HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 31 January … · 1/31/2018 · NZREX Briefing Paper (Dr David Hughes) NZREX is a shorthand term for a doctor who has graduated from a recognised

Counties Manukau District Health Board – Hospital Advisory Committee

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 31 January 2018

Venue: Room 101, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu Time: 1.00pm Committee Members Dr Lyn Murphy – Committee Chair Dr Ashraf Choudhary – CMDHB Board Member Catherine Abel-Pattinson – CMDHB Board Member Dianne Glenn – CMDHB Board Member Mark Darrow – CMDHB Board Member Rabin Rabindran – Deputy Chair

CMDHB Management Gloria Johnson – acting Chief Executive Phillip Balmer – Director Hospital Services Vanessa Thornton – acting Chief Medical Officer Jenny Parr – Director of Patient Care, Chief Nurse & Allied Health Professions Officer Avinesh Anand, Deputy CFO Provider Margaret White, Chief Financial Officer Dinah Nicholas - Secretariat

APOLOGIES

REGISTER OF INTERESTS • Does any member have an interest they have not previously disclosed? • Does any member have an interest that may give rise to a conflict of interest with a matter on the agenda?

PART 1 – Items to be considered in public meeting AGENDA

1.00pm 1. AGENDA ORDER AND TIMING Page No.

2. CONFIRMATION OF MINUTES 1.05pm 1.10pm

2.1 Confirmation of Minutes of the Hospital Advisory Committee Meeting – 15 November 2017

2.2 Action Items Register

6-10

11-12

3. PROVIDER ARM PERFORMANCE REPORT 1.15pm

1.30pm 1.40pm 1.50pm 2.00pm 2.10pm 2.20pm 2.30pm 2.40pm 2.50pm

3.1 Executive Summary (Phillip Balmer) 3.2 2017/18 Hospital Services Workplan 3.3 Balanced Scorecard 3.4 Finance Report (Margaret White) 3.5 Emergency Department, Medicine and Integrated Care (Brad Healey) 3.6 Surgery, Anaesthesia and Perioperative Services (Mary Burr) 3.7 Central Clinical Services (Ian Dodson) 3.8 KidzFirst and Women’s Health (Nettie Knetsch) 3.9 Adult Rehabilitation and Health of Older People (Dana Ralph-Smith) 3.10 Mental Health and Addictions (Tess Ahern) 3.11 Facilities (Phillip Balmer) 3.12 Middlemore Central (Dot McKeen)

13-18 19-22 23-25 26-31 32-38 39-45 46-49 50-57 58-60 61-64 65-68 69-70

Afternoon Tea Break (3.00 – 3.10pm)

4. CORPORATE REPORTS 3.10pm 3.20pm

4.1 Director Patient Care, Chief Nurse and Allied Health Professions Officer (Jenny Parr)

4.2 Human Resources Report (Phillip Balmer)

71-103

104-106

5. INFORMATION PAPERS 5.1 Q1 2017-18 Non-Financial Summary Report 107-124

3.30pm 6. RESOLUTION TO EXCLUDE THE PUBLIC 125

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Counties Manukau District Health Board – Hospital Advisory Committee 31 January 2018

BOARD MEMBER ATTENDANCE SCHEDULE – HAC 2018

Name

15 Dec 2017

31 Jan Feb 14 Mar 23 Apr May 6 June 18 July 29 Aug Sept 10 Oct 21 Nov Dec

Dr Lyn Murphy (Chair) X

No

Mee

ting

N

o M

eetin

g

N

o M

eetin

g

N

o M

eetin

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Catherine Abel-Pattinson (Deputy Chair)

Dr Ashraf Choudhary x

Dianne Glenn

Mark Darrow

Rabin Rabindran

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HAC MEMBERS DISCLOSURE OF INTERESTS

31 January 2018 Member Disclosure of Interest

Dr Lyn Murphy (HAC Chair) • Member, ACT NZ

• Director, Bizness Synergy Training Ltd • Director, Synergex Holdings Ltd • Trustee, Synergex Trust • Member, International Society of

Pharmacoeconomics and Outcome Research (ISPOR NZ)

• Member, New Zealand Association of Clinical Research (NZACRes)

• Senior Lecturer, AUT University School of Inter professional Health Studies

• Member, Public Health Association of New Zealand Dr Ashraf Choudhary

• Board Member, Otara-Papatoetoe Local Board • Member, NZ Labour Party • Chairperson, Advisory Board Pearl of Island

Foundation • Co-Patron, Bharatiya Samaj Charitable Trust

Catherine Abel-Pattinson (HAC Deputy Chair)

• Board Member, Health Promotion Agency • National Party Policy Committee Northern Region • Member, NZNO • Member, Directors Institute • Husband, Director Blackstone Group Ltd

Dianne Glenn • Member, NZ Institute of Directors • Life Member, Business and Professional Women

Franklin • Member, UN Women Aotearoa/NZ • President, Friends of Auckland Botanic Gardens and

Chair of the Friends Trust • Life Member, Ambury Park Centre for Riding

Therapy Inc. • Member, National Council of Women of New

Zealand • Justice of the Peace • Member, Pacific Women’s Watch (NZ) • Member, Auckland Disabled Women’s Group

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Mark Darrow

• Chairman, Primary Industry Training Organisation Incorporated (ITO)

• Chair, Remuneration Committee, Primary ITO • Ex officio, Finance and Audit Committee, Primary

ITO • Independent Director, Motor Trade Association • Chair, Investment Committee, Motor Trade

Association • Director, New Zealand Transport Agency (NZTA) • Chair, Finance and Audit Committee, NZTA • Independent Director, Balle Bros Group • Chair, Finance and Audit Committee, Balle Bros

Group • Member, Investment Committee, Balle Bros Group • Director, Advisory Board, Courier Solutions Ltd • Chairman, The Lines Company Ltd • Chair, Remuneration Committee, The Lines

Company Ltd • Chairman, Armstrong Motor Group (Advisory Board) • Director, MCD Capital Ltd • Chairman, Signum Holdings Ltd • Chairman, Toloda Properties Ltd • Trustee, Tudor Park Trust • Director, Tudor Park Farm Ltd • Justice of the Peace

Rabin Rabindran

• Chairman, Bank of India (NZ) Ltd • Director, Solid Energy NZ Ltd • Director, Swift Energy NZ Ltd • Director, Swift Energy NZ Holdings Ltd • Director, Kowhai Operating Ltd • Director, NZ Liaoning International Investment &

Development Co Ltd • Director, New Zealand Health Partnerships • Singapore Chapter Chairman – ASEAN New Zealand

Business Council External Appointee TBC

External Appointee TBC

External Appointee TBC

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HOSPITAL ADVISORY COMMITTEE MEMBERS’ REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 31 January 2018 Director having interest Interest in Particulars of interest Disclosure date Board Action Dr Lyn Murphy

Allied Health Initiative for Education & Development (AHIED)

Senior Lecturer, AUT School of Inter-Professional Health Studies

30 November 2016 8 March 2017

That Dr Murphy’s specific interest be noted. The Committee agreed that she may remain in the room and participate in any discussion but be excluded from any voting, if applicable.

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Minutes of Counties Manukau District Health Board

Hospital Advisory Committee Held on Wednesday, 15 November 2017 at 1.30pm

Room 101, Ko Awatea, Middlemore Hospital, Hospital Road, Otahuhu, Auckland

PART I – Items considered in Public Meeting

BOARD MEMBERS PRESENT

Lyn Murphy (Committee Chair) Catherine Abel-Pattinson Dianne Glenn Mark Darrow Rabin Rabindran

ALSO PRESENT

Gloria Johnson (acting Chief Executive) Margaret White (Chief Financial Officer) Avinesh Anand (Deputy CFO, Provider) Phillip Balmer (Director Hospital Services) Vanessa Thornton (acting Chief Medical Officer) Jenny Parr (Director of Patient Care, Chief Nurse & Allied Health Professions Officer) Janet Haley (Senior Communications Advisor) Dinah Nicholas (Secretariat) (Staff members who attended for a particular item are named at the start of the minute for that item)

PUBLIC AND MEDIA REPRESENTATIVES PRESENT

Emily Ford, Manukau Courier attended the public section of this meeting. APOLOGIES

An apology was received and accepted from Dr Ashraf Choudary.

DISCLOSURE OF INTEREST/SPECIFIC INTERESTS

The Disclosures of Interest were noted with no amendments. There were no specific interests to note with regard to the agenda for this meeting.

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1. AGENDA ORDER AND TIMING

Items were taken in the same order as listed on the agenda.

2. COMMITTEE MINUTES 2.1 Confirmation of the Minutes of the Hospital Advisory Committee meeting held on 4

October 2017 Resolution (Moved: Dianne Glenn/Seconded: Mark Darrow) That the minutes of the Hospital Advisory Committee meeting held on 4 October 2017 be approved. Carried

2.2 Action Item Register

Noted. 3. INFORMATION PAPERS 3.1 Hospital Technology Update

Stuart Barnard and Sarah Thirlwall took the Committee through a presentation which provided an overview and update on hospital technology.

3.2 NZREX Briefing Paper (Dr David Hughes) NZREX is a shorthand term for a doctor who has graduated from a recognised medical school in a country that is not considered to be comparable to the New Zealand health system. These doctors have had to pass the NZREX exam within the last 5 years. There are 21 countries considered to have a comparable health system to New Zealand - doctors from these countries do not have to sit the NZREX exam and have far fewer requirements in order to practise medicine in New Zealand. For a country to be recognised as having a comparable health system to New Zealand it must fit within the Medical Council of NZ criteria. MCNZ organises 3 sittings of the NZREX exam each year and numbers are limited to 28 per sitting. The next three exams are fully booked. The next available exam is in November 2018. In the metro-Auckland region, there have been 22 expressions of interest from successful candidates in the past 12 months. Six of these have been employed in the region. Doctors who pass the NZREX have to undertake prevocational training in an identical manner to newly graduated New Zealand medical students. This is independent of whether the doctor has 1 year or 20 years of medical experience. In the immediate future, the Resident Doctors Association MECA has led to the development of new rosters that attempt to limit the impact of fatigue on junior doctors. This has resulted in the need for extra house officers and registrars to be recruited. However, as it currently

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stands, these additional roles are not suitable for NZREX doctors. Further development and discussion would be required to allow NZREXs to take advantage of this increase in roles.

By 2020, MCNZ has mandated that all prevocational trainees spend at least three months in a community based attachment. The shift of workers into the community will impact on the availability of staff in the hospital and again this may be an opportunity for NZREXs. However, NZREXs themselves will be required to undertake a community based attachment also and these will be limited. There are a number of SMOs who have shown great commitment to the plight of the NZREXs and have organised clinical observerships in each of the hospitals and have developed roles for NZREXs. However, these observerships are short in duration and any roles developed are ad hoc. Access to these opportunities is not based on merit or a transparent application process. A workshop was held in late October with key opinion leaders in post graduate medical education. The purpose of the workshop is to develop more consistent processes for application for observerships and more robust methods of assessment of readiness for work whilst acknowledging the funding constraints that the DHBs and HWNZ operate under and the Ministry’s priority for graduates of New Zealand medical schools.

3.3 Inpatient Experience Survey

The Nine Fundamentals of Care - Fundamental care involves actions on the part of the healthcare team that respect and focus on a person’s essential physical, psychological and relational needs to ensure their physical and psychological wellbeing. The delivery of this care often goes unnoticed in part because it is primarily concerned with meeting everyday basic human needs we take for granted. It was noted that the current survey is very long, some 60-odd questions and needs to be narrowed down.

4. PROVIDER ARM PERFORMANCE REPORT Phillip Balmer introduced the report highlighting:

Project Initiatives - across the hospital Services, 108% of the target benefit for the first three months of the financial year has been delivered (end of Q1). Benefits are exceeding target for ACC and ARHOP savings which have contributed to delivering a favourable variance to target for Q1. Mitigations are in place to ensure that benefits are delivered as per the plan and where that is not possible, alternative benefit avenues are considered. Finance Report - the Committee asked for a report for the next meeting (31 January) on what the last three years of non-resident bad debts has looked like. Emergency Department, Medicine and Integrated Care Bowel Screening Programme – Meeting with MoH next week to discuss funding of the programme. Implementation may have to be deferred for a year whilst funding is secured. It is important to get this right. Eligibility Policies – Currently awaiting feedback from the MoH on what their position is on the draft policies. Once received, these will be presented to HAC for feedback.

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Mental Health and Addictions

Cultural Toolkit – the Cultural Toolkit for integrated Mental Health and Addiction Service was launched in September. The website and associated resource booklets are designed to enhance the cultural competency and capability of all staff working with Maaori tangata whaiora and whanau and to encourage Whanaungatanga across services. Adult Rehabilitation and Health of Older People Acute Stroke Ward – the ward has mostly been open at 16 beds however, with fluctuating stroke numbers, this has been increased to 20 beds. Discussions are underway with regard to the model of care and nursing staff levels required for 20 beds. Mr Balmer advised that a report would be submitted to the next HAC meeting (31 January 2018) on some of the initiatives that are working in the community to reduce fractures in older people.

5. CORPORATE REPORTS 5.1 Director Patient Care, Chief Nurse and Allied Health Professions Officer (Jenny Parr)

Certification – comprehensive work is underway targeting reporting, training and clarity about responsibilities for the overdue controlled documents (policies, procedures and guidelines). The Committee asked for a report to the next HAC meeting (31 January 2018) in relation to controlled documents (learning from the internal audit) and the action plan to resolve the outstanding issues. Allied Health Awards - the Committee asked that letters of congratulation be sent to the finalists.

5.2 HR Report The report was taken as read. 6. RESOLUTION TO EXCLUDE THE PUBLIC

Resolution (Moved: Dianne Glenn/Seconded: Mark Darrow) That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

2.1 Public Excluded Minutes of 4 October 2017

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes For the reasons given in the previous meeting.

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3.1 Patient Experience and Safety Report

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32 (a)]

Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S9(2)(a)]

Carried

The open session of the meeting concluded at 4.48pm.

SIGNED AS A CORRECT RECORD OF THE COUNTIES MANUKAU DISTRICT HEALTH BOARD HOSPITAL ADVISORY COMMITTEE MEETING OF 15 NOVEMBER 2017. Dr Lyn Murphy, Committee Chair

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Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.


Hospital Advisory Committee Meeting – Public Action Items Register – 31 January 2018

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

Standing Items

4.10.17 2.4 Summary of Annual Leave Cash-Ups for Hospital Services Directorate – provide a quarterly report showing, for those staff that have had annual leave paid out, their current leave balance, leave accrual and leave taken. This report will not specifically identify particular individuals due to privacy issues.

31 January/14 March

Margaret White/ Phillip Balmer

31.1.18 – Report currently unavailable due to competing priorities with Health Select Committee responses. Report will be available for the next HAC meeting.

15.11.17 5.1 Certification – provide a quarterly report showing progress being made against each corrective action.

14 March Jenny Parr

15.11.17 6.11 Medicine - Bowel Screening Programme regular update each meeting.

31 January Brad Healey Refer Item 3.5 on today’s agenda.

15.11.17 2. Patient Survey –regular update on the response rates to the patient survey and the complaints review process.

31 January Jenny Parr Refer Item 4.1 on today’s agenda.

15.11.17

6.1 Hospital Services 2016/17 Project Initiatives Update (as part of the Executive Summary).

31 January

Phillip Balmer Refer Item 3.1 on today’s agenda.

15.11.17

5.1 System Level Measures Update (as part of the Executive Summary). Quarterly full report.

31 January 14 March

Phillip Balmer

Refer Item 3.1 on today’s agenda.

15.11.2017 5.1 Certification/Controlled Documents – report back in

relation to the controlled documents (learning from the internal audit) and the action plan to resolve the outstanding issues.

31 January Jenny Parr Refer Item 4.1 on today’s agenda.

15.11.2017 4.9 ARHOP – report back on some of the initiatives that are working in the community to reduce fractures in older people.

31 January Dana Ralph-Smith Refer Item 3.9 on today’s agenda. A more comprehensive response, such as strength and balance programmes, will be provided 23 April.

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Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.


DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

15.11.2017 4.4 Finance Report – report back on what the last three years of non-resident bad debts has looked like.

31 January Avinesh Anand Refer Item 3.4 on today’s agenda.

4.10.2017 3.4 Finance - update on supply chain management and clinical supplies, including what the region is doing on enhancing the supply chain generally and an update on the One-Link contract currently being renegotiated.

Date TBC Margaret White

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Counties Manukau District Health Board Hospital Advisory Committee Provider Arm Performance Report

Recommendation It is recommended that the Hospital Advisory Committee: Receive the Hospital Services Report covering activity in November 2017. Prepared and submitted by Phillip Balmer, Director Hospital Services Executive Summary

Glossary

ABD Acute Bed Days COPD Chronic Obstructive Pulmonary Disease ED Emergency Department FCT Faster Cancer Treatment GP General Practitioner/ General Practice PHO Primary Health Organisation SLM System Level Measures Overview The challenges associated with the high volumes and acuity of medical admissions for adults and children that we have experienced in recent months have begun to reduce in November. Acute surgical demand however continues to increase. The December/ January holiday season saw a significant increase in both spinal and burns patients, the combined spike in demand tested both regional and national ICU/HDU capacity and capability to provide a quality of care for these patients. The ongoing increase in patient demand, both in terms of volume and complexity, throughout 2017 across almost all services has largely been met by through the commitment care and expertise of our clinical teams. However it highlights that there is an urgent need for ongoing investment in our facilites, staff and resources. As we take a break over the holiday season it is a great time to acknowledge our staff and thank them for their contributions over the year. We continue to acknowledge that quality patient care can only be achieved through the dedication and commitment of our people, and in their willingness to work as a team across a range of services. At this time it also important to acknowledge the long-standing contributions departing Counties staff members have made, including the retirement of Mr Wilbur Farmilo (Deputy Chief Medical Officer) in December, and the announcement that Denise Kivell (Director of Nursing) will be leaving in February.

