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Australian Industrial Relations Commission Transcripts |
TRANSCRIPT OF PROCEEDINGS
Workplace Relations Act 1996 19157-1
SENIOR DEPUTY PRESIDENT LACY
DEPUTY PRESIDENT IVES
COMMISSIONER LEWIN
BP2007/4059
s.423(3) - Notice of initiation of bargaining period
Health Services Union
and
Austin Health
(BP2007/4059)
MELBOURNE
10.04AM, THURSDAY, 18 SEPTEMBER 2008
Continued from 17/9/2008
Hearing continuing
PN2662
SENIOR DEPUTY PRESIDENT LACY: Good morning. Mr Langmead, before we kick off this morning I just want to clarify something with you. Was any increase in the work value a matter of issue during the bargaining period?
PN2663
MR LANGMEAD: A wage increase certainly was, your Honour.
PN2664
SENIOR DEPUTY PRESIDENT LACY: Sorry, what?
PN2665
MR LANGMEAD: A wage increase certainly was.
PN2666
SENIOR DEPUTY PRESIDENT LACY: Yes. But you said in your opening that the 16 per cent represented some retrospectivity or something like that as well, didn't you?
PN2667
MR LANGMEAD: Yes, your Honour. Well, the statistics on movements in real wages indicate that in order to return this group of employees to where they were as of the date of their last increase would require an immediate 7 per cent increase. In terms of retrospectivity I'd have to check my instructions but it was certainly sought during the bargaining period. I don't know what date that was but I would expect that it's probably the date of expiry or the nominal expiry date of the last agreement, I think was 1 October last year and I'm sorry, your Honour, you also I think asked about productivity?
PN2668
SENIOR DEPUTY PRESIDENT LACY: No, I was asking whether or not increases in the value of the work was a matter at issue during the bargaining period.
PN2669
MR LANGMEAD: Yes, in the sense that the employers said that they were constrained by Victorian Government guidelines which required productivity or work value offsets in order to offer over and above a certain figure and so in that sense it certainly was a live issue. Again I'd have to check my instructions but I understand that the union's response was, well, we've already achieved that by what we've been doing since the last increase.
PN2670
SENIOR DEPUTY PRESIDENT LACY: Perhaps I wrongly suggested Mr Parry should curtail his cross-examination then in the circumstances.
PN2671
MR LANGMEAD: As I understood the discussions last night and certainly my response was in relation to material which went back beyond 2000.
PN2672
SENIOR DEPUTY PRESIDENT LACY: 2000.
PN2673
MR LANGMEAD: And my indication was that we put in that material - well, we put in a lot of material to try and inform the Bench, with respect, what these employees do, whether the professionals have evolved from, but to the extent we will be saying there's been any change in work value it will be - it certainly wouldn't be going back to the last arbitrated outcome which was in 2000.
PN2674
SENIOR DEPUTY PRESIDENT LACY: Yes. But Mr Parry's cross-examination went to demonstrating that any increases or any changes in the nature of the work since 2000 has been rather evolutionary rather than revolutionary.
PN2675
MR LANGMEAD: Well, that's another argument anyway, your Honour, and we would say, well, even if that were so it would nevertheless meet the criteria for recognising that change in work value.
PN2676
SENIOR DEPUTY PRESIDENT LACY: Yes, all right. Mr Parry, did you want to say anything? Perhaps I did you a disservice yesterday in suggesting that you try and curtail the cross-examination on every paragraph.
PN2677
MR PARRY: If the Commission pleases. The vast majority of the material I'm cross-examining on is stuff that starts with the, "In the last decade".
PN2678
SENIOR DEPUTY PRESIDENT LACY: Yes.
PN2679
MR PARRY: And that seems a deliberate part of the material we have presented to us and my cross-examination is drawing obviously a contrast with that in the material that was produced.
PN2680
SENIOR DEPUTY PRESIDENT LACY: Yes, I understand.
PN2681
MR PARRY: And I'll curtail it as much as I can but I anticipate if I miss something and I can see it coming up in a submission somewhere that this is a change in the last 10 years, we may well want to contest that.
SENIOR DEPUTY PRESIDENT LACY: Yes, very well. Thanks, Mr Parry.
Mr Cook.
<GRAHAM WILLIAM COOK, RECALLED ON FORMER AFFIRMATION [10.10AM]
<CROSS-EXAMINATION BY MR PARRY, CONTINUING
PN2683
SENIOR DEPUTY PRESIDENT LACY: Yes, Mr Parry.
PN2684
MR PARRY: If the Commission pleases.
PN2685
Mr Cook, I think we were up to the section of your statement dealing with ultrasound or sonography and in paragraph 67 of your statement you refer to technological developments in the last 10 years and then you set out a range of matters?---I'd just like to state, your Honours, that I've had to rely on evidence from my senior sonographer on the ultrasound matters. Since its inception ultrasound has developed into a profession inside really of its own separate qualifications and separate accreditation requirements and whilst I have a basic understanding of the principles and the applications of ultrasound examinations I have had to rely on advice from my senior sonographer as far as technical innovations and current work practices go.
PN2686
So this statement in paragraph 67 through to 82 is not your knowledge but something that you've been told by somebody else?---Yes.
PN2687
You see, when you say or you've sworn to in paragraph 67:
PN2688
Technological developments in the last 10 years include certain matters.
PN2689
That's not something you know yourself?---I know one or two but I wouldn't have a broad of the technological developments in ultrasound.
PN2690
You see, your statement refers to 3D ultrasounds and Ms Dunlop told us about 3D ultrasounds in 1999 in paragraph 43 of her statement and I think we agreed yesterday there's no reason to doubt the truth of what Ms Dunlop said?---What paragraph, sorry?
PN2691
43?---43. No, but the complexity and frequency of these examinations has increased over the intervening years.
PN2692
Was that your knowledge or was something you've been told by - - - ?---That's something I've been told.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2693
And your references to new vascular Doplar imaging machines, indeed I think
Ms Dunlop in paragraph 44 and the next few paragraphs tell us much about Doplar ultrasound and colour Doplars and tissue Doplar imagine
and these are parts of which you refer to here so presumably we can assume that the vascular Doplar imaging techniques were around
in 1999?---They were but the combination of beam mode imaging techniques with vascular Doplar techniques has only occurred within
the last two years.
PN2694
Again you're relying on what you've been told?---I am, yes.
PN2695
And you say or your statement includes the introduction of beam mode imaging techniques but think, in paragraph 43, Ms Dunlop told us about B flow imaging, I assume B flow imaging is the same as B mode imaging?---No, the B mode imagine currently discussed in paragraph 67 is a 3D imaging technique which has been developed over the last couple of years and which has been used in conjunction with the Doplar imaging techniques within the last two years.
PN2696
And again you're relying on what you've been told?---That's correct.
PN2697
I think you refer to traducers in there, I think you mean transducers, don't you?
---Transducers, yes.
PN2698
And they're the things that are on the end of the cord that is placed on the body?
---They're the equipment which produces the sound waves and receives the echo signals and produce the ultrasound image.
PN2699
All right. And you say there's higher resolution ones that have been introduced?
---That's right.
PN2700
And again I'm assuming this is what you've been told?---Yes.
PN2701
Your statement refers to in paragraph 68 - I'm sorry, I withdraw that. At the end of paragraph 67 refers to the use of ultrasound in interventional procedures. You will note that Ms Dunlop gives a fair bit of evidence about the use of ultrasound in interventional procedures?---Which paragraph?
PN2702
Of Ms Dunlop?---Ms Dunlop, yes.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2703
Paragraph 43 where she speaks of interventional procedures as a new application of ultrasound which she describes later and then later in her statement in paragraph 57 and onwards she deals with intervention of radiography. So my proposition is the use of ultrasound in interventional procedures is certainly not a development of the last 10 years?---It would have been in its infancy 10 years ago but it is now used routinely. We do many interventional procedures in ultrasound at the Alfred.
PN2704
Yes. Ms Dunlop didn't say anything about it being in its infancy at all in her statement. Indeed she described the use of it I think in times as developments in the last 12 years or in the last 10 years in paragraphs 43 and 44. Have you had the opportunity to look through Ms Dunlop's statement at all overnight?---Yes.
PN2705
DEPUTY PRESIDENT IVES: Mr Parry, was Ms Dunlop's statement as far as you're aware the subject of any challenge back at the time that it was before the Commission?
PN2706
MR PARRY: I've looked through the employers statements and not in any material or great contested sense, your Honour, and indeed the Full Bench found, as we will take you to, that there wasn't difference between the employers evidence and the evidence of Ms Dunlop.
PN2707
DEPUTY PRESIDENT IVES: Thank you.
PN2708
MR PARRY: For fairness we will put transcript and the employers material before the Full Bench hopefully to make good that proposition if it be challenged in any way.
PN2709
DEPUTY PRESIDENT IVES: Thank you.
PN2710
MR PARRY: The next paragraph goes on with tissue harmonics. You say commencing from the early 2000s but Ms Dunlop told us in 1999 about what she described in paragraph 43 as harmonic imaging. That would be a similar thing I assume?---I don't know.
PN2711
You don't know. And paragraph 46 she also spoke about tissue Doplar imaging. Again I assume that's something you don't know much about?---No.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2712
And in paragraph 69 she refers to various intra cavity studies. I think she refers to transrectal prostrate, various obstetric trans - - - ?---That's my statement?
PN2713
Sorry?---That's my statement you're referring to?
PN2714
Yes, 69s?---Yes.
PN2715
And Ms Dunlop told the Commission in paragraph 43 about the prostate transvaginal and so forth, so presumably they were techniques that were being used back in 1999?---Yes.
PN2716
And your next day paragraph dealing with colour pulse wave Doplar I think and other vascular imaging techniques, you say developed within the last decade but Ms Dunlop was telling us about colour Doplar ultrasound in paragraph 46 and vascular imaging techniques in paragraph 44 in 1999, so presumably those techniques were around?---There were but I think the techniques would have been refined and a bit more complex and more widely used now than they were in 1999.
PN2717
You would think but you don't know?---I would think, yes.
PN2718
And paragraph 71 deals with changes in technology have brought a massive demand for ultrasound and I think Ms Dunlop in paragraph 39 spoke about a sustained growth in ultrasound for the past 10 years and an increase in the complexity of the examinations. That's been an ongoing theme in the world of ultrasound, hasn't it?---It has continued, yes. Ultrasound examinations at the Alfred have increased by 63 per cent in the last four years.
PN2719
And I'm assuming you're telling us what somebody has told you?---The statistics are my statistics.
PN2720
I see, they're statistics. And in your paragraph 71 you speak about sonographers continually increasing their knowledge of anatomy, physiology and pathology and Ms Dunlop told us in 1999 in paragraph 48 that, and I quote:
PN2721
Doplar studies have required medical imaging technologists to acquire a more comprehensive knowledge not previously required of anatomy, physiology and pathology.
PN2722
So presumably there's always a demand for increase in the knowledge of anatomy, physiology and pathology in this area of practice?---That's correct, but the rate of needing to keep up to date has increased. As the technology evolves faster it takes longer and takes more study to keep yourself up to date.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2723
But that's your general proposition, isn't it?---Yes.
PN2724
Yes. But in the world of sonography you rely on others for that?---What I've been told, yes.
PN2725
Yes. And your paragraph 71 deals with the independent expertise of sonographers and I think yesterday I took you to paragraph 40 and paragraph 72 deals with rural and remote practice and I think I dealt with that yesterday so we won't deal with that again. You go on with the application of ultrasound in pregnant woman. That's been around for what, 20 years?---Yes.
PN2726
And paragraph 74 deals with -
PN2727
Advances in technology within the last five years have seen the advent of 3D ultrasound.
PN2728
I think we can accept that it's not for the last five years that have seen the advent of those things, is it?---4D ultrasound, yes.
PN2729
Sorry?---4D ultrasound, yes, within the last five years.
PN2730
What about 3 D?---No.
PN2731
No. It's been around since will into the 90s, hasn't yet?---Yes, but it's uses have been expanded again over the time.
PN2732
And 4D is a development of 3D, isn't it?---Yes.
PN2733
Yes. And vascular ultrasound I think has been dealt with in paragraph 44 of
Ms Dunlop's statement as in your paragraph 76. You refer in paragraph 78 to research being done on the use of 4D ultrasound imaging
to contrast image - media, sorry. Firstly, that's what you've been told by this lady who you work with?---That's correct, yes.
PN2734
You would accept, I suppose, the proposition that there's at any point in time research being done on a lot of things?---Yes.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2735
Not only in your area but in the world of allied health?---Yes.
PN2736
As in the world of medicine generally?---Yes.
PN2737
Now, the next page of your statement deals with mammography and screening programs. Your statement - mammography has been a technique used in medical imaging technology since the early 90s?---No, well before that.
PN2738
Well before?---Yes.
PN2739
So the screening you refer to - - - ?---The screening program in 1995.
PN2740
Right. And that screening program has continued?---That's correct, yes, has expanded.
PN2741
Right. And what that screening was really bring patients firstly to the MIT rather than having to be referred by a doctor?---Yes.
PN2742
Now, over the page there is intra operative theatre imaging (theatre radiography). Operating theatre radiography has been around for many years?---Yes.
PN2743
The use of mobile X-ray machines has been around for many years?---That's correct.
PN2744
And image intense vocation devices have been around for many years?---Yes.
PN2745
You refer to examinations now include and you set out some and I think your first one is digital subtraction angiography?---That's correct.
PN2746
Do you know, I think I might have asked you this yesterday, Linda Mayberry, who's a medical imaging technologist at St Vincent's Hospital?---Section?
PN2747
Page 11.
PN2748
SENIOR DEPUTY PRESIDENT LACY: The question was do you know her?
---I've spoken to her. I've never met her. I've spoken to her on the phone and by email.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2749
MR PARRY: Yes. I think you said in your evidence yesterday you'd spoken to her about this case and this evidence?---Yes.
PN2750
She told the Commission in 1999 of new digital subtraction angiography being installed in 1995 at St Vincent's. Were you aware of that?---Was I there at St Vincent's or was it - - -
PN2751
Are you aware that new digital subtraction angiography equipment had been installed in 1995 at St Vincent's?---Yes, but is that in theatre?
PN2752
Sorry?---Is this digital subtraction angiography equipment being installed, used in theatre or in the department?
PN2753
Right. So it wasn't used in theatre, do you know that or is that an assumption you're making?---The statement I’m looking at is talking about digital subtraction angiography and interventional radiography, that would be fixed digital subtraction equipment in the main X-ray department.
PN2754
Right. And paragraph 90 of your statement refers to intra operative use of ultrasound and I think ultrasound was used for intra operative use as Ms Dunlop was telling us in 1999 in paragraph 43?---Yes, that's correct but it would have expanded and increased in usage since then I would think.
PN2755
And you refer to mobile CT scanners in paragraph 90?---Yes.
PN2756
And where are they in operation?---There is a proposal for a mobile CT scanner to be use at the Alfred Hospital in the intensive care department so the intensive care patients don't need to be moved to the main X-ray department.
PN2757
Those instructing me have not heard of a mobile CT scanner in any Victorian hospital?---It is currently a proposal by the director of emergency, Dr Mark Fitzgerald.
PN2758
Yes. The fact is that there are no mobile CT scanners in any hospital in Victoria?
---Not at this point in time but there is a proposal.
PN2759
And paragraph 91 deals with advances in medical techniques and theatres are open 24 hours a day and on call staff being available. It's always been the position in the world of medical imaging technology that staff need to be available out of hours?---That's correct but the things they're being called in to do out of hours are far more complex than they used to be in the past.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2760
Well, Ms Dunlop at paragraph 122 and onwards of her statement told the Commission about the bulk of work being done out of hours at various hospitals and that in paragraph 126:
PN2761
Medical imaging technologists on call must be competent in general radiography, fluoroscopy, operating theatre procedures, CT angiography, ultrasound and MRI.
PN2762
So that presumably was true back in 1999?---It was, yes.
PN2763
And remains true?---It is but we're being called in for more complex procedures now and more often.
PN2764
And she also went on and said in paragraph 127 about working independently and competently and working under higher levels of pressure and responsibility during a normal shift. Presumably you would say that was true in 1999 and remains true?---And increases. It's increasing now as well. The pressure is increasing and the responsibility is increasing.
PN2765
You're still dealing with intra operative imaging and paragraph 92 speaks of intra operative examinations being technically difficult exacerbated by the sterile clear environment and the fact that the patient is completely draped. That's ever been thus, hasn't it?---It is, yes, but again we're doing more complex examinations in that environment.
PN2766
Yes. But your point here is about the imposition of the sterile clear environment and the draping of the patient and my only point and I think you've accepted is it's ever been thus in theatre work?---That's correct. In the previous paragraph I mentioned advances in surgical techniques and mobile imaging modalities which is where the role has significantly changed in theatre and it's a difficult environment to work in. With these advances it's even more difficult.
PN2767
Paragraph 93 deals with advances in orthopaedic procedures and the development of the interlocking nail for long bone fractures. I assume that there are advances in orthopaedic procedures every year?---Yes.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2768
The next page deals with the impact of digital acquisition of images and I think we dealt with this yesterday when I took you to paragraphs
81 and 82 of
Ms Dunlop's statement and I think we agreed that CR and DR were introduced before - were well in place by 1999?---No.
PN2769
You don't agree with that?---CR was already in place in two hospitals in Victoria in 1999. It's now widespread throughout all the hospitals and there were no DI units at that time.
PN2770
All right. The manipulation in paragraph 97 by the MIT at a computer work station, that was being done in 1999?---In two hospitals.
PN2771
All right. Well, it was being done at least at St Vincent's, it was being done at least at the Royal Children's and it was being
done at least at Ballarat Hospital?
---Yes, okay, yes.
PN2772
And it may well have been other places, mightn't it?---I don't think so.
PN2773
Do you know?---I'm pretty sure that it wasn't being done in many places in 1999.
PN2774
What do you base your sureness on? You didn't even know about Ballarat?---I did. I've just forgotten about it. We mentioned Ballarat yesterday. I'd forgotten Ballarat had been mentioned.
PN2775
Right. Do you know whether there were any others with computerised radiography in 1999 or are you just making an assumption?---I don't believe there were any others.
PN2776
But you don't know, don't you?---Not positively but based on my experience in the profession I don't believe there were any others.
PN2777
Professional development, this is paragraph 103, you say that MITs must formally and informally keep pace with international best practice and participate in programs. That's always been the case with MITs, hasn't it?---It was made compulsory in 2005.
PN2778
That wasn't my question. My question was it's always been the case that MITs have to keep pace with international best practice and participate in professional programs?---It's always been the case that MITs have tried to keep pace with international best practice but now it's compulsory.
**** GRAHAM WILLIAM COOK XXN MR PARRY
PN2779
You say in paragraph 104 about other requirements -
PN2780
To practice as a sonographer an MIT must now -
PN2781
And you have the word now in there -
PN2782
undertake a postgraduate course of practical and theoretical training.
PN2783
Mr Lightfoot told us in paragraph 27 of his statement that in 1999 and I quote:
PN2784
The complexity of ultrasound operations has required all MITs specialising in ultrasound in allied health services to undertake a graduate diploma in ultrasonography from RMIT or an equivalent postgraduate qualification.
PN2785
Were you aware of that in 1999?---Yes, yes.
PN2786
And Ms Dunlop told us a similar in paragraph 42 and paragraph 80. So it's not a new requirement about sonographers undertaking postgraduate courses of practical and theoretical training is it?---No, sonographers are now administered by the Australian Sonographers Accreditation Registry and their qualifications must be recognised. Their education courses must be recognised. They must maintain CPD in order to keep their ASAR registration and they can't work as a sonographer unless they have ASAR registration.
PN2787
In your next paragraph 106 I think we agreed yesterday that it's not a four year bachelor degree, it's a three year degree at RMIT, one year internship and at Monash a three year and then the next year six months further study and six months practical?---That's correct.
PN2788
Yes?---But it is a four year degree before you qualify. You can't be a qualified radiographer and receive a certificate of accreditation from the Australian Institute of Radiography unless you have completed the minimum number of clinical hours which is what they do in their last year.
PN2789
And it was the position back in 1999 that the qualifications were three years plus a year of internship or four and a half - I'm sorry,
three and a half plus the six
month - - - ?---In 1999 the RMIT degree was the only one available.
Yes. If the Commission pleases, I would tender the statement of Jenny Dunlop.
**** GRAHAM WILLIAM COOK XXN MR PARRY
EXHIBIT #R8 STATEMENT OF MS DUNLOP, 13/09/1999 AND ATTACHMENTS THERETO
MR PARRY: I tender the statement of Craig Lightfoot.
