Executive Director, Women, Youth and Children

Director, People Strategy and Services

Executive Director, Quality and Safety

Executive Director, Pathology

ACT Chief Nurse

Chief Finance Officer

Director, Performance Information

Director of Research

Executive Director, Business and Infrastructure

Executive Director, Rehabilitation, Aged and Community Care

Manager, Internal Audit and Risk Management

Executive Director, Cancer, Ambulatory and Community Health Support

Patient Experience Leader

Manager, Canberra Hospital Foundation

Chief Allied Health Adviser

Executive Director, Medicine

Executive Director, Policy and Government Relations

Chief Information Officer, E-health and Clinical Records

Executive Director, Surgery, Oral Health and Imaging

Executive Director, Critical Care

Director, Clinical Support Services

Director, Strategic Projects

Acting Senior Manager, Communications and Marketing

Director, DonateLife ACT

 

Safety and Quality Committee This committee provides high-level advice to the Executive Council on all matters regarding quality and safety and ensures impacts on patient safety are considered in decision making. This committee:
  • sets the strategic direction, priorities and objectives for safety and quality across the organisation
  • provides oversight of clinical practice improvement, quality improvement, accreditation, clinical governance matters (including sentinel events), consumer engagement and clinical policy.

    Director-General (Chair)

    Deputy Director-General, Strategy and Corporate

    Deputy Director-General, Canberra Hospital and Health Services

    Clinical Director, Clinical Governance Unit

    Executive Director, Quality and Safety Branch

    Manager, Internal Audit and Risk

    Chief Health Officer, Population Health

    Executive Director, E-Health and Clinical Records

    Director, Performance Information

    Executive Director, Business and Infrastructure

    Acting Deputy Director-General, Health Infrastructure and Planning

    Executive Director, Policy and Government Relations

    Chief Allied Health Advisor

    Chief Medical Administrator

    ACT Chief Nurse

    Health Care Consumer and Carer Representatives (2)

    Patient Experience Leader

    Executive Director, Surgery, Oral Health and Imaging

    Executive Director, Women, Youth and Children

    Executive Director, Critical Care

    Executive Director, Cancer, Ambulatory and Community Health Support

    Executive Director, Rehabilitation, Aged and Community Care

    Executive Director, Mental Health, Justice Health and Alcohol and Drug Services

    Executive Director, Pathology

    Executive Director, Medicine

    Medical Advisor, Clinical Governance

    Director, DonateLife ACT

    Work Health and Safety Committee This committee comprises executive members, health professional members and health and safety representatives. Its role is to:
    • facilitate cooperation between ACT Health and staff to instigate, develop and carry out measures designed to ensure the health and safety of staff
    • assist in the development of standards, rules and procedures relating to health and safety that are to be complied with in the workplace
    • provide work health and safety advice and recommendations on strategies, allocation of resources and legislative arrangements
    • address whole-of-agency work health and safety issues unable to be resolved at division or branch level.

    Director-General (Chair)

    Director, Workplace Safety

    To achieve a quorum, at least half of the members of the committee must be staff who are not nominated by ACT Health.

    Two representatives from each division/branch Tier 2 Health and Safety Committee - one manager and one Health and Safety Representative.

    Other members as co-opted

    Information Communication and Technology Committee The role of this committee is to:
    • oversee the development of Health Directorate information management and information and communications technology (IM&ICT) plans, policies and frameworks, as required, ensuring whole-of-government issues are considered
    • monitor lifecycle ICT asset management frameworks, strategies and policies consistent with best practice
    • monitor portfolio IM&ICT risks
    • monitor, review and manage ICT assets, services and delivery and financial performance and infrastructure risk across the Health Directorate
    • ensure whole-of-ACT Government and Health Directorate IM&ICT policies and standards are implemented across the organisation
    • prioritise IM&ICT initiatives
    • evaluate proposed IM&ICT initiatives and recommend supported business cases for all major IM&ICT projects to Executive Council
    • review and report the status of ICT projects under development and, if required, recommend strategies to rectify significant variances of these.

    Deputy Director-General, Strategy and Corporate (Chair)

    Deputy Director-General, Canberra Hospital and Health Services

    Deputy Director-General, Health Infrastructure and Planning

    Chair, Clinical Working Group or representative

    Chief Information Officer, E-health and Clinical Records

    Director, Performance Information

    Executive Director, Business and Infrastructure

    Executive Director, Policy and Government Relations

    Chief Health Officer, Population Health

    Chief Nurse

    Chief Medical Administrator

    Executive Director, Critical Care

    Executive Director, Cancer, Ambulatory and Community Health Support

    Executive Director, Rehabilitation, Aged Care and Community Care

    Executive Director, Surgery, Oral Health and Imaging

    Executive Director, Women, Youth and Children

    Executive Director, Mental Health, Justice Health and Alcohol and Drug Services

    Executive Director, Pathology

    Executive Director, Medicine

    Executive Director, Shared Service ICT or representative

    Chief Executive, Calvary Public Hospital or representative

    Health Care Consumer representative

    ACT Medicare Local representative

    Redevelopment Committee This committee is the chief decision-making body for the ACT Health Infrastructure Program (HIP). It is responsible for providing advice, monitoring progress and monitoring risk in the HIP.