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The hospital-wide balanced scorecard, finance, and human resources reports included in this report provide a consolidated view of organisational performance, and we have also provided a high level overview of our 2017/18 initiatives programme. Financial Position We remain focussed on maximising revenue opportunities and improving efficiencies to return the DHB to a breakeven position with our financial performance continuing to improve. Further detail on our financial performance is included in the ‘Financial Results’ section of this month’s reports, showing a $282k favourable variance against budget for the month of November 2017, YTD $1.4M favourable. Initiatives Portfolio Delivery of our 2017/18 initiatives work plan is continuing; 133 projects are regularly monitored. It is particularly pleasing to see 49 of these projects already in the execution phase. Also of note is the realisation of financial benefits associated with our initiatives portfolio. Further detail is provided in the ‘Initiatives Programme’ section of this month’s report. National Health Targets Performance against the three national health targets for which the Hospital Services Directorate is responsible for is summarised below. Elective Surgery

Note: Performance against the Elective Surgery target is reported one month in arrears.

Description The volume of elective surgery will be increased by an average of 4,000 discharges per year.

October (actual)

Not Achieved 99%

November (indicative)

Achieved 99.5%

Note the pressure continues on both ESPI 2 (FSAs) and ESPI 5 (Treatment) in a number of services. This will take close clinical case management over the next few months. Both Surgical & Perioperative Services Governance and Management teams are focused on this challenge.

Cancer Treatment

Description 90% of patients receive their first cancer treatment (or other management) within 62 days of being referred with a high suspicion of cancer and a need to be seen within two weeks.

November (indicative)

Achieved 93%

Note: Performance against the Elective Surgery target is reported one month in arrears.

From 1 July, 2017, the MoH implemented technical changes to the FCT target, excluding patients who breach for patient choice or technical considerations.

The net impact of the technical changes means CM Health has achieved 93% performance for the 6 month period June 17 – Nov 17, and for the September quarter at 94%.

The FCT project team is reviewing current resource used for FCT and identifying requirements beyond the FCT project funding to maintain sustainable tracking and oversight of performance.

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This includes consideration of the Cancer Tracker and other roles that are fixed term to ensure there is clear identification of any additional resource requirement may be needed on a permanent basis. Ongoing funding will also be required for maintenance of the programmes

Emergency Department

Description 95% of patients will be admitted, discharged, or transferred from an emergency department within six hours

November Not Achieved 90%

The Emergency Department has sustained ‘winter’ like levels of demand well into spring. Healthy Together Programme Update Health Alliance has been improving our systems ahead of the upgrade to Concerto Portal 8, planned for February to April 2018. Slow searches and screen freezes have been reported by users on the Concerto Portal 6, and Éclair systems. Diagnostic testing by CM Health, healthAlliance and Orion Health staff has assisted with understanding the problems. While Concerto Portal 8 uses a new technology platform designed to improve search efficiency, other systems need to work well too. Health Alliance has upgraded the systems that hold CM Health data ahead of the Concerto upgrade. Some staff have already reported improvements. In early 2018, health Alliance will also double the data capacity of their network connections to CM Health. The good news for CM Health is that the capacity of our local Wi Fi and devices do not appear to contribute to performance problems. Another diagnostic challenge is to identify the reasons for delayed chart views and updates for e-Vitals. healthAlliance is working to solve this with the vendor for the Patientrack software. We are working with WDHB and Orion to create a single patient view forward rounds that will simplify and speed up the process to access patient related information. Other Highlights As part of our winter and summer lessons learned process we recognised that the summer of 2016 did not bring a reduction in patient demand and hospital occupancy. In particular acute surgery demand peaked over a sustained period at historical levels. This year, we staffed to enable recovery on the days in between the statutory days, so managed the heavy workload. This meant we were able to manage the increase in theatre minutes due to the high acute presentations over this period, without significant patient delays in accessing theatre. The graph below identifies theatre outputs from 4 Dec 2017 to 14 January 2018.

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The National Burn Centre had an influx of acute work, major burns and high need patients moving into the Christmas period. This required a move into contingency planning for the holiday period. We liaised with all other DHBs, and in particular regional burn units closely during this time, and managed cases both internally and nationally during that time. The National Burns Unit staff did an excellent job coordinating the management of burns patients nationally during a very busy period. Manukau Surgery Centre (MSC) theatres and wards were closed over Christmas and opened again on 8 January 2018 as planned. Elective surgery began again on 8 January 2018. Of note we have also begun our refurbishment of the CSSD unit (sterilisers) at MSC and this is progressing well. This is due for completion in mid-February. Medical Oncology evaluation of the pilot has been completed, and the Regional Local Delivery of Medical Oncology Steering Group has agreed to widen the current scope, to enable more capacity of patients to receive treatment at CM Health. A smaller regional group will undertake the next phase at an operational level. Three key areas of treatment have been identified for the next phase, as they have high volumes and minimal additional resource requirements. The Adult Mental Health building construction continues to progress positively. There have been some changes for visitor and staff parking to accommodate the next phase of building. There were some delays experienced as a result of issues with subcontractors during December. This means it will be March before the clinical service can start orientation to stage 1 of the new building with patients now scheduled to move in at the end of April 2018. The Contractor advises there is no change to the Stage 2 completion date of April 2019. System Level Measures: Acute Bed Days Regular update to HAC Key Message "Working Together" is part of the metro Auckland region's system level measures plan, to improve health outcomes for our populations. Together with our PHO partners we are working to reduce the days our patients spend in acute care, by improving the delivery of care for patients with COPD, Heart Failure, Stroke and cellulitis. The changes will improve the value of the care we deliver across the whole of system, by reducing hospital activity, improving quality and patient experience. Background key messages Aim - Our aim is to improve the value of the care we deliver across the whole of system to ensure patients receive the right care, in the right place, at the right time.

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Measures - Acute bed days is an important indicator of a communities' health, and reflects the ability of primary and secondary care to meet the needs of its community. Through this programme, we aim to reduce acute bed days, the rate of 28-day readmissions, and ED presentations. Focus population - Patients with COPD, HF, Stroke, and Cellulitis are disproportionately represented in health outcome indicators, such as mortality rates and acute care utilisation. Improvement efforts will begin by focusing on care delivered to these populations. Priority areas - Cross-continuum and multi-disciplinary work teams have identified the following areas for improvement: • Care transitions for populations of focus from discharge planning to 7-day primary care follow-

up. Develop and test evidence-based bundles of care to guide treatment in primary care. • Rehab attendance and completion rates of patients with COPD and Heart Failure • Advanced care planning and end-of-life care • Delivery of care in the acute setting for patients with stroke and Heart Failure • Roll out - Over the next twelve months, frontline clinical teams from across the system will use

existing programmes and resources to improve care for these populations of focus.

As next steps: • A Ko Awatea project manager/improvement advisor will provide overarching programme

management. She has been working with the Heart Failure team, and has been with Counties for a number of years as a pharmacist.

• A matrix of the existing projects and project leads will be presented to clinical leads in early January. The meeting is critical to obtaining buy-in to a programme of work and solidifying plans for work.

• All General Managers are being asked what they need from programme to support work progression.

• Measurement group work. o developing the outcome measure dashboard. o Exploring possibilities to report Proactive Primary Care and POAC data by condition. o continue to explore opportunities to utilize ANZAC QI data.

Each work stream has accomplished great work to understand the current state, and establish priorities for improvement. We recognize that working across care-settings and disciplines is challenging, but offers much possibility and benefit. It is important for us to develop a collective plan for achieving results, and then regularly share our progress across the programme.

Areas of Improvement Related Projects Initial Aims

Improving Care Transitions

Early Supported Discharge Patient Education Material 7 Day Post-Discharge Visit Electronic Discharge

Summary

Aim: improve care transitions for populations of focus from discharge planning to 7-day primary care follow-up.

Developing Primary Care Bundles

Aim: develop and test evidence based bundles of care to guide treatment within primary care.

Enhancing Rehab Support

Better Breathing

Aim: improve rehab attendance and completion rates of patients with COPD and HF.

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Improving Access to End of Life Care

Aim: improve access to and receipt of end-of-life care.

Improving the Acute Care Flow

Timeliness of Furosomide Injection Acute Cardiology Referral

Process Hyper Acute Stroke Pathway

Aim: improve the delivery of care in the acute setting for patients with Heart Failure and with Stroke.

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Hospital Services 2017/18

December Work plan Report

Project Delivery Overview

Moving into FY17/18, Hospital Services is undertaking an ambitious workplan consisting of a number of service-led transformation, improvement, and revenue initiatives aligned with our Healthy Together strategy. A number of these are building and continuing with projects already underway, while others have been established to drive our strategic goals around improving services for patients, and maintaining financial sustainability. Each of these initiatives has identified benefits (either financial benefits, non-financial benefits, or both) which are being tracked, and a standardised process whereby all active Hospital Services initiatives are reported on each month by the respective managers is in place. Plans for FY17/18 Nine key outcome areas have been identified which work will align to; these cover the improvement of System Level Measures (SLMs), as well as providing safe, high quality healthcare, technology enablement to improved systems and processes, regional design for services, and improving revenue. Figure 1: Key Outcome Areas FY17/18:

Delivery Progress Delivery of the FY17/18 workplan is well underway now. Across Hospital Services Divisions and related programmes, there are 130 total projects being monitored, which range from localised service improvements through to major transformational activities. There are 22 projects currently in initiation, which largely relate to new project focus areas for FY17/18 which are being established. In total 43 projects are now in Execution, with 11 already in Benefits Realisation. Figure 2: Breakdown of project delivery by Division, End November 2017:

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Project Area Phase: 1. In

itiat

ion

2. P

lann

ing

3.

Exec

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n

4.

Clos

e O

ut

5.

Bene

fits

Real

isat

ion

On

Hold

Gran

d To

tal

ARHOP 1 2 3 6 Central Clinical Services 1 2 1 1 5 Emergency Care, Medicine and Integrated Care 9 2 3 1 3 2 20 Facilities and Asset Management 5 8 6 1 1 1 22 Healthy Together Technology – Hospital Services 2 2 4 1 2 11 Hospital Services Information Systems 1 1 1 3 Kidz First & Women's Health 2 5 2 9 Mental Health & Addiction 4 8 1 1 14 Middlemore Central 1 1 1 1 1 5 Surgical, Anaesthesia and Perioperative Care 3 6 10 6 1 5 31 System Level Measures Improvement Programme 4 4 Grand Total 22 32 43 11 11 11 130

Since the last report, two projects have moved forward from Initiation into Planning and Execution, with two projects also moving into Benefit Realisation.

Figure 3: Project Portfolio Movements by Phase

Number of initiatives in phase

Delivery Phase Aug ‘17 Sep ‘17 Dec ‘17 Shift since last report 1. Initiation 31 24 22 -2 2. Planning 26 30 32 2 3. Execution 47 49 43 -6 4. Close Out 11 7 11 4 5. Benefit Realisation 4 9 11 2 On Hold 14 11 11 -

The following figure shows the number of initiatives within each division, and the current status of these projects:

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Benefits Realisation

The full year financial benefit target for CMH is $30.367M across all areas of the organisation. In total, $17.677M of this target is directly attributable from Hospital Services initiatives (excluding cross-directorate & whole of system benefits) CMH FY17/18 Financial Benefit Targets:

Division / Directorate delivering saving: Budgeted Full Year Target ($M)

ARHOP $1.004

Central Clinical Services $0.110

Corporate $4.022

Emergency, Medicine, Integration $0.869

Facilities Management $2.170

Funder Governance Integrated Care $3.133

Governance $2.268

Hospital Services $0.986

Human Resources $0.197

Kidz First $0.547

Ko Awatea $2.100

Mental Health and Addictions $0.890

Middlemore Central $0.238

Non-Clinical $6.100

Surgery, Anaesthetic and Perioperative Services $3.986

Whole of System $0.970

Women’s Health $0.777

Grand Total $30.367

021


Monthly tracking and reporting is in place across all of these initiatives, with regular reporting to ELT now in place identifying any issues around benefit realisation, and how these are being mitigated Of the $17.677M of benefits being delivered directly through Hospital Service initiatives, a performance breakdown is presented below. Hospital Services Benefits Delivery at end of November ’17 (Month Five / Q2)

Division Bu

dget

ed

Targ

et

FY17

/18

($M

)

Curr

ent

Fore

cast

FY

17/1

8 ($

M)

YTD

Targ

et

($M

)

YTD

Actu

al

($M

)

Varia

nce

($M

)

% o

f Tar

get

Del

iver

ed

ARHOP 1.004 1.004 0.418 0.708 0.290 169%

Central Clinical Services 0.110 0.554 0.046 0.153 0.107 333%

Emergency, Medicine, Integration 0.869 0.869 0.362 0.000 (0.362) 0%

Facilities Management 2.170 2.280 0.708 0.115 (0.594) 16%

Hospital Services 0.986 0.986 0.117 0.117 0.000 100%

Kidz First 0.547 0.547 0.228 0.228 0.000 100%

Mental Health and Addictions 0.890 0.890 0.371 0.494 0.123 133%

Middlemore Central 0.238 0.238 0.099 0.000 (0.099) 0%

Non-Clinical 6.100 4.963 2.542 3.524 0.983 139% Surgery, Anaesthetic and Perioperative Services 3.986 3.986 1.661 1.395 (0.266) 84%

Women’s Health 0.777 0.777 0.324 0.324 0.000 100%

Grand Total 17.677 17.094 6.876 7.057 0.181 103% Across the whole Hospital Services directorate, 103% of the target benefit for the first five months of the FY has been delivered (end of Q1). Benefits exceeding target for ACC (within ‘Non-Clinical’) and ARHOP savings have contributed to delivering a favourable variance to target, and Central Clinical Services have been able to deliver additional benefits not originally budgeted. Overall, the CM Health-wide organisational benefits plan is tracking at $8.74M YTD Actual Benefit vs. $11.78 YTD Target. Mitigations are in place across all intiatives to ensure that benefits are delivered as per plan, and where this is not possible, alternative benefit avenues are considered. Additionally, a pipeline of savings opportunities is being developed, to provide a longer term picture of where benefits can be delivered.

022


BALANCED SCORECARD

Trend by monthFY17-18 Nov-17 Target Var Actual Target Var

Emergency Department - 6 hour Length of Stay target 90% 95% -5% 89% 95% -6%FCT % of high suspicion first cancer treatment within 62 days (indicative result) 100% 90% 10% 94% 90% 4%Elective surgery discharges 1,212 1,368 -11.4% 6,389 6,634 -3.7%


Total Caseweight 6,880 7,300 -5.8% 37,565 37,693 -0.3%Acute Caseweight 5,396 5,689 -5.2% 30,131 29,846 1.0%Elective Caseweight 1,485 1,611 -7.8% 7,434 7,847 -5.3%Total Discharges - performace compared to prior year. 8,518 8,818 -3.4% 44,772 44,129 1.5%Outpatient First Specialist Assessment Volumes 4,280 4,517 -5.2% 21,174 22,740 -6.9%Outpatient Follow Up Volumes 10,894 10,649 2.3% 54,814 53,904 1.7%Virtual First Specialist Assessments (GP consult and nonpatient appointments) 397 376 5.6% 2,378 1,875 26.8%Budgeted FTEs 6,352 6,250 -2% 6,193 6,268 1%Operating Costs ($000) $74,736 $73,781 -1% $367,766 $368,368 0%Personnel Costs ($000) $51,658 $51,920 1% $257,254 $258,817 1%Financial Result Total ($000) -$2,518 -$2,801 10% -$10,175 -$11,562 12%Reduce clinical outsourcing ($000) $2,172 $2,398 9% $11,722 $11,911 2%

Trend by monthFY17-18 Oct-17 Target Var Actual Target Var

Excess Annual Leave dollars ($000) - estimated cost for excess $3,846 $1,205 -$2,641 $3,657 $1,201 -$2,457Adult Rehabilitation and Health of Older People $80 $78 -$2 $71 $84 $13Medicine, Acute Care and Clinical Support $396 $251 -$145 $424 $283 -$141Surgical and Ambulatory Care $1,535 $495 -$1,040 $1,440 $480 -$960Mental Health $349 $201 -$148 $318 $177 -$141Women's Health and Kidz First $681 $180 -$501 $667 $176 -$490

% Staff Annual Leave >2 years 11.6% 5.0% -6.6% 11.3% 5.0% -6.3%Adult Rehabilitation and Health of Older People 5.1% 5.0% -0.1% 4.2% 5.0% 0.8%Medicine, Acute Care and Clinical Support 7.9% 5.0% -2.9% 7.5% 5.0% -2.5%Surgical and Ambulatory Care 15.5% 5.0% -10.5% 15.0% 5.0% -10.0%Mental Health 8.7% 5.0% -3.7% 9.0% 5.0% -4.0%Women's Health and Kidz First 18.9% 5.0% -13.9% 18.9% 5.0% -13.9%

HOSPITAL SERVICES BALANCED SCORECARD November 2017*Red variance figures: non-favourable result for the indicator

Nat

iona

l Ta

rget

s

Year to date

Ensu

ring

Fin

anci

al S

usta

inab

ility

Year to date

Enab

ling

Hig

h Pe

rfor

min

g Pe

ople

Average last 12 months

023



% Staff Turnover (YTD no. voluntary turnovers by average headcount) 8.2% 10.0% 1.8% 10.1% 10.0% -0.1%% Sick Leave 3.3% 2.8% -0.5% 3.0% 2.8% -0.2%Workplace Injury per 1,000,000 hours 2.6 10.5 7.9 3.1 10.5 7.4

Nov-17 Target Var Nov-16 Target VarWorkforce Population Workforce Population

Maaori 7% 16% -9% 7% 16% -9%Pacific 13% 23% -10% 12% 23% -11%Asian 33% 23% 10% 30% 23% 7%NZ European / non-specified/ other 47% 38% 9% 51% 38% 13%