EXHIBIT #R9 STATEMENT OF MR LIGHTFOOT, DATED 20/09/1999
MR PARRY: And the statement of Linda Mayberry.
EXHIBIT #R10 STATEMENT OF MS MAYBERRY, DATED 22/10/1999
PN2793
MR PARRY: And I think yesterday I also referred to a statement of a David Berlowitz which was a statement dated 15 September 1999, I will tender that also.
PN2794
SENIOR DEPUTY PRESIDENT LACY: Berlowitz, was it?
PN2795
MR PARRY: Berlowitz, B-e-r-l-o-w-i-t-z.
PN2796
SENIOR DEPUTY PRESIDENT LACY: Yes, all right.
PN2797
MR PARRY: Your Honour, I'm conscious of Deputy President Ives observation. I will at some stage tender the lot as it were because to address the issue that his Honour raised.
SENIOR DEPUTY PRESIDENT LACY: Yes.
EXHIBIT #R11 STATEMENT OF MR BERLOWITZ, DATED 15/09/1999
PN2799
MR PARRY: If the Commission pleases, I have nothing further.
PN2800
SENIOR DEPUTY PRESIDENT LACY: Thanks, Mr Parry. Re-examination, Mr Langmead?
MR LANGMEAD: Yes, thank you, your Honour.
<RE-EXAMINATION BY MR LANGMEAD [10.40AM]
PN2802
MR LANGMEAD: Mr Cook, yesterday you were asked some questions about angiographic procedures and you were asked about the statement of Jenny Dunlop in paragraph 61 I think about interventional angiographic procedures and at one point you made a distinction between inter operative interventional angiographic procedures and other interventional procedures. Were the procedures you were describing the same as described by Ms Dunlop or are they different?---I’m a bit confused by Ms Dunlop's statement because the point of an interventional angiographic procedure is so that you do the procedure in an X-ray room in the main X-ray department and the whole point of the procedure is to stop the patient having to go for an operation.
**** GRAHAM WILLIAM COOK RXN MR LANGMEAD
PN2803
Yes?---So we've got an increasing number of interventional angiographic procedures in our department and we do do some in the theatre but the whole point of the intervention is stop theatre operation having to go ahead.
PN2804
I think that Mr Parry was asking you about intra operative, evidence you gave about intra operative interventional angiographic procedures?---Yes.
PN2805
And I was just seeking to ascertain whether that's any different to what is referred to in Ms Dunlop's statement at paragraph 61?---Well, we certainly do more interventional procedures in the main department and more complex procedures. The ones we do in the operating theatre tend to be checking that the results of an operation are okay, so we are again doing more of those but I wouldn't call them interventional.
PN2806
Now, Mr Cook, you said in response to a question from Mr Parry that there were far more students than interns. Are you able to tell the Commission, are you able to quantify that for the Commission?---We currently have a total of 60 students and interns who come through the department at various times during the year. This has significantly increased with the introduction of the Monash course. We now have two universities who send students for clinical placements to X-ray departments. Being a large hospital with all of the modalities we are a popular spot for RMIT and Monash to send students for practical training in specialised areas and in just general areas. They've significantly increased over the years. When I took over as chief radiographer 15 years we had a total of 17 students and interns in the department. We now have 60.
PN2807
SENIOR DEPUTY PRESIDENT LACY: Sorry, were you going to say something else?---No, that's fine.
PN2808
Does the internship program involve the hospital making available a number of places at its initiative?---It does, yes.
**** GRAHAM WILLIAM COOK RXN MR LANGMEAD
PN2809
Or is it regulated to make available a number of places?---The hospital makes available places for interns based on advice from the Professional Accreditation Advisory Board of the Australian Institute of Radiography and we currently have - it varies, depending on how many students are coming out of university, but we usually have six to eight interns. They're partially funded by the Health Department but there is a shortfall in the funding and the hospital has to make up the wages, the difference in the wages.
PN2810
Yes, thanks, Mr Langmead.
PN2811
MR LANGMEAD: How do those numbers compare with say five years ago,
Mr Cook?---I think it's gone up - off the top of my head it's probably gone up from about 43 to 60 or 48 to 60. I'm not quite sure
about that.
PN2812
Now, you've referred in your evidence to currently conducting 80 trials, has the number of trials increased at all in say the last five years?---Yes, with the introduction of the clinical research unit as part of radiology it's significantly increased.
PN2813
And Ms Dunlop said that MITs have participated in 445 examinations for clinical trials. How many examinations are required for your 80 trials?---I don't have the exact figure but our general radiography which is only one area which does trials performs 500 exams a year on its own and on top of that we have other trials in CT, ultrasound, MIT, Dexter which is bone densitometry. So we do - I don't have the exact figures but I know we do more than 500 in general X-Ray alone.
PN2814
Now, you said that some hospitals might still be operating on a 16 slice CT, did you mean by that they only had 16 slice machines or that they are still using 16 slices - - - ?---Some of them may only have a 16 slice machine. Sandringham currently only has a four slice machine.
PN2815
Okay. And when was the 16 slice machine introduced?---I'm not sure off the top of my head, six or seven years ago.
PN2816
And I think you said that IVP has been replaced by CT scanning within the last four or five years?---IVP for renal colic.
PN2817
Yes?---Yes.
**** GRAHAM WILLIAM COOK RXN MR LANGMEAD
PN2818
And was that done with a 16 slice machine when you first started doing it?---It was, yes.
PN2819
Could it be done with a four or eight slice machine?---I don't know.
PN2820
Now, the colleague who advised you about MRI, who is that person?---Amanda Hunt, she's the level 4 radiographer in charge of MRI at the Alfred.
PN2821
Yes. And that MRI is part of your department?---It is, yes.
PN2822
And she reports to you?---Yes.
PN2823
And the person who advised you about ultrasound?---Was Judy Wells, the level 4 sonographer at the Alfred and she reports to me too.
PN2824
Yes, thank you, your Honour.
SENIOR DEPUTY PRESIDENT LACY: Yes, thank you for your evidence,
Mr Cook, you're excused.
<THE WITNESS WITHDREW [10.49AM]
PN2826
SENIOR DEPUTY PRESIDENT LACY: Yes, Mr Langmead.
PN2827
MR LANGMEAD: I call Michelle O'Rourke.
PN2828
MR PARRY: If the Commission pleases, my junior will take this or deal with this witness.
SENIOR DEPUTY PRESIDENT LACY: Thank you, Mr Parry.
<MICHELLE THERESE O'ROURKE, AFFIRMED [10.50AM]
<EXAMINATION-IN-CHIEF BY MR LANGMEAD
PN2830
THE SENIOR DEPUTY PRESIDENT: Yes, Mr Langmead.
PN2831
MR LANGMEAD: Ms O'Rourke, can you please state your name and address?
---Michelle Therese O'Rourke, (address supplied).
PN2832
And what is your occupation?---I'm a speech pathologist.
PN2833
Have you caused to have prepared a statement for use in these proceedings?
---Yes, I have.
PN2834
Are there any amendments you wish to make to that statement?---Yes, please. At paragraph 18 it should read:
PN2835
At Melbourne Health city campus neurosurgeons operated one extra half day per fortnight for six months until the end of the 2007/8 financial year.
PN2836
And the rest is the same. At paragraph 19 it should read:
PN2837
In addition, at the Melbourne Health Royal Park inpatient rehabilitation unit the number of - - -
PN2838
SENIOR DEPUTY PRESIDENT LACY: Sorry, inpatient rehabilitation?---Yes, inpatient rehabilitation unit -
PN2839
the number of dedicated neurological rehabilitation beds rose from 20 to 22 and fluctuating up to 23 when there is an increased number of neurological patients that need rehabilitation. These beds were allocated - - -
PN2840
Can you just wait a moment?---Yes, sorry.
PN2841
Yes?---
PN2842
These beds were allocated to the neurological stream without increasing allied health's resources. This change in bed card allocation has increased the number of patients that each speech pathologist needs to clinically manage at any given time which in turn impacts on the workload and nature of work undertaken by the speech pathologists.
PN2843
And paragraph 64 should be deleted.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2844
MR LANGMEAD: Is your statement otherwise true and correct?---Yes.
Yes, I tender that.
EXHIBIT #A19 WITNESS STATEMENT OF MS O'ROURKE, DATED 11/08/2008 AS AMENDED
PN2846
SENIOR DEPUTY PRESIDENT LACY: I should say almost as rewritten.
PN2847
MR LANGMEAD: Now, what is your classification?---I'm a chief speech pathologist grade 2.
PN2848
And how many employees are you responsible for in your department?---15 operationally but there are another 11 with some vacancies, three vacant positions at the moment that I am professionally responsible for.
PN2849
Yes. And why is it that you're not operationally responsible for those persons?
---Because they work in community programs that are managed through an operational structure.
PN2850
And when you say you're professionally responsible what does that involve?
---The practical reality of what I can do is I'm responsible for making sure that they're credentialed, that they're able to - we
provide some PIM entering, some professional development, they attend professional development meetings. They might ring for professional
advice and assistance. We might help with up skilling. We're doing that with regard to video thoracoscopy and I may be - I'm often
called on to sit on interview panels with the operational managers to appoint these speech pathologists to make sure that they're
skilled and also to partake in performance appraisals.
PN2851
If I can take you to paragraph 12 of your statement, you've referred to significant increase in a number of referrals, are you able to quantify that at all?---Yes, I am. In one of our awards in particular we've had a 13 per cent increase in referrals to the speech pathologist on that ward since 2005. So from 2005 compared to 2006 was a 13 per cent increase and 2007 maintained at that level, so there's been a 13 per cent increase over the last couple of years.
PN2852
Has that been accompanied by any increase in staffing?---No.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2853
Now, in paragraphs 18, 19 and 20 you've referred to Melbourne Health, how do you know that information?---I've spoken with two speech pathologists at Melbourne Health, one who works in the acute campus and one who works in the inpatient rehabilitation unit.
PN2854
And who are those people?---The inpatient rehabilitation speech pathologist is someone called Bronwyn Cox and the acute campus is Gracie Tomolow.
PN2855
I should have asked you in respect of paragraph 4 do you have regular contact with other speech pathologists at other health services?---Yes, I do.
PN2856
Are you a member of any professional body?---Yes, I'm a member of Speech Pathology Australia.
PN2857
Does that have meetings?---I'm involved with a group called the Speech Pathologists in Leadership and Management and I regularly - that's senior clinical and chiefs, so managers and senior clinicians and we meet regularly about every six weeks, six to eight weeks.
PN2858
Do you remember any other professional group?---From time to time I've been involved in different interest groups. Last year I was involved in a group of speech pathologists looking at electrical stimulation and how that could be applied to practice in speech pathology.
PN2859
In paragraph 21 again you've referred to a significant increase. Are you able to quantify that increase, this in the range of medical settings?---Yes. Particularly in the past couple of years speech pathologists have been required to attend into the emergency department a lot more. I was working at Dandenong Hospital in the acute area. I'm now in the subacute area but I was in the acute area at Dandenong Hospital and I left there in 2005. But we were seeing a lot of patients in the emergency department either to prevent an admission so we could redirect them somewhere in the community if they did need to be admitted or to progress their admission so they could eat and drink before they got up onto the ward. We've also had a lot more referrals into the intensive care unit at Dandenong Hospital for tracheostomy management and there's also been an increase in seeing patients with tracheostomy management in the intensive care unit who are on the ventilator. In the past we would only see people who were off the ventilator but now we're seeing people when they're on the ventilator and helping to wean them off the ventilator through the use of speaking valves that help to normalise the airway. So we're certainly involved there. We've also had increased referrals in the area of anterior cervical neck discectomy infusion where the surgeons operate on the neck and come in through the front and so you get some bruising, changes to the neck that impact on swallowing so we have a lot more referrals there and also - - -
PN2860
Can I just interrupt you?---Yes.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2861
When you say you have a referral, what does the speech pathologist do in respect of those referrals?---Okay, which sort of population or just the general referral?
PN2862
The referral you just spoke of?---Okay. Well, we would always conduct a physical examination of the head and the neck so what we call a bulbar examination. So we examine the cranial nerves that are used for speech and swallowing and we would assess swallowing function with or without food, with and without food, depending on if the patient is say for trialling food or fluid. We assess the efficacy of the cough. We look at their breathing and we also look at their communication, their ability to communicate, if there are any cognitive changes or problems with language or with speech or with hearing or if they're non verbal because of a tracheostomy in situ. We might provide them with an alternative means of communication if possible and help the multi disciplinary team understand how to communicate with that patient. We'd also recommend safe eating and drinking if possible if we have to modify consistencies or we may recommend that the patient be kept nil by mouth and may require alternative feeding.
PN2863
I'm sorry, I interrupted you. I think you were describing the range of medical settings?---Yes, yes. We're also particularly when I was at Dandenong Hospital, being more involved in pre admission clinic so when a patient is going to be coming in for surgery they've found that if they have a meeting with the team before they go in for surgery they understand what's going to happen to them and what they need to do when they're in the hospital and then when they go home what supports they might need and what the changes are. So I've commenced doing that in about really probably 2005 at Dandenong Hospital where I was being called to attend the pre admission clinic for patients who were having surgery to the head and neck to go and explain to them about the changes that would happen and if they woke with a tracheostomy I'd be explaining that and have models and things so that the patients would not wake up freaked out because sometimes the surgeons, doctors sometimes think that they've explained things to the patient and then we find after that the patient or the family actually, perhaps that they've talked in jargon and they may not have got the message so the allied health team can certainly help the patients journey be less fraught with worry and things that they're not sure about.
PN2864
In the second sentence in paragraph 21 you've spoken of the rapid increase in demand, are you able to put any figures on that?---With regard to the ICU at Dandenong I've got a little chart if that helps and I've put a trend line on it.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2865
Well, perhaps you can tell the Commission what that chart informs you?---Okay. It starts in January 07 and - - -
PN2866
DEPUTY PRESIDENT IVES: Is that an attachment to the witness's statement or is that just something the witness has in the box with her?
PN2867
MR LANGMEAD: I think the latter, your Honour?---Yes.
PN2868
DEPUTY PRESIDENT IVES: I'm sorry?
PN2869
MR LANGMEAD: I think the latter.
PN2870
DEPUTY PRESIDENT IVES: Right.
PN2871
MR LANGMEAD: That isn't attached to your witness statement, is it?---No, it's not. No, no, it's not. So in January 07 the number of patients were eight and the occasions of service which is the number of times that the speech pathologist would see that patient would be - was 25 and it's risen. In February 08 it was 16 patients so that's double and 65 occasions of service and in March it was 11 patients and 50 occasions of service and the trend line that I've done on the little chart just shows an increase over time with both numbers of patients and the occasions of service.
PN2872
And has that been accompanied with any increase in staff?---Not that I’m aware of.
PN2873
And have there been any increases in critical care services?---Well, this is an area of critical care, yes.
PN2874
Now, in paragraph 22 again you've said there's been an increase in the - well, first of all you say over recent years. Over what
period are you talking about there?
---Particularly the last two to three years.
PN2875
Yes. And you've said there's an increase in the acuity and medical complexity. Are you able to explain that with any greater detail?---Well, patients that - with the aging population we're finding that patients might be admitted with something - I don't know, they might be admitted with a respiratory infection or something of that nature, or even a collapse at home or something like that and what we're finding is that they're admitted into hospital and they have a lot more co morbidities, a lot more other illnesses in their past history that impact on their level of function and need to be managed so they might have some neurological past history like a stroke or a progressive neurological disease like Parkinson's or even just have an undiagnosed dementia or something like that that is impacting on their ability to function. Then they might have been functioning at home and then they have a chest infection or something that reduces their current status and they come into hospital and I think everything goes off. The brain sort of has a global response and swallowing can go off and they can get really unwell and so we find that we're needing to manager a lot of those different things that way.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2876
Yes. And you say that you were intervening at an earlier stage of the admission, what did you mean by that?---Well, so like in the emergency department or in intensive care unit.
PN2877
And how does that compare with the past?---Well, in the past we would very rarely go into the emergency department and we certainly didn't - you can see that we're getting more referrals into the intensive care unit so that's been steadily increasing over time.
PN2878
And what has that meant to your work?---Well, it puts enormous pressure. There's a lot more work that we have to try and fit into the day because we don't have extra staffing.
PN2879
Now, in paragraph 23 first of all you said:
PN2880
One of only two major paediatric services providing high acuity services -
PN2881
Where are they located?---At Monash Medical Centre and Dandenong Hospital.
PN2882
And you've said;
PN2883
Significant time and effort has to be spent providing specialist training and education to community based clinicians.
PN2884
When you say significant what do you mean by that?---The senior clinician in paediatrics at Monash told me that she spent approximately one day a week over three months to up skill a clinician and she had no backfill for that so she still had to manage her case load back at Monash while she was trying to up skill this clinician.
PN2885
And in paragraph 24 you've said that:
PN2886
In the inpatient area these patients require more time.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2887
Are you able to comment on how much time?---Yes, at Dandenong in 2003 there was approximately one to two referrals into the special care nursery there over the course of the year so I was the person employed there and I was told that - and I'm not a paediatric speech pathologist, and I was told that there would be one to two referrals a year and you would get assistance from the paediatric clinician at Monash who could come over to help you. But now it's really increased so that they're seeing on average about eight babies a year and they're often - the babies that I saw when I was there, they were - when the paediatric clinician came over she said that they weren't very cut and dried sort of cases. Like she couldn't pinpoint why they were having trouble. We would see a baby, just to clarify, with regard to their ability to suck and swallow so they're not able to feed and so the paediatric clinician will be assessing the baby for their ability to suck and swallow with food and without food and so she was finding that it wasn't a very - they weren't easy cases that she could just pinpoint what was wrong and say to me, well, you need to do this and therefore that will work that way. I had to really do a lot of reading and trying to find out and a lot of liaising with her to try and manage these babies.
PN2888
In paragraph 26 you've said that - you've spoken about the patients movements to assist them more quickly from acute to subacute, yes, from acute to subacute and from subacute to community based. What does that do for the speech pathologist's work?---Can you just ask that again, please?
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2889
Well, you've said it places a greater burden on them, are you able to explain why that is so?---Well, they're moving more quickly so they're coming across from the acute area more medically unstable and needing different sorts of intervention to actually get them able to participate in the rehabilitation program. So you might need to see them more frequently with regard to their swallow safety and their chest condition and for the community speech pathologists they've told me that they're seeing patients now in the community with tracheostomies, with nasal gastric tubes which never happened before with a neurological patient because nasal gastric tubes can move and can be a bit unsafe. It's not ideal to send a neurological patient with a nasal gastric tube but they're now having to develop skills in that area and deal with that because the patients are discharged earlier and without the feeding options sorted out. In the past we would never discharge patient with a nasal gastric tube. They would have had a peg which is a more permanent tube into their stomach inserted prior to discharge but the community speech pathologists have said over the past two years they've had about three in the community where they've had nasal gastric tubes in situ when they've been at home.
PN2890
Yes. When you say -
PN2891
The acuity of the patients in subacute and community based care is much greater as other patients who are coming in through inpatient services.
PN2892
What do you mean by that?---It means they're sicker. Acuity just means sickness. It's just a jargon term, sorry.
PN2893
Okay. And why is that the case?---Well, I think it's the case because they're discharged. Their length of stay is getting shorter in acute and they're being discharged to subacute when they may not be quite ready for rehab but they're holding up an acute bed and there's pressure on the acute bed so they put them into the rehab bed and we have to manage them when they're actually quite sicker and we have a weekend speech pathology service. We're the only subacute facility that we're aware of who have a weekend speech pathology service and we've found that we did an analysis of that service last year and 38 per cent of the patients coming across from acute to that service, the new referrals on the weekend had to have their diet and fluids downgraded because they weren't swallowing safely enough. So in the past someone would come across and we would expect they would be pretty stable on whatever diet and fluid they were on when they came to subacute, but we're finding that we had to really thoroughly assess and get to the patient straight away to make sure that they are safe so that they're not aspirating.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2894
Okay. In paragraph 29 you've referred to increased knowledge of an ability to use a range of clinical assessments and instrumental evaluation tools and you've mentioned fibre optic endoscopic evaluation swallowing. When was that introduced?---Well, it's really only been used probably over the last two to three years and the professional association, Speech Pathology Australia released a position paper on it in 2007. So it's only really recent and it's not being used widely yet because of safety issues and it's considered an advanced practice skill. So you can't just go and pick it up and use it. You have to actually meet the parameters as set out by the professional association in their position paper in order to practice that, so a lot of things you need to do.