    Director-General (Chair)

    Deputy Director-General, Canberra Hospital and Health Services (Chair)

    Deputy Director-General, Strategy and Corporate

    Chief Finance Officer

    Deputy Director-General, Health Infrastructure and Planning

    Chief Information Officer, E-Health and Clinical Records

    Executive Director, Business and Infrastructure

    Director, People Strategy and Services

    Representative of Director, People Strategy and Services

    Chief Executive Officer, Calvary Health Care ACT

    Chief Minister’s Representative, Chief Minister, Treasury and Economic Development Directorate

    Director-General, Commerce and Works Directorate

    Budget Management and Analysis Branch, Chief Minister, Treasury and Economic Development Directorate (Treasury representative)

    Executive Director, Shared Services ICT

    ACT Health Care Consumers' Association

    Infrastructure Finance and Advisory, Chief Minister, Treasury and Economic Development Directorate

    Executive Construction and Program Director, Health Infrastructure and Planning

    Senior Finance Manager HIP, Health Infrastructure and Planning

    Director, HIP Branch, Shared Services Procurement

    Principal Solicitor, ACT Government Solicitor's Office

    Senior Manager, Health Infrastructure Business Support

    Acting Senior Manager, Health Services Planning Unit, Health Infrastructure and Planning

    Workforce Innovation and Reform Committee This committee provides executive leadership on the implementation of the ACT Health Workforce Plan 2013-2018 and other aligned workforce plans as an organisational priority. The committee:
    • receives six-monthly reporting against the endorsed actions of the plan and documents progress
    • determines further ACT Health workforce reform in line with the national agenda and the broader objectives of ACT Health and the ACT Government.

    Deputy Director-General, Strategy and Corporate (Chair)

    Director, People Strategy and Services

    Executive Director, Clinical Support Services

    Director, Workforce Policy and Planning Unit

    Senior Manager, Health Services Planning

    Executive Director, Mental Health, Justice Health and Alcohol and Drug Services

    Executive Director, Surgery, Oral Health and Imaging

    Executive Director, Women, Youth and Children

    Executive Director, Cancer, Ambulatory and Community Health Services

    Executive Director, Critical Care

    Executive Director, Rehabilitation, Aged and Community Care

    Executive Director, Pathology

    Executive Director, Medicine

    Chief Medical Administrator

    ACT Chief Nurse

    Chief Allied Health Advisor

    Additional attendees are co-opted as required for specific issues.

    Audit and Risk Committee This committee provides independent assurance, assistance and advice to the Director-General regarding audit, risk control and framework, external accountabilities and responsibilities, and appropriate internal controls.The committee consists of five members:
    • Chairperson - external and independent of the directorate
    • Deputy Chairperson - external member, appointed for a fixed period
    • two Deputy Directors-General
    • an ACT Health senior executive.
    The Director-General and the Manager, Internal Audit and Risk Management, are invited to all meetings. The secretariat role is performed by the Internal Audit andRisk Management Branch.

     

    As well as these committees, governance meetings are established at the Tier 2 level within the Strategy and Corporate group and the Canberra Hospital and Health Services group, Population Health, and Health Infrastructure and Planning.

    Senior staff from divisions and branches are involved in these meetings and key information is cascaded down from the Tier 1 level via groups, divisions and branches to unit level across ACT Health.

    A range of forums provide the opportunity for stakeholder input into health services. Some of these include:

    • Medical Staff Council (monthly) - ongoing
    • Nursing and Midwifery Leaders meeting (monthly) - ongoing
    • Allied Health Forum (monthly) - ongoing
    • Director-General Forums (six-weekly) - ongoing
    • Leadership Network (three times a year) - ongoing
    • ACT Region Integrated Regional Clinical Training Network - ongoing
    • Private Hospitals Liaison Committee - ongoing
    • Healthcare Consumers Liaison Committee - ongoing
    • GP Liaison Network - ongoing
    • Southern Local Hospital Network District Liaison Cross-Border Operational Meeting - ongoing
    • ACT Medicare Local/ACT Health Liaison Committee
    • ACT Health/Community Services Directorate Liaison committee (quarterly) - ongoing
    • ACT Health/Human Rights Commission (annual) - ongoing
    • Health Emergency Management Sub-Committee (quarterly) - ongoing
    • Alexander Maconochie Centre - Health Policies and Advisory Group - meets quarterly
    • Aboriginal and Torres Strait Island Health Forum.

    ACT Local Hospital Network Council

    In 2011, the ACT Local Hospital Network Council was established under amendments to the Health Act 1993.

    It is responsible for providing strategic advice to the Director-General of ACT Health on matters critical to the ACT Local Hospital Network's success. The council meets at least six times a year.

    Each financial year the council is required to present to the Minister for Health a report on the state of the local hospital network and any recommendations relating to the improvement of health services by the local hospital network that the council considers necessary.

    Clinical Senate

    The Clinical Senate provides a forum for a multidisciplinary group of clinicians, health experts and consumers with diverse perspectives to share their collective knowledge in discussing strategic clinical issues. The Senate is required to provide evidence-based advice and recommendations to the Director-General of ACT Health and the Chair of the ACT Medicare Local, with the aim of improving patient care outcomes. Meetings are held three or four times a year.

    The Clinical Senate reports to the Director-General of ACT Health and the Chair of ACT Medicare Local, who consider and respond formally and transparently to all recommendations.

    The membership of the Senate reflects the range of views that would be encountered across the full breadth of the community on significant clinical strategic issues. Members are appointed following due consideration of clinical skills and/or knowledge, capacity to make a contribution, clinical influence, consumer input and multidisciplinary coverage.

    The Senate comprises up to 40 members, the majority of whom are clinicians with direct clinical duties. In addition to ex-officio members, membership consists of specialist medical practitioners, specialist dental practitioners, nursing and midwifery representatives, academic staff, allied health professionals and consumer representatives.