% e-medication reconciliation - high risk patients within 48hrs (Oct-17) 80% 80% 0% 77% 80% -3%% Serious Pressure Injuries rate / 100 Patients (database failure, manual collation continues Remedy sought for 2018)

N/A 3.5% ~ N/A 3.5% ~

Falls causing major harm rate / 1,000 bed days (Oct-17) 0.00 0.00 0.00 0.04 0.00 -0.04Adverse Events: % of admissions affected by ≥4 triggers (Sept-17 data) 1.3% N/A N/A 1.2% N/A N/ACentral Line Associated Bacteraemia (CLAB) rate / 1,000 bed days in ICU (Oct-17) 0.00 0.00 0.00 0.00 0.00 0.00Rate of S. aureus bacteraemia rate / 1,000 bed days (Oct-17) 0.00 0.00 0.00 1.10 0.00 -1.10

Q3 FY17 Target Var Actual Target Var% 75+ years assessed for the risk of falling # 99% 90% 9% N/A N/A N/A% 75+ years assessed for falls risk with falls intervention plans # 94% N/A N/A N/A N/A N/A


% Magnetic Resonance Image (MRI) scans completed within 6 weeks from referral 52% 85% -33% 57% 85% -28%% Computerised Tomography (CT) scans completed within 6 weeks from referral 91% 95% -4% 93% 95% -2%% urgent diagnostic colonoscopy within 14 days 97% 85% 12% 98% 85% 13%% diagnostic colonoscopy patients within 42 days 77% 70% 7% 69% 70% -1%% surveillance colonoscopy patients within 84 days 84% 70% 14% 88% 70% 18%% cardiac STEMI-PCI (angiography) <120mins - Northern Region 78% 80% -2% 78% 80% -2%% Coronary Angiography within 90days (1mth arrears) 100% 95% 5% 94% 95% -1%ESPI 2: No. patients waiting >120 days for FSA - Elective ∆ 35 0 -35 35 0 -35.0ESPI 5: No. patients waiting >120 days treatment - Elective ∆ 31 0 -31 31 0 -31Radiology - Inpatient radiology completion times <24hrs 90% 95% -5% 91% 95% -4%Radiology- Emergency Care radiology completion times <2 hrs 92% 95% -3% 94% 95% -1%FCT - % confirmed diagnosis first cancer treatment within 31 days 93% 85% 8% 94% 85% 9%% Radiology results reported within 24 hours 55% 75% -20% 48% 75% -27%

Tim

ely

Year to date

Firs

t, D

o N

o H

arm

(Saf

ety)

Year to date

#Quarterly reporting Year

Enab

ling

Hig

h Pe

rfor

min

g Pe

ople

(con

t.) Average last 12 months

Workforce DiversityMonth to date

024



Average Length of Stay - Acute Inpatient 2.9 3.0 0.0 2.9 3.0 0.1Average Length of Stay - Acute Arranged/ Elective 1.5 1.4 -0.2 1.7 1.4 -0.3Middlemore Hospital % patients to discharge lounge or home by 1100hrs 18% 30% -12% 20% 30% -11%Acute Readmissions within 7 days - Total 2.4% 2.9% 0.5% 2.5% 2.6% 0.1%Acute Readmissions within 28 days - Total (1 month in arrear) 6.4% 6.9% 0.5% 6.9% 6.8% -0.1%Acute Readmissions within 28 days - 75+ years (1 month in arrear) 10% 12% 1.3% 11% 11% 0.7%Emergency Department Presentations - 75+ year olds 957 807 -150 5,485 4,035 -1,450% clinical summaries (meddocs) authorised <7 days of creation 65% 95% -30% 68% 95% -27%% of patient outliers - not on home ward <5% 4.5% 5.0% 0.5% 6.8% 5.4% -1.4%

% DHB Mental Health Services - children/ youth (0-19years) seen by 3 weeks for non-urgent 70% 80% -10% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (0-19yrs) 4.1% 3.2% 1.0% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (20-64yrs) 4.0% 3.2% 0.9% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (65+yrs) 2.3% 2.6% -0.3% N/A N/A N/A


Outpatient - First Specialist : Follow-up Clinic ratio 39% 42% 3% 39% 42% 3%Outpatient - Did Not Attend rates - Maaori 20% 10% -10% 20% 10% -10%Outpatient - Did Not Attend rates - Pacific 17% 10% -7% 17% 10% -7%Theatre List Utilisation 93% 83% 9% 92% 83% 9%Day of Surgery Admissions (DOSA) 93% 90% 3% 91% 90% 1%Day Case Rate (Elective/ Arranged) 64% 65% -1% 65% 65% 0%% Medical Assessment patients with Length of Stay < 28 hours 79% 65% 14% 82% 65% 17%No. Hospital bed days occupied (against forecast open beds) 20,590 21,136 2.7% 109,258 110,131 0.8%No. Length of Stay outliers (LOS >10 days)* 45 143 218% 666 697 5%

Syst

em In

tegr

atio

n (E

ffec

tive)

Year to date

Quarterly Reporting Year to date

Effic

ient

Year to date


% smokers receive smokefree advice / support -Total 96% 95% 1% 96% 95% 1%% smokers receive smokefree advice / support - Maaori 95% 95% 0% 96% 95% 1%% smokers receive smokefree advice / support - Pacific 98% 95% 3% 96% 95% 1%% smokers receive smokefree advice / support - Asian 93% 95% -2% 95% 95% 0%

% Women (45-60yrs) with Breastscreen in 24months - Total 2630 2400 230 70% 70% 0%% Women (45-60yrs) with Breastscreen in 24months - Maaori 282 289 -7 66% 70% -4%% Women (45-60yrs) with Breastscreen in 24months - Pacific 516 377 139 79% 70% 9%

Trend by month FY17-18 Nov-17 Target Var Actual Target VarPatient experience Survey data very good/excellent - month (n=290) and YTD (n=1194) 83% 90% -7% 81% 90% -9%

NOTES* performance is against previous year's actual∆ ESPI interim results subject to change

P&W

CC Year to date

Equi

ty

Year to date

Volumes Screened % Screened in last 24 months

025

*Due to rounding, numbers presented throughout this document may not add up precisely to the totals provided.


Financial Results - Provider Arm

Glossary ACC Accident Compensation Corporation FTE Full Time Equivalent MoH Ministry of Health WIES Weighted Inlier Equivalent Separation (activity based measurement) YTD Year to Date

Actual Budget Variance Variance Actual Budget Variance Forecast Budget Variance$(000) $(000) $(000) Prior $(000) $(000) $(000) $(000) $(000) $(000)

IncomeGovernment Revenue 74,667 73,580 1,087 F 371,026 369,583 1,442 F 888,949 884,559 4,391 FPatient/Consumer Sourced 1,445 985 460 F 5,838 4,956 882 F 12,728 11,846 882 FOther Income 2,195 2,097 98 F 9,813 10,676 (863) U 26,931 25,548 1,383 FFunder Payments - - 0 F - - 0 F - - 0 FTotal Income 78,307 76,663 1,645 F 386,677 385,215 1,462 F 928,609 921,953 6,656 FExpenditure Personnel 50,046 50,977 931 F 248,784 254,113 5,328 F 605,526 609,227 3,701 FOutsourced Personnel 1,612 943 (669) U 8,470 4,704 (3,766) U 14,989 11,174 (3,814) UOutsourced Clinical 2,171 2,398 227 F 11,723 11,911 188 F 28,242 27,352 (890) UOutsourced Other 3,224 3,254 30 F 16,230 16,270 40 F 39,008 39,048 40 FClinical Supplies (excluding Depreciation) 11,088 10,047 (1,040) U 51,060 49,936 (1,123) U 122,387 117,412 (4,975) UOther Expenses 6,592 6,163 (428) U 31,498 31,437 (62) U 74,531 73,864 (666) UTotal Operating Expenditure 74,734 73,782 (950) U 367,765 368,371 605 F 884,682 878,076 (6,605) U

Total Operating Surplus/(Deficit) 3,573 2,880 694 F 18,912 16,844 2,067 F 43,927 43,877 51 FDepreciation 2,637 2,661 24 F 13,198 13,305 107 F 32,325 31,932 (393) UInterest - 27 27 F - 134 134 F 322 322 0 FCapital Charge 3,453 2,994 (459) U 15,888 14,970 (918) U 38,356 35,928 (2,428) UTotal Depreciation, Interest and Capital Charge 6,090 5,682 (408) U 29,085 28,409 (676) U 71,003 68,182 (2,821) U

Net Surplus/(Deficit) (2,516) (2,802) 286 F (10,174) (11,565) 1,391 F (27,075) (24,305) (2,770) U


Medical Personnel 15,783 16,865 1,082 F 79,782 83,433 3,651 F 194,052 197,785 3,733 FNursing Personnel 19,475 18,993 (482) U 96,589 95,445 (1,145) U 232,605 230,547 (2,058) UAllied Health Personnel 7,022 7,026 4 F 33,675 34,900 1,225 F 82,588 84,056 1,468 FSupport Personnel 2,300 2,352 53 F 11,494 11,912 419 F 28,511 28,776 265 FManagement/Administration Personnel 5,466 5,740 275 F 27,245 28,424 1,179 F 67,770 68,063 293 FTotal (before Outsourced Personnel) 50,046 50,977 931 F 248,784 254,113 5,328 F 605,526 609,227 3,701 FOutsourced Medical 820 480 (340) U 4,243 2,388 (1,855) U 7,422 5,618 (1,804) UOutsourced Nursing 272 52 (220) U 1,362 259 (1,103) U 1,725 623 (1,103) UOutsourced Allied Health (6) 2 8 F 194 9 (185) U 304 20 (284) UOutsourced Support 57 0 (56) U 251 2 (250) U 253 4 (250) UOutsourced Management/Admin 470 409 (61) U 2,420 2,046 (374) U 5,284 4,910 (374) UTotal Outsourced Personnel 1,612 943 (669) U 8,470 4,704 (3,766) U 14,989 11,174 (3,814) U

Total Personnel 51,658 51,920 262 F 257,254 258,817 1,563 F 620,515 620,401 (114) U


Central Clinical Services (7,398) (7,468) 70 F (36,897) (37,102) 204 F (89,257) (89,461) 204 FEmergency Medicine and Integration (14,071) (13,774) (297) U (69,907) (69,202) (705) U (166,884) (165,188) (1,696) UMiddlemore Central (2,421) (2,462) 41 F (12,358) (12,483) 125 F (30,009) (30,061) 52 FARHOP (3,534) (3,576) 42 F (17,522) (17,780) 259 F (42,489) (42,489) 0 FMental Health (5,968) (5,956) (12) U (29,478) (29,601) 123 F (71,441) (71,441) 0 FSurgical & Ambulatory (15,926) (16,331) 405 F (77,498) (79,432) 1,933 F (187,635) (187,635) 0 FWomen & Child Health (5,804) (5,974) 170 F (29,077) (30,059) 981 F (72,455) (72,481) 25 FFacilities Services (1,735) (1,779) 44 F (9,525) (9,211) (314) U (22,952) (21,540) (1,412) UProvider Management 59,259 59,543 (285) U 296,862 298,358 (1,496) U 716,576 716,071 505 FInnovations Hub & Ko Awatea (1,241) (1,301) 61 F (6,178) (6,414) 235 F (15,280) (15,347) 67 FIntegrated Care (3,678) (3,725) 48 F (18,595) (18,641) 46 F (45,250) (44,733) (516) UNet Surplus/(Deficit) (2,516) (2,802) 286 F (10,174) (11,565) 1,391 F (27,075) (24,305) (2,770) U

Surplus / (Deficit) by DivisionMonth

Consolidated Statement of Financial PerformanceCMDHB Provider

Month Year to Date

Personnel Costs By Professional Group Month Year to Date Full Year

Year to Date Full Year

Full Year

026



Case weight Activity Overall growth in acute volumes has continued to flatten in November, with year-to-date (YTD) volumes being just 1% ahead of contract – main growth areas continue to be in General Medicine and General Surgery. Compared to last year, acute volumes are slightly higher at 2.2%. Electives continue to track under contract, with year to date volumes being 6.3% behind contract and 6.9% behind prior year to date. The shortfall in elective volumes stems from the shortage of theatre space, due to acute demand and anaesthetist vacancies. Outsourced surgical volumes account for 8% of the total year to date elective volumes. Finance Overview The Provider Arm produced a $286k favourable variance against budget for the month of November 2017, YTD $1.4M favourable. Key staff shortages and delays in securing appointments continue into December, resulting in favourable variances to budget for the month and year to date. Cover has been provided by locums, bureau,

Actual Contract Variance Variance Actual Contract Variance VarianceVolume Volume Volume % Volume Volume Volume %

M00001 - General Medicine Inpatients 1,321 1,335 (14) U -1.0% 7,656 7,502 153 F 2.0%S00001 - General Surgery Inpatients 774 722 52 F 7.2% 3,938 3,546 392 F 11.1%S45001 - Orthopaedic Inpatients 660 673 (14) U -2.0% 3,249 3,305 (56) U -1.7%W10001 - Maternity Inpatients 495 619 (123) U -19.9% 2,994 3,001 (7) U -0.2%S60001 - Plastic & Burns - Inpatients 390 465 (74) U -16.0% 2,280 2,281 (1) U -0.0%M05001 - Emergency Medical Services Inpatients 370 375 (4) U -1.2% 1,922 1,963 (41) U -2.1%M55001 - Paediatric Medicine Inpatients 228 254 (26) U -10.3% 1,473 1,726 (253) U -14.7%W06003 - Secondary Neonatal 224 284 (60) U -21.1% 1,435 1,448 (13) U -0.9%All Others 939 962 (24) U -2.5% 5,190 5,074 115 F 2.3%Total Acute WIES 5,401 5,689 (288) U -5.1% 30,136 29,846 289 F 1.0%S45001 - Orthopaedic Inpatients 445 438 7 F 1.5% 2,191 2,125 66 F 3.1%S00001 - General Surgery Inpatients 326 394 (69) U -17.4% 1,745 1,914 (169) U -8.8%S60001 - Plastic & Burns - Inpatients 244 236 7 F 3.2% 1,202 1,146 56 F 4.9%S30001 - Gynaecology Inpatients 116 141 (25) U -17.7% 571 693 (122) U -17.6%S25001 - ORL Inpatients 116 129 (13) U -10.4% 539 627 (88) U -14.0%S40001 - Ophthalmology Inpatients 106 127 (21) U -16.4% 482 615 (133) U -21.6%M10001 - Cardiology - Inpatients 56 49 8 F 15.8% 218 252 (34) U -13.4%S70001 - Urology - Inpatients 29 41 (11) U -27.9% 158 197 (39) U -19.7%All Others 15 29 (14) U -48.9% 128 150 (22) U -14.5%Total Elective WIES 1,453 1,584 (132) U -8.3% 7,235 7,719 (484) U -6.3%

Total WIES 6,854 7,273 (419) U -5.8% 37,370 37,565 (195) U -0.5%

Total IDF WIES 692 859 (166) U -19.3% 3,982 4,346 (364) U -8.4%

This Year Last Year Variance Variance This Year Last Year Variance Variance % %

Acute WEIS 5,401 5,708 (307) U -5.7% 30,136 29,477 658 F 2.2%Elective WEIS 1,453 1,601 (148) U -10.2% 7,235 7,737 (502) U -6.9%Acute Discharges 7,063 7,253 (190) U -2.7% 37,559 36,658 901 F 2.4%Elective Discharges 1,455 1,565 (110) U -7.6% 7,216 7,471 (255) U -3.5%Births 626 574 52 F 8.3% 3,151 3,058 93 F 3.0%ED Discharges 9,517 9,284 233 F 2.4% 49,258 48,147 1,111 F 2.3%FSA Volumes 4,280 4,663 (383) U -8.9% 21,174 21,993 (819) U -3.9%FU Volumes 10,809 11,430 (621) U -5.7% 54,178 53,963 215 F 0.4%

Month

Month

Year to Date

Year to DatePrior Period Comparisons

Contract Performance

027



overtime, casual staff and outsourcing. Plans for early recruitment to address immediate demand pressure, and winter capacity will be in place by January 2018. The Initiatives Programme was delivering ~103% of target benefit for the hospital/ provider services as at November 2017. Mitigations are in place to ensure benefits are delivered to plan, and where this is not possible, alternative benefit avenues are being considered. The cost impact of the over delivery of acute volumes, and the revenue adjustment for the under delivery of the YTD elective programme are offset by vacancies, the ACC arrears programme and a favourable movement in creditors. Major YTD variances are explained below: Revenue Overall, revenue is $1.6m favourable for the month, and $1.5m favourable YTD, reflecting the following major year to date movements:

• ACC arrears initiative - one-off contribution - $3.9m YTD favourable. • Tahitian burns - $477k favourable • Under-delivery of the YTD elective programme, partly due to higher than contracted acute

volumes through the winter months, $2.4m. • Reversal of MoH revenue adjustment at 30 June 2017, offset by personnel costs, $687k. • Lower than anticipated retail sales in Retail Pharmacy $889k, offset by a reduction in cost of

goods sold (Other Expenses). • Reduction in donation revenue $574k.

Expenditure Overall operational expenditure is $950k unfavourable for the month, and $605m favourable YTD. Net Personnel Costs - $262k favourable for the month, favourable $1.56m YTD. The overall favourable variance in personnel costs reflect vacancies across the services (partly offset by outsourcing), as well as the delay in approving new roles pending confirmation of the 2017/2018 budget. These roles are being actively recruited. Plans to recruit FTE to address immediate demand pressure and winter capacity will be finalised in January. Overall FTEs are 20 FTE favourable to budget (including outsourced personnel).

• Net Medical staff costs are $1.8M favourable YTD (5 FTE); $741k favourable for November - reflecting continuing vacancies across the services in difficult-to-recruit to positions, and the delay in approval of new roles, mainly in Anaesthesiology, Radiology and Mental Health. These vacancies continue to be actively recruited.