PN2895
Okay. And pulse oximetry?---Yes, pulse oximetry. Pulse oximetry is measuring the oxygen saturation in the blood and it's something that nurses and physios have been doing for quite some time but speech pathologists are starting to use it in their practice because the research is starting to show that whilst someone's say drinking a drink and they've got the pulse oximeter on you can find some minor fluctuations in the oxygen concentration that may indicate that that person's aspirating. So it's really - we purchased a pulse oximeter in our department in 2007, last year we purchased a pulse oximeter so it is relatively new.
PN2896
And I doubt that I'll pronounce this correctly, but cervical ausculation?---Cervical auscultation is the use of a stethoscope on the front of the neck to listen to the swallowing sounds. It's really been increasing usage from around 2002 but it's becoming a lot more widespread and there are courses that you can go to to help you interpret those sounds and how to use a stethoscope because that's not something we're trained to use in our undergraduate or our masters degree programs.
PN2897
Okay. Electrical stimulation?---Now, that's a very new one and the position paper which is attached to my witness statement in draft form was only released I think the week before last it's officially released and it's not widespread used either. It's been used in a couple of centres and it's considered an advanced practice and there's not a lot of evidence base for it so it should really be used with caution because of the possibility of risk to patients.
PN2898
Yes. And that's exhibit MO5, is it?---Yes, I think it's 5. I'll have a look. Yes, that's MO5.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2899
What about speaking valves, how long have you been using those?---Yes, the Passy-Muir valve, it's been around for a while but its use hasn't been that widespread. I introduced the Passy-Muir valve into speech pathology tracheostomy work at Dandenong Hospital in 2006 and prior to that no-one was using it there and now it's become standard practice that it's used all of the time.
PN2900
And digital fluoroscopy?---Yes, digital fluoroscopy - - -
PN2901
Digital fluoroscopy machine?---Digital fluoroscopy. With the advance in new technologies in the past the fluoroscopy machine, and most of the machines that are around Melbourne are an analogue machine, but Casey Hospital and Dandenong Hospital only just recently purchased new machines and the new machine is a digital machine and it runs on a very different premise to the old analogue machine and the fluoroscopy machine is not just used for the speech pathology procedure. We're a very minor part. The machine is used for a lot of other imaging. And what we've found is that when they were using it say for a cardiac use to image the heart they needed a static picture and so the machine was set to parameters that were okay for that sort of static picture but a video thoracoscopy is a fluid dynamic procedure so what we're doing is we're giving people food and fluid of different consistencies with barium inside and we're watching. It's a continuous X-ray. It's not a single still picture or a set of still pictures. It's a continuous X-ray where we're looking at where the food is going, if it's going into the trachea, into the larynx, if it's going into the oesophagus where it ought to be going and if it's getting stuck how the patient's manipulating it in the mouth and all of those sorts of things. So we needed a different parameter and what we were finding, the machine was set in pulses so it was just taking pulses and we were missing really important parts which means the procedure was potentially missing aspirations. So it was very difficult for us to be able to interpret the film and to make recommendations about the patient's swallowing because the pulses were set too far apart. So we had to you - you know, I communicated with people even over in the United States to try and find out if they had digital machines and how to make it work and so ultimately we got to a level that was okay but it took a lot of work and a lot of explanation with the radiology people for them to understand what it was exactly that we were needing to do.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2902
In paragraph 30 you've said that -
PN2903
Speech pathologists are now required to intervene in an earlier stage and perform more invasive diagnostic procedures.
PN2904
Are you able to provide some detail of what you mean there?---Okay. So that's again really with respect to the patients being on the ventilator in the tracheotomy intensive care unit setting where that was never done in the past. The fibre optic endoscopic - - -
PN2905
When you say the past, which past are we talking about? When did you start doing this?---I've never done it because it's a really particular skill but at Monash Hospital they've just started probably in the last couple of years intervening with patients on the ventilator and certainly at the Austin Hospital they have a really best class model of tracheostomy management. They have a multi disciplinary team which is also what we started to do at Dandenong to try and enhance best practice and they've been intervening, you know, probably over the last five years with regard to the ventilator patients.
PN2906
DEPUTY PRESIDENT IVES: I think we heard yesterday that physiotherapists were also intervening with patients on ventilators?---Yes.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2907
Where is the demarcation if you like between you and the physiotherapist?---Yes, what a physio does. When we work together in an inter disciplinary team we do that, we work together, but a physio is really concerned with the respiratory status and they're able to measure - we can't measure respiratory status of a patient. We're primarily looking at their swallowing function and their communication. A physio wouldn't look at those things. But certainly what the physio tells us about the chest status will help us make decisions about where we go with attaching a speaking valve for example. So if the patient is having a lot of sputum plugs, copious amounts of sputum, a speaking valve will be contra indicated because it could just get all clogged up with sputum. So the different team members have their areas of expertise but we all rely on that expertise in order to inform our own practice and how we apply it.
PN2908
Thank you.
PN2909
MR LANGMEAD: Thank you, your Honour. Now, in paragraph 33 you've spoken of developing increased skills and knowledge in the area of COPD?---Yes.
PN2910
When did that come about?---In 2003 in Southern Health the pulmonary rehabilitation program in Southern Health hired a speech pathologist for the first time so the evidence has been building over a number of years with regard to the impact of COPD on swallowing and also communication because of the respiratory support issues and it's only really in 2003 that we actually got a speech pathologist attached to that program.
PN2911
And NMES is what you were talking about before in relation to the draft paper?
---Mm.
PN2912
I think you said it's only just come about?---Yes, that's right. It's only just been released in the last couple of weeks by Speech Pathology Australia. But prior to that we've set up an interest group in 2006 where we started meeting and talking about it and then we took it to the association to say we think there are significant patient safety issues that need to be addressed and we really pushed for them to work then towards developing a position statement.
PN2913
Paragraph 36 you've spoken of technological changes in communication practice including advances in electronic communication devices. Can you give an example of something that falls into that category?---Yes, a Lightwriter is one of the classical electronic communication devices which is a machine that the patient can type into and then the machine will produce a voice and speak whatever's being typed in. There are other devices, one being the McCore that has - there's different complexities in some of these items so the Lightwriter the patient needs to be able to either type or use a head pointer, that is, have cognitive ability to use a type face. But the McCore might have just pictures with sentences programmed in that the patient only has to touch a particular item. So perhaps for food they might touch that and it might say could I have something to eat or I'm hungry or something like that programmed into it and we can program a lot of those phrases and words for the patient.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2914
Yes. Do you know what a non electronic communication assessment service is?
---Yes, it's a relatively new service, NECAS. It commenced in 2005 and the NECAS was originally a pilot that's now been permanently
appointed and it's for non electronic communication devices. So it's for communication books, so a patient who can't use an electronic
device might have a communication book that will have different pictures in it at whatever level of complexity that the patient is
able to cognitively use. So this scheme is set up to - it can design the - I mean the speech pathologist still needs to say what
level and what it needs to be in but they can produce the device for us or the book for us. There's a whole range of different services
that they provide and from that scheme, because of the increase in the use of these sort of electronic and non electronic, we call
them alternative and augmentative communication devices, they started at the Communication Resource Centre which is a division of
Scope in Box Hill. They're started a regular meeting called AAC in Hospitals Forum, so where the hospitals are getting together
and looking at how they use these devices and how we can support each other.
PN2915
Now, in paragraph 41 you've referred to Western Health. First of all, how did you acquire that information?---I've had communication with Abbey Bean from Western Health.
PN2916
And she's a speech pathologist?---Yes, she's a speech pathologist.
PN2917
Yes. And do you know what the changes have been in the waiting lists?---Yes. In 94/95 they had received - sorry, 89/90 there were 115 new referrals. In the following year there was 121. By 94/95 there was 124 per cent increase and by 2002 it had increased up to 187 per cent increase. So the current data shows that over the past three years referral numbers have grown by a further 13 per cent and it's now approximately 350 referrals per year.
PN2918
Is there any change in complexity?---This states that they have rated the complexity has increased by 50 per cent.
PN2919
DEPUTY PRESIDENT IVES: How do you come up with a rating like that?---I have rated it. That's what I've been told by the speech pathologist at ..... I'm not able to say, sorry.
PN2920
Thank you.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2921
MR LANGMEAD: Do you rate cases by complexity?---We have in my department a system called clinical planning and complexity is a very - may be seen as an arbitrary term in terms of yes, their complex and how do you measure that. So that we're doing in my department is we're using time as a measure of complexity so we plan our case load every week. We meet in our - we've got two streams in my department, acute rehabilitation stream and an aged rehabilitation stream and each patient is rated in terms of how much time is expected that they will be needing from that particular speech pathologist for the week. So we're using time as a measure because - - -
PN2922
DEPUTY PRESIDENT IVES: So you've either got a speech pathologist who's got a lot of complex cases or you've got a very lazy speech pathologist?---Well, I don't think we've got - we're not finding we've got lazy speech pathologists. We've got a target and we're able then to shift resources around. If someone's case load is less then we can say, well, my case load is a bit less this week, I'll be go over and help you over there because you've got a lot more requirements. So it's actually helped enormously with team functions and a sense of ownership across the whole department rather than just being thinking about the particular ward or case load that that person's dealing with and I've found over doing it, we've been doing it now since 2006 when I started there, that we tend to under estimate rather than over estimate.
PN2923
COMMISSIONER LEWIN: Is the time determined by the - well, what factors determine the time that's required?---There's a lot of factors that determine the time. Obviously the patient condition and their need with regard to whatever their condition might be but there's also we factor into that if we have to do key liaison person duties which is a key contact person for the family and support for the family, communication between the team and the family and the patient. There's also, you know, meetings that you might have to attend with regard to the patient. So we have to - - -
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2924
What sort of meetings would they be?---Yes, okay. We attend every ward. Southern Health Subacute Services have developed a strategy to change our practice into more into disciplinary functioning so we have to attend two case conferences every week and in a case conference the patient will be discussed and the team goals addressed and we say how we're progressing towards those goals. So that's twice a week that we have to go through the whole list of patients and do that and a new change is we all must attend a daily briefing every morning where all of the patients are discussed with a view to discharge. So the meetings about the patients have increased which reduces available treatment time which increases pressure.
PN2925
DEPUTY PRESIDENT IVES: So presumably something that can be time consuming but not necessarily complex so you using time as a sort of measure of complexity would be a bit fraught, would it not?---Well, is it a complex social issue because the family are struggling to deal - so it could be complex from a medical point of view like in terms of their swallow is very complex and we're trying to diagnose what's going on, if they're needing a lot of therapy with regard to their swallow or their communication. So it could be complex from that point of view or it could be a complex social situation where the family and the patient are having a lot of difficulty adjusting and you need to be spending a lot of time in effective counselling and informational counselling. So there are various sorts of levels of complexity.
PN2926
MR LANGMEAD: The daily meetings to discuss discharge, firstly, when have you started having them?---I think they started about two months ago.
PN2927
And why do you think there's a need for such meetings?---Because we're under enormous pressure to discharge patients as soon as possible and this is the operational stream's way of making us accountable and making us discuss discharge.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2928
In paragraph 46 you've referred to an increased focus on ensuring competency and evidence based standards and the requirement of time and access to literature in order to bring that about. Are you able to say when this increased focus came about?---It's been building over time but it's particularly in the past four to five years it's become much more prominent and it's just almost now become a pillar of the way you have to do your work and whenever you're suggesting a change or wanting to implement a therapy you need to say why that you're doing it that way. In my department I've said before that we do cranial nerve assessment of the head and neck and we don't know - we all have been doing it for a long time but how are we doing it, how is that person doing it versus how someone else is doing it. So we've developed in our department an evidence based process for doing that and a rating scale so that when Joe Bloggs sees someone they're doing the same thing and it's an evidence based process and they know that Adwina, whoever, is doing the same thing.
PN2929
When did you develop that process?---It's been developing since really last year we started it and it's almost ready for rolling out now.
PN2930
In paragraph 49 you've referred to the external professional development but you say -
PN2931
There's little organisation or responsibility to help fund or backfill absences.
PN2932
Is there any funding for professional development?---The current policy in the department has $200 per head for professional staff but - - -
PN2933
For what period?---Per financial year.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2934
Yes?---But in the budget that just came in that was cut and now it's about 167 per head, but that doesn't include weekend staff. They don't have any allocation for professional development funding.
PN2935
Is that adequate?---No.
PN2936
How much do you think it would need?---How long's a piece a strong? You know, some of the courses, you know, you can do a two day course. I'm going to a conference in October called Rehabilitation Without Walls and the cost of that for a two day conference was $555.
PN2937
And who pays for that?---I've paid it for myself and I've received permission to be reimbursed for $200. That's my allocation but that was before the - I put that in before the budget was set at $167, so I've overspent my allocation. I owe the department how much?
PN2938
Now, in paragraph 51 you refer to mandatory training and then you set out in the dot points. Is that provided during work time?---Yes, yes, it is. But there are more than those dot points. They've been added to and they're called mandatory training packages and we've just been given a schedule month by month that the whole department have to complete that allocated mandatory package training for that month. So September might be back safe, the next month might be EQuIP, the next month might be health promotion, clinical documentation. There's a whole new raft of other ones that we've been told we have to do and we have to do them in this scheduled timeframe.
PN2939
And the ones that are during work time, they take you away from clinical duties?
---Yes.
PN2940
And is there any allowance made for that in provision of staff?---No.
PN2941
In paragraph 52 you speak about the undergraduate and masters level courses, which institutions have additionally offered courses and when?---Okay. Latrobe University has always been the university that produces speech pathologists in Victoria and in 2000 they started a masters course which was for people from other degree, who already had an undergraduate degree in some other area could start masters, do a two year very fast track masters course, a very intensive six semesters in two years versus eight semesters over four years and Charles Sturt University up in Albury/Wodonga they started an undergraduate speech pathology course and I'm not exactly sure when but it would have been around about that same time. They certainly weren't doing it when I finished in 97 so it might have been 99/2000, something around that time that Charles Sturt started.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2942
When did you say in paragraph 54 when did compass when was compass rolled out?---Compass was rolled out last year.
PN2943
What difference to your work has it made?---One of my speech pathologist who had to recently do a compass on a student said that on average a compass would take approximately three hours to complete. With the old system it would take about one hour. But then that’s actually just to complete the paper work and then you have to have a session with a student where you go through it and that generally takes about two and a half hours, whereas in the past it would have been about one hour.
PN2944
Further in 59 you’ve said that having a single manager across sites without deputies or site chiefs creates a huge workload what sort of components in your workload?---Well as I said before I’ve got the operational management as well as the professional management and the operational steam of sub acute and rehab services where I’m working develops as part of the patient centred care model that they call the 20/20 that all of the allied health medicals have to sit on a leadership on each ward. So every rehabilitation ward will have a leadership group that comprises the nurse unit manager, a medical consultant, one or two depending on the streams in that ward and an allied health manager. So the leadership group is responsible for length of stay, team functioning, education of staff, orientation to the ward of staff and we have to meet, we’ve been told we are supposed to meet weekly. We have to meet as a leadership group weekly and we’ve had to do presentations to the executive we’ve done our second one – we did one last year and we’ve had to do another one this year, so we’ve had to get together and answer particularly – particular questions that they’d asked us to answer. So this year’s one was a SWOT analysis, strengths, weaknesses, opportunities and threads that we had to do a power point presentation and present to the executive and that’s a significant amount of time. For me my ward is based at, my leadership group is at Dandenong hospital and my office is based at Kingston so I have to travel over to Dandenong every week. I mean I do that to see my staff as well but it’s a significant amount of extra work.
PN2945
COMMISSIONER LEWIN: Do you fit this all into your ordinary hours?---Yes and I have to do a lot of work at home, you know a more paper work sort of stuff, but yes these sort of things I have to fit into my ordinary hours.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2946
All right what amount of work in hours per week do you have to do at home?---I would at home, on average I would work at least I don’t know three to four hours a week at home. I’ve got an office at home, I get some of my emails directed to home so that I can emails at home, we don’t have very sophisticated technology at Southern so you can’t – I’m not at a level where I’m allowed to have a computer access at home, but I’ve worked out how to direct my emails at home, so I can access as a forwarding option. But we also have to representative allied health on a lot of different committees and there are two continuing areas that the big banner part of Southern Health that I work under and sub acute and rehab is the sort of smallest, it’s not that small, but it’s a different stream a sub stream of continuing care so we used to have to attend senior leadership meetings for the sub acute and rehab stream and now we’re told we have to attend the continuing care ones as well. We have to I’m on the quality committee representing allied health, we’re having redevelopments so we’re having to – and I’ve had to I just can’t fit in the meetings so I’ve actually delegated that meeting to one of my senior clinicians. I’m on – because we’ve got an operational professional split I have meetings with the operational stream, I have meetings with the professional stream. They had a - we’ve got Aged Residential Services in our area which is nursing homes and hostels and the wards at Kingston don’t meet the Aged Care accreditation standards because they are old, so they’ve built a whole new facility so we’ve been involved in scoping the allied health staffing for that as well. I’m on a clinical review panel, which is Southern Health wide panel that looks at adverse clinical events and how to problem solve to avoid those sorts of things. I was asked to be on a new committee just a couple of weeks ago called a self funded ward committee that was looking at making revenue for the health service. Also they were reviewing the way we prepare and make thicken fluids in at Kingston, so I was on a committee looking at that as well. There’s the health smart that’s been rolled out across the whole of Victoria so I was nominated to be on that committee as well. And from time to time different things come up where you’re asked to just drop and run and you have to go to a meeting and yes, always evolving different things that you have to do that are not necessarily with regard to your department.
PN2947
MR LANGMEAD: Because you operate across sites do you have to physically travel from your office, your office is at Kingston?---Yes at Cheltenham, yes.
PN2948
You have to travel to other sites?---Yes.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2949
How do you get there?---By my car, I drive.
PN2950
Do you receive any reimbursement for use of your car?---No, I don’t I claim it on tax.
PN2951
Sorry you?---I claim it on tax, because I don’t have a budget line for travel expenses in my budget.
PN2952
COMMISSIONER LEWIN: Are you travelling during the course of your ordinary working day between one place of work and another?---Yes, I travel a lot and since I become the manager I’ve travelled an additional, I just did my tax, over 1,000 kilometres more for the last financial year.
PN2953
MR LANGMEAD: In section E you’ve referred to retention, and say retention of existing staff and recruitment of new staff is consistently difficult in speech pathology and you’ve attached a report about these matters?---Yes.
PN2954
Why do you think it’s difficult to retain staff?---Working conditions, pace load, stress, lack of support, lack of respect for the professional skill base. It is demoralising sometimes. It’s difficult to when you are trained to do a job and you can’t do the job because of the time pressure and the number of patients that you have to see, we can only focus in on this little part of the patient, when you know there’s a whole level of stuff that they need and so there’s no job satisfaction in that in actually being able to do therapy with a patient and achieve their goals. It feels sometimes that you’re putting out fires. You are just running to the next emergency just to cope to deal with it to keep the patient stable, to get them out, because that’s the whole pressure discharge. The quality of care seems to be missing from the executive levels, its discharge, patient flow, not about the quality of care. When you raise the issue of quality of care and in my area we have our professional meetings and our operational meetings and the operational manager says, you’re going to your touchy feely meetings now, that’s how he thinks of professional issues. It’s not taken seriously, it’s not valued it’s not respected.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2955
And in terms of professional development you mentioned the $200 what about leave to go to conferences, courses and the like, is that readily available?---Well it’s obviously at the discretion of the chief or the manager. So in my department yes it is and it’s encouraged. I mean we’ve got our five days per annum, but I don’t stick with that, because I have a commitment as the chief to professional development. So if it was particularly relevant and to that person’s professional development plan and skill development then I wouldn’t say they couldn’t go. But we also have to look at cover because we don’t have back fill for professional development leave. So there’s a professional development opportunity coming up in Melbourne with regard to video fluoroscopy that’s a world renowned expert in video fluoroscopy and really it would be great if the whole department could go, such is the calibre of this speaker. But we can’t do that we have to be able to provide some form of service even if it’s only a skeleton service for that day so that you know the majority of the staff can go, but we don’t have any backfill, so.
PN2956
If staff leave do they continue as speech pathologists elsewhere?---Sometimes and sometimes not. I’ve – since I’ve been in Southern Health left me think how many have left the profession. Well in the hospital sector, maybe about five or six in the past five years who have left and are no longer practising as speech pathologists.
PN2957
What sort of work do they do?---Well they do – one is working at the professional association, one went into pharmaceutical industry selling pharmaceutical stuff, one went into working for the TAC doing sort of case management role in the TAC. One went and worked for Melbourne City Mission as a case manager role and one did a writer’s course and has just recently had a non professional article published. She just emailed it to me yesterday.
PN2958
Okay so are any of those doing clinical work as speech pathologists?---Not that I’m aware of.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2959
Do speech pathologists in Southern perform any work in excess of ordinary hours, not necessarily under direction but without pay?---Yes.