Actual Budget Variance Actual Budget Variance Actual Budget VarianceMedical Personnel 16,603 17,344 741 F 84,025 85,821 1,796 F 854 859 5 FNursing Personnel 19,746 19,045 (702) U 97,951 95,704 (2,247) U 2,906 2,808 (98) UAllied Health Personnel 7,016 7,028 12 F 33,868 34,908 1,040 F 1,133 1,173 39 FSupport Personnel 2,356 2,353 (4) U 11,745 11,914 169 F 511 534 23 FManagement Personnel 5,936 6,150 214 F 29,664 30,469 805 F 915 966 50 FTotals 51,658 51,920 262 F 257,254 258,817 1,563 F 6,320 6,340 20 F

Personnel by Professional Group - Permanent and Outsourced

Month $$$ Year to Date $$$ Year to Date FTE

028



• Net nursing staff costs are $2.24M unfavourable YTD (98 FTE); $702k unfavourable for November- reflecting the significant and sustained increase in clinical demand during a busy winter period.

• Net Allied Health staff costs are $1M favourable YTD (39 FTE); $12k favourable for November - representing vacancies across the services that are being actively recruited to, mainly Anaesthetic Technicians, Social Workers, Psychologists and Occupational Therapists.

• Net support personnel are $169k favourable YTD (23 FTE); $4k unfavourable for November. Vacancies in engineering, sterile supplies, cleaners and hotel services are partially offset by overspend in security and interpreters.

• Net management and administration personnel are $805k favourable YTD (50 FTE); $214k favourable for November, reflecting vacancies across all areas.

Non-Staff Costs

• Clinical Outsourcing costs are $188k favourable YTD ($227k favourable for November), representing a positive timing adjustment to Regional Pacific contract expenditure. This was offset by outsourced MRI volumes and an increase in the volume of elective work outsourced to private hospitals to mitigate the impact of increased acute demand in Orthopaedics, General Surgery, and Plastics.

• Clinical Supplies costs are $1.1m unfavourable YTD ($1m unfavourable for November), reflecting the high clinical demand beyond the winter peak, with significant increases in treatment disposables, instruments and equipment and pharmaceuticals.

• Other expenses are $62k unfavourable YTD ($438k unfavourable for November), reflecting overspends in Hotel Services and Facilities costs, offset by underspends in retail pharmacy costs (matched by reduced revenue) and favourable movements in creditors (relating to June 2017 year-end revenue accruals).

• Interest, Depreciation and Capital Charge costs are $676k unfavourable YTD ($408k

unfavourable for November) principally driven by a revision to Capital Charge costs. Forecast to Year End The year-end forecast currently stands at a deficit of $27m, a $2.7m unfavourable variance against budget, reflecting our commitment to increase clinical capacity to respond to both the immediate demand pressure and the facilities remediation programme, as well as prepare for the 2018 winter. The unfavourable variance may be reduced if we are able to realise elective volume and revenue targets. Looking Ahead The 2018/19 budget setting round has commenced with a focus on planning that is currently underway, including;

• Delivery of our 2017/18 initiative programme that will extend to 2018/19 • Facilities Master Planning – Immediate Demand and Facilities Remediation Programmes, to

confirm our capacity requirements over the next 3-5 years and align our facility investments. • Recovery Plan – three year pipeline of savings opportunities.

029



Responses to Action Items Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 15.11.2017 – Finance Report “Report back on what the last three years of non-resident bad debts has looked like”. “Ineligible patients” refers to non-New Zealand citizens who received care but who, under the ‘2011 Eligibility Direction’ are not entitled to receive publicly-funded healthcare. Eligibility determination is complex and case-specific, and it can take some time to collect and assess the facts against the criteria. Our approach is to provide required acute care immediately, and have our Eligibility Team complete a determination of entitlements. All patients requiring treatment for an acute injury or illness will be treated, regardless of their eligibility for funded services. Services that are not billable include for example, infectious disease, maternity care for an ineligible person who has an eligible partner, and those with Australian or UK reciprocal health agreements etc. As per table 1 below, the non-resident debt as at 30-Jun-17 was $5.4m.

Debt collection and Write-off processes The process for debt collection is as follows: • healthAlliance (our shared support agency) process and send invoice to patient, • Phone-call made to the patient for payment, or to agree a payment plan, • Follow up letter sent to patient who has not responded to invoices and phone-call, • A second and final letter is sent when patient has not responded to first letter and phone call, • Final phone-call is made to patient who has not responded before submitting account for approval

to write-off, • When a patient advises they are unable to make payment, and a sponsor has been identified, CM

Health/healthAlliance pursues the sponsor for payment, • Immigration New Zealand is advised of the debt incurred by the patient.

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Where there is no response to reminder letters and phone calls, accounts are written-off to a debt collection agency at 90 days (local or international depending on the patient’s whereabouts). Table 2 - Bad debt write-off for the last 3 years:


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Emergency Department, Medicine & Integrated Care Glossary NBSP National Bowel Screening Programme DNR Did Not Return Echo An Ultrasound examination of the heart FCT Faster Cancer Treatment FSA First Specialist Appointment MRT Medical Radiology Technician NIV Non-invasive ventilation Service Overview The Emergency Department, Medicine and Integrated Care service is managed by Brad Healey, General Manager, with Clinical Directors/Heads Dr Carl Eagleton (Medicine), Dr Jeremy Dryden (Emergency Care), Dr Sally Urry (Breastscreen), and Clinical Nurse Directors To’a Fereti and Annie Fogarty. Responses to Action Items Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 15.11.2017 – National Bowel Screening Programme “Provide a regular update on the Bowel Screening Programme”. CM Health has been working closely with the National Bowel Screening team at the Ministry of Health for the past year to plan for the implementation of the National Bowel Screening Programme for the CM Health population from July 2018. A range of issues with available funding, clinical and facility capacity, and required IT infrastructure investment have needed to be flagged and resolved. As part of our planning, we worked with the National Bowel Screening team to develop a model of service delivery that maintains consistency with the underpinning National Bowel Screening Programme. In order to implement the programme on a financially sustainable basis within the scheduled start date of July 2018, we will set up our programme resources in a different way to that originally envisaged and supported by the MoH National Bowel Screening team. Highlights BreastScreen As at 30 November, Total BreastScreen coverage exceeded the national target of 70% coverage (for women 50-69 years) at 70.2%, with coverage for Maaori at 66% and Pacific at 78.7%. Coverage had dropped during the year due to MRT shortages, but the service is again fully staffed, and has an additional mammography machine giving the capacity to screen more women. BreastScreen Counties Manukau continues to implement strategies to increase Maaori screening volumes. We are focussing on inviting Maaori women on the DNR lists for Manukau SuperClinic and the Mangere sub-site during December. The mobile unit will be off the road from 8 December 2017 to 8 January 2018 for maintenance. We will commence advertising on radio and Maaori TV in early 2018.

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The service has commenced screening on Sundays at MSC once a month, in addition to Saturday and evening clinics. These after-hours clinics are always booked in advance, and are very popular. Early indications are that more Maaori and Pacific women are attending Sunday clinics than clinics on a Saturday. Dermatology The Dermatology/Infectious Disease Clinical Nurse Specialist (CNS) is completing orientation, and in early 2018, will set up clinics for complex eczema/ cellulitis patients at MSC, and also locality clinical in Mangere/ Otara. These clinics are intended to reduce hospital presentations and admissions for these conditions. Rheumatology New Gout booklets, translated to Samoan and Tongan, were launched in November. This is part of an ongoing project that aims to provide easy-to-understand information to people with Gout, and improve the understanding and management of Gout in the community. Immediate Demand and Facilities Infrastructure Teams are putting significant effort into supporting the programme Business Case, to address the immediate demand for additional facilities and workforce. We have are prepared detailed business cases covering General Medicine, Cardiac Cathlab, and Gastroenterology Procedure Room Capacity. We have completed (and the Board has approved) the business case for the expansion of the Scott Dialysis Unit. Emerging Issues

Update on previously reported issues

Issue Date reported Update Gastroenterology challenge of maintaining FCT and MoH Targets

August 2016 CM Health has maintained the MoH targets for colonoscopy in November. This was possible through outsourcing and some SMOs doing additional lists in-house. Over the holiday period, productivity will be reduced significantly, with the service closed for a number of days, and the SMOs who do additional lists taking annual leave. This will result in approximately 260 elective colonoscopies procedures not done over this time. As demand continues to increase, the potential for an increase in the colonoscopy waiting list in the next 4 months is high.

Lung Function Accreditation

April 2017 The plan to redevelop the MSC lung function laboratory, and create a second testing space has been agreed by all parties, and is now being implemented.

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Cancer – Capacity related breaches related to CM Health services.

Sept 2017 November performance was 100%. All breaches, regardless of reason, are reviewed at a tumour stream level and areas for service improvement are identified. Cancer Nurse Coordinators are working closely and communicating with the cancer tracking team.

Acute Demand Update Emergency Department During November, ED presentations totalled 9,517, which is a 2.6% increase over November 2016. Year-to-date (YTD) presentations are 59,625 - a 3.4 % increase from YTD last year. In November, daily average patient presentations to the department were 317.

Emergency Care Length of Stay National Health Target Patient volume and bed demand pressures mean that the hospital has been unable to reach the six-hour target; achieving 90% for November against a target of 95%. This is due to a variety of factors, consistent high surge presentation rates and continued high hospital occupancy after winter. The graph below shows daily performance against this target.

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Daily ED performance against the six hour target – November 2017

Integrated Care – Ambulatory Services Update The text scheduling pilot with Referral and Appointment Centre and Customer Service Centres has been implemented by all services, with some variation for particular clinics. Analytics reports are being further refined by Decision Support, to provide accurate and efficient information to services on 120-day waits status and patient domicile to improve monitoring of key targets The continued challenge of having sufficient space at MSC and in localities, with all alternate space ideas are being considered and discussed. Current available space is being analysed, to determine other uses, and staff with rarely used office spaces are being asked to make it available for larger groups. The IPM upgrade did challenge the teams at MSC, and localities with the significant growth in information required to be reported to the Ministry of Health. This is impacting on the clinical teams. The Clinical Systems Support Team continues to provide support to iPM users as they become accustomed to the process changes that have been introduced. When it is identified that a number of staff are struggling with a new process, user guides directly relating to the issue are written and circulated. A register of all issues has been developed to keep track of these and the work-around developed. Faster Cancer Treatment (FCT) Update From 1 July, 2017, technical changes to the FCT target exclude patients who breach for patient choice or technical considerations. CM Health has achieved 93% performance for the 6 month period June to November 2017, and has achieved the target for the September quarter at 94%. The FCT project team is reviewing current resources used for FCT, and identifying requirements beyond the FCT project funding to maintain sustainable tracking and oversight of performance. This includes consideration of the Cancer Tracker and other roles, which are fixed-term. Funding will also

035


be required for the Cantrack web-based service to enable tracking and monitoring of patients across tumour streams. Regional performance data has indicated that Maaori feature more prominently in capacity breaches, usually as a result of ‘just-missing’ pathway milestones. A focused piece of work is being developed to closely micro-manage Maori patients on the lung pathway, in a bid to achieve key milestones in a timely manner. Performance will be measured against data obtained prior to the project starting, and recommendations for other streams will be made depending on results. Renal Update Renal in-centre treatments are down 2.5%, in part due to strategies to stem the numbers of in-centre dialysis patients, we have implemented the "Home and Kidney First" policy. This has resulted in the number of in-centre patient volumes plateauing for the last 16 months. This is favourable result, as we are aiming for fewer patients to be on dialysis. Home therapy patients are down for various reasons, including less people coming onto dialysis in general due to improvements in management of CKD and pre-dialysis care, more Advance Care Plans in place, and more transplantation, from the home therapy population. All of this is a result of positive action to reduce dialysis in our population. The service is also reviewing the model of care for home dialysis patients, both PD and HD, in order to increase the number of people on home therapies, which have plateaued at 43%. This will involve reorganising the home therapy units, and utilising the Rito 2 dialysis facility as a prototype of the “Reception Unit” put forward in the future plans at Manukau. The negotiations for the national peritoneal dialysis (PD) contract have been concluded, and we are now waiting for the contracts to be drawn up. CM Health is set to make considerable savings with the new contract, so we are keen to get the contracts completed, in order to recognise these savings. Pharmac will be issuing an RFP in Jan/Feb 2018 for a national haemodialysis (HD) contract round. This is a complex area and will take more than a year to complete. Our Renal Services Nurse Practitioner is leading the establishment of a national database for chronic kidney disease (CKD)/pre-dialysis patients. This is the first of this type of database in NZ, and will help inform future planning of services required, and care as well as enabling research on this group of people, and potentially develop care that slows or stops the progression of CKD.

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Trend Rating Commentary (by exception)FY17-18 Nov-17 Target Var Actual Target Var

Total Caseweight 2,330 2,410 -3.3% 13,094 13,145 -0.4%Elective Caseweight 64 71 -9.9% 305 368 -17.1%Acute Caseweight (includes Intensive Care Unit) 2,266 2,339 -3.1% 12,789 12,777 0.1%Outpatient First Specialist Assessment (FSA) Volumes 1,316 1,497 -12.1% 6,816 6,915 -1.4%Outpatient Follow Up Volumes 3,728 3,761 -0.9% 17,997 17,639 2.0%Virtual First Specialist Assessments (FSAs) 106 186 -43.0% 838 915 -8.4%

Trend Rating Commentary (by exception)FY17-18 Oct-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years 7.9% 5.0% -2.9% 7.5% 5.0% -2.5%% Staff Turnover 12.4% 10.0% -2.4% 11.1% 10.0% -1.1%% Sick Leave 3.5% 2.8% -0.7% 3.0% 2.8% -0.2%Workplace Injury per 1,000,000 hours 0.0 10.5 10.5 19.8 10.5 -9.3


No. Falls causing major harm 0 0 0 0 0


% Radiotherapy commences in 4 weeks 100% 100% 0% 100% 100% 0%% Chemotherapy commences in 4 weeks 100% 100% 0% 100% 100% 0%% of patients admitted, discharged, transferred from ED within 6 hrs

90% 95% -5% 91% 95% -4%improving performance, but still stuggle to meet TBS times - capacity and flow are still a challenge

P1 (urgent) % diagnostic colonoscopy patients receive the procedure within 14 days 97% 85% 12% 98% 85% 13%P2 (routine)% diagnostic colonoscopy patients receive the procedure within 42 days 77% 70% 7% 69% 70% -1%% surveillance colonoscopy patients receive their procedure within 84 days of planned date 84% 70% 14% 88% 70% 18%P1 (urgent) % diagnostic gastroscopy patients receive the procedure within 14 days 98% 85% 12% 99% 85% 14%P2 (routine)% diagnostic gastroscopy patients receive the procedure within 42 days

44% 70% -38% 41% 70% -29%Volume & waiting times are slowly decreasing, as doing more gastroscopies. SMO who does a large volume of the gastroscopies on sick leave

% surveillance gastroscopy patients receive their procedure within 84 days of planned date 85% 70% 13% 83% 70% 13%% cardiac STEMI - PCI (angiography) within 120 mins - Northern Region Target (Note this KPI is measured one month in arrears).

78% 80% -2% 78% 80% -2%Fewer PCI's performed than the previous month, has helped lift performance against the target

% Coronary Angiography within 90days (1 month in arrears) 100% 95% 5% 94% 95% -1%Medical Assessment – Triage 3-5 patients seen within 60 minutes 78 60 18 31 60 -29 Testing possible model of care in Acute AssessmentDoor to Cathlab suspected Acute Coronary Syndrome < 3 days (median time) 76% 70% 6% 70% 70% 0%General Medicine - Seen By Time (minutes)1st Time to be seen Triage 1 & 2 patients (median time in minutes) 35 30 -5 33 30 -31st Time to be seen Triage 3 - 5 patients (median time in minutes) 89 60 -29 87 60 -27 Unable to meet - due to surge presentation of patients 2nd Time to be seen Triage 1 & 2 patients (median time in minutes) 58 30 -28 62 30 -322nd Time to be seen Triage 3-5 patients (median time in minutes)

71 60 -11 80 60 -20Reflects busyness of specialties able to see patients in required time

FCT - % high suspicion first cancer treatment within 62 days - MOH Health Target 100% 90% 10% 94% 90% 4%FCT - %confirmed diagnosis first cancer treatment within 31 days 93% 85% 8% 94% 85% 9%

EMERGENCY DEPARTMENT, MEDICINE AND INTEGRATED CARE SCORECARD November 2017

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Average Length of Stay - Acute 3.5 3.5 0.0 3.4 3.5 0.1Acute Readmissions within 28 days - Total 8% 10% 2% 13% 10% -3%Acute Readmissions within 28 days - 75+

11% 10% -1% 15% 10% -5%Overall YTD rates high, and reflective to the increased demand, work pressures and complexity. The readmission rate this month has improved

% of patients on home wards in General Medicine

31% 75% -44% 31% 75% -44%

Higher than expected volumes with high occupancy saw more outliers. A small change is currently being trialled - to outlie patients in specific areas per team to minimise the impact on wards & teams

% of Outliers on non-medicine wards18.0% 0.0% -18.0% 18.0% 0.0% -18.0%

Not possible to achieve - occupancy is higher than the capacity for General Medicine wards


% Discharges from transit lounge or home by 1100hrs

14% 30% -10% 18% 30% 12%

The discharge by 11am rate is falling - but small improvement this month. Nurse led Discharges and systems continues.With summer demand likely to be some positive change on discharges by 11am. Improvement may include simplifying EDS, and also looking at potential solutions to discharge clerking

% Discharged from Medical Assessment Unit by 1100hrs

35% 40% -5% 32% 40% -8%

Model of care is currently being evaluated by a project team to see how improvements can be made in MA. A nurse coordinator role is being trialled in MA, aim of improving flow and discharges. Nov discharges by 11am from MA improved

% of patients < 28 hrs discharged from inpatient wards 11% 10% 1% 10% 10% 2%Implement Home First Renal policy - (increase Continuous Ambulatory Peritoneal & HD rate)

43% 50% -7% 43% 50% -7% Overall dialysis numbers are down 8 from October, Haemodialysis is down 9, but home haemodialysis is up 1. Peritoneal dialysis has increased by 1, 4 transplants in November.