PN2960
Why is that?---There’s not enough hours in the day there’s just – and everywhere I’ve worked in speech pathology and even in allied health, we’re very driven. Very patient focus, wanting to get – you know have very high standards of wanting to get the job done and if that means coming in early and leaving later doing things at home, because we have a lot of professional pride and we care about the patients and we want to do a good job.
PN2961
Do you have any budget for overtime?---No.
PN2962
Do you think that Southern management know that people work this extra time?---Yes, I think they do.
PN2963
Well you certainly know?---Yes, I certainly know that’s right.
PN2964
Do you discuss it with your - the person you report to?---Yes.
PN2965
What would happen if that unpaid work wasn’t performed?---Well I think you’d find that you might have an impact on discharge because things wouldn’t be done, people wouldn’t be able to go home.
PN2966
SENIOR DEPUTY PRESIDENT LACY: Just before you go on Mr Langmead, you said earlier you worked three to four hours a week at home, do you work any additional hours at work as well?---Yes, every day.
PN2967
How much?---I get in early.
PN2968
How many hours a day do you do at work every day additionally?---I would work, I never leave, I’m often at work at quarter to eight and 8 o’clock is starting time, and I very rarely leave before 5 o’clock in the evening, so you know, at least half an hour to 40 minutes at work.
PN2969
COMMISSIONER LEWIN: Each day?---Each day.
PN2970
Could I just ask you a question about the evidence you gave about the attrition of the professional practitioners?---Yes.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2971
I just wanted to get a sense of what the rate of attrition actually was so ion order to do that, you said there was five people left, over a – can you tell me over what period of time?---Well I’d say over the last five years.
PN2972
Over the last five years?---That I’m aware of, that I’m personally aware of.
PN2973
Right and well are you able to give any evidence about the number of professionals in that category that would have been – well what was the establishment of the department from which that attrition occurred?---The establishment, what do you mean by the establishment?
PN2974
How many people in the area were there employed in that profession from which those people departed?---So I’m talking about more than one, because I’ve worked over two departments over that time.
PN2975
What I’m trying to get a picture of is if you have say 10 people working in a professional capacity in an area, and one of them leaves each year and leaves the profession the rate of attrition of the professional capital is 10 per cent per annum, if you understand the question?---Yes, I see what you’re saying. In my department there are now 15 staff, but that’s only recently we probably had about 12 before then so yes.
PN2976
MR LANGMEAD: Do you think there’s any need for a dedicated clinical education person in your department?---Yes, I do.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2977
Why is that need?---Well the it’s very difficult to fit it all in the day and to keep up skilled and updated so we’re all accountable now about maintaining skills so in video fluoroscopy we have a yearly maintenance program to make sure that everyone is operating at a clinically safe level with fluoro also with voice that we’re assessing voice, there’s a DVD program that we run where people have to listen to different voices and assess it. We also with tracheostomy management in an acute setting there are now competencies that you have to pass before you’re actually able to see tracheostomies independently and when you move to a sub – so there’s the need to educate new staff and to maintain skills make sure staff are still using – because the evidence is – the evidence base is developing all the time, so you need someone to be able to manage that evidence base and make sure that current clinical practice is aligning with that evidence base. In the sub acute areas, because the tracheostomies that we have entering into sub acute are few and far between there’s a real issue of skills, lost, deskilling in those areas. So if we had a clinical educator who could develop best practice for tracheostomy as an example across Southern Health when a patient comes across to sub acute care we could have the clinical educator making sure that we are aligning with that best practice meeting, the developmental needs, the learning needs of the staff who are managing that and making sure it’s all aligned. We had a case of a tracheostomy coming across to one of our residential wards from acute last year and the nursing clinical educator was involved in attending the acute site and assessing the patient and then going then tot the residential services and making sure that they were properly up to date with how to manage that patient and how to trouble shoot if there were problems. I thought that was a really excellent model of what we would really be able to use in making sure our skills are up to date.
PN2978
Now how many grade 4’s are in your department?---None.
PN2979
Do you have grade 3’s?---Yes, I’ve got two.
PN2980
Do you think either of those should be reclassified?---Yes, one of them.
PN2981
As a grade 4?---Yes.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2982
What about grade 2’s?---Yes, I’ve got one grade 2 who is based full time at the Dandenong site and she if I’m not there, she has to manage a lot of site issues and manage the – be responsibility for the clinical case load. She is a very experienced grade 2 and she had previously had worked in another health services as a grade 3 and she’s operating, I would think she could be classified at the moment as a grade 3.
PN2983
Are you aware of a recent incidence of someone being reclassified?---Yes.
PN2984
What happened in that instance?---In Southern Health in the acute services there was a speech pathologist based at the Moorabbin hospital who is a specialist ion the head and neck area, which is a highly specialised area of speech pathology that requires particular skill and expertise. She was working not just at Moorabbin but having to educate staff across the acute department and also she travels to Dandenong almost every day where she’s seeing patients over there and she, after a struggle, was recently reclassified, but it had to come to the Commission in order for her to be reclassified.
PN2985
Yes with regard to the two people you’ve identified in your department who are under classified is that something that you can rectify?---No.
PN2986
Why is that?---Reclassification is not even allowed to you know, it’s a no, no more EFT, no reclassifications it’s a closed door.
PN2987
Who says that to you?---Management.
PN2988
Thank you your Honour.
**** MICHELLE THERESE O'ROURKE XN MR LANGMEAD
PN2989
COMMISSIONER LEWIN: Just before the cross-examination commences could I just ask you I’m not quite sure from your statement what the qualifications base for a speech pathologist?---There at the moment two qualifications, so there’s a four year under graduate degree, which could be undertaken at La Trobe University or Charles Sturt and then there’s a two years masters degree but that’s all changing next year. But at the moment that’s what it is.
PN2990
All right so if you were employed as a new graduate on entry, is there any training structured training within the institution that is recognised, subsequent to employment?---No.
PN2991
So that it’s not as if there’s like an intern year or anything of that nature?---No. We have to train people on the job.
PN2992
Yes but there’s no period into - - -?---Like diplomas - - -
No, I’m not talking about a tertiary qualification recognised by the University system, I’m talking about a training qualification internally developed within the health system, such as an internship type of recognition, such that one progresses after a year or anything of that nature?---No.
<CROSS-EXAMINATION BY MS SIEMENSMA [12.07PM]
PN2994
MS SIEMENSMA: Ms O’Rourke, Commissioner Lewin has just asked some questions about the qualification, speech pathologists in Victoria they don’t have to be registered do they?---No, they don’t but they need to be eligible for membership of the professional association.
PN2995
Yes and the professional association that you referred to the Speech Pathology Association of Australia, that’s a voluntary membership isn’t it?---Yes, it is.
PN2996
You said in answer to Mr Langmead’s questions that part of what you do as a chief is that you are both – you are professionally accountable for some staff, you said that part of that involved creditentialing staff. The creditentialing that occurs when they first come on board isn’t it?---Yes, that’s right.
PN2997
Thereafter it might appear every few years just to make sure that they are still up to date and are still doing what they should do?---Well that’s a new – that hasn’t happened in the past but that a new initiative that’s being rolled out at Southern Health called creditentialing a scope of practice it’s being rolled out for Southern Health that’s another committee that I’ve been invited to be on, looking at how that will work so they’ve had a steering committee that created a package which is a three part package for creditentialing and scope of practice and now they’re looking at the implementation phase.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN2998
Yes you say in paragraph 7 of your statement you talk about speech pathology generally you say that speech pathologists have unique skills and knowledge that encompass all aspects of communication and swallow function?---Yes.
PN2999
To put that comment in some context you’d agree with me that while it’s true that speech pathologists do look at aspects of swallowing and speech, language, there are a number of other health professionals medical practitioners, ear, nose and throat people, gastroenterologists and the like they also look at speech and swallow airway function and the like?---I don’t – I wouldn’t say that they look at speech and swallow. Speech pathologists are very much the professional who are the experts in that area. We work in an inter disciplinary team so the ENT is certainly – if you think of a – if we’re talking about swallowing and when we do in servicing of our team members we would say that they are part of the dysphagia team because we’re working together but as I was explaining about the physio before, they’re a separate and might impact the way we might perform our role as with an ENT we would need them to – the ENT makes the medical diagnosis, we’re not able to make the medical diagnosis.
PN3000
But they also have skills in swallowing function and look at that part as well as speech pathologists they also look at aspects of swallowing?---Well they might look at to be technical, they might look at the function of vocal fold movement, they might look at pooling, or comment on pooling of secretions in parts of the throat.
PN3001
Yes?---But they are not really the person who is skilled to talk about swallow function.
PN3002
My point being that there are some aspects of speech pathologists look at and other related aspects that are the medical practitioners to look at in terms of swallowing, airways, things like that?---Well certainly in regard to airways, with regard to swallowing, no I don’t agree with that.
PN3003
You go on to refer in paragraph 10 to a variety of different causes of problems with communication and swallowing, you refer to things like, cleft pallet, learning disorders, hearing impairments and so on, many of these things are things that you learn about as a speech pathologist when you go to university aren’t they?---Yes they are.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3004
That’s been the case for many years? The same training program at
university?---No, it’s not the same training program. I mean they may be the disorders that we look at but they’ve been
major changes in the way that we deal with them and the way we interface with them and the evidence base that underpins them. So
the training course itself has changed substantially over the years.
PN3005
Do you know Michelle Kotis?---Yes, I do know Michelle Kotis.
PN3006
Michelle Kotis will give evidence that she studied these things at university some 18 years ago and I take from what you’ve
said you won’t disagree with that, you just say well you might learn some different things now related to those
areas?---Well the – the professional association have documents that indicate the major changes and shift in training that have
occurred over the years so whilst they’re very broad parameters of diagnostic groups of patients we might be involved in, we
learn more than just what the things are, we learn about how to deal with them and the therapeutic processes, how to diagnose and
therefore the training has had to change over time to accommodate those changes.
PN3007
Yes, and so what people study now rather than 18 years ago, might be new developments, but you still learn the same thing, you still learn about learning disorders, hearing impairments, Parkinson’s disease, those sorts of things to get a theoretical base at university or?---Yes, you do.
PN3008
You go on to say in paragraph 11 that there’s been an increase in responsibility and expectation, and that’s required a rapid increase in the range of skills and knowledge. Ms O’Rourke the expectation in the medical community has always been that speech pathologists when they treat and manage people will deliver best evidence based treatment isn’t it?---Has always been?
PN3009
Has always been for 10 years or more?---I think the impetus and the focus on evidence based practice has certainly increased over the last five years, so.
PN3010
But there was a requirement of evidence based practice 10 years or more
ago?---Yes.
PN3011
Do you know a Mr Andrew Day?---Yes I do.
PN3012
I might hand you a copy of his statement your Honours this is a statement from the 2000 MF's Mr Andrew Day being at that stage a grade 2 speech pathologist at the North Western Health Care Network. Ms O’Rourke do you have a copy of that?---Yes I do.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3013
In paragraph 20 Mr Day says:
PN3014
In the last five years –
PN3015
So he was talking about 1994 to 1999:
PN3016
-there’s been a significant development of evaluation methods-
PN3017
He goes on to say:
PN3018
-Including the use of objective and empirical outcome measures and indicators to evaluate clinical progress.
PN3019
And that was true to evaluate clinical progress and that was true was Mr Day said at that stage was true wasn’t it?---Yes.
PN3020
So really this evidence based practice and need for objective measures has really been developing since 1994 if not earlier?---It has been evolving so but the emphasis on it then was less than it is now.
PN3021
But you’ve always had to be accountable as a speech pathologist. At point 2 objective and evidence based practice?---Yes.
PN3022
Speech pathologists as you’ve said deal with disorders affecting speech and swallowing, and what you do as I understand it is
you assess, you evaluate, you can’t treat disorders, the objective being to try and restore people’s function if that’s
possible and if not, then to teach them compensatory techniques. They are the same course skills that speech pathologists have used
for many, many
years?---Yes but they’ve been built upon.
PN3023
Well there may well have been for instance technological developments over the years, but what you still do is the same function, the same role?---It’s beyond technological and I’ll just take you to dysphagia assessment and management as an example. In the past managing dysphagia relied a lot more on compensatory strategies, so modification of diet and fluids. Now we are really the evidence base has been proliferating and a lot of the areas that we work in there’s a lot more research being undertaken and articles being generated and so the emphasis on dysphagia management has moved to more actual therapy, actually you need to do a video fluoroscopy or a FEES, sometimes to really look at the structure and the function and then to target your therapy to the physiology. so rather than just treating the symptom of the coughing when they are eating or drinking, you need to say well why, why are they aspirating, it’s because the cricoids cartilage isn’t opening and we need to target our therapy for that. It’s because they’ve got pharyngeal wall dysfunction and we need to target our therapy to that. It’s because their tongue base is weak, or their tongue is weak and we need to really target therapy for that. Or their larynx isn’t elevating, there’s a lot of different reasons but we need to really pin point why it is, what’s causing the symptom, what’s the physiological rationale, aetiology and target our therapy to suit that so then we’ll take toll stimulation as an example of the therapy we might use to try and get a swallow to be initiating quicker, as an example, but you need to have the physiological underpinning to justify that.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3024
Speech pathologists have always treated dysphagia - - -?---Sorry dysphasia dysphagia speech impairment?
PN3025
Dysphagia?---Okay language impairment.
PN3026
No, dysphagia with a g, swallowing?---Okay, swallowing, okay.
PN3027
They’ve always treated dysphagia?---Yes.
PN3028
They’ve always evaluated problems with swallowing, that’s always been part of their role?---Yes, there are different ways of evaluating it now.
PN3029
Yes and video fluoroscopy has been used by speech pathologists now for more than 10 years?---Yes.
PN3030
You refer to - - -?---Can I just clarify that point, we have used it for more than 10 years but in the early stages we were using it really for diagnostic purposes and now we’re using it for rehabilitation purposes so a fluoro will last a lot longer, because we get a patient to go through a range of therapeutic and compensate the strategy in the fluoroscopy in the procedure so that we can really see that if they do that what happens if they are doing that and what happens and so it’s a lot more involved than just going in, are they aspirating, yes they are, take them out and change their diet.
PN3031
You refer in paragraph 12 through put of patients and the increase that you say in the number of referrals to speech pathology in recent years?---Yes.
PN3032
You referred earlier in your oral evidence to the need to do referral examinations, this morning you were speaking about referral examinations?---Head and neck, oral examinations.
PN3033
You used the word referral examinations?---I don’t recall using referral examinations, I think I said oral head and neck examinations.
PN3034
Okay and a speech pathologist has always done head and neck examinations as part of trying to decipher what is the problem with speech and language?---Yes, that’s right we have.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3035
COMMISSIONER LEWIN: Where does that take us, I mean I’m struggling a little bit with the thesis that underlines the propositions that have been put to the witness because they seem simplistic? I mean Isaac Newton was a physicist wasn’t he? So physics is the same as it always was, the field of physics hasn’t changed since Isaac Newton?
PN3036
MS SIEMENSMA: Well Commissioner to - - -
PN3037
COMMISSIONER LEWIN: Apart from the detail of the questions the general proposition that because speech pathologists have studied the activities of certain parts of the body located in the head and the neck, as a general proposition, how does it advance our understanding of this now?
PN3038
MS SIEMENSMA: It might become clearer when I ask some questions about technological change.
PN3039
COMMISSIONER LEWIN: All right.
PN3040
MS SIEMENSMA: You refer to the increasing number of referrals and you’ve talked about the aging population and the increasing complex acuity of the patients and I understood what you said before to be in the sense that you may have elderly people that attend the hospital and might have dual diagnosis, there might be a speech related problem and there might be a non speech pathology related problem. You’d agree with me that really the fact that people are aging now is something that has been happening for quite some time, so you have always dealt with aging people as speech pathologists?---Yes, but there’s quite a lot of evidence about the increase impact of the aging population on hospital admissions and on the – there’s some evidence around about the swallowing of communication incidence increasing because of the increase in the aging population.
PN3041
Yes, so when Mr Day says back in paragraph 22 in 1999 that elderly patients may also have cardiac and related medical complications which have to be to take into account in treatment?---Yes.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3042
That is something that has developed for more than a decade, that elderly people have been coming and they’ve had dual diagnosis?---Yes but there is more of them and there’s more of them.
PN3043
In terms of throughput of people coming in for treatment you’d agree that there’s also been a great deal of investment in ambulatory care and community health over that same period which assists you to divert some of this throughput to community services?---No, that’s not true.
PN3044
You don’t disagree do you that there has been investments, there are now community health?---I agree but when the patient is in the hospital we can’t just divert them out the door, they’re their for an admission, we have to deal with their admission and we have to manage them whilst they’re in the hospital. So the fact that there’s increased ambulatory funding, doesn’t change what we need to do on a day to day when they are actually sitting their in the bed in the hospital.
PN3045
Yes, but perhaps many years ago you would have had to see the treatment right through, whereas now once they reach a certain stage you can now have them cared for in the community rather than have them dealt with in the hospital?---Yes and that’s a concern because in the community they get less intensity and frequency of treatment. Our community speech pathologist would only be able to see a patient maximum of two to three times a week if they were lucky, whereas they can be seen daily in the hospital system.
PN3046
Presumably people that then receive treatment in the community are less acute than people admitted as inpatients in the hospital?---Well my community therapists are telling me that they’re finding that the patients are more – are sicker in the community now, so they’re seeing patients with a lot more pep tubes, nasal gastric tubes and some tracheotomy management so if you’re saying compared to what the current inpatient load is yes, but over time that acuity has risen.
PN3047
You refer in paragraph 14 to allied health guidelines?---Yes.
PN3048
You make the comment there that the number of patients should be approximately 10 to one being 10 patients to one physiotherapist?---It’s not 10 patients to one, it’s 10 beds to one.
PN3049
Ten beds to one, yes?---Yes.
PN3050
When one goes to those guidelines and first of all I’ll take you – you accept these are just guidelines these aren’t mandated in any way they are just?---They are guidelines they are not mandated.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3051
Yes when one goes to those guidelines, we see for a number of different disorders and conditions, it’s substantially less than 10 to one. For example with the spinal injuries it’s point one - - -?---It depends on the aetiology of the patient and that’s an illogical – that comment, which paragraph are you talking about?
PN3052
Spinal injury but I mean we can take a number of them amputees, point zero two five?---Which paragraph were you referring to again, sorry I’m lost?
PN3053
This is on the annexure on page 8 the first annexure on page 8 there are some tables?---No, no, you referred me originally to a paragraph in my statement?
PN3054
Paragraph 14 which attaches the guidelines?---Thank you. That should probably read, I’m just checking the wording of that that should probably read with a neurological aetiology to be more specific. So yes, it depends on the aetiology of the patient what the ratio is but these guidelines have been developed from I provided input to the version 10 that the current version with regard to the complex co-morbidities because they didn’t appear in the previous version, because we’re getting a lot more referrals into those patients, so I was wanting to have some acknowledgement and so I used the departmental data to inform that committee so that they then put that in there. So that should probably read neurological aetiology.
PN3055
Yes and not all of the patients that are referred to in this 10 to one, should be considered as requiring high level intense assistance
from a speech
pathologists?---Well it depends on the - - -
PN3056
Yes it depends on their condition and on their need?---Yes.
PN3057
Some will require more than others?---That’s right.
PN3058
At the end of that paragraph you talk about rehabilitation requiring report writing, documentation, liaising with family and carers, team planning and meetings, again these are the sorts of core functions that speech pathologists carried out for many years?---Yes, perhaps more meetings.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3059
You say in paragraph 20 that there has been an increase in throughput or a focus on throughput targets. Throughput targets have been part of the responsibility of an allied health professional now for at least 10 years haven’t they?---I don’t agree, we certainly hadn’t – it’s a reasonably new phenomenon of having throughput targets and I spoke with the clinician at Melbourne Health who provided me with data around that those throughput targets and she said that Melbourne Health those actually having throughput targets discussed in the department perhaps there may have been targets at a higher level but they were talking about, but she said it was first discussed about 12 months ago, when a target of five discharges was set per week and that this has increased to nine and now is at 10. Certainly in my experience on the leadership group we only had last year we were provided access to target length of stay. So part of the role of the leadership group is to every week we have to look at the list of patients and their is a computer program that is open to us where we can see what is the target length of stay and how the patient is travelling. So if you’re over length of stay you’re in red, until you have the patients all red, or you know, have a –you can very visually see a red to green if you’re under the length of stay target which is based on a state average for that diagnostic group. So it is certainly a really increased focus that we’re having to look at length of stay, having to manage length of stay, in a very much more accountable way and focused way where we have to really look at it. So that’s really only happened last year for us.
PN3060
Michelle Kotis gives evidence and she graduated about 10 years earlier than you did, if she gives evidence to say look she has been aware of the need for throughput targets in speech pathology for many, many years, would you disagree with her?---I’m not sure when the last time Michelle Kotis worked in a clinical capacity.
PN3061
She would be - - -?---I’m talking about clinicians and this level being aware of these things and I’m telling you what my experience is and I’m not sure when Michelle Kotis last worked in a clinical capacity where she would know what it was like for people who work at that level.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3062
In talk in paragraph 15 about the increasing number of referrals, from 1989 right up to the period 2002, presumably if we went back to the 1960’s what we’d see is a steady increase in the number of referrals, people coming for allied health care in hospitals?---I think the Western Health team have found a really huge increase so I think I said before 124 per cent and 187 per cent something like that, so they are really quite major jumps, not just a gradual incremental increase.
PN3063
Yes part of your responsibility as a speech pathologist is to prioritise patient care?---Yes.
PN3064
To work out who is urgent and who needs more care than others and that’s something that you have probably done since you started
as a speech
pathologist?---yes, that’s right.
PN3065
Speech pathologists have always dealt with fluctuations in demand in patient care, you agree with that?---Yes.
PN3066
Some of these technological developments that you’ve mentioned in your evidence have helped speech pathologists with aspects of their task, do you agree with that?---When you say helped, what do you mean?
PN3067
Let me give you an example. Some of the say the video fluoroscopy that I think you agreed have been around for more than 10 years obviously that helps speech pathologists then assess swallowing functions, so they spend less time then diagnosing what the problem is?---I wish video saved us time but doing a fluoroscopy actually increases the amount of patient time that is required because doing a fluoro it’s a complex procedure you then have to review the film and you know, when we look at – when we do a report of a film we don’t just look at it and go oh yes, their safe or they are not safe. We look at a whole range of areas and muscle function and laryngeal function and tongue function and we rate it and that’s all an evidence based package that we’ve developed in our department that we have to up skill new staff on and maintain skill base on. So a fluoro actually if I was going to manage a patient without doing a fluoro just using clinical bedside assessment, I’d save myself time. I may not be as accurate or aware of what I needed to do but I would save time if I didn’t do fluoro, but fluoro helps me target my therapy into the right area, but it takes more time.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3068
That way it gives you a benefit in terms of doing the job, knowing how to treat people knowing accurately what the problem is?---It’s a benefit for the patient I think.
PN3069
You also talk about in your statement a development, paragraph 42, group therapy at the Western and you say that that has helped move patients through 56 per cent, get through 56 per cent more patients?---I’ll just find that paragraph. Yes, yes, that’s what my colleague at Western told me.
PN3070
Right so you don’t know yourself, you’re just relying on her?---Yes, that’s right I’ve relied on what Abbey Beene from Western Health told me.
PN3071
Yes and what you would do as a speech pathologist in a group therapy session, although you’ve got a lot of people in the group you’re still using the same skills, the same methods in getting through 56 per cent more people?---Group therapy is a skill in itself and there’s quite a lot of books about how to run groups, it’s not just the same as doing a one on one case. So running groups is challenging and you need to engage with a lot of different people and pitch the group to the level that’s of benefit for everybody. So it is a particular skill and you know we’ve purchased in our department various resources that can help the speech pathologist gain the skills to run a group because it is a particular skill.
PN3072
Yes but presumably what people are being taught in the group therapy, is the same more or less what they’d be taught one on one?---Not necessarily, a group could be a lot more functional, so you might be doing more functional communication in the group as opposed to working on it, I don’t know if you know, when I say functional if you know what I mean, it’s more practical. Real life situation as opposed to one on one where you might be working on a drill of naming pictures as an example. If you were wanting to work on a patient’s word finding ability you might give them photos of different things and get them to name them but then when they are in a group and they’re having to actually pull the words out and communicating with others, it’s a different function.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3073
You’ve referred also to some guidelines the second annexure to your statement some guidelines they help you also prioritise and organise what you do at work. Organise the throughput and how many people you deal with and what the clinical load is?---Yes, it also helps the staff to feel that it’s okay not to get everything done. That they’ve got a guideline of how much is an expectation. When we implemented this system one particular staff member was feeling extremely pressured with the number of patients that she had to see, but by actually giving her permission to say its okay this is your target it helped reduce a bit of stress.
PN3074
From paragraph 21 you talk about the increase in complexity of patient acuity, when you say that do I take it that you make that comment on the basis of what you were explaining earlier the time basis, the fact that you time people, since 2005 and you say therefore because they take time, they’re more complex?---No, no, as I also said before about the medical complexity and the complexity of the swallowing condition, they might have a pharyngeal pouch or they might have a you know, the like the speech pathologist they might be working with someone with a laryngectomy or something like that or there might be social complexities, or they might have multiple co-morbidities that make them unable to perform certain things or impacts on their health so there’s a range of complexities.
PN3075
Like with the co-morbidities these conditions have always existed, people aren’t coming up with new, these conditions have always existed, so what basis do you say?---Okay I’ll give you an example, we see a large number – one of our wards has aged orthopaedic patients so elderly people who have had a fall and had a fracture. A lot of these patients have co-morbidities that might have a neurological basis like a stroke or a Parkinson’s disease or something like that or dementia in their past history and they’ve been managing at home, swallowing wise as an example, fine without any problems. They have a fracture they come into hospital and the swallow goes off. So it may have been stable before they came in but with the advent of this fracture and the illness, perhaps they’ve had surgery the brain gets addled, the swallow goes off sometimes because orthopaedic units are not traditionally seen as an area that speech pathology work in, particular in acute, the patient might be aspirating and it’s been missed and they get to sub acute and they’re suddenly developing a raging chest infection that we need to manage. So we need to firstly diagnose that that’s what is happening and then manage their swallow and hopefully they’ll bounce back to get into their pre-morbid stage, sometimes they don’t.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3076
COMMISSIONER LEWIN: Can I just understand this. What I understand from your evidence is that you’re essentially combining this demographic profile issue in terms of age with the complexity of co-morbidity? That is to say the relative incidence of aged patients with co-morbidities is increasing?---Yes.
PN3077
Therefore the complexity of the therapeutic demands rise accordingly?---Yes.
PN3078
Your Honours would that be convenient?
PN3079
SENIOR DEPUTY PRESIDENT LACY: Is that a convenient time? Yes, 2.15.
<LUNCHEON ADJOURNMENT [12.42PM]
<RESUMED [2.17PM]
PN3080
SENIOR DEPUTY PRESIDENT LACY: Would you resume the witness box Ms O’Rourke? Thank you Ms Siemensma.
PN3081
MS SIEMENSMA: Ms O’Rourke before lunch we were talking about patient acuity, you say in paragraph 21 speech pathologists are involved in the management of swallowing difficulties, tracheotomies intensive care and high dependency units?---Yes.
PN3082
Now I assume that speech pathologists over the last 10 to 15 years have worked with tracheotomies in high dependency units in hospital?---Yes.
PN3083
Your point really is that this is just becoming more common?---Yes and increased referrals, yes.
PN3084
The same point really that you made really with the co-morbidities on elderly people they’ve always existed it’s just more frequent?---Yes.
PN3085
DEPUTY PRESIDENT IVES: Well presumably a greater range of co-morbidities it there are more people there is likely to be a greater range of co-morbidities?---That’s true.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3086
MS SIEMENSMA: But presumably there aren’t new diseases these are things that you’re coming across the same sorts of presentations, the same sorts of conditions?---Well I mean there are new diagnoses happening in medicine that might come to our attention because a patient, diagnosed with one – some of the – and there are always new advancements, so there are some cerebella degenerative diseases that sort of newly diagnosed as such that we might become involved with. I was involved with a case that was extremely rare involving tuberculosis in the throat that is sort of newly, newly diagnosed in the past they thought it might have been a cancer, and treated it like that, but in actual fact they’ve discovered now that it’s a form of tuberculosis, much more common in the UK where there’s a lot of migrants from the subcontinent and from Africa but you know we had a case back here. So there are new diagnoses that we might come in touch with.
PN3087
But it is fair to say that for the most part the co-morbidity that you’re seeing with elderly people are the same sorts of conditions that you’ve always treated?---Yes.
PN3088
You go on at paragraph 22 and following to talk about the shorter hospital stays and the flow on them for community care. Can I suggest that that’s a development that has occurred over many years for more than a decade there’s been an increase in the treatment in the community?---The DHS have actually made a concerted effort to fund more ambulatory – you see it’s a particular strategy of DHS to fund more ambulatory services so, it’s actually a new initiative.
PN3089
But in terms of community care where you say there’s a reduced length of stay and then people being discharged into the community, you accept don’t you that treatment in the community is something that has been occurring over many years?---Yes, it has.
PN3090
In fact Mr Andrew Day comments on this in his witness statement at paragraphs 24 and 25:
PN3091
The reduction in average length of stay in Victorian public hospitals has meant that rehabilitation of sub acute patients have increased –
PN3092
And he talks about the impact on health professionals in a rehabilitation setting. What he says there in paragraphs 24 and 25 you don’t disagree with those, do you?---I’ll just have a read. I think that still applies but it’s the length of stay is reducing and has reduced significantly since that time, so it’s become more pertinent and more of a fact than it was earlier.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3093
This is true and this was true then and it’s true now?---To a large extent.
PN3094
The speech pathologists in the community they essentially use the same course skills but in a different setting don’t they?---Well it’s – I find that difficult to – I’m not sure, when you say course skills, I mean we assess communication, we assess swallowing and then we intervene. But the intervention in the community is very different to one that might take place in a hospital, because in the community you are needing to deal with a patient in the home, perhaps help them reintegrate into their life. There was, some of our community therapists recently just gave a presentation about development of a social inclusion model where they were touching base with particular community areas, like migrant services and things like that where they were making real connections with these people so that they could help their clients reintegrate into their normal areas that they would socialise in or to work. So reintegrating someone to work or to school which might happen in a community is a very different skill to doing an impairment based therapy in an in patient hospital.
PN3095
I understand that but I guess the reintegration into the community that is part of the skill of the speech pathologist and something the speech pathologists have always done?---Yes, but you can’t reintegrate in the community in a hospital setting unless you take the client out on a visit. So it is – well we recognise it as a very different as a sub speciality. We recognise that the speech pathologists who work in the community see themselves as specialised in that area. So often if I was employing a new speech pathologist and they didn’t have in patient I would look for a new staff member who had in patient experience and skill, as would employing in the community when I’m on interview panels with the community operations managers, they’ve always got questions in there about what is your experience in the community and working a community based team, because they recognise that it is a particular skill.
PN3096
You speak paragraph 24 about patients requiring more time to manage and you refer again to evidence based practice and I think you
accepted earlier when I took you to Andrew Day’s paragraph at 25, that this is something that existed 10 years ago and I think
your point is that it’s more of a focus now, but it did exist
then?---Yes.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3097
in paragraph 25 you talk about the reduction in the mortality rate and the fact that survival rates are improving and you talk about brain injuries and premature birth. Can I take you to paragraph 22 of Mr Day’s statement?---Yes.
PN3098
You’ll see where he says its drug and:
PN3099
As technology and drug management improves and the patients are surviving brain acquire brain injury –
PN3100
This isn’t a new development survival rates have improved for more than a decade haven’t they?---They have improved.
PN3101
For 20 years, 30 years survival rates have continued to improve?---And they are continuing to improve. The mortality is declining. The in 2006 the standardised death rate was six per 1000 population and it continues and life expectancy is extending. So over the past 20 years life expectancy has improved by 5.8 years for males and 4.3 years for females. So it’s a sort of, it’s a continuum that keeps going on and it’s getting more significant as we go along.
PN3102
Yes and the treatment of brain injury patients and premature babies I take it that these are things that speech pathologists have always done, and what you’re saying is they just do a little bit more of it?---They do more and the way that we work, it’s very much the inter disciplinary model of care, is a really strong push. So we work as a team, it’s not just the speech you’re doing, this so there are skills in working in the team and working together and developing those skills with the babies. So it’s a highly specialised area of work.
PN3103
Yes and one presumably that speech pathologists have worked with babies and assisted in that area for many years?---I believe so, it’s not - - -
PN3104
COMMISSIONER LEWIN: They’ve been working with human beings at all times, haven’t they?
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3105
MS SIEMENSMA: Well in terms of assisting babies, learning to fed, reflux, things like that that has continued?---Yes. well we see the most difficult babies because the midwives and the lactation consultants are very skilled with some of the you know, some of the more easier sort of things, we get to see the ones that have really got quite difficult problems, and the midwives are extremely skilled so we get to see the more difficult babies. Some of the babies I saw were withdrawing from heroin and having Down Syndrome and things of that nature, they might have had some hypoxic brain injury during birth. So we really see the tougher end of the spectrum.
PN3106
You speak in paragraph 26 of various rehabilitation programs can I take you to paragraph 29 of Mr Day’s statement he talks about the home based rehabilitation?---Yes.
PN3107
So from paragraph 29 through to 30 you’ll see Mr Day says:
PN3108
Home based rehabilitation is a relatively new service introduced in the last four years.
PN3109
So that would have been about 1995, you accept don’t you that the home based rehabilitation is something that has been done at least since 1995?---Yes but there have been quite significant increases in the number of beds, the number of staff, that sort of thing, that’s been part of the DHS model is to increase the ambulatory care. That’s one of those examples where rehab in the home has had a major increase. Increase in workload, increase in staff.
PN3110
You go on then to speak about role innovations, paragraph 27 and 28 we’ve spoken – we touched on dsypagia the swallowing condition, Mr Day says in his statement that La Trobe University offered at that stage in 1999 a graduate certificate in dsypagia, you agree with that?---Yes, they did.
PN3111
They still do don’t they?---No, they don’t, they no longer offer that graduate certificate on dyspagia, they haven’t done for a few years. I can’t remember when they stopped it but it’s been a while.
PN3112
I’ll come in a few moments to some of the technological, the tools that you discuss in paragraph 29. At the end of paragraph 29 you say:
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3113
Speech pathologists have been required to have a more comprehensive understanding of anatomy and physiology.
PN3114
Speech pathologists have always had to have an extensive knowledge of anatomy and physiology haven’t they?---It’s really that statement goes to the fact yes, we studied it at university, but now we really have to have a very thorough working knowledge of it, we use it in the earliest phase, like I was saying before with regard having to really understand what the physiology is and then target your treatment to that physiology. in the past in dysphagia management when people weren’t doing a lot of fluoro you didn’t have to know all that anatomy. I know you studied it at uni, but you study things at uni that you may not actually in the practice phase of life use very often. What we are finding now with dysphagia is that you really do need to know it and you’re using it to underpin your therapy program.
PN3115
You made the comment earlier this morning that there were changes in university programs now?---Yes.
PN3116
As I understand it as of next year some of the university courses will have student speech pathologists students studying at first year with would be medical students?---La Trobe doesn’t have a medical course, so it won’t be medical students.
PN3117
Michelle Kotis will give evidence to say that she studied extensive anatomy and physiology when she was at uni many, many years ago and in terms of her training if she were to go back into practice having not practised for 18 months, she would not require a great deal of refresher training to get her up to speed. Is that something you would disagree with?---Emphatically.
PN3118
You touch on some of the tools then – I withdraw that – there obviously had been technological developments over the years, not only in speech pathology but in all allied health professional work. You say in paragraph 29 that speech pathologists are required to have a increased knowledge and ability to use tools. These diagnostic tools that you refer to do you agree that these assist you in your role of assessing and evaluating conditions?---Yes, they do.
PN3119
They help you to target the therapy?---Yes, they do.
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PN3120
So to that extent they help you with your evaluation skills?---Yes, they do.
PN3121
Presumably the idea is that the sooner that you can diagnose somebody the sooner you can treat them and hopefully the better the result?---Yes, but it depends on the nature of the condition. We deal with a lot of people with progressive neurological conditions as well. So Parkinson’s disease, motor neurone disease so it’s not always an ameliorative process it might be an attempt to stabilise and to prevent further decline, so it depends on the nature of the condition.
PN3122
There will be some people who if you treat earlier they will get better
earlier?---well the evidence is starting to show that, the earlier treatment and intensity of the treatment, the amount of time, the
evidence is starting to show that that’s significant and that’s the sorts of workplace pressure for us, because we’re
not able to give the time to therapy that we’re wanting to give to therapy because we know the evidence shows improves the
patient outcome.
PN3123
This morning you spoke about video fluoroscopy and I think you said that to your knowledge it was used mainly for diagnostic purposes and in the last 10 years more so for treatment is that right?---Yes, that’s right.
PN3124
Can I take you to paragraph 36 of Mr Day’s statement in that he says:
PN3125
In speech pathology for example video fluoroscopy is now being used to produce a video image of the swallowing process for assessment and treatment, and swallowing problems, previously –
PN3126
So this is pre 1999:
PN3127
-it was used for predominantly for diagnostic purposes.
PN3128
Do you accept that as at 1999 video fluoroscopy was then being used for treatment of swallowing problems?---Yes, I accept that.
PN3129
I notice that he goes on to say in paragraph 37:
PN3130
Other changes in the last 12 years –
PN3131
I take it then that vide fluoroscopy had been used at least early in the nineties, many years before Andrew Day’s statements?---I’m not able to say exactly when fluoro’s started I could put my hand on a paper that would tell us, we’ve got that in the speech pathology Australia have a position paper on fluoro on how to use it and that sort of thing and it would tell you the history, but I can’t pull that figure out of my head I’m afraid.
PN3132
In paragraph 29 you refer to another tool, which we might call FEES?---Yes.
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PN3133
That is a tool for also evaluating swallowing?---That’s right.
PN3134
As I understand that’s a tool that has been used for many years by the medical profession and you say increasingly by speech pathologists?---FEES is not being used by the medical profession. Endoscopes have been used by the medical profession but FEES is actually a specific procedure around evaluating swallowing which is done by a speech pathologist in conjunction with medical professionals in some cases. In most cases probably an ENT but the actual FEES is a very new procedure used by speech pathologists scopes have been used by Doctor.
PN3135
Except at the Austin the use of FEES is carried out under the supervision of an ear, nose and throat surgeon?---In conjunction with so it’s done at Monash our head and neck specialist there she does FEES. I think she passes the scope I think she’s able to pass the scope. They do it in a clinic, inter disciplinary clinic style, so the ENT would be there, but certainly in terms of diagnosing the swallowing problem, it is totally the realm of the speech pathologist. The ENT will comment on structure and diagnose anything that they see that might be abnormal, but the swallowing function is the role of the speech pathologist.
PN3136
Both video fluoroscopy and FEES are then used for – or are tools to identify and treat the swallowing problem?---Yes, they are.
PN3137
As I understand video fluoroscopy involves radiation exposure and have limitations such as patients have to be upright, and they have to be able to follow verbal commands, is that right?---yes, for the most part, I mean you can still fluoro someone who is cognitively quite challenged. You may not be able to get – you’d be doing more of a diagnostic fluoro than a treatment efficacy fluoro like that. But you could still fluoro someone, I’ve fluoroed people who are totally non verbal and in horrible tub chairs that they can’t sit up very well, it’s not ideal, but you can do it, if you can transfer them to the suite.
PN3138
And FEES really is seen to have the benefit of being speedier, doesn’t have radiation can be done more readily at the bedside?---That’s right.
PN3139
But it’s not that common FEES?---No, not in Australia because it is considered an advanced practice skill. So it would be unethical for a speech pathologist to use it without acquiring that advance practice skill.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3140
You refer to a few other tools in paragraph 29 pulse oximetry?---Oximetry yes.
PN3141
Now that as I understand is the instrument that is attached to your finger when you go into surgery that monitors how much oxygen is in your blood?---Yes, it does. It’s used in a lot of areas, not just surgery but yes.
PN3142
It’s used widely in ICU and can be used in the community?---It’s used at the bedside, just about on every ward.
PN3143
What that’s involved for speech pathologists then is that they read the oxygen level?---That’s right the concentration in the blood of oxygen.
PN3144
And Michelle Kotis will say that that is not particularly difficult and there’s noting particularly innovative about it, it’s just another tool available to speech pathologist?---It’s a tool that hasn’t been used by speech pathology in the past and the trick in using it is to understand – there’s no trick to use it, you put an oximeter on someone’s finger but it’s being able to read the change in the readings and to understand the clinical significance of that and for that knowledge you have to have the evidence based knowledge to know what the significant change in the SBO2 from the medicine – it’s a tool that’s been around, but it hasn’t been used by speech pathologists and it’s being used by us and in a different way than it had ever been used before.
PN3145
Michelle Kotis will say it’s not particularly difficult to read and to utilise this technology to read oxygen levels?---No, it’s not difficult to read, but you need to use what the clinical significance of it is.