% Women with Breastscreen in last 24 months - total 2630 2400 230 70% 70% 0%% Women with Breastscreen in last 24 months - Maaori 282 289 -7 66% 70% -4%% Women with Breastscreen in last 24 months - Pacific 516 377 139 79% 70% 9%

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Volumes Screened % Screened in last 24 Months

The service continues to work on strategies to increase Maaori coverage.

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Surgery, Anaesthesia & Perioperative Services Glossary

ESPI Elective Services Patient Flow Indicator FSA First Specialist Assessment ORL Otorhinolaryngology SMO Senior Medical Officer WIES Weighted Inlier Equivalent Separations YTD Year to Date Service Overview

Surgery, Anaesthesia, and Perioperative Services is managed by Mary Burr (General Manager), with Dr Mark Moores (Clinical Director, Surgery, Anaesthesia and Perioperative Care), Dr Tony Williams (Clinical Director, Critical Care Complex), Jacqui Wynne-Jones (Clinical Nurse Director, Surgery, Anaesthesia and Perioperative Services), and Annie Fogarty (Clinical Nurse Director, Acute and Critical Care Complex).

Highlights Volumes • Acute discharges are 56 cases higher than contract for the month or 3.33%. The comparative

figures YTD are 134 cases and 1.62% over contract. • Total Surgical patients (excluding Gynae) treated and discharged for the month was 2,953

compared with a contract of 3,053, and 2,831 for November 2016. • Hip and Knee discharges are 86 patients ahead of monthly target of 73 (YTD 401 achieved v 357

target), and cataracts discharges are 144 patients ahead of target (YTD 707 achieved). This gives us a good buffer for the target results as we go forward.

• Acutes WIES are 7.65% higher than contract for the month and 4.35% over YTD. • Outsourced elective patients totalled 84 for the month (YTD 395), compared with a target of 83

for the month and 421 for the year. • We continue to manage very high acute surgical volumes, with demand not abating post-winter. Safety Surgical Safety audits (Health Quality and Safety Commission) – 1,700 audited moments were completed from July to October 2017. Theatre Performance Overall Acute Theatre Performance Acute outputs increased during November 2017 to 122,071 minutes which is higher than at the same period last year by 6,930 acute minutes.

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Elective Performance at MSC Continue to maintain the elective theatre utilisation rates at 82.3% for the year-to-date.

Elective Access

Target

Result October (actual)

Result November (indicative)

Description -The volume of elective surgery will be increased by an average of 4,000 discharges per year.

Achieved ☐ 99.0% Variance from Plan: 73

Achieved 99.5%

Objective - Sustain ESPI 2 (FSA) and ESPI 5 (Treatment) wait time targets

FSA: 20 breaches Treatment: 34 breaches

FSA: 35 breaches Treatment: 49 breaches

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Emerging Issues

Updates on previously reported issues

Challenges Date reported Update

Critical Care (ICU) beds under increasing demand

27 July 2016 Patient flow through the unit was stable. November 17: 153 admissions for the Critical Care Complex, there were 20 admissions for children.

Demand on Ophthalmology and Otorhinolaryngology (ORL) Services

27 July 2016 We continue to make progress with our delayed follow-ups, and we are part of the National Programme to monitor and improve these results. Utilising Nurse Virtual Reviews, and looking at options for Technician-led and virtual review options. All long waiting patients are being sent personalised letters to inform of delays, and offer advice on self-care.

Potential machinery failure in the MSC Sterile Supply Unit

8 March 2017 The CSSD refurbishment programme will start in 8 Jan 2018. Strong contingency plan in place, to ensure we do not lose too much productivity during this period.

Anaesthetists’ shortage 15 Oct 2017 Service Sizing currently being completed by an independent consultant. Recruitment is ongoing and a plan is in place for a continual recruitment drive until optimal agreed FTE is reached.

Elective performance is under threat due to sustained high acute volumes and anaesthetists shortage.

15 Oct 2017 Pressure continues on both ESPI 2 (FSAs) and ESPI 5 (Treatment) in a number of services. This will take close management over the next few months. Both SAPs Governance and Management teams will be focussed on this challenge.

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Critical Output Targets: November 2017

Activity Commentary

Month’s Critical Output Targets

Total surgical patients (excluding Gynae) treated and discharged for the month was 2,953 compared with a contract of 3,053 and 2,831 for the corresponding month of the previous year. Year to date actuals were 14,789 patients in comparison with contract of 14,900 and 14667 for the previous year.

This shows an increase of 122 patients year-on-year, for the five month period, and is attributable to an increase in acute workload set off partly by reduced electives for the period.

Outsourced elective patients totalled 84 for the month (YTD 395), compared with target of 83 for the month, and 421 for the five months to end November 2017.

Internal elective productivity (excluding outsourcing) is 0.3% or 17 patients lower for the five months of this year, and 66 patients lower than contract for the same period.

Hip and Knee actual is 86 patients treated (YTD 401), against target of 73 (YTD 357),

Cataracts actual is 144 patients (YTD 707) vs target of 116 (YTD 563)

Bariatric patients treated are an actual 23 (YTD 49), compared with target of 14 (YTD 67). Bariatric YTD outputs are below target, as one surgeon who specialises in this procedure on leave. A plan to address this shortfall is in place and will be on target by December/ January.

WIES Acutes WIES 7.65% higher than contract for the month and 4.35% YTD.

Electives WIES is 18.41% below flexed contract for the month and 2.8% below contract YTD.

The month's elective outputs were impacted by cancellations on the day of surgery, and the mix of work carried out, together with a correction of outsourced outputs based on the cube-data rather than DSS reports.

Overall outputs are 110 WIES below contract for the month (YTD 221 WIES over Contract). Acutes are 147 WIES over contract for the month (YTD 411 WIES) and Electives are 257 WIES below contract for November (YTD 190 WIES behind).

If we compare our performance with the previous financial year, Electives are 574 WIES or 8.01% lower year to date. This comparison is between the outputs in WIES 17 for 17/18, compared with WIES 16 in the previous year.

It must be noted that part of this variance is due to Surgical DRGs having in general a lower WIES per case in 17/18 compared to 2016/17, and partly due to reduction in volumes over the period.

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Discharges/ ESPI

Acute discharges are 56 cases higher than contract for the month or 3.33%. The comparative figures YTD are 134 cases and 1.62% over contract.

Elective discharges (inpatients /day patients) were 156 patients lower than contract and 245 patients YTD.

Overall, 100 patient discharges lower than contract and 111 YTD.

In comparison with that of last financial year, acute discharges are 304 patients over, and elective patients are 182 patients under.

Overall, therefore we are 122 patients higher, compared with the corresponding period of the last financial year.

ESPI Results:

ESPI 2 FSA (120-day FSA threshold): There were 35 patients breaching mostly in orthopaedics.

ESPI 5 Treatment (120-days treatment threshold): Elective patient cancellations at CM Health facilities, mainly due to a backlog as a result of high acute demand, resulted 31 patients (excluding Gynae) breaching for the month.

This resulted in a Red ESPI for November.

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November 2017


Total Caseweight (Provider view) 3,215 3,325 -3.3% 16,459 16,238 1.4%Elective Caseweight 1,141 1,399 -18.4% 6,597 6,787 -2.8% see narrativeAcute Caseweight 2,074 1,926 7.7% 9,862 9,451 4.3%Acute discharges 1,741 1,685 3.3% 8,400 8,266 1.6%

Elective Surgical Discharges 1,212 1,368 -11.4% 6,389 6,634 -3.7%Shortfall on Inpt Elective discharges only. Outsourcing report provided by DSS does not agree with the CUBE data .

Virtual FSAs/Follow ups -(GP consult and nonpatient appointments) 149 128 16.6% 746 651 14.5%Personnel Costs ($000) $12,920 $13,381 3.4% $63,946 $66,338 3.6%Financial Result Total ($m) $15,926 $16,331 2.5% $77,498 $79,432 2.4%

Reduce clinical outsourcing ($000) $533 $451 -18.2% $2,385 $2,166 -10.1%Outsourcing required (due to list cancellations), for elective volumes. $ unfavourable due to subcontracting weighted towards Ortho, but procedure volumes YTD are under budget (395 vs 421)

Trend Rating Commentary (by exception)FY17-18 Actual Target Var Actual Target Var

% Staff with Annual Leave > 2 years 15.5% 5.0% -10.5% 15.0% 5.0% -10.0%% Staff Turnover 8.3% 10.0% 1.7% 9.7% 10.0% 0.3%% Sick Leave 2.7% 2.8% 0.1% 2.5% 2.8% 0.3%Workplace Injury per 1,000,000 hours 0.0 10.5 10.5 10.20 10.5 0.3


Hand Hygiene compliance rate (based on Gold Audit) - Ward 11 76% 80% -4.0% 74% 80% -5.9%Pressure Injuries / 100 patients 0.0 0.0 0.0 0.0 0.0 0.0Falls causing major harm / 1000 bed days 1.0 0.0 1.0 1.0 0.0 1.0Severe Pressure Injury (ungradeable) per 1000 bed days 0.0 0.0 0.0 0.0 0.0 0.0Surgical Site Surveillance for Major joints-

Antibiotics given 0-60mins before "knife to skin" 90% 95% -5% 91% 95% -4%2 grams or more Cefazolin given 100% 100% 0% 100% 100% 0%Appropriate skin preparation 99% 100% -1% 99% 100% -1%

CLAB rate/ 1000 line days 3.0 0.0 -3.0 3.0 0.0 -3.0Rate of S. aureus bacteraemia per 1000 bed days 0.2 0.0 -0.2 0.2 0.0 -0.2VTE - Ortho (Acute and Elective) 3.0 2.0 -1.0 16.0 0.0 -16.0

Trend Rating Commentary (by exception)

FY17-18 Nov-17 Target Var Actual Target Var

Pre-operative Length of Stay Days (from admit to surgery) 1.06 1.0 -0.06 1.22 1.0 -0.2 Substantial improvement for the month- good progress being made

ESPI 2 No. patients waiting >120 days for FSA - Elective (Surgical Services incl Gynae)

35 0 -35.0 35 0 -35.0 see narrative

ESPI 5 No. patients waiting >120 days Treatment - Elective (Surgical Services incl Gynae)

31 0 -31.0 31 0 -31.0see narrative

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SURGERY, ANAESTHESIA & PERIOPERATIVE SERVICES SCORECARD

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Average Length of Stay - Acute Inpatient incl Burns 3.91 3.8 -0.1 3.85 3.8 -0.1Average Length of Stay - Acute Inpatient excl: Burns 3.90 3.8 -0.1 3.81 3.8 0.0Average Length of Stay - Acute Inpatient excl: Burns and Spinal Ortho 3.90 3.8 -0.1 3.80 3.8 0.0Average Length of Stay - Electives 1.09 1.5 0.4 1.15 1.5 0.4


Theatre list utilisation - % used MMH/MSC 88% 85% 3% 83% 85% -2% Improved theatre utilisation for the month (3% in excess of target)Theatre session utilisation - % used MMH/MSC 89% 95% -6% 95% 95% 0% Low session utilisation due to list cancellation for AcutesElective Theatre turnaround times- Mins (MSC only) 14 15 1 14 15 1Elective cancellations - Day of surgery as % of all Elective (all reasons)- SAPS only 9% 5% -4% 9% 5% -4% see narrativeDay of Surgery Admissions (DOSA) 93% 90% 3% 91% 90% 1%Day Case Rate (Elective/ Arranged) -Subspecialties in SAPS only Adults/kids 64% 65% -1% 65% 65% 0%MMH % patients discharged to discharge lounge or home by 1100hrs 26% 30% -4% 26% 30% -4%MMH % patients discharged to discharge lounge or home by 1100hrs -GEN SURG 25% 30% -5% 28% 30% -2%MMH % patients discharged to discharge lounge or home by 1100hrs- ORTHO 23% 30% -7% 23% 30% -7%MMH % patients discharged to discharge lounge or home by 1100hrs- PLASTICS 33% 30% 3% 28% 30% -2%Ratio FSA/FU clinic ratio 36% 31% 5% 36% 31% 5%Outpatient DNA rates - overall- Surgical Services only 9% 10% 1.5% 8% 10% 1.8%Outpatient DNA rates - Maori (FSA) - Surgical Services only 16% 10% -6.4% 15% 10% -5.0%Outpatient DNA rates - Pacific (FSA)- Surgical Services only 15% 10% -4.8% 13% 10% -3.2%


% of hospitalised smokers receiving smokefree advice & support -Total (Surgical)

94% 95% -1% 94% 95% -1%follow up occuring


Patient Experience Survey - month (n=91) and YTD (n=91) 96% 90% 6% 89% 90% -1%

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045


Central Clinical Services

Glossary CT Computed Tomography eMR Electronic Medicine Reconciliation ePA Electronic prescribing and administration IANZ International Accreditation New Zealand IV Intravenous MRI Magnetic Resonance Imaging MRT Medical Radiation Technologist PGYI Post Graduate year 1 VTE Venous Thromboembolism Service Overview The Central Clinical Services Division is managed by Ian Dodson (General Manager), with Clinical Directors/ Heads Dr Ross Boswell (Laboratory), Dr Sally Urry (Radiology), Dr Mary Christie (Histopathology), and To’a Fereti (Clinical Nurse Director). Highlights Laboratory The Patient Blood Management clinical specialist nurse started in November, signalling the start of the new Patient Blood Management project. The project will target improved appropriate usage of red blood cells in the management of iron deficiency anaemia. Similar initiatives nationally and worldwide have significantly improved management of anaemia, and pre-operative optimisation of iron levels, which results in better surgical outcomes. Pharmacy and Medication Safety In November, the House Officer (PGY1) Orientation included four Pharmacy education sessions, on anticoagulation prescribing (warfarin and IV heparin), VTE prevention, opioid-induced constipation prevention, and insulin safety. The e-Medicines Project is progressing, and is expected to be delivered on time. • E-Pharmacy preparation and pharmacy staff training was completed in November and e-

Pharmacy was successfully installed in December 2017. Key go-live issues were mainly associated with integration between e-Pharmacy and Pyxis occurred, and the project team is working to resolve issues as quickly as possible.

• ELT has approved ePA project to continue, with expansion across all five ARHOP areas. The MedChart project (phase 1) is progressing with an anticipated go-live from May 2018. Super user training and user acceptance tests are scheduled in January.

Emerging Issues Laboratory Services Turnaround times for November were impacted by the poor IT performance, when the system became unstable, variable and ultimately untenable. The system was rolled back to the previous Exadata platform which it had been moved in late October. An incident review has been requested from healthAlliance Information Technology services.

046



Issue Date reported Update Reduced Radiologist FTE Sept 2016 The Radiologist FTE will improve slowly, however the

current ability of the Radiology service to meet the demands placed upon it is challenging. As at November 2017, service is 3.79 FTE down, and 3 staff are on parental leave, with a further 3 to go on parental leave in early 2018. We are advertising internationally, and are in discussions via Recruitment with Global Medical, on long-term locum options. This shortage, accompanied by the MRT workforce issues continues to provide a challenging environment to meet MoH targets. Volume of unreported non-urgent general x-rays has been reduced from 3,515 (August) to the current figure of just under 1,000 (end November). This continues to be a focus point for the SMO’s.

General x-ray service Sept 2016

The impact of the MRT staff shortage on our general x-ray waiting list is marked. The current waiting list is just under 4,000. In discussion with the Clinical Director and MRT team leader, we are now planning to recommence evening sessions (17:00-20:00), as soon as new employees commence. As the staffing levels increase, we expect that the waiting list will start to level and then decline. Outsourced and contracted plain-film reads will continue to manage the increased volume of scanning.

Histopathology Lab March 2017 IANZ have been kept informed of the progress to date, and are aware that to progress a move in to a new space, we are waiting the outcome of the seismic review of the Galbraith Building. The recent laboratory reconfiguration has provided the best possible workflow given the space constraints.

MRT FTE

Apr 2017 Good progress has been made with the ED X-ray issues, around patient safety and patient flow. This work continues. November 2017: 13 FTE under budget, however by

047


the end of December, this will have reduced to 7 FTE. New MRT recruits will commence from Monday 13 November through to January 2018.

Commentary on Performance against National Health Targets MRI – 85% of community referred MRI scans completed within 6 weeks: Not achieved (33%) A combination of a lack of availability of MRI scanning time (equipment) has contributed to this result, as well as MRI technicians deployed to assist in general X-ray. Outsourcing continues at the higher rate of 50 per week. Private providers are at capacity with accepting outsourced volumes. CT – 95% of community referred CT scans completed within 6 weeks: Not achieved (91%) Acute demand for November was just under 400/week, with elective demand slightly reduced to just under 300. The MRT staffing shortage has had an effect on the CT staffing, with CT-trained technicians being utilised to provide service. Improved staffing in December should have a positive impact on CT production. Food Service – Patient Satisfaction Report Update The Food Service Agreement includes a KPI for patient satisfaction survey responses, with a monthly survey carried out, aiming for 150 responses per month. For November, Compass distributed 165 surveys, with 114 patients responding, along with 37 staff. In addition, the Cemplicity CM Health patient survey responses from post-discharge survey are monitored, with a variable monthly response rate. The Cemplicity patient satisfaction rating for food in November was 84%, compared with 79% in October. The Compass patient satisfaction rate is 98.8% this month, compared with 98.0% last month. Three areas scored less than 95% satisfaction – appearance of meals, taste of meals, and temperature of the hot food. The patient survey comments provided 16 constructive comments. The temperature of hot food is consistently lower than the other elements of satisfaction. Compass will be asked to add this to the improvement plan, and to target action on this. A Compass Continuous Improvement plan has been developed from the feedback received over the last three months.