PN3146
Is your evidence that that’s particularly difficult of speech pathologists?---I’m not saying it’s difficult but you need to be up with the evidence base, so you need to be abreast of the evidence that is emerging. It is an area that has got a lot of evidence emerging, so you need to be keeping yourself up to date with that.
PN3147
So provided you are taught to read oxygen levels and the effect of that that’s how it impacts on speech pathology?---Yes.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3148
SENIOR DEPUTY PRESIDENT LACY: How long does it take to learn the skill of reading?---Well it’s not a difficult – I mean when you work a trachyostomy and physios used to always have the use to pulse oximeter therma cells to when you are deflating a cuff you’d be keeping an eye on it. So it’s not something we’re not used to, but we’re using it in a different way to actually to understand when someone is eating or drinking what are the changes then. It’s not hard to read it, it’s just a little meter that just shows a decline, but you’ve got to make sure that the patient is stable, you’ve got them at a resting stable rate, some patients are not stable, especially if they’ve got respiratory disorders, so you need to make sure that it’s an appropriate tool for what you’re trying to measure. That you can get a stable reading, and then when they are eating and drinking, I think it’s at plus or minus 2 drop, so it’s easy enough to read. But - - -
PN3149
DEPUTY PRESIDENT IVES: So how do you interpret the variations, so you read them, you get some variations, how do you interpret those?---Well the evidence is coming through that a drop of minus 2 may, not does, may indicate that the patient is aspirating. So it’s just another tool that we can use at the bedside that we can say well maybe they are aspirating we might have to take them to fluoro, but we might not be able to take them to fluoro, so we’d be looking at that information in combination with what is their test status, are they spiking temperatures, what are the medical staff reporting, how are they having chest x-rays that are looking a little bit like they are getting some consolidation. It is a tool in a raft of things.
PN3150
SENIOR DEPUTY PRESIDENT LACY: But as I understand your evidence it’s only recently been introduced as a tool for speech therapists?---For swallowing yes, for assessing swallowing in a food and drink or so.
PN3151
When you say recently, how long ago? ---We only purchased one last year and it’s probably really only been used in the last two to three years.
PN3152
How long did it take you to learn how to read the not how to read it, or how to interpret the changes in readings?---Well I read a few articles, I don’t know, articles, a few hours I suppose.
PN3153
Okay, thanks.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3154
MS SIEMENSMA: You also comment on cervical auscultation?---Auscultation, yes.
PN3155
This is used as an adjunct bedside swallowing assessments, it’s something I suggest that’s been around for 10 years at least in speech pathology?---In swallowing. When I first started practising it wasn’t wide spread at all. I started using it in let me think when – maybe 2000, 2001 but it wasn’t wide spread at that time but it’s becoming a lot more so.
PN3156
So your evidence is that it was around 10 or more years ago, but it’s becoming more wide spread?---Not 10 or more, when did I say 2000, yes, so yes, but I don’t know when it started, I don’t know when it started, but it’s reasonably recent that it’s becoming more wide spread.
PN3157
So if Michelle Kotis gave evidence that it’s been around for 10 years or so, and it is something that is becoming more wide spread, that’s something you couldn’t disagree with?---No, I wouldn’t disagree with that.
PN3158
The electrical stimulation you also speak about neuromuscular electrical stimulation that is something quite controversial in speech
pathology isn’t
it?---Yes, well controversially it hasn’t got a strong evidence base, so it’s with caution.
PN3159
No and it’s not something that is widely used by speech pathologists?---No, not yet, but it is being used.
PN3160
I think one of your attachment 5 is a working paper on NMES?---Yes.
PN3161
I note at page 3 it says:
PN3162
There continues to be discrepancies and inconsistency in the literature regarding the effectiveness and safety of NMES in the treatment dysphagia.
PN3163
That’s under current literature, something you agree with?---Yes.
PN3164
Over the page on page 4, the second paragraph:
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3165
There is another body of literature that suggests NMES is not effective in swallowing rehabilitation and indeed has adverse affects on swallowed function.
PN3166
You accept that that’s part of the discussion at the moment about NMES?---It is indeed and that’s why the position paper states that if a speech pathologist is going to use it that they are obliged to contribute to the literature on it because it is not, the jury is not out so to speak.
PN3167
It’s not widely used it’s still - - -?---But it’s developing because of the safety issues, the development of this position paper was generated by the clinicians who heard about it, and we were concerned that people would be using it and the potential for patient safety. So we started a working party and then this was the outcome of that working party so that the professional association could have apposition on it so that speech pathologists wouldn’t be going out and using it indiscriminately and potentially putting patients at risk.
PN3168
DEPUTY PRESIDENT IVES: Just on that subject, do you or your department have any involvement in randomised trials for that sort of thing so you can establish some evidence base for it?---We haven’t but I know that at Melbourne Health they were successful in getting a small grant from the professional association to do a trial. But they were having to go through ethics to get that approved and I’m not sure that they’ve started yet, certainly Melbourne Health are going down that track.
PN3169
MS SIEMENSMA: You also comment on speaking valves used with tracheotomies these have been used for a very long time for more than a decade haven’t they?---Not in my experience and certainly when I came to Southern Health they were not used widely at all. At Dandenong Hospital or even at Monash Medical Centre and they’ve got quite a large ICU there, so they’re pretty standard now, but that’s really come into play over the last five years.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3170
Michelle Kotis will say that the use of speaking valves was around even when she was training in the 1980’s and she will say that any development in them is really in the quality, the fact that they are more durable and they give rise to less infection?---I’m pretty sure the ventilator valves were not around back when Michelle Kotis was training. There are two types of valves, there are lots of different types of valves, but there are valves you use when the patient is on the ventilator and ones you use off the ventilator, and I don’t think that the ventilator valves were around when that long ago. Certainly they haven’t been very widely used until more recently.
PN3171
Michelle Kotis her instructions weren’t with in relation to ventilator valves, I take it you disagree that they were around in the 1980’s the speaking valves for tracheotomies, or is it that you just don’t know?---No, no there have been valves around but I’m not sure when the particular Passy-Muir one was actually developed by a patient in the States who wanted to be able to talk, because he had a permanent trachyostomy and he wanted to be able to talk and he’s the one actually who developed the valve in the very first place and the Passy-Muir which is the valve that we use is his – it’s his sort of valve it’s evolved in it’s ability to the resistance to air when you’re breathing and stuff like that, it’s evolved in terms of it’s function over time. But it’s the only one way speaking valve in existence because he patented it very early. But they might have been around but they weren’t used very often and in those days they used to cork tracheostomies where they used to put a cork – I mean what a valve does is it allows the patient to breath in through the trachy while they’ve got a valve there that then will cut off the air and let the air move up through the larynx so they can speak. You’ve got to have a – there’s a cup on the trachy too that’s got to be deflated so the air can go up and so the patient can speak. The Passy-Muir is one way in that the patient’s breath normalises. With a cork they can’t breathe in through there so it’s like sticking your finger in it, and they have to breathe through their trachyea with this obstruction in the way. they have to breathe in and out through their mouth passed this obstruction so the beauty of the speaking valve is that they can breathe in through here and then it goes up in the normal way and it helps to normalise the swallowing process and the valving – there are what they call barrow resectors or air resectors in the throat and in the larynx itself, so having a normal air flow through there can actually enhance swallowing can actually normalise vocal performance, the voice performance because the vocal chords atrophy if you are not getting air and you are not using them. So it’s a therapeutic tool, we’re really using it. And the evidence has really been coming out a lot more strongly on the use of these valves for not just speaking perhaps when Michelle in training they would have thought that it was a touchy feely thing that speech is just wanting people to talk. It’s now actually being used as a therapeutic tool to assist people to get the trachy out because we’re finding that normalisation of the airway improves the muscle function, improves the swallowing, improves the breathing ability to cough and to clear and it actually is helping weane people from the trachy and get it out.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3172
So there were speaking valves many years ago and your evidence is they are better quality?---Much better quality.
PN3173
Okay all of these tools that you discuss in paragraph 29 these diagnostic tools I suggest that a change, the skills that you need to clinically interpret as a speech pathologist they just help you target your therapy?---Can you say that again?
PN3174
They don’t’ change these tools do not change the fact that you have to interpret what the problem is, what the swallowing problem is they help you target your therapy?---And to diagnose what the problem is and where the breakdown in swallow is occurring, yes.
PN3175
You say in paragraph 40 that speech pathologists are the primary clinicians in the management of people with dysphagia?---Yes.
PN3176
That’s always been the case?---Yes.
PN3177
Paragraph 33 you talk about chronic obstructive airways disease?---Yes.
PN3178
That’s essentially a lung disease in the airways?---Mm.
PN3179
It’s caused by smoking isn’t it?---It can be one of the main causes, yes.
PN3180
That disease has been around for many years?---Yes, it’s gone under a lot of different names, used to be called emphysema, it used to called – it’s called COPD now, it was called other things, it’s got a lot of different names.
PN3181
COMMISSIONER LEWIN: Why is that?---I think in the medical terminology we got more specific, so I don’t know what emphysema actually stood for, but they realise that it’s not just the lungs or this area, it’s the whole airways system.
PN3182
So does it denote a more detailed description of the disease?---Yes, I think so and probably a more accurate description of the disease.
PN3183
So it sort of unpacks all of the different factors, descriptively?---Yes.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3184
MS SIEMENSMA: So in dealing with chronic obstructive airways disease you as a speech pathologist use your skills as part of a multi disciplinary team to treat the condition?---Yes.
PN3185
It’s not that it is a new condition, it’s just that you’re involved in treating that particular disease?---Yes, we’re involved in treating it because speech pathologists were obviously getting referrals and then started to develop an evidence base around well what is it about COPD that is impacting on communication and swallowing. So that’s another area that the evidence is really starting to build up and we’re being recognised as having a role. I mean you can still find Doctors in the hospital who don’t know that speech pathologist works with these people and that they ought to refer someone with COPD to a speech pathologist so there’s a large component of educating our colleagues that the evidence suggests that these people have you know quite significant swallowing problems and that we ought to be involved with them.
PN3186
Just going back very quickly to paragraph 29 the various tools that you refer to in paragraph 29 they are now taught in theory at the base tertiary level in university?---I don’t believe FEES is taught it might talk about it, that it’s another tool, but there is certainly not – it’s an advanced practise skill.
PN3187
Do you know that for a fact or are you just guessing?---I know that for a fact, there’s a FEES position paper appended to my statement will tell you its’ an advanced practice skill.
PN3188
Yes, but do you know for a fact that it is not studied as part of the tertiary degree?---I’m pretty sure about that.
PN3189
But you don’t know?---I - - -
PN3190
COMMISSIONER LEWIN: Is it asserted that it is?
PN3191
MS SIEMENSMA: On my instructions, yes.
PN3192
COMMISSIONER LEWIN: Right so you’re bringing evidence to that?---That FEES is taught in the undergraduate university degree.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3193
MS SIEMENSMA: Those are my instructions.
PN3194
COMMISSIONER LEWIN: Are you able to say since when?
PN3195
MS SIEMENSMA: Not at this stage?---I’m really, really surprised by that and certainly I would be interested to know more about that.
PN3196
In terms of going back to paragraph 36 and the area where you talk about technological change as a professional you are expected to keep up with clinical advances and keep pace with changing practises in your field don’t you?---Yes.
PN3197
And that's true not only for speech pathologists but presumably for all allied health professionals?---Yes.
PN3198
You refer in paragraph 37 onwards to various programs. At paragraph 38 you talk about a program that involves a person in the team being appointed the key contact person for dealing with the family?---Yes.
PN3199
This is the KLP?---Yes.
PN3200
Andrew Day, in paragraph 31, has spoken about the difficulties of dealing with the family. I might take you to paragraph 31 of Mr Day's statement?---Yes.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3201
He speaks about the fact halfway down that it makes the overall treatment more time consuming, that it's added a counselling role for staff, a lot of time being spent explaining the treatment process and advising and instructing family and carers. Presumably appointing someone as the key liaison person assists in reducing, sort of double handling the queries and to free up the time of the other people on the team to get on with what they're supposed to be doing?---You would still deal with the family with regard to your area of expertise so you would still be doing a lot of educational and effective counselling there with family members, that doesn't change. What the KLP role does, it's a whole - we've got a whole web based education program on how to be a KLP and what the roles of the KLP are, what the roles are not, you know, they're still - it's very clear about the disciplines for staff and you're dealing with that. But this is an additional new role that is part of this new model that is really involved. You have forms you have to fill in, you've got to go to the patient within 24 hours of them arriving and you need to talk to them about what are their goals. And when we say goals to patients they think that that's jargon, so we have to frame it in a way that makes sense, you know, what are you wanting to achieve from your stay in rehabilitation, what can't you do now that you'd like to do by the time you go home. So you have to have this interview with the patient and the family if the patient can't - you have to write down these team goals, the patient's goals, and then you take it to the team meeting, and then the staff have filled out issue sheet in the file and then you talk about that and you create team goals so that the patient's goals meld with the team goals to get them to where they want to go by the time they leave. After the team meeting, the case conference, you have to go back and feed back to the patient in non jargonistic, user friendly language what was the team's outcome from that meeting. So there are additional duties that are required and that the project manager who runs this project has quantified that it's at least an additional one and a half hours per week per KLP role and, you know, those of us who have done that role find that, you know, that's light on. Sometimes it can be more than that. So a full time person is supposed to be KLP for two people, and some of us find that you end up doing more than that.
PN3202
Can I suggest that appointing somebody a KLP in fact saves time? There's an up front commitment and up front work, but at the end of the day it reduces the time spent with patients on an individual basis?---It doesn't reduce the time at all, and the model is not about reducing time. The model is about patient centred care, it's about making sure that what we're doing has the patient front and centre so we're not deciding what they want. So it's giving that patient the voice to have real input into their care and what the team do in their treatment plan.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3203
And if the speech pathologist is not appointed the KLP but somebody else in the team is, that must save some time in dealing with patient queries because to an extent they will now go through the KLP for the most part?---Well, the KLP would talk about, you know, these are your communication goals that we discussed in the meeting. But to actually unpack those goals and explain them the speech pathologist still needs to spend the time with the family and the patient explaining and working out what that is, so it doesn't really reduce the time at all. The KLP role is a team liaison person, it's about helping the team meet the patient's needs. It doesn't take away from what we do in our other roles.
PN3204
SENIOR DEPUTY PRESIDENT LACY: Sorry, can I just ask a question? Do you not have any objective of trying to provide these services in a more timely basis or to reduce the time in which you provide them?---My understanding of the model and the way it's been presented to us and it's been researched is not that it's not - it's actually they expect - in fact there's a document from the DHS that says patient centred care is more time - takes more time. There's an admission that it takes more time. It's not something that is designed to make things faster. Actually having that conversation with patients and getting their views and their goals, it's a time factor.
PN3205
I thought you said earlier in your evidence that time is the way in which you measure complexity of your task, is that right?---That's with regard to, yes, a particular patient, yes, and rating a patient. It's a bit like a rating system. But I'm talking about - I suppose what I'm trying to say is I'm talking about this model of care is not generated from speech pathology, it's generated from the rehab model of care that's designed - has been created by our organisation, and the objective of that is to decide patient focus care.
PN3206
COMMISSIONER LEWIN: It's sort of like customising the therapy to meet preferred outcomes that are capable of being achieved?---Yes.
PN3207
I think Harley Davidson did that sort of thing with motorcycles. You don't necessarily always get the same one?---Well, I think there's been a lot of criticism of health professionals over the years, that people talk at them, tell them what they want, what they need, without actually getting the patient's perspective.
PN3208
So you get a one size fits all prescribed model of care rather than a customised model of care which is patient centred?---That's right.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3209
MS SIEMENSMA: And despite the fact that if you are not the KLP on the team you might still have to deal with queries, most of them would still go through the KLP person?---The queries that would go through the KLP person might be about discharge, when you're going home, that sort of thing, but you would still deal with the explanation about - so if a patient had aphasia, as an example, that you were trying to talk to the patient about and the family about how to communicate with that patient, what method worked, what's their level of comprehension, you still need to do that discussion with the family and the patient. That's not something that the KLP - the KLP is a different role. The role is a link about the hospital stay and what the general goals are, but the specific treatment stuff you're still dealing one on one.
PN3210
In the past though you might have had to deal with queries about discharge and hospital stay, queries that now go to the KLP instead of you?---Well, I don't know. I mean, the people who may have handled all of those sort of queries, you know, patients might ask a number of different people, and until we have a case conference and a team meeting and make a decision you might not be able to answer it. But we have two of those a week now. So it's just a little bit more focused.
PN3211
In paragraph 41 you talk about paediatric models, and this is something that you've relied on?---Yes, that's right.
PN3212
At the bottom of that paragraph it says "Speech pathologists now provide services to much younger children and have an increased
focus on prevention, provision of home based services and provision of community development." These sorts of programs presumably
reduce problems later down the track, the prevention focus?
---Yes.
PN3213
And so in that way they might work to divert the - if they've lost a leader in a way they might divert the would be patient because you now prevent them coming to you?---Well, given the figures that the Western Health paediatric referral service, you know, that they've been receiving has gone escalating through the roof, I don't know.
PN3214
And this is the reference to the complexity and the people at the centres that you would - - -?---That's right, that she told me.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3215
That was the measure based on time?---No, that's in my department, the measure based on time, that's not in that. I don't know how she rated that 50 per cent complexity.
PN3216
In paragraph 44 onwards you talk about professional development. Part of being a professional involves the need to read and keep abreast of developments in clinical practice, reading and writing, do you accept that?---Yes.
PN3217
And it's not true to say that all staff have to do work in their own time is it?
---Well, they do, but whether they have to. They feel professional compulsion to do that because there's not enough time in the
work day.
PN3218
So they're not directed to, they choose to?---They're not directed to.
PN3219
Michelle Kotis will say that the number of supports given by health services to assist speech pathologists to undertake research and to further their professional development, and she'll say that at Eastern for instance there's a research program for allied health to allow them to undertake post graduate studies and perform research, and under that scheme the staff are released from their normal duties and they participate in a formal education session and have a senior clinician as a supervisor to assist them. Is that something that you know about?---No, it's not.
PN3220
Other health services like Northern Health, they offer financial grants to allied health to undertake research programs?---There's a DHS program that I believe was - that you can get some four hours a week, but there's very limited number of places, but it's not a health service based program.
PN3221
There's also provision for study leave in the industrial instrument?---Yes, but it's not that field.
PN3222
You speak in paragraph 51 about a variety of training programs, everything from fire training to manual handling, falls prevention. This is standard training for allied health professionals isn't it?---No. Falls prevention, there's been a lot of - I mean, I think in the past physios might have done it, but there's been a whole proliferation of these sorts of things that are now rolled out to everybody, and the basic life support, which is like a CPR, was only introduced to the whole of allied health to have to do it as well in Southern Health in about 2003 or around about then. So we didn't always have to do that. We certainly didn't have to do - these programs are formalised web based packages that take, I don't know, maybe 30 minutes to do, and you have to do them on the web so then they can take account that you've done them, and then the manager gets a report every month to say who's done what, and then you get red marks if you haven't had your staff do it. So there's a lot more of them. When I first started in the health system we did fire training and that was it, and now we've got - every month there's a calendar that we have to do a different one.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3223
And this you refer to as annual training?---Yes, mandatory annual.
PN3224
And these are things that obviously help you do your job, things like the manual handling, life support training, and these are things that help you in your day to day work?---Well, basic life support - - -
PN3225
Well, let's take manual handling and life support training?---Yes, they do. They do. And then that program is tailored for our particular circumstances. So we get the physios who train us in that to help us with manoeuvring a patient in the bed, donning of fluoro jacket, that sort of stuff.
PN3226
At paragraph 52 you talk about students?---Yes.
PN3227
And it's always been the case that the hospital's speech pathology takes students as part of the training?---It's not mandatory, and now community college don't take students at all. It's really - it's encouraged but it's something that the department makes a decision to do. We see it as a professional responsibility to help train up, but it's certainly not compulsory.
PN3228
And it's something that you've always done, take students?---I personally have but not all speech pathologists do.
PN3229
And presumably that helps you develop skills in teaching and training?---Well, it's interesting you say that, because I think we would be really greatly assisted by having some formalised training in how to supervise students because we're sort of thrown into it when we - you know, one minute we're a student, the next minute we're supervising students, and it's a particular skill, and being able to separate and to be objective and those sorts of things would be really - and that could be adopted, a clinical educator, it would be great.
PN3230
In the EBA a speech pathologist grade 2, part of their classification involves supervision of speech pathology students?---Yes.
PN3231
That forms part of the grade 2 speech pathologist's role?---In the award?
PN3232
Yes?---That they can take?
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3233
They can in the EBA?---In the EBA, yes, they do.
PN3234
DEPUTY PRESIDENT IVES: Does a student have to do a certain number of hours with a clinician to get their degree in the first place, is that correct?---Yes. There's different - at different year levels there's different clinics, we call them clinics, a certain number of hours, depending on the type of that clinic. So they need to - but it's not only the hours that they need to do. There's a very complex tool of competency that they have to achieve in order to pass, yes.
PN3235
MS SIEMENSMA: And presumably training of students, this assists - the more students you take, the more students you train, a bit of quality speech pathology will filter through over the years?---One would hope so. But training of students take a lot of extra time. It's a huge burden on a department to take a student. It slows down the functioning of the department and we don't get extra EFT to help us do that, so it's a bit of a love job really.
PN3236
You refer in the second last part of your statement to the structure and disadvantages of not having achieved at each start. You don't suggest for instance at places like the Williamstown Hospital which has one EFT in speech pathology that they need a chief?---I used to work at the Williamstown Hospital, and there are - I would think that they could use a chief.
PN3237
With one EFT?---Yes.
PN3238
What, that person would become a chief, would they?---Well, they may have a clinical - the chief might have a clinical role as well but - - -
PN3239
They have got no one to supervise though with one EFT?---If they were a supervisor themselves? A manager doesn't - the supervision - the manager doesn't clinically supervise. It's clinical supervision which is different from staff supervision.
PN3240
No. But with one EFT surely that's warranted - - -?---One EFT may be more than one person because in speech pathology there's a lot of part time staff. When I was at Williamstown the position was point 8 EFT, and I used to work across the campus somewhere else. But I don't saying one EFT is necessarily going to be one person.
PN3241
No, I accept that. But it's not a sufficient number of staff I suggest to warrant a chief at that site. Even if you made one person the chief the remainder of that one EFT is not sufficient to justify a chief at that site?---That's if you consider that the chief role is just about staff management. The chief role is broader than staff management, and there are a lot of site based issues that could be addressed and that chief could represent speech pathology or allied health on committees and other things in helping to develop models of care and that sort of thing. We do a lot of work that's not actually about the staff that we're responsible for.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3242
In the last part of your statement you talk about retention and issues of attrition?
---Yes.
PN3243
And you say that there's a recognised shortage of speech pathologists?---Yes.
PN3244
You in fact attach an article to your statement, the last attachment, and that is a survey that was conducted hand in hand with Speech Pathology Australia, the association?---It was done by the University of Sydney, and I know Speech Pathology was a - I think it's a sponsor or - I can't think of the exact terminology.
PN3245
I think it's referred to in the article as an industry partner?---Industry partner, but it was done by the University of Sydney, yes.
PN3246
And that article refers to having received 18 responses from speech pathologists throughout Australia?---Yes.
PN3247
And we don't know from the people who responded and the subject of that particular research whether they were people who worked in hospitals or private or public hospitals, whether they worked in schools, whether they worked in kindergarten?---I believe the article they claim that the numbers that they received was representative of the - the distribution was representative of the profession.
PN3248
I think they say that the respondents were from across Australia, but they certainly haven't broken it down into where these people worked, whether they were in rural places, whether they were in metropolitan, whether they worked in private, public health, kindergarten?---I don't know if speech is working in kindergartens. That could be a new area. I read it again last night and my understanding is that they claim that the sample was representative of the spread of speech pathologists, but I can't find that right now.
PN3249
Well, under summary it says "Most investigations of this issue have been conducted on small samples from limited geographical and professional context, thus restricting the generalisability of their findings." And I think that is a problem that they complain about in this paper?---Yes. Look, it's a smaller sample size but it's a qualitative study rather than a quantitative study.
PN3250
Early this morning you were talking about an increase in referrals, and I think you said there'd been a 13 per cent increase with no increase in EFT?---That's right.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3251
And then later in your evidence you said that your own department had, I think, 12 staff members and they've now got 15?---Yes. I can explain that. Our weekend service, we had a staff member who worked part time during the week and then did the weekend as well, and that really wasn't sustainable, she didn't want to stay in that position. So we changed the weekend service to a job share arrangement. So it's the same EFT, I've just got different staff, because no one wants to work every weekend. So in order to retain and attract staff I had to add five people to the service. So it's the same EFT with five people rostered on doing it, and some of those people work in the department as well, so that's why it's only an increase of three rather than five. But yes, it's a job share arrangement for the weekend service.
PN3252
You said that people had left, I think five people had left, left the profession but not left - - -?---There's more that have left the service but they've gone to other jobs, but left the profession.
PN3253
COMMISSIONER LEWIN: Sorry, could I just ask you, I'm assuming therefore for the purpose of your evidence that those who have left the department and gone to other jobs have remained in the profession?---Of I'm aware. I don't know. I don't always keep - - -
PN3254
So your evidence is given about you're only referring to people who you know have left the profession?---Yes.
PN3255
MS SIEMENSMA: And that was the inquiry I was going to make, Commissioner. I have no further questions. May I tender the statement of Andrew Day?
SENIOR DEPUTY PRESIDENT LACY: Yes.
EXHIBIT #R12 STATEMENT OF ANDREW DAY DATED 15/09/1999
PN3257
SENIOR DEPUTY PRESIDENT LACY: Thank you Ms Siemensma. Mr Langmead, I just wanted to ask a question.
**** MICHELLE THERESE O'ROURKE XXN MS SIEMENSMA
PN3258
When you were being asked a question about the need for a chief where you've got one EFT you said we do a lot of work that is not with our own staff. What sort of work is that? Is that the meetings and things like that that you've referred to earlier in your evidence?---Yes, to a large part.
PN3259
Well, what drives that? Is that something you volunteer for or is it a requirement of your job?---It's becoming - yes, the leadership group definitely is a requirement. We were told - we were given a job description, a role description around that, and we weren't really happy at having to take on that additional work, but we were told you will do it. And then they took our job descriptions and they said that they were going to re-write the job descriptions to include that leadership group in the job description, but they haven't brought that back to us yet. But we were certainly told that we had to do that and occasionally you'll be tapped on the shoulder and told that they want you to represent at a meeting. This latest one that I was asked to go to, I got an email at quarter to four to say you have to attend this meeting at 9.30 in the morning. And it's not really expected that you say, well, I am not going. So there are a lot of things that we're asked to do, and we're complaining. The allied health - I've been an allied health manager in this kind of team for a year, I've only been there for a year, but there are colleagues in my team who have been there for a long time and they're all really straining under the work load at the moment because these demands are just getting greater and greater. And my colleagues, some of them have been a manager for 20 years, they're saying that they've never felt more pressure than they do, and the workload, that they're not coping with at the moment.
PN3260
Thank you. Anything arising out of that Ms Siemensma?
PN3261
MS SIEMENSMA: No, your Honour.
PN3262
SENIOR DEPUTY PRESIDENT LACY: Thank you. Yes, Mr Langmead, any re-examination?
MR LANGMEAD: Yes, thank you, your Honour.
<RE-EXAMINATION BY MR LANGMEAD [3.24PM]
PN3264
MR LANGMEAD: Ms O'Rourke, when you were a grade 2 did you have to attend any of those sort of meetings that you've just described?---Yes. When I was at Dandenong my manager was based at Clayton and she asked me to attend the allied health managers meeting, so I attended those meetings with the managers.
**** MICHELLE THERESE O'ROURKE RXN MR LANDMEAD
PN3265
You were asked about membership of the association, and I think you said you have to be a member?---No, you have to be eligible for membership.
PN3266
You have to be eligible, I see. Now, you were also asked about your paragraph 22, and just to clarify things can you explain again what the increase in acuity of people within the hospitals means?---So it's around - the patients when they're coming, say in sub acute services, they're coming earlier from acute because they're being discharged earlier and so they're a bit sicker. Acuity just means sickness.
PN3267
Okay, thank you. And the increase in the medical complexity?---Yes. So that's a lot of more co-morbidities that are impacting on the patients.
PN3268
You were asked about Mr Day's statement, and he speaks of a reduction in an average length of stay in Victorian hospitals at that time. Do you know whether there's been any reduction in the average length of stay since 1999?---Yes, there has. I think it's continuing to drop. I think your hospitals report from the DHS indicates that it's continuing to drop.
PN3269
Yes, thank you. And in relation to throughput targets do throughput targets and achieving those require you to have a skill of prioritising patients?---Yes, they do.
PN3270
Is that the only skill required for achieving targets?---Well, it's really - I mean, it's the team that achieves the targets together, so one, you have to balance the different factors as to why that patient can or can't go home, why they are safe or not safe to go home. So there might be a speech pathology reason because they're not able to eat and drink safely, or it might be an OT reason, that their rails are not installed. So you need to be really aware of the whole team issues in order to be able to, as a team decide, because we decide that as a team. It's not one person saying that person is now at the door. We decide that as a team.
PN3271
Thank you, your Honour.
SENIOR DEPUTY PRESIDENT LACY: Thank you Mr Langmead. Thank you for your evidence Ms O'Rourke.
<THE WITNESS WITHDREW [3.28PM]
PN3273
SENIOR DEPUTY PRESIDENT LACY: Yes, Mr Langmead?
PN3274
MR LANGMEAD: The next witness is Ms Giles, who I think somebody has just gone out to get her now.
PN3275
DEPUTY PRESIDENT IVES: Sorry, perhaps I can raise something while we're waiting Mr Langmead. One of the things that seems to be coming out of this evidence, or the main thing in fact to me at least, is that the witnesses when they're faced with the material from the previous matter before the Commission seem to be saying two things. One, that there's an increase - let me put it another way - a greater quantitative intensity in the circumstances that they now face and a greater complexity in the technology that they're required to put into practice. There doesn't seem to be beyond that a great deal that they've been able to single out as being something new that's happened since then except to the extent that it's a greater intensity or more technologically complex. Is that the point that you're trying to make Mr Langmead, or is there a point beyond that?
PN3276
MR LANGMEAD: Well, can I say two things, your Honour? One is that yes, it is the point, but secondly, that may be the case in respect of those paragraphs to which they are able to draw the comparisons. There are many other instances where the previous statements don't deal with things at all, and so we can say it's a combination of those two factors.
PN3277
DEPUTY PRESIDENT IVES: So you say that beyhond that there are totally new functions that are not simply a greater quantitative intensity or simply a greater complexity of technology? There are things that have come in in that period that weren't there before at all?
PN3278
MR LANGMEAD: Yes.
PN3279
DEPUTY PRESIDENT IVES: Okay, thank you.
PN3280
MR LANGMEAD: And in due course, your Honour, we'll point those out to the Commission.
PN3281
DEPUTY PRESIDENT IVES: Yes, thank you.
SENIOR DEPUTY PRESIDENT IVES: We have Ms Giles. We haven't sworn her yet or affirmed her.
<SUSANNE GILES, AFFIRMED [3.32PM]
<EXAMINATION-IN-CHIEF BY MR LANGMEAD
PN3283
MR LANGMEAD: Ms Giles, could you state your name and address for the transcript please?---Susanne Giles (address supplied).
PN3284
And what's your occupation?---I'm an occupational therapist working as an allied health manager in Western Health.
PN3285
Have you caused to have made a statement for use in these proceedings?---Yes.
PN3286
Do you have a copy of that?---Yes.
PN3287
And is it dated 20 August and signed by you?---That's right.
PN3288
Yes, I tender that. I'm sorry, I should have asked you is it true and correct?---It is.
Yes, I tender that.
EXHIBIT #A20 STATEMENT OF SUSANNE GILES DATED 20/08/2008
PN3290
MR LANGMEAD: Ms Giles, you're the chief of OT at Western? You have to speak?---Yes, I am, yes.
PN3291
Thank you. And in paragraph 5 you have identified that you're the Vice President of Occupational Therapy Australia, Victoria, and you say that you're the Chair of OTA Vic Workforce and Professional Issues Committee. What does that committee do?---That committee is a sub committee of the board of OTA Vic which brings together representatives from all of the major health services in Victoria, rural and metropolitan, occupational therapy managers, to identify and address issues related to workforce and traditional issues, so things like this current EBA negotiation. The group prepared a response to the EBA articulating our concerns. It might also cover other professional issues such as credentialing and that kind of thing.
PN3292
How many people are on this committee?---Six.
**** SUSANNE GILES XN MR LANDMEAD
PN3293
And did you discuss your witness statement with those members of that committee?---Yes, I did. Yesterday we had a meeting, and in preparation for this hearing I requested their permission to represent their views to the Commission, which are a lot of the things that are mentioned in my witness report.
PN3294
And could you tell the Commission which health services that those people represent?---Yes. They're the managers of the Alfred, which is I think based - Southern Health sub acute, the Austin Hospital, the Dandenong Hospital which is part of Southern Health, and Monash which is part of Southern Health, and the Melbourne Health occupational therapy manager.
PN3295
Thank you. Now, if I can take you to paragraph 10 of your statement?---Yes.
PN3296
In addition to the director of nursing and the executive director that you've identified are there any other nursing managers?---There are directors of - there are nurse unit managers for each of the wards in the three hospitals of the health service, and a variety of assistant nursing managers.
PN3297
Could you tell the Commission in brief terms what it is that an OT does?---That an OT does?
PN3298
Yes?---Occupational therapists, very briefly, assess an individual's occupations in the domains of personal care, domestic work, leisure and spiritual kind of aspects of their life with a major role in optimising that person's function to return to their lives, which includes their home and their work and everything, if that's appropriate, as best they can and as independently as possible.
PN3299
Now, as I understand it there are five streams within your occupational therapy department?---Yes.
PN3300
Can you tell the Commission what those streams are?---Yes. The way we identified those streams for occupational therapy, which is not the same necessarily for the other allied health disciplines, is that we have acute, aged care, rehabilitation, paediatrics and plastics and hand therapy.
PN3301
Now, do you have any grade 4s in those streams?---We don't. We do not. We have no grade 4s in any allied health area in the health service.
**** SUSANNE GILES XN MR LANDMEAD
PN3302
Do you think there's any need for grade 4s?---Definitely.
PN3303
How many would you say you need?---In my own area I would need four, one for each stream except for the plastics stream, which I think could be covered through the acute cohort.
PN3304
And why do you need grade 4s in those streams?---I think that one of the main reasons we need grade 4s is in relation to the clinical education and actually clinical competence type of aspects of our service. I think we need to remember that everything we're doing today and any other time around these things is hopefully related to providing the very best possible service to our patients that sit in the beds and wherever around the place, and from an allied health perspective and from an OT perspective in this case we can't do that without actually making sure that every single person that's laying a hand on that patient is doing that in the best most efficacious kind of way. So we can't do that unless we can pay attention to educating all of those staff properly into what they need to be doing, making sure it's the most best evidence based practice that can be done, and having a lot of systems in place to ensure all along the way that the education is in place, that the supervision is in place and that all of those other mechanisms to make sure that that person is operating appropriately. And at the moment without grade 4 staff or enough grade 3 staff for that matter it is difficult to deliver that.
PN3305
Now, how do you cope without grade 4 staff?---The grade 3 staff tend to take on aspects of what are listed as a grade 4 role in the current EBA in regards to clinical education and so on, and a lot of the work that needs to be done, particularly around research and credentialing and so on, just doesn't happen.
PN3306
Why don't you have grade 4s?---Because the health service just cannot afford them, full stop, no money.
PN3307
DEPUTY PRESIDENT IVES: Ms Giles, do you deal with psychologically or psychiatrically impaired people as well?---No, not - no. That's a separate - it's separately run through Melbourne Health Service.
PN3308
But it's still occupational therapy?---Occupational therapists work extensively in psychiatry, and I've had some clinical experience many years ago as an OT working in psychiatry and I have links with services but I don't manage them.
**** SUSANNE GILES XN MR LANDMEAD
PN3309
MR LANGMEAD: In paragraph 13 you refer to evidence based standards. Firstly, has there been any changes in the reliance on evidence based standards in, say the last five years?---Yes, indeed. I think that with the rise of, you know, the term that you'll hear a lot around clinical governance and management of clinical risk and those kind of things, evidence based practice as a term has burgeoned to be very pivotal to any system or whatever in a health service or anywhere else for that matter. So it's certainly the word on everyone's lips. In fact in our own health service with Western Health, provision of evidence based practice and up to date research and that kind of thing is a really pivotal part of the strategic plan for the organisation and is a subject, I might add, of a lot of capital funding from DHS for a research precinct. So it's a really big ticket item.
PN3310
Now, as well as a need for grade 4s, they're clinical positions are they?---Yes.
PN3311
Yes. Do you see any need for a dedicated clinical education role?---Yes, very much so, linked into the things I just said before, that if we could have a clinical educator, at least one clinical educator for each discipline in allied health we could then have someone who could be selected for skill and experience in that area who could be then deployed to pay attention just to those kind of aspects of the work rather than having to fit that in around all of the other bits and pieces they do at the moment, which is how we manage it.
PN3312
Now, in relation to the profile of patients coming into the hospital has there been changes there that you've noticed, say in the last five years?---Over the last five years I would say - and it's mostly anecdotal, I think everyone would be saying it - that the patients who get into hospitals are usually much sicker, often older, have far more what we call co-morbidities related to their admission. So for example someone might come in with a very simple condition seemingly, like having a urinary tract infection or something like that, which attracts not a very big wait for money for the health service, but from an allied health perspective when we examine them we might find that they've got a very old frail carer, that they have got a lot of other things wrong with them like diabetes or heart disease or arthritis or whatever, whatever, they might be dementing, et cetera, and their system at home is falling over, and they will then take a lot of resource to move through the system, particularly for allied health, so that puts an increased burden on allied health staff.
PN3313
COMMISSIONER LEWIN: When you say particularly for allied health?
---Because allied health are pivotal to discharge planning or discharge - not just planning, discharge of the patient. So for occupational
therapy for example we have a very major role in, as I said, assessing that person's overall functioning, in particular how things
are at home for them so that we can make sure that when they get out the door they're going to be able to stay there and not be re-admitted
back to the hospital.
**** SUSANNE GILES XN MR LANDMEAD
PN3314
All right, I understand that part, but I'm just trying to connect it with the occupational outcome?---Well, in terms - - -
PN3315
It's just a lack of understanding on my part?---Yes. In terms of the term occupations, a major occupation for most people is, for example, dressing yourself, right? So if someone comes into the hospital who - - -
PN3316
I didn't understand it that way?---Yes.
PN3317
That's what I'm trying to clarify. If you could appreciate we've got a bit of a sort of specialised perspective here, and occupations tend to have a work related connotation?---Yes. So for an occupational therapist they would define occupations around all of those things that someone has to do throughout - within their life on a day to day and a year to year basis to remain at home.
PN3318
So there's no particular focus on work?---No. But there could be with some patients, but most of our - - -
PN3319
Just part of the spectrum?---Yes. Most of it isn't about work, it's about all of those other things, and particularly with these patients we're talking about.
PN3320
MR LANGMEAD: Commissioner, I believe the Minister recently had some confusion over the word occupation.
PN3321
COMMISSIONER LEWIN: What, the occupation of the Minister or - - -
PN3322
MR LANGMEAD: No, in her direction on award modernisation.
PN3323
COMMISSIONER LEWIN: Confusion about work.
PN3324
MR LANGMEAD: Ms Giles, do you conduct exit audits for staff who leave?
---Yes, I do.
**** SUSANNE GILES XN MR LANDMEAD
PN3325
And what do they give as explanations for leaving?---Variety, ranging from moving to other jobs, travelling overseas and things like that in regards to some of the younger therapists, to others will be leaving and many of the more senior staff will be leaving to gain employment at a higher rate of pay or classification elsewhere within the public sector or outside the public sector, so we tend to lose a lot of senior experience that way.
PN3326
COMMISSIONER LEWIN: What do they go and do?---They go on to maybe jobs in areas like DHS or other places as project managers or - - -
PN3327
Management positions?---Not necessarily management positions, but doing different kinds of work.
PN3328
Non therapeutic work?---Yes. Or some people will go to the private sector, you know, to take on jobs where they're going to get more money. Some people go to other health services where the higher classifications do exist.
PN3329
MR LANGMEAD: Could you tell the Commission what Health Power is and what it involves?---Health Power is the statistics program, computerised statistics program that collects work load information for all of the allied health staff in Western Health, and it's also used in Melbourne Health and Northern Health, so it's a very comprehensive system where people put in everything. They put in all of their work stats related to work with patients or with groups and things like that as well as the non clinical things like attending at meetings, going to PD or education sessions, that kind of thing. So it gives us a very good picture of the entirety of someone's work. So from that we've got some very good evidence about what people do.