048



% Staff with Annual Leave > 2 years 9.3% 5.0% -4.3% 9.6% 5.0% -4.6% Leave planning in Laboratory started to reduce outstanding leave balances% Staff Turnover 2.4% 10% 8% 2.6% 10% 7%


% electronic medication reconciliation completed for high risk patients within 48hrs

77% 80% -3% 80% -80%


% MRI scans completed within 6 weeks from acceptance of referral 52% 85% -33% 57% 85% -28% MRT staff FTE increase from mid Nov - 2 MRI graduates, will help alleviate. % CT scans completed within 6 weeks from acceptance of referral 91% 95% -4% 93% 95% -2% Almost at target, new trainees commencing in 2018Radiology - Inpatient radiology times < 24hours 90% 95% -5% 91% 95% -4%Radiology ED radiology times < 2 hours

92% 95% -3% 94% 95% -1%

Laboratory -Test turnaround time (TAT) within 60minsPotassium 94% 90% 4% 97% 90% 7%Haemoglobin 99% 98% 1% 99% 98% 1%PT/INR

97% 98% -1% 97% 98% -1%Slightly off targets due to some issues with the IT system that have been resolved

Troponin 1 for ED 91% 90% 1% 93% 90% 3%Histology - All - 5 working days 90% 90% 0% 90% 90% 0%Breast - 3 working days 98% 80% 18% 97% 80% 17%Non gynae FNAs - 3 working days 88% 90% -2% 91% 90% 1%Blood Bank - antibody screen within 4 hours 97% 90% 7% 96% 90% 6%MicrobiologyCSF cell count <30mins 92% 90% 2% 95% 90% 5%ESBL screens <2days

94% 95% -1% 94% 95% -1%Slightly off targets due to some issues with the IT system that have been resolved

CDT (C. diff Toxin) <25hrs 92% 90% 2% 94% 90% 4%UCHM (Urine Chemistry) <60mins 93% 90% 3% 93% 90% 3%% radiology results reported within 24 hours

55% 75% -20% 48% 75% -27%SMO still working with reduced FTE. Outsourcing has been set up- number of unread reports reducing overall.


% transcribed clinical summaries (meddocs) authorised <7 days of creation65% 95% -30% 68% 95% -27%

Ongoing work with clinical services to improve review and acceptance of transcription

Tim

ely

Year to date

Significant MRT & Radiologist short staffing impacts this target, however a focus is on this aspect. Staff doing extra shifts to manage volumes. Pilot/tirals being run in ED to improve turnaround times

Syst

em

Inte

grat

ion

(Eff

ecti

ve) Year to date

Safe

ty

Year to date

CENTRAL CLINICAL SERVICES SCORECARD November 2017

Enab

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Hig

h Pe

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g 12 month average

SCORECARD

049


Women’s Health and Kidz First

Glossary ALOS Average Length of Stay CS Caesarean Section HCA Health Care Assistant KF Kidz First LMC Lead Maternity Carer Service Overview Kidz First and Women’s Health is managed by Nettie Knetsch (General Manager), with Dr Wendy Walker (Clinical Director Kidz First), Sarah Tout (Clinical Director Women’s Health), Thelma Thompson (Director Midwifery), and Michelle Nicholson-Burr (Clinical Nurse Director).

Highlights Activity Summary For Nov 2017, discharges in Kidz First Medical were up by 6 on the previous November. ED presentations (2,098) were up 13 for the month. In summary, the past 5 months have seen 504 more ED presentations. Of note, remain the high number of presentations between 4.00 pm and midnight. Neonatal Unit Discharges from the Neonatal Unit were down by 15 babies for the period YTD November 2017 and the WIES is down by 63 YTD reflecting the sudden decrease in overall admissions from the last week in July and throughout August and beginning of September. However, since mid-September and through all of October the Unit has been very busy again with occupancy for November reaching 94% (based on resourced 32 cots for November). We anticipate that the WIES therefore will increase significantly in December, or possibly in Jan/Feb 2018 (more than 50% of babies admitted to NNU were level 3) when these babies will be discharged (based on ALOS of 21 days YTD). Births There were 544 births at MMH and 82 at the 3 community units, a total of 626 births for the month which is 52 births more than November 2016. YTD the variance is 93 births (3%) more which is the first time we have seen an increase above 1.5% as the birth rate has been extremely stable since 2014. The distribution of births continues to see a further decrease of 22 in the Primary Birthing Units YTD across the 3 Units and 115 more births at MMH. However, occupancy for postnatal stay at the Primary Birthing Units (in particular Botany and Papakura) remains high reflecting the utilisation of the Units for women transferring from MMH after birth to the Units. Staff and Patient Engagement As part of the Living our Values project on the Maternity Wards, one of the aims is to increase the amount of feedback received from hospitalised antenatal women from 0% to 15% by 1 March 2018, to capture their inpatient experience and improve care provision.

050


This initiative has now started and in the process of completing four PDSA cycles. These PDSA cycles include: the introduction information script, cue card, tablet administration and the process for capturing the completion of the survey on the ward patient white board. We now have 3 HCAs assisting the women with completion of the survey and have seen an immediate increase in number of Patient Satisfaction Survey responses for the month. Staff sickness for Kidz First in November came down to the usual post-winter sick leave levels. For Women’s Health, staff sickness continued to be higher than previous year reflecting the pressure on the workforce due to vacancies and increasing acuity. Regular update on Maternity Clinical Information System (MCIS) Ministry of Health: Other than the ongoing work on the national Clinical Advisory groups and an upcoming meeting of the new National Steering Group on 15 December 2018 there has been no further communication from Ministry of Health.

Local CM Health Development: Letter of Agreement with Clevermed extended till 28 February 2018. There has been no further contact from Ministry of Health on the amendments to PHE (Participating Health Entity) agreement for CM Health, to reflect that we have now been going for almost 3 years. Update on previously reported issues

Issue Date first reported

Update

Neonatal Unit capacity

April 2016 Occupancy for November increased to 94% (resourced 32 cots). Regional neonatal capacity report was finalised, with presentation to regional forums and to align with the regional LTIP work. The report has now been discussed at the SRG meeting with a recommendation for CM Health to model out taking all level 2 babies back from ADHB as soon as stable. The current maternity model allows CM Health women to birth at ADHB facilities, and hence some 250 babies per annum with a CM Health-domicile staying at ADHB facilities. With our projected growth and repatriating these babies the CM Health Unit will have to resource up to 32-34 cots as soon as possible and has to start planning for increasing physical capacity to 46 over the next 12 months to accommodate the growth and return of the babies previously staying at ADHB. Our physical capacity growth will allow ADHB to stay with their current cot capacity and be able to always accommodate the quaternary (surgical and cardiac) babies from ADHB, WDHB, NDHB and CM Health. Meetings in December to progress the regional management of cots and transfer of babies processes, and

051


set up a work plan for 2018 to review models of care across all 4 Units (including Northland) in particular in regard of the management of level 1 babies (low acuity neonates) and where they can best be manages (maternity ward or even consider paediatric wards).

Caesarean Section (CS)rate

January 2017 CS rate for November YTD decreased slightly to 26%, YTD the rate is 28% (2% up on last year). The increase is all in acute CS. The CS rate and processes are reviewed routinely with the clinical team. An electronic pathway for elective CS will go live in December. At the June regional Women’s Health meeting significant increases in CS rates were also reported from Auckland and Waitemata, and the region will continue with data analysis and clinical discussion to understand what is driving the significant spike across the region over the past 7 months. Midwifery (both LMC and self-employed) and junior medical staff shortages may well be a factor in this increase as well as the impact of new practice guidelines. We have appointed a new Specialist Obstetrician, whose focus will be on the Birthing and Assessment area. She will be involved in the Birthing and Assessment Improvement Project which is starting in December 2017.

Midwifery workforce

January 2017 The data presented by HWNZ highlighted the specific Auckland issues, but was not complete - it had missed DHB employed community midwifery FTE. Feedback was provided, and the Midwifery Strategic Advisory Group is finalising their work plan in September which will be signed off by HWNZ Board, and then distributed to DHBs. Unfortunately, we are still awaiting the updated data from HWNZ on the overall midwifery numbers required by DHB at this stage. The regional GMs, CDs, and Directors of Midwifery continue to meet monthly to provide updates on the current regional midwifery shortages. Each DHB has different pressures, with ADHB currently having the biggest employed midwifery shortfall, and CM Health having shortages in the senior midwifery positions (particularly in Birthing and Assessment) as well as LMC shortages. We have commenced the advertising for the May 2018 new graduate co-hort.

052


The local Midwifery Strategic Staffing group meetings continue, with representation from both MERAS and NZNO to discuss local short term strategies and act on feedback and ideas from the midwifery workforce. The Clinical Maternity Co-ordinator roles been recruited to compliment the current night time model, and the 3 additional staff are currently being orientated to the role. The full 24/7 roster will be in place early January 2018. This senior midwifery role will be pivotal across the Women’s Health service, creating a consistent single point of contact for 24/7 bed management and patient flow across Birthing and Assessment, Maternity Ward and the 3 Units.

Improvement Actions Birthing and Assessment Improvement Project Birthing and Assessment are in the process of commencing an improvement project with the support of two improvement advisors from Ko Awatea. The project team have their first meeting scheduled for 7 December and have invited associate charge midwives managers, core midwives, registered nurses, health care assistances, ward clerks and LMC midwives. Following this meeting a project charter will be developed and a further meeting will be arranged prior to Christmas. Community Midwifery Services All normal ultrasound reports are now being viewed and notified to community midwifery staff on-line through safe site access with local community ultrasound providers. This quality improvement enables better visibility and more timely access to ultrasound results. All Well Child Referrals to Plunket are now being sent electronically by community midwifery. In collaboration with Plunket, a standard email template, secure email links and process have been created to enable an audit trail of all referrals between the two organisations. This is to ensure timely and traceable well child referrals. The plan in 2018 is to build similar electronic, auditable referral processes between the community midwifery service and the other local well-child providers.

053


Trend Rating Commentary (by exception)FY17-18^ Nov-17 Target Var Actual Target Var

Acute Caseweight - Paediatric Medicine Inpatients 228 254 -10% 1473 1726 -15%Acute Caseweight - Emergency Medicine - ED 71 70 1% 343 368 -7%Acute Caseweight - Inpatient Paediatric Intensive Care Unit 1 2 -50% 8 13 -38% small numbers & variances

Acute Caseweight -Secondary Neonatal Unit 79 156 -49% 730 793 -8%Sept/Oct/Nov admissions will be reflected in Dec 2017 and Jan 2018

Acute Caseweight - Paed Surg - accounted under Adult Surgery 152 140 9% 734 688 7%Elective Caseweight - Paed Surg - accounted under Adult Surgery 104 91 14% 420 442 -5% Small varianceTotal Discharges - Paediatric Medicine Inpatients 424 417 2% 2508 2450 2%Total Discharges - Emergency Medicine - ED 256 239 7% 1278 1252 2%Total Discharges - Inpatient Paediatric Intensive Care Unit 1 3 -67% 13 14 -7%Total Discharges - Secondary Neonatal Unit 19 24 -21% 137 152 -10% Small decrease in discharges YTDTotal Discharges- Acute Paed Surg - counted in Adult Surgery 188 183 3% 858 776 11% high volumes in NovemberTotal Discharges- Elective Paed Surg - accounted under Adult 156 139 12% 659 607 9% high volumes in NovemberED attendances 2098 1915 10% 11265 10761 5% Demand in ED remains highPaed Medicine - 1st Attendance 212 212 0% 1004 1041 -4%Paed Medicine - Subsequent Attendance 413 336 23% 1762 1651 7%Non-Contact FSA - Any Medical specialty -- Paed Medicine 33 48 -31% 248 234 6%Non contact Follow Up - Any health specialty - Medical 8 0 71 0 Introducing new measureBudgeted FTEs 307 294 -4% 296 294 -1% Additional revenues and vacancies in neonatal Operating Costs ($000) $315 $352 11% $1,717 $1,756 2%Personnel Costs ($000) $2,493 $2,469 -1% $12,338 $12,589 2% Vacancies in neonatal unit staffingFinancial Result Total ($000) -$2,472 -$2,633 6% -$12,537 -$13,406 6% Additional revenuesReduce Clinical Outsourcing ($000) $6 $7 14% $38 $33 -15% Offset against revenues

Trend Rating Commentary (by exception)FY17-18^ Oct-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years 16.7% 5.0% -11.7% 17.1% 5.0% -12.1% Monitoring trend% Staff Turnover 8.1% 10.0% 1.9% 12.3% 10.0% -2.3% Monitoring trend% Sick leave 3.4% 2.8% -0.6% 3.3% 2.8% -0.5% Monitoring trendWorkplace injuries recorded per 1,000,000 hours 0.0 10.5 10.5 10.8 10.5 -0.3


Neonatal Rate of medication errors/1000 bed days per month 4.3% 3.6% -0.7% 4.5% 3.2% -1.3% small varianceNeonatal Care CLAB rate per 1000 line days per month 0.0 0.0 0.0 N/A N/A N/ACLAB insertion bundle compliance - NNU 97% 100% -3% 95% 100% -5% small varianceCLAB prevention maintenance bundle compliance- NNU 92% 100% -8% 90% 100% -10% small varianceEmergency trolley checks (compliance with checking) 97% 100% -3% N/A N/A N/A No data for NNUHand hygiene (compliance with checking) 89% 80% 9% N/A N/A N/ASafe sleep - audits compliance 89% 100% 0% N/A N/A N/AHealth and Safety Environmental Audit (Bi-monthly) 100% 100% N/A N/AViolence Intervention Programme (VIP) Screening 57% 80% -23% 64% N/A N/A Monitoring progress

Enab

ling

High

Pe

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ople

12 month average

Firs

t, Do

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Harm

(Saf

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Year to date

KIDZ FIRST SCORECARD November 2017En

surin

g Fi

nanc

ial S

usta

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ility

Year to date

Lower average WIES, & volumes not at 2015/16 level

SCORECARD

054



ED 6 hour target - National Health target (Kidz First ED) 97% 95% 2% 97% 95% 2%ESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 0.0 0.0 0.0

Trend Rating Commentary (by exception)FY17-18^ Nov-17 LY Act Var Actual YTD* Var

Admission Rate Babies in the first year of life (Total) 19% 18% -1% 21% 21% 0%Admission Rate Babies in the first year of life (Maaori) 27% 24% -3% 25% 25% 0%Admission Rate Babies in the first year of life (Pacific) 25% 22% -3% 28% 28% 0%

ALOS (raw)- Kidz First - Surgical - Surgical Floor 1.79 2.28 0.5 1.90 2.10 0.2ALOS (raw)- Kidz First Medicine - Kidz First Wards 2.40 2.78 0.4 2.73 2.70 0.0 Small variancesALOS (raw)- Kidz First Medicine - ED Short Stay (hrs) 4.80 4.42 -0.4 4.63 4.26 -0.4 Small variancesALOS (raw) - Kidz First - Neonatal 18.6 20.8 2.2 20.7 21.1 0.4


Outpatient DNA - FSA 5% 9% 4% 8% 10% 2%Outpatient DNA - Follow up 13% 8% -5% 13% 12% -1% Monitoring trend and process


Patient experience survey v good/excellent- month (n=9) YTD (n=26) 78% 76% 2% 69% 76% -7% very small numbers responding

NOTESLY Act - Last year actuals^FY17-18 - fiscal year 2017 and fiscal year 2018

Effi

cien

t Year

P&W

CC Year to date

Syst

em In

tegr

atio

n (E

ffec

tive

)

Year to date

Tim

elyYear to date

055



Acute Caseweight - Gynaecology Inpatients- acute 131 123 7% 731 625 17% High acuity, volume only small increaseAcute Caseweight - Secondary Neonatal Womens health 145 128 13% 703 654 7% Reflecting babies progressing from neonatal unitAcute Caseweight - Inpatient maternity care primary maternity facility (one month in arrear)

753 732 3% 2960 2903 2%

Acute Caseweight - Women's Health secondary 495 619 -20% 2994 3001 0% Likely to be phasing of coding issuesElective Caseweight - Gynaecology Inpatients - elective 116 141 -18% 571 693 -18% Theatre and Anaesthetics impactsHysteroscopy 27 22 23% 86 107 -20% catch up plan in placeTotal Discharges - Gynaecology Inpatients- acute 231 246 -6% 1275 1267 1%Total Discharges - Secondary Neonatal Womens health 192 162 19% 889 806 10%Total Discharges - Inpatient maternity care primary maternity facility 713 665 7% 2804 2626 7%Total Discharges - Women's Health secondary 1046 1140 -8% 5982 5932 1%Total Discharges - Gynaecology Inpatients - elective 110 128 -14% 545 617 -12% Theatre and Anaesthetics impactsGynaecology - 1st Attendance 270 264 2% 1237 1294 -4% Offset by virtual FSANon-Contact FSA Gynae Virtual 0 43 -100% 250 220 14%Non-Contact FSA Maternity 137 33 315% 553 161 243% New from March 2017, reflecting ability to VFSA in MCISFirst Obstetric Consults S/B Doctors

279 284 -2% 1299 1393 -7%YTD 56 - non-resident chargeable & overseas-eligible check pending. Takes 3 mths for eligibility status to be confirmed.

DHB non-specialist antenatal consults

943 1440 -35% 5071 7346 -31%

Volumes similar to last year's actual. YTD 868 non-resident chargeable & overseas eligible checks pending. Takes 3 mths to confirm eligibility status. Not including antenatal visits while inpatient

Gynaecology - Subsequent Attendance 301 273 10% 1331 1339 -1%Subsequent Obstetric Consults F/U S/B Doctors

245 264 -7% 1221 1294 -6%YTD 43, non-resident chargeable & overseas eligible check pending. Takes 3 mths for eligibility status to be confirmed.

DHB non-specialist postnatal consults 1119 1264 -11% 5,746 6446 -11% Not including postnatal visits while inpatientBudgeted FTEs 372 356 -4% 357 356 0% Midwifery vacancies

Operating Costs ($000) $471 $468 -1% $2,399 $2,339 -3%High bureau usage, due to midwifery vacancies & sick leave. High clinical supply usage - due to more C-sections and inductions

Personnel Costs ($000) $2,911 $2,941 1% $14,479 $14,653 1% Midwifery vacancies

Financial Result Total ($000) -$3,324 -$3,341 1% -$16,532 -$16,653 1%High sick leave & use of bureau staff- due Midwifery vacancies

Reduce Clinical Outsourcing ($000) $9 $6 -50% $49 $30 -63%High bureau usage, due to midwifery vacancies and sick leave, MDES expenses offset against maternity review board funding

Trend Rating Commentary (by exception)FY17-18^ Oct-17 Target Var Actual Target Var

% Staff with Annual Leave > 2 years - (one month in arrear) 20.3% 5.0% -15.3% 19.9% 5.0% -14.9% Remaining midwifery vacancies% Staff Turnover - (one month in arrear) 10.5% 10.0% -0.5% 12.7% 10.0% -2.7%% Sick leave - (one month in arrears) 3.8% 2.8% -1.0% 3.3% 2.8% -0.5% Remains high in OctoberWorkplace injuries recorded per 1,000,000 hours - (one months in arrears) 0.00 10.5 10.5 8.6 10.5 1.9

Enab

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Hig

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g Pe

ople

12 month average

WOMEN'S HEALTH SCORECARD November 2017

Ensu

ring

Fin

anci

al S

usta

inab

ility

Year to date

SCORECARD

056



Emergency trolley checks (days checked) per month 76% 100% -24% N/A N/A N/A No data for Papakura Birthing UnitHand hygiene (compliance with checks) per month 79% 80% -1% N/A N/A N/A No data for Maternity N&S, Pukekohe, Papakura, BotanySafe Sleep audits compliance 100% 100% 0% N/A N/A N/AHealth and Safety Environmental Audit (bi-monthly) 100% 100% 0% N/AViolence Intervention Programme (VIP) Screening 78% 80% -2% 68% N/A N/A improving trend


ED 6 hour target - National Health target (Gynae) 85% 95% -10% 80% 95% -15% Monitoring in placeESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 0.0 0.0 0.0ESPI 5 - No. waiting > 4 months for treatment - Elective 15.0 0.0 15.0 57.0 0.0 57.0 due to theatre and anaesthetists staffing issues


% transcribed clinic letters authorised <7 days created 85% 95% -10% 84% 95% -11%ALOS Women's Health - babies (WNB and Neonates) 3.30 3.00 -0.30 3.20 3.30 0.10 Small variances across ALOS measuresAverage Length of Stay Gynaecology - Middlemore 1.75 1.54 -0.21 1.80 1.57 -0.23 reflecting Acuity and complexityAverage Length of Stay Gynaecology - MSC Inpatients 1.01 0.71 -0.30 0.89 0.70 -0.19 Small variances across ALOS measuresAverage Length of Stay Obstetric (DHB Mat) (1 month in arrear) 2.40 2.47 -0.07 2.46 2.35 0.11 Small variances across ALOS measuresAverage Length of Stay Obstetric (Ind. Mat) (1 month in arrear) 2.31 2.10 0.21 2.30 2.27 0.03 Small variances across ALOS measuresAverage Length of Stay Vaginal Deliveries overall 2.34 2.89 -0.55 2.23 2.80 -0.57

Maaori - 1st time mothers 2.45 2.86 -0.41 2.80 2.54 0.26Pacific - 1st time mothers 4.25 2.75 1.50 3.24 2.75 0.49 One woman with LOS of 43 days


FSA / Follow up ratio - Gynae 1:1.11 1:1.1 1:1.08 1:1 small variancesDNA - Midwifery Antenatal clinics - First 13% 13% 0% 16% 14% -2%DNA - Midwifery Antenatal clinic - Follow up 9% 13% 4% 13% 13% 0%DNA - Doctor Antenatal clinics- FSA 10% 13% 3% 12% 13% 1%DNA - Doctor Antenatal clinics - Follow up 7% 12% 5% 11% 11% 0%

Trend Rating Commentary (by exception)FY17-18^ Nov-17 Target Var Actual YTD* Var

Outpatient DNA - Maaori (Gynae) 18% 13% -5% 12% 10% -2%Outpatient DNA - Pacific (Gynae) 13% 9% -4% 12% 10% -2%Outpatient DNA - Maaori (Obst) 20% 26% 6% 24% 10% -14%Outpatient DNA - Pacific (Obst) 11% 17% 6% 16% 10% -6%


Patient experience survey very good/excellent- month (n=65), YTD (n=227) 78% 76% 2% 95% 76% 19%

NOTES

^FY17-18 - fiscal year 2017 and fiscal year 2018

Monitoring DNA Rate

Year

P&W

CC Year to date

Effic

ient

Year

Tim

ely

Year to date

Syst

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tegr

atio

n (E

ffec

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Year

Firs

t, Do

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(S

afet

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057


Adult Rehabilitation and Health of Older People

Glossary ACC Accident Compensation Corporation ACE Acute Care of Elderly ARHOP Adult Rehabilitation and Health of Older People ASRU Auckland Spinal Rehabilitation Unit AT&R Assessment, Treatment and Rehabilitation Services HBSS Home Based Support Services SMO Senior Medical Officer

Service Overview The Adult Rehabilitation and Health of Older People Division is managed by Dana Ralph-Smith (General Manager) with Dr Peter Gow (Clinical Director), and Lynne James (Clinical Nurse Director). Responses to Action Items Actions previously assigned by the Hospital Advisory Committee are reported back on in this section. HAC Meeting 15.11.2017 – Adult Rehabilitation & Health of Older People Report “Report back on initiatives that are working in the community to reduce fractures in Older People”. The whole-of-system programme has only recently been implemented; and there is limited available data to demonstrate activity and outcomes. It is anticipated data will be available for the March-April 2018 reports. Included below are the activity figures for the Fracture Liaison Service (FLS). The service aims to identify all fragility fractures presenting to secondary care, and provide follow-up with the patient, primary care, and hospital clinicians to prevent further harm. FLS is progressing well, to exceed annual targets based on estimated prevalence of fragility fracture presentations.

Jul – Dec 2017

Number of People seen by FLS

6 monthly targets

Aged 65-74 138 150

Aged 75-84 210 150

Aged 85 and over 157 150

More comprehensive information about other services, such as strength and balance programmes will be available in the April report. The programme only commenced in January, and is currently only seeing small numbers of participants. Highlights Activity ARHOP continues to exceed budgeted bed-days YTD and per month. Occupied bed days had been 1,200 above target YTD. In late 2017, the demand was primarily driven by increased admissions to ACE beds, and to the Acute Stroke Service. There is a slight decrease in the number of bed days compared to October, across all services except for ACE, reflecting the decrease from mid-winter demand.

058


Divisional Planning ARHOP held its annual planning day to assist in setting priorities for the division for 2018-19. There were excellent presentations from subject-matter experts, and members of Executive Leadership Team, and the day was well attended by the wider ARHOP leadership team. Service managers will continue operational business planning before re-grouping with the senior leadership team early next year. Technology eReferrals have been implemented successfully across Health of Older People (HOP), and Acute Allied Health services. Within HOP services, having a sole SMO managing the triaging role has released significant time for the Community Geriatric Team. E-Vitals systems are planned for roll-out across all ARHOP wards in early 2018. Community Loan Equipment Provision Auckland metro-DHBs have been working alongside healthAlliance procurement team and Invacare to drive improvements to customer service, reporting, and cost reductions. A major success has been the reductions of 16.5% in the monthly community rental spend in August to November, compared to June to July. Update on Previously Reported Issues

Issue Date reported Update Safe Moving and Manual Handling

15 July 2017 Training has been provided to a number of Allied Health and Nursing staff with an interest in patient handling. These volunteers will visit 1-2 wards each in December, and collect data to inform the baseline assessment. Communications have been sent out to Charge Nurse Managers and Service Managers of the pilot wards. Wards are starting to confirm their availability for the baseline assessment. Following data collection, the data will be analysed and findings will be reported to service leadership, HMT, and ELT.

System-wide (acute) clinical demand

17 August 2017 Seasonal pressures have subsided, and delivery as per clinical Models of Care across services is being restored. There are increasing numbers of patients with complex social issues resulting in barriers to discharge across ARHOP wards. Charge Nurse Managers continue to work through individual cases with their Multidisciplinary teams to identify, address and resolve these situations.

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Spinal Inpatient ACC Revenue ('000s) $565 $607 -6.8% $4,650 $3,230 44.0%Non-acute Rehabilitation ACC Revenue ('000s) $1,148 $396 189.7% $4,820 $2,258 113.5%Budgeted FTEs 505 481 -5.0% 501 481 -4.2% Nursing personnel - extra beds open in Ward 31 due to demand requirementsOperating Costs ($000) $4,091 $4,145 1.3% $20,998 $20,701 -1.4%Personnel Costs ($000) $3,018 $3,286 8.1% $15,957 $16,436 2.9%Financial Result Total ($000) $3,534 $3,576 1.2% $17,522 $17,780 1.5%Reduce clinical outsourcing ($000) $316 $302 -4.8% $1,482 $1,509 1.7%


% Staff with Annual Leave > 2 years (1) 5.1% 5.0% -0.1% 4.2% 5.0% 0.8%% Staff Turnover (2) 12.0% 10.0% -2.0% 14.3% 10.0% -4.3%% Sick Leave (3) 2.8% 2.8% 0.0% 3.0% 2.8% -0.2%Workplace Injury per 1,000,000 hours (4) 0.0 10.5 10.5 14.3 10.5 -3.8


Falls - % of falls assessments done in first 6 hours (5) 99% 100% -1% 98% 100% -2%Falls - % of Interventions completed 93% 100% -7% 95% 100% -5%Pressure Injuries - % of assessments done in first 6 hours 99% 100% -1% 98% 100% -2%Pressure Injuries - % of interventions completed 87% 100% -13% 94% 100% -6%% Over ride rate of Pyxis on AT&R wards (excludes Ward 31) 15% 15% 0% 16% 15% -1%


% Acute Stroke Patients Transferred to Inpatient Rehab within 7 days 33% 80% -47% 57% 80% -23%Some complex and medically unstable patients, therefore not admitted within 7 days. Senior staff to ensure increase in communication and timely admission to neuro

% Patients Referred to Community Stroke Rehab seen within 7 days 26% 80% -54% 48% 80% -32%Significant vacancies exist within the service. Resoruces increased to improve ability to accept high intensity patients within timeframe


% Acute Stroke Patients Admitted to Organised Stroke Unit 90% 80% 10% 81% 80% 1%

% Eligible Patients Thromboylsed6.8% 8% -1% 11% 8% 3%

Continued late presentations from community excluding thrombolysis. Two patients went for clot retreival directly (appropriate pathway) but not included in this KPI

Acute 7 Day Readmission Rate (excludes Stroke and ACE) - Current Month 3.4% 2.9% -0.5% 3.8% 2.9% -0.9% SMOs review readmissions monthlyAcute 28 Day Readmission Rate (excludes Stroke and ACE) 12.1% 11.0% -1.1% 10.0% 11.0% 1.0% SMOs review readmissions monthly

FY17-18 Nov-17 Target Var Actual Target VarNumber of Patients Seen by ED Geriatrics Service 57 50 7 N/A 50% Patients Seen by ED Geriatrics discharge to Community (inc Respite and POAC) 53% 50% 3% N/A 50%


MMH % patients discharged to discharge lounge or home by 1100hrs 21% 32% -11% 28% 32% -4% CND to follow-up with Wards


% Acute Stroke Patients Admitted to Organised Stroke Unit - Maori/Pacific 94% 80% 14% 79% 80% -1%

% Acute Stroke Patients Transferred to Rehab within 7 days - Maori/Pacific 0% 80% -80% 55% 80% -25%Seven patients were transferred to IP rehab. Three Maori/Pacific. These patients not transferred in the 7 day due to high complexity.


Patient experience rated good or above - month (n=21) and YTD (n=116) 100% 90% 10% 86% 90% -4%

CND has followed-up with wards. Remains high priority. Will work to improve documentation and reporting

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Mental Health & Addictions Glossary MH&A Mental Health & Addictions ILoC Integrated Locality Care

Service Overview The Mental Health and Addictions Division is managed by Tess Ahern (General Manager) with Dr Peter Watson (Clinical Director) and Anne Brebner (Clinical Nurse Director).

Highlights

Acute Mental Health Unit - Progress Update The new building is really starting to take shape. A key milestone has been achieved, with the first part of level-one being completed shown in the photo. The second photo shows one of the two sample bedrooms which are nearing completion, with all the cabinetry and fittings in place. All the future site visits with staff will be used to gain feedback to see what improvements are needed before the contractors start completing the remaining bedrooms.

Feedback from staff following the regular site visits is very positive, and everyone is eager to move in. We are anticipating staff having access

to orientate to the new building in late January, with patients moving in early March. Minister of Health attendance at opening of the new Surgery at Beachlands The Te Rawhiti Clinical Nurse Specialist, Clinical Head of Integrated Care Adult Mental Health and Clinical Director for MH&A’s attended the opening of the new Surgery at Beachlands. The Minister of Health was also in attendance, and it was a great opportunity to highlight the benefits of the recently launched MH&A ILoC team. The Beachlands Practice staff provided a very positive briefing regarding the benefits of engagement with the Eastern ILoC team to the Minister of Health.

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Patient Safety Week – Medication Safety Te Rawhiti Community Mental Health Team participated in the hospital-wide Patient Safety Week, which this year focussed on Medication Safety. The waiting-room was decorated with displays that encouraged people to become more aware of how to be safe with medication. The team decided to showcase some of the medication-related resources they had developed over the last few months and develop some new ones. The team were lucky enough to win first prize, of a catered lunch from subway and a local café, along with Keep Cup for all staff. Working with the Mental Health Commissioner Professional Leader Peer Support, Consumer and Family Whaanau Centred Care, Cassandra Laskey and Family Advisor Sue Cotton, assisted with the planning and facilitation of a national piece of work on behalf of Kevin Allan, the Mental Health Commissioner. Six separate forums were held in the Auckland metro-area, and in Northland for adult consumers, youth consumers and family whaanau. The purpose of the consultation forums was to test the new Health & Disability Commissioner’s Mental Health and Addictions monitoring framework and its initial findings. All participants were deeply appreciative of the opportunity to contribute to this piece of work, and were extraordinarily generous in the deeply personal experiences shared during the sessions. As well as providing valuable insights into the experiences of people using mental health and addiction services across the northern region, this opportunity enabled us to strengthen the working relationships with colleagues across the region, and particularly in Northland. They will review the summaries, and the final report prior to release by the Office of the Health & Disability Commissioner in February 2018. Proposal to reconfigure Community Mental Health services: Mental Health and Addiction (MH&A) have been working for some months on a proposal to reconfigure Community Mental Health services. This reconfiguration proposal is a key pillar of the strategic approach to implement a new model of care, which is requiring a level of change across all parts of the system. The transformation programme of change involves four core components:

1. a greater emphasis on a holistic approach to physical and mental wellbeing; 2. a more focused and deliberate episodes of specialist care; 3. a collaborative response to addictions and mental health; and 4. a strategic approach to the commissioning and provision of NGO support services (re-

design and re-procurement). The reconfiguration relates specifically to point 2, with a goal that teams have a clear focus on the delivery of purposeful and appropriate episodes of care, and are part of the new ILoC (Integrated Locality Care) teams alongside primary care, NGOs and AOD. There is no reduction in funding or FTE positions. The changes proposed include new teams, new ways of working and a new leadership structure, alongside work locations changes for some. We will continue to use existing community bases/ facilities and expand into Pukekohe Hospital site. The Consultation process commenced in October, with Union engagement, forums for staff and wider communication to the sector. Confirmation of decisions will be occurring in early 2018.

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Emerging Issues Activity Due to the high acute demand, the occupancy in Tiaho Mai remains high.