PN3330
Does it enable you to work out how complex that work is?---Well, yes, insofar as it can tell us exactly what someone is doing ranging from particular interventions they might make with a patient through to some particular project or whatever they might be working on.
**** SUSANNE GILES XN MR LANDMEAD
PN3331
And are you able to make any comment about the complexity of work of OTs to, say five years ago?---A good question. I would say that probably for everybody over the last five years, and it's probably not just confined to allied health, but in this case that's what we're talking about, that there is much greater requirement for accountability. So people need to be being very accurate about how they put things in. When you look at what people are doing there is a greater expectation to be involved in things that are not so clearly clinical any more, so even people at a more junior level or particularly middle level like a grade 2 level staff will be having responsibility around maybe representing their discipline or their area, say at a program manager meeting around a particular - development of a particular clinical strategy, or they might be having to be part of the committee that looks for example at statistics per se for the health service, and data management and things like that. So there are a lot of different arms to what we do now that did not exist before or might have been confined more to different levels of staff before, and a lot of it linked in with the clinical governance stuff that I spoke about before too.
PN3332
DEPUTY PRESIDENT IVES: At a hospital level where are the lines of demarcation between the occupational therapists and the physiotherapists?---Well, I think - - -
**** SUSANNE GILES XN MR LANDMEAD
PN3333
I mean in respect of the patient where do you start and the physiotherapists stop, or vice versa?---Yes. It would probably be better to address that by thinking about a particular patient, but generally I think the answer is that each discipline, we work together quite closely, and so each discipline has got a very good idea about what they think their unique contribution to management of a patient is. So, for example, a physiotherapist, if we're working with someone like, I don't know, an elderly person that comes in with falls for example, the physiotherapist would probably be more concerned with looking at that person's mobility and transfers on and off things and managing steps and whether they need a gate aid, and what their balance is like, and a whole lot of things like that. Occupational therapists would be probably more concerned, as I said earlier, with how are they managing at home, who is there to support them and how are they managing, what kind of assistance do they need, are they managing to do their cooking, do they have to do that anyway, that sort of thing. Speech pathologists will obviously look at swallowing and those kind of things. Psychologists might look at whether they're competent to make decisions or whatever. So those kind of things. But having said that, there are always - and a social worker will look at the social situation and everything. But there's always some crossover in any team intervention around a patient, but I think the lines are pretty clear. I'm not sure what else you want to know about that.
PN3334
Well, I noted that you made some mention of hand therapy?---Hand therapy, yes.
PN3335
That's something that occupational therapists do? How does that differ from what a physiotherapist would do for example with hand?---In hand therapy, hand therapy is probably one of those areas where hand therapists are often physiotherapists or occupational therapists. In Western Health they are all occupational therapists and the role they do is often more acute, but the occupational therapists who work as hand therapists in Western Health would always be having in their mind and in their assessment of the patient that thing that we were talking about, about assessment of their occupations. So whilst they might be doing some very prescriptive work around, say managing swelling or lack of range of movement or something like that in somebody's hand, at the same time they will be wanting to know a lot about what that person is wanting to do with their hand and what they've done before, where they're going, that kind of thing, and they'll be addressing those things at the same time. But hand therapy is probably one of those areas where there is a lot of overlap in terms of the actual things that you would do at the acute stage.
**** SUSANNE GILES XN MR LANDMEAD
PN3336
MR LANGMEAD: Ms Giles, have you read the statement of Ms Cariss?---I've read it quite briefly, having only had access to it before.
PN3337
Yes. Insofar as she describes the work of occupational therapists, do you agree with what she says?---Yes.
PN3338
Yes, thank you. If you'd mind waiting there for somebody to ask you more questions.
SENIOR DEPUTY PRESIDENT LACY: Yes, Ms Siemensma?
<CROSS-EXAMINATION BY MS SIEMENSMA [3.53PM]
PN3340
MS SIEMENSMA: Ms Giles, have you read the witness statement of Rebecca Power, the director of allied health at Western Health?---Yes, I have.
PN3341
I see that she says that she disagrees with your description of the management structure in two respects, and I just wanted to check whether you contested this. She says first of all the chief speech pathology is not full time, it's a point 8 position. Do you agree with that?---Yes. Can I say that I read that with surprise because I at no point in my witness statement mentioned anything about full time or part time. I didn't say that it was a full time position. In fact I think that's a bit irrelevant whether it's full time or part time because my comment was more around the scope of those roles rather than anything else. And I didn't mention - further to that, I did not mention specifically anything about the psychology manager, and I'm very well aware that they're not covered by this award.
PN3342
Okay. So the point that she makes about the psychology manager being full time, she says it's the only chief position that carries a clinical load, would you agree with that?---Yes, it's true, and it's because that person has only about two staff.
PN3343
You say the grade 3s are required to perform managerial and administrative functions, and you'd agree that it's generally an agreed perception that as you increase from a grade 1 through to grade 2 through to grade 3, the percentage of your clinical work load reduces slightly?---Yes.
PN3344
And so as a rule of thumb a grade 3 will perform more clinical and managerial work than a grade 1 or a grade 2?---Yes, indeed.
PN3345
And the amount of clinical and non clinical mix will vary across positions?---Yes, with some qualification, yes.
**** SUSANNE GILES XXN MS SIEMENSMA
PN3346
And across disciplines as well?---Yes.
PN3347
And so there are some senior clinicians at Western who are perhaps almost entirely clinical, and others have more of a weighting towards non clinical responsibilities?---That's right. But most of them would have quite a sizable clinical load. And in fact when one of the issues with the Western Health structure in regards to the amount of EFT that we have to perform clinical work is that it was felt - and this has not changed - with an expectation that all of the senior clinicians will have a 70 per cent clinical load. So the minute you try to take some of that away and reduce it down to, say 60 or 50 or whatever, you have then got a real hole with picking up where that extra clinical work, particularly when it is highly specialised and needs less support than some of the grades, where that will go, because it actually equates to more than the loss of, say 20 per cent.
PN3348
I take it that you'd accept that providing some level of non clinical work to grade 3s is appropriate?---Yes.
PN3349
Because it does help them develop managerial skills and capabilities?---I think that there's - I want to take a step back. So I agree with the principle that a grade 3 will have some of their work that is not specifically directly clinical. The way grade 3 positions were set up, and most people who take grade 3 positions expect from, or many of them do expect from it is that that non clinical kind of component that you're talking about should be and was intended to be non clinical work that is more around, say service development, program development, clinical - enhancement of clinical kind of practice. And some of the stuff that I'm talking about in relation to the work that now is done through that non clinical component tends to be much more operational kind of stuff like management of leave or working out who can have an ADO and that kind of thing. So those are the kind of tasks. And sometimes different sort of - but those are the kind of tasks that people take exception to. And in regard to the question about exit interviews, some senior clinicians who leave jobs express great frustration at those kind of tasks, and understanding that by default they end up in their lap they don't like it.
PN3350
Is it true to say that the chiefs at Western don't really have a clinical work load?
---No, they don't have a - - -
**** SUSANNE GILES XXN MS SIEMENSMA
PN3351
They're mainly non clinical?---They are all non clinical except for their strong focus on being responsible for all of the professional standards and so on for the health service. For example in my case another big part of my role is supervision of all of the senior clinicians, so from that perspective that fits into that clinically related sort of area, but it's not actually doing therapy, no.
PN3352
And would you agree that providing administrative and managerial responsibilities and non clinical responsibilities to grade 3 in fact helps them develop skills for promotion eventually?---Not necessarily. It depends what they want to do. And if you've got a grade 3, I think that every - how I would run supervision with a grade 3 would be to find out what it is that they want to do, whether they want to progress into a pathway which is a managerial sort of pathway like mine or, indeed, it's into a more clinically focused job like a sort of grade 4 position might look like. From that perspective if you've got someone that wants to be a manager, then yes indeed, that some of these tasks may well assist them to get there. If they're someone that doesn't want to do that, that's not a help at all.
PN3353
You said in your oral evidence that there are grade 3s doing teaching?---Yes.
PN3354
And in the certified agreement, page 43 and 44, a description of senior clinician, which I understand involves grade 3s, extends to lecturing in their clinical speciality?---Yes.
PN3355
Teaching undergraduates, postgraduates, providing education to staff?---Yes.
PN3356
So that teaching role is already encompassed within a senior clinician description?---Indeed it is, but I see that as different than the potential for a clinical educator position which would have a much broader, more strategic over arching kind of role than the teaching and training that's embedded in a grade 3s role where it's usually related to a particular clinical area and that sort of thing.
PN3357
And the senior, the clinical educator, that would obviously involve Western Health having to recruit?---Yes.
PN3358
Comment on the chief structure, I wanted to ask you in terms of, say Williamstown, if one looks at, say the level of EFT in podiatry, they've only got 2.9 staff?---Yes.
**** SUSANNE GILES XXN MS SIEMENSMA
PN3359
In speech pathology they've got one EFT?---Yes.
PN3360
I take it you're not suggesting that it's appropriate across the board to have chiefs at every site?---No. I would think that would clearly be really silly and I would not support that. I think there are different ways that you can manage that.
PN3361
Rebecca Power comments that it would be excessive and involve a duplication of tasks. That is something you don't disagree with?---In terms of Williamstown?
PN3362
In terms of Williamstown but, I mean, the same may be true of other sites, say rural services or regional areas, there will be some campuses where this is not appropriate?---Yes. I would say yes, there will be some campuses where it's not appropriate, but it would need to be looked at from an individual level, and particularly around rural things which are quite different to metropolitan.
PN3363
You comment in paragraph 19 of your statement about complexity and the fact that there's no recognition in the classification of pay scales to recognise complexity of working across several sites. Now, the certified agreement, the EBA, that remunerates people based on EFT doesn't it?---Yes.
PN3364
And I suggest it's almost impossible to have a remuneration system based on complexity of one's job, it's just too subjective?---Well, I don't know that that's necessarily so. I think that one of the things that we have done through the workforce and professional issues - - -
PN3365
SENIOR DEPUTY PRESIDENT LACY: Is that a matter the witness has to answer or is that a matter for us?
PN3366
MS SIEMENSMA: Well, it's probably a matter for the Bench, yes.
PN3367
You say in paragraph 14 about cost centres. Now, as a chief remunerated based on your EFT, that includes staff you're operationally responsible for as well as the ones you're professionally responsible for. And so for instance with the sub acute and ambulatory cost centre they're not in the allied health budget for cost centre, but you may be professionally responsible for people in that area?---I am professionally responsible for them, not may.
**** SUSANNE GILES XXN MS SIEMENSMA
PN3368
And the people in that area will count not only for your EFT but they will also count in terms of EFT to whomever they are organisationally responsible for, operationally responsible for?---Yes.
PN3369
So even though your classification is based on EFT it will include people in other areas in other cost centres?---Who have professional accountability to me, and that aspect of accountability takes a lot more time and skill than the operational accountability in my opinion, as I've said.
PN3370
And your remuneration therefore takes into account the work that you do and your skills in being professionally responsible for other people outside your cost centre?---I suppose it does up to a point, yes.
PN3371
I have no further questions.
SENIOR DEPUTY PRESIDENT LACY: Thank you Ms Siemensma. Yes, Mr Langmead?
<RE-EXAMINATION BY MR LANGMEAD [4.04PM]
PN3373
MR LANGMEAD: Ms Giles, you've just answered a question in relation to - I think the thrust of it, and I think you tended to agree,
but the thrust of it was that if the people you are professionally responsible for but who may not work for the OT department, the
occupational therapy department, are counted in your EFT?
---Mm.
PN3374
Yes. But they may also count in somebody else's EFT?---Yes.
PN3375
Now, how can that be if they're occupational therapists?---Well, that's what I - I was struggling with that myself actually. In terms of who manages those other people they are managed, you know, operationally through team leaders and people who I don't know are necessarily paid under the allied health EBA, so I have no idea how that works, I don't know. And in terms of all of the occupational therapy staff other than the aged care assessment service staff that work in Western Health they are absolutely within the occupational therapy service, and we have had a document that has been consulted across all of the program managers in those areas and so on and within allied health, and between allied health managers to articulate what all of that means. It's a very comprehensive document that talks about professional versus operational accountability and enshrines that notion that those staff, whether they're physios, OTs, whatever, sit within their disciplines, and that the cost centre arrangement is purely pretty much an accounting exercise really because they're separately funded, those services. So they're very much part of the therapy services. All of the work they do fits across streams across the three health, the three sites and so on.
**** SUSANNE GILES RXN MR LANGMEAD
PN3376
Yes, thank you. Thank you, your Honour.
SENIOR DEPUTY PRESIDENT LACY: Thank you, Mr Langmead. Thank you for your evidence, Ms Giles, you're excused.
PN3378
MR LANGMEAD: Your Honour, your associate advised us earlier that we were going to be required to vacate the premises by 4.15.
PN3379
SENIOR DEPUTY PRESIDENT LACY: Yes. Apparently electricians have got priority over us.
PN3380
MR LANGMEAD: Yes. And I'm not sure whether Mr Booth is even still here because I think he has been sent aware, your Honour, and the three minutes wouldn't have been sufficient.
PN3381
SENIOR DEPUTY PRESIDENT LACY: I think Commissioner Lewin might have a few questions for you Mr Langmead.
PN3382
COMMISSIONER LEWIN: I was just wondering whether or not you could provide us with some information, or perhaps in conjunction with the respondents you might provide us some information. Can you provide us with a profile of the employees covered by the proposed determination by sex?
PN3383
MR LANGMEAD: Sorry, Commissioner?
PN3384
COMMISSIONER LEWIN: That is to say there will be a certain number of men and a certain number of women covered by the determination. Could you provide that please in conjunction with the respondents if possible? The second question is, I gather from the exhibit that compared the rate of increase in the real value of the wages of the employees that the union has available to it the capacity to produce some information that is statistically based. How was that exhibit obtained?
PN3385
MR LANGMEAD: The wages rates?
PN3386
COMMISSIONER LEWIN: You tendered an exhibit which showed the rate of increase in the real value of the wages of the employees to be covered by the determination. Do you remember reading that? We had a little interchange about that.
PN3387
MR LANGMEAD: Yes. They're all based on the ABS statistics referred to in the document.
PN3388
COMMISSIONER LEWIN: I understand that's the source of the information. The question that I asked was, what expertise was used in order to produce that? Is that within the union's staffing or was it provided from a consultant or an adviser?
PN3389
MR LANGMEAD: It was provided by a consultant to the union.
PN3390
COMMISSIONER LEWIN: I'm not questioning the efficacy of it or the veracity of it, in case you need to relax about that. I was actually just seeking some information if that's available over a relatively appropriate time span of the relative real values of the graduate entry rate of pay, the real increase in the value of the graduate entry rate of pay, and a comparison with the rate of growth as a real value of the classification rates of pay. I don't know whether you are comfortable with an understanding of what I have sought. Do you need me to reduce it to writing?
PN3391
MR LANGMEAD: I think I've got it in writing, Commissioner. It's the relative real value of the graduate entry rate, the real value of the graduate entry rate.
PN3392
COMMISSIONER LEWIN: And rate of growth.
PN3393
MR LANGMEAD: The rate of growth.
PN3394
COMMISSIONER LEWIN: So you could use the same time period if you like that you used for the first exhibit.
PN3395
MR LANGMEAD: Yes.
PN3396
COMMISSIONER LEWIN: And the rate of growth in the real value of the other classifications. If you obtained that information that was exhibited in the first instance from a statistician, I think the purpose, the comparative purpose of the information is all readily apparent to your adviser.
PN3397
MR LANGMEAD: Yes, Commissioner. Commissioner, would it be sufficient to meet your purposes with the classification rates, each classification - sorry, many of them are at the same rate as it were.
PN3398
COMMISSIONER LEWIN: Yes. They're banded or whatever.
PN3399
SENIOR DEPUTY PRESIDENT LACY: Thank you Mr Langmead. Mr Parry, did you want to say something?
PN3400
MR PARRY: Yes, if the Commission pleases. At the start of this proceeding I think a long time ago there were orders about witness statements, and there was an order, and my learned friend and I agreed for witnesses to be out of court. What has happened since is there's been a lot of documents put up in opening, perhaps the one Commissioner Lewin is referring to, firstly. Secondly, there's been a lot of evidence led in-chief, much of it which hasn't been responsive in particular to what we have said, but rather introducing a whole lot of new material. Now, we are obviously conscious of our obligations in respect of witnesses, but we're in a position where to practically get instructions on these things we will need to speak to some of the witnesses about some of the matters and call further evidence about it.
PN3401
Now, that's a difficulty I suppose for us, but it would be a curious position if we couldn't get instructions about things that have been raised in-chief here, but rather wait for the witnesses to turn up and ask them a question at large.
PN3402
SENIOR DEPUTY PRESIDENT LACY: Yes. The normal course would be for you to raise it with Mr Langmead. I mean, as far as I'm concerned I see your point and I see no reason why you should not have access to the witnesses for further instructions to respond on the new material that's been raised by witnesses in the witness box. But couldn't you simply check with Mr Langmead that you're going to do that?
PN3403
MR PARRY: Well, yes. But, for example, Ms Blackburn gave about an hour and a half's evidence-in-chief yesterday. Ms O'Rourke spent two hours in a stream of consciousness that sometimes we'll have to go back and look at, and there might be things there that we have to get instructions on. Now, I'll certainly raise it with my learned friend, but it will be raised on a more macro level rather than a micro level, if that makes any sense.
PN3404
SENIOR DEPUTY PRESIDENT LACY: Yes.
PN3405
MR PARRY: So I thought I'd put that position on the record.
PN3406
SENIOR DEPUTY PRESIDENT LACY: I understand. I see no reason why you should not be entitled to get instructions on those matters that have been raised, those new matters in the course of evidence today or yesterday.
PN3407
MR PARRY: Or the day before.
PN3408
SENIOR DEPUTY PRESIDENT LACY: Or the day before, yes.
PN3409
MR PARRY: As the Commission pleases.
PN3410
SENIOR DEPUTY PRESIDENT LACY: Mr Langmead, you wouldn't have any objection to that would you, Mr Parry getting further instructions in relation to the new evidence or the new material that's been raised in the course of witnesses giving their evidence?
PN3411
MR LANGMEAD: No, your Honour.
PN3412
SENIOR DEPUTY PRESIDENT LACY: It was my understanding that the witness statements would contain all of the evidence, all of the evidence-in-chief that is, obviously with a right of reply.
PN3413
MR LANGMEAD: Yes. As it turns out our instructions changed over time, your Honour.
PN3414
SENIOR DEPUTY PRESIDENT LACY: Yes. I think it has gone further than just reply in the case of Ms O'Rourke for example.
PN3415
MR LANGMEAD: We concede that, your Honour.
PN3416
SENIOR DEPUTY PRESIDENT LACY: Yes, all right. Anything else? 10 am tomorrow morning.
<ADJOURNED UNTIL SATURDAY 20 SEPTEMBER 2008 [4.14PM]
LIST OF WITNESSES, EXHIBITS AND MFIs
GRAHAM WILLIAM COOK, RECALLED ON FORMER AFFIRMATION PN2682
CROSS-EXAMINATION BY MR PARRY, CONTINUING PN2682
EXHIBIT #R8 STATEMENT OF MS DUNLOP, 13/09/1999 AND ATTACHMENTS THERETO PN2790
EXHIBIT #R9 STATEMENT OF MR LIGHTFOOT, DATED 20/09/1999 PN2791
EXHIBIT #R10 STATEMENT OF MS MAYBERRY, DATED 22/10/1999 PN2792
EXHIBIT #R11 STATEMENT OF MR BERLOWITZ, DATED 15/09/1999 PN2798
RE-EXAMINATION BY MR LANGMEAD PN2801
THE WITNESS WITHDREW PN2825
MICHELLE THERESE O'ROURKE, AFFIRMED PN2829
EXAMINATION-IN-CHIEF BY MR LANGMEAD PN2829
EXHIBIT #A19 WITNESS STATEMENT OF MS O'ROURKE, DATED 11/08/2008 AS AMENDED PN2845
CROSS-EXAMINATION BY MS SIEMENSMA PN2993
EXHIBIT #R12 STATEMENT OF ANDREW DAY DATED 15/09/1999 PN3256
RE-EXAMINATION BY MR LANGMEAD PN3263
THE WITNESS WITHDREW PN3272
SUSANNE GILES, AFFIRMED PN3282
EXAMINATION-IN-CHIEF BY MR LANGMEAD PN3282
EXHIBIT #A20 STATEMENT OF SUSANNE GILES DATED 20/08/2008 PN3289
CROSS-EXAMINATION BY MS SIEMENSMA PN3339
RE-EXAMINATION BY MR LANGMEAD PN3372
THE WITNESS WITHDREW PN3377
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