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Overtime costs ($000) $185 $149 -24.4% $985 $745 -32.3% High acute demand, off-set by community vacanciesBudgeted FTEs 683 705 3.1% 661 705 6.2%Operating Costs ($000) $6,030 $6,018 -0.2% $29,775 $29,908 0.4%Personnel Costs ($000) $5,334 $5,679 6.1% $26,337 $28,209 6.6%Financial Result Total ($000) $5,968 $5,956 -0.2% $29,478 $29,601 0.4%


% Staff with Annual Leave > 2 years 8.7% 5.0% -3.7% 9.0% 5.0% -4.0% Managers work with individual staff to reduce annual leave% Staff Turnover 10.4% 10.0% -0.4% 10.5% 10.0% -0.5%% Sick Leave 4.2% 2.8% -1.4% 3.6% 2.8% -0.8% Sick leave reviews undertaken with staff with high sick leaveWorkplace Injury Per 1,000,000 hours 0.0 10.5 10.5 11.7 10.5 -1.2


Number of Seclusion events/ 100,000 6.2 5.0 -1.2 N/A N/A N/A )

Seclusion hours/ 100,000 57 50 -7 N/A N/A N/A)All seclusion events are reviewed at the weekly risk review meeting

Number of Clients Secluded/ 100,000 4.6 3.0 -1.6 N/A N/A N/A )


Shorter wait times for non urgent mental health and addiction Services (%< 3 week wait) - 12 months rolling

0-19 years 70% 80% -10.0% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 1,58020-64 years 84% 80% 4.0% N/A N/A N/A65+ years 86% 80% 5.6% N/A N/A N/A

Shorter wait times for non urgent mental health and addiction Services (%< 8 week wait)- 12 months rolling

0-19 years 92% 95% -3.5% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 1,58020-64 years 95% 95% -0.4% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 2,70865+ years 95% 95% 0.4% N/A N/A N/A


Access rate - Number of CM domiciled unique clients seen by all MH services ((PRIMHD reporting services include AOD and NGO services) 12 months as a % of population) - Total

0-19 years 4.1% 3.2% 1.0% N/A N/A N/A20-64 years 4.0% 3.2% 0.8% N/A N/A N/A65+ years 2.3% 2.6% -0.3% N/A N/A N/A Meeting the wait time targets - no build-up of a waitlist

Readmissions to Tiaho Mai within 28 days - Total (1 month in arrears) 10.1% 12.0% 1.9% 6.8% 12.0% 5.2%


Inpatient Occupancy - Tiaho Mai Acute Mental Health Unit 91% 85% -6.4% 96% 85% -10.6% Signifies overcrowdingNumber of Tiaho Mai Inpatient LOS >35 days

15 10 -5.0 11 10 -0.6Some patients not responding to treatment & a number waiting for beds at Tamaki Oranga


Access rate - Number of CM domiciled unique clients seen by MH services (PRIMHD) 12 months as a % of population - Maori

0-19 years 6.4% 4.5% 1.9% N/A N/A N/A20-64 years 9.2% 7.7% 1.5% N/A N/A N/A65+ years 2.7% 2.6% 0.1% N/A N/A N/A

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MENTAL HEALTH SCORECARD November 2017

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Facilities and Asset Management Glossary CE Clinical Engineering CIO Chief Information Officer EECA Energy Efficiency & Conservation Authority HMT Hospital Management Team ICR Investor Confidence Rating LTIP Long-Term Investment Planning Process NCS Non-Clinical Support WoF Warrant of Fitness Service Overview The Facilities and Asset Management division is led by Philip Healy (General Manager). The division is responsible for Engineering Infrastructure Services, Facilities, Property Management, Capital Planning, Capital Development/Construction/Programmes, Clinical Engineering, Transportation and Fleet Management, Enterprise Asset Management, Procurement & Contract Management, Energy Management, Environmental Sustainability, Infrastructure/Facilities, IT Systems, Hazardous Substance, and Facilities Safety Compliance/Management. Highlights CM Health Asset Information System The CapEx management system has gone live (cloud hosted), and is currently being utilised the Asset team. System development is currently on-going. Development of Non-Clinical Support (NCS) Hub Non-clinical support and Facilities are working though several initiatives to improve NCS performance and service delivery efficiently by identifying and enhancing key elements such as communications (Smart RT) and coordination. This is focused on reviewing and improving the Task Manager tool. These improvements are geared to using existing systems to collect data to improve visibility of non-clinical support staff, and use the information to operationally to inform service improvement plans. Facilities and Facilities Master-planning 2018 Resource Bid Facilities, in coordination with the planning team have presented to Finance and the Leadership team, with a budget bid to support the upscaling of Facilities, Engineering and Asset Management capabilities in 2018/19. The plan seeks to remediate some key resource and capability burdens, and to support the delivery of the 2018 Facilities Remediation and Capacity Development programme of works. A progressive three-year approach to redeveloping facilities capability and capacity is envisaged. The capital programme will be delivered through a programme management office tasked with the development of the facilities remediation programme. Fleet Replacement Plan The healthAlliance RFP for the Northern Regions lease vehicles concluded, with a panel of suppliers identified. Agreement of the master-lease documents between the suppliers and healthAlliance has been frustrated, and is holding-up the first batch of CM Health vehicles being replaced with lease vehicles. A

065


request for a quote for seventy CM Health vehicles was unsuccessfully utilised by hA as negotiating leverage to get the lease companies to sign the healthAlliance documents. Further delays will jeopardise the replacement plan, and ultimately affect savings targets. CM Health Fleet team are now progressing the lease transactions with the incumbent suppliers. A work plan for implementing the fleet review has been developed in two sections, one for process and policy, and one for vehicle replacement. An independent supplier has been identified for a booking system as well as fleet management, and the new system will be rolled out in the New Year. Environment and Energy The annual CEMARS Audit has taken place, and CMDHB was successful in the recertification process. CMDHB achieved a strong result, with a 20% reduction from the baseline. EECA has also conducted its annual audit of the Energy Management processes and framework, and awarded a three-star rating, out of a total achievable four stars. A 16% process improvement is required to achieve the highest four-star rating. As with clinical engineering, our environment and energy functions are seen as taking a national leadership position in assisting to develop evidence and best practice. Good progress has been made in developing and implementing organisation-wide policies. Emerging Issues Scott Building Sanitary Drainage Due diligence undertaken upon the Scott Building relating to the development of the recladding proposal by Hawkins Construction has identified a series of issues with the existing sanitary drainage system. Alexander and Company have been engaged to undertake a formal review of the systems and advise CM Health on the extent of the issues. It is envisaged that should there be a system-wide issue, this will be addressed during the Scott recaldding works. Asbestos-Galbraith Basement; Galbraith Basement – interim and long-term remediation options continue to be reviewed. Service level agreement(s) with hA need to be sighted, to enable key relocation activities. Air monitoring continues, levels remain below trace levels, and therefore continue to be considered at ‘safe to occupy’ levels. Plant room 6 has been reviewed, final scope of asbestos remediation works still to be derived. The PABX room has been determined as a high-risk location, interim restrictions now in place. Further PABX options review underway and scoping for suitable remediation; facilities are unable to provide elimination of risk due to complexities of space. The impact on operation is being worked through, and request for quotes underway for specialist asbestos management providers is currently on-going.

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Issues Date reported Update Asset Management Function Financial Reporting –need for formal capital policies

September 2017

The Asset Management team in-conjunction with the Finance function liaising with the Board Asset and Capital Committee Chair are implementing capital policy. This involves developing and implementing a suite of capital policy documents outlined below; • Capital Accounting for Fixed Assets, policy

document • Capital Approval and Acquisitions, policy

document • Capital Budgeting, policy document • Capital Disposal and Salvage of Assets,

policy document • Capital Seed Funding. policy document • Capital post-implementation review, policy

document

Power Outage Incident Middlemore Site

September 2017

A risk-based infrastructure review aligned to the approach ADHB have undertaken, has been proposed and is being progressed by Facilities. The Remediation Programme underway will assess the range of risks across all of our sites, and inform decisions on subsequent remediation requirements.

Facilities Remediation Plan

August 2017 Facilities are working with Planning, focusing initially on the remediation programme. Remediation Programme capacity delivery plan are progressing through the Better Business Case process. A series of investment management workshops have been conducted, and the on-going Asset condition reviews are progressing in parallel.

Facilities Funding Maintenance Repairs and Operations

July 2017 Evidence to date (as previously reported) would indicate a large underfunding and resource discrepancy related to CMDHB, specifically the funding of Facilities maintenance. Facilities are now seeking to review budget 2018/19 to seek approval to invest in critical resources and funding uplifts.

067


Galbraith Seismic Recommendations

June 2017 High-level Galbraith infrastructure and services relocation plans have been developed. Seismic remediation and services relocation magnitude of cost appraisals have also been completed. Other requirements have been identified and will form part of the wider seismic review program.

Asset Risk and Condition Survey

May 2017 The survey will further inform CM Health’s long-term investment planning process, provide asset risk and single point of failure profiling. The asset risk and condition survey will also be utilised in conjunction with CM Health’s the investor confidence rating.

Middlemore & Manukau SuperClinic Cladding Investigations

May 2017 Formal cost estimates have been developed for each of the facilities, based upon the detailed works plans developed for the Scott Building reclad. Alexander & Company have completed their formal appraisals. This will progress through approvals to define remediation timeframes and facility rectification plans.

Galbraith Asbestos Identification

April 2017 Asbestos has been identified within the Galbraith Building. Testing has been undertaken in these areas, and contaminated areas cordoned off. Facilities have completed a relocation plan for staff in the Galbraith Basement area, and two alternatives relocation plans.

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Middlemore Central Glossary AWM Assessment Workload Measurement CapPlan a capacity planning tool CNM Charge Nurse Manager CCDM Care Capacity Demand Management group MMC Middlemore Central NZNO New Zealand Nurses Organisation SSHW Safe Staffing Healthy Workplace Service Overview Middlemore central is managed by Dot McKeen (General Manager) with Dr David Hughes (Clinical Director). The Division is responsible for Daily Operations Unit, Bureau service, Transit Nurses, Discharge Lounge, Emergency Response and Non-Clinical Support Services (Cleaners, Orderlies, Security, Translators, and patient transport) Highlights In late 2017, Middlemore Central hosted visit by Jo Gibbs, Director Provider Services, and Margaret Dotchin, Chief Nursing Officer, from Auckland District Health Board. The visit informed their evaluation of Middlemore Central, and how it is used. Discussions also included the winter and summer planning process; Lessons Learned session, and occupancy forecasting. Of particular note on the visit, were the make-up and goals of Middlemore Central Governance Group; and the operational inclusion of clinicians. A copy of our current winter and summer plans were shared with Auckland DHB. Care Capacity Demand Management Limitations are being identified with the available reporting tools within the AWM tool, which are needed to guide Charge Nurse Managers in effective decision-making for rosters and staff allocation. Given that 15 DHBs currently use Trendcare, and that tool is recognised by both the SSHW and the NZNO for the safe management of staffing levels, it was suggested that the Trendcare (vendor and CCDM) present to the Steering Group for a comparison. A paper is now being prepared to update ELT and inform further discussions. The CCDM Steering Group was invited to visit to Waikato DHB in October, to participate in the evaluation of the acuity data being produced and used by Waikato DHB using the McKesson Assessment Workload Management tool. As the only two DHBs using the tool, we are working with the SSHW unit to allow comparison with other DHBs (Trendcare data), and further work is to be undertaken

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Summer Plan The Summer Forecast was completed, and approved by the Middlemore Central Clinical governance group. Rosters were prepared in line with the Summer Plan, particularly over the Christmas / New Year period. A Dashboard of the Patient Journey Work continues on a visual dashboard, which will allow us to track and trace (electronically) the patient entire journey from Emergency Department through to the ward. Middlemore Central continue to monitor and report on a range of variables, including Emergency Department presentations, beds/ admission numbers, forecast and actual occupancy, patient age and clinical speciality, Isolation Beds requirements, discharge lounge use, discharge times, Patient outliers, and Bureau watch requirements and roster cover. Bureau Recruitment Recruitment to the internal bureau continues, to ensure availability of casual staff to replace/ cover nursing staff sick leave etc. Recruitment continued in November, bringing the available casual RN numbers (headcount) to 187, and HCAs up to 298. Operational support for Discharge Processes The Medicine (3 pm) weekday Round, with the General Medicine Flow Coordinator, Clinical Head of General Medicine, APAC nurse and MMC Duty Manager is continuing to occur. This assists with identifying potential discharges for the following day, so that discharges can be progressed as early as possible the next morning. Nurse Facilitated Discharges have been a significant contributor to the early discharge of patients, which has been improving for general medicine teams and has improved patient flow. Non-Clincial Support services Middlemore Central continues to oversee the operational management of Cleaners, Orderlies, Security, Transit Nurses, Linen Services and Translators.

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Director of Patient Care, Chief Nurse & Allied Health Professions Officer Prepared and submitted by Jenny Parr, Director of Patient Care, Chief Nurse & Allied Health Professions Officer, with updates provided by the Directorate of Patient Care including Nursing, Midwifery and Allied Health in the hospital, and Primary and Integrated Care. Highlights Chief Nurse, MoH Jane O’Malley spent a day in Counties prior to Christmas. A requested key area to visit and discuss was the Mental Health Integration & Community Transformation programme of work. Jane was impressed with Community Central and her patient Safety Leadership Round in Critical Care. Jane spent time with the Clinical Leaders in the Director of Patient Care Directorate. The Pu Ora Matatini Midwifery Scholarship awards were held on 7 December 2017. The Tindall Foundation has supported this under the “Grow Our Own Workforce” for the past 7 years at Counties Manukau Health. As a result, there are now 24 Maaori midwives in South Auckland and 58 future midwives studying through AUT. In January 2017 the DHB had four departments auditing hand hygiene and collected 374 moments. In December 2017, 35 wards were actively auditing, with 23 of those capturing over 100 moments per month. This has been achieved through a planned approach led by Rachael Hart, Hand Hygiene Co-ordinator/Clinical Nurse Specialist.

Leadership Changes Jane O’Malley resigned from her MOH role in late December 2017 after 7 years in the role. She is to taking up the Chief Nurse National Plunket role. Denise Kivell, Director of Nursing has also announced that she will be leaving CM Health in February 2018. She has been DON at CM Health for 10 years, and a valued and well-connected clinical leader at Counties for over 26 years. She has championed the role of nursing in health care, supported development of innovative models of care and contributed nationally via roles, including 4 years as Chair of Nurse Executives NZ. Denise was the first Charge Nurse Manager of Kids Medical, and has worked across a number of areas prior to her current role. Her Counties career exemplifies a strong belief in the importance of service and staff development, which strengthens our ability to provide the best care for our population. There will be several opportunities to celebrate Denise’s contribution, before her last working day on Friday 16 February 2018.

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Annelize de Wet stepped down from the Acting DAH role as of the end of 2017, having led these staff groups for the previous 12 months. Wendy McKinstry has been appointed as the Acting Director of Allied Health for six months while permanent arrangements for leadership of the Allied Health Scientific and Technical workforces is finalised. Wendy first started at CM Health as a graduate physiotherapist in 1998, and has held various clinical and leadership roles within the organisation over this time. She is enthusiastic for the opportunity to provide leadership and direction to the Allied Health, Scientific and Technical workforce at CM Health, with a focus on excellent patient care every day. She is passionate about CM Health achieving great outcomes with our community; and the value of working in inter-professional teams for the benefit of patient care. CM Health Disability Strategy Implementation Plan Engagement Events - Update Two community disability engagement meetings were held during November and December 2017, to listen to the community about their needs and suggestions on how CM Health can be better engage and meet their needs regarding their disabilities and access of services. Sam Dalwood the disability coordinator of Waitemata assisted with the facilitating of the small groups. The first meeting was held in conjunction with Te Roopu-Waiora; a Maori community NGO, with a specific Maori focus- and 30 people from the community attended and participated. Interpreters were utilised for the hearing impaired attendees. The second engagement meeting was held at the Pacifica Community centre at MIT with a Pacifica focus. Vaka Tautua partnered with CM Health to facilitate the event. Although 41 people accepted and booked for the event, only 16 turned up on the day with apologies from people because of health issues and some had forgotten about the event. The main activity for both sessions was to listen to the community’s experiences and needs and suggestions on how CM Health can respond better and offer accessible services to meet the disability needs of the consumers. Attendees participated well and all their experiences were captured by the group facilitators. This information will be collated, themed and send back to participants for comments before it will be compiled into a report aligning with the outcomes of the disability strategy. This will be amalgamated into the implementation plan of the disability strategy for the Metro Auckland region, and presented to DiSAC. The costs involved for the running of the events went towards food, koha for participants, venue hire and interpreters. Service Demands The festive season also saw sustained high demand for health services, both in hospital and in the community. December saw over 10,000 people attend our Emergency Care department, which is more usual of mid-winter, and over half were admitted. Of the total seen, 45% presented between 4pm and midnight. In particular, the statutory holidays saw well in excess of 300 presentations per day at Emergency Care with a flow on to the hospital wards. All acute capacity reopened in early January.

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Most wards, teams and units took the opportunity prior to Christmas to acknowledge the hard work and commitment of staff, via a variety of events and shared festive cheer. During December, many of the wards and patient areas were decorated, and the Christmas choir, and the ‘Pay it Forward’ week were both excellent examples of our Counties spirit and values. Workforce Nursing For December, there were 138 FTE Nursing/Midwifery open vacancies. Of the open recruitment, an initial 91 FTE were approved in December – the residual remaining open from prior months. Of the total vacancies, across the entirety of CM Health, there are 11.1 FTE of Senior Nursing roles, 2.8 FTE of Enrolled Nurse roles, along with 88 FTE of Registered Nurse vacancies (42 FTE of that in community/ambulatory services, including 29 in Mental Health community teams). Health Care Assistant (HCA) recruitment is for 5.0 FTE (including 3.0 FTE in mental health). There are also 29.1 Midwifery vacancies, but this includes 20 spaces across the three 2018 intakes for the New Graduate programme.

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Weekly EC Presentations by Calendar Year

2014 2015 2016 2017 2018 UCL

106 123 126

97 104 107 89

129 105 100

85 97 87 95 85 79 64

88

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Recruitable vacancy per month Taleo data - Nurses, HCA & Midwives

RN only…total FTE…

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The 2017 cohort Completion Ceremony occurred on 18 January 18. Of those completing from the January 2017 NETP cohort, 53 of the 56 working across CM Health have secured on-going employment with our wards and team, one is leaving Counties, and we are working with two to look at options across our services. There were also 10 working in Primary Care during 2017. The Mental Health NESP cohort of 16 have retained 14, with two choosing to move to other DHBs outside of Auckland.

Our January 2017 NETP cohort graduates included the largest ever number of male graduates for general nursing, with most usually electing to work in Mental Health The NETP and NESP cohorts commenced on 22 January 18 with a Whakatau. The New Entrant to Practice (NETP) intake has seen 70 placements offered to graduates on (58 FTE), with a further 2 places offered in Primary Care. Mental Health also has 14 New Entrant to Specialist Practice (NESP) starting. In preparation for the new ‘Taiho Mai” and the consistent vacancy rate, Mental Health and Addiction are investing in an increase in numbers New Graduates (NESP) numbers to a total of 25 for 2018. This will impact heavily on teams to support this; the CND is working with the teams to establish clear support structures to manage this programme. (a) Nursing Workforce Hotspots

Both Emergency Care and Neonatal Unit have resumed ‘recruitment campaigns’ for additional nursing staff, in part due to on-going additional clinical workloads. Mental Health is working on long term approach to supporting and growing community service nursing, particularly for Child and Youth roles.

(b) Community Health Teams Skill Mix It has been identified that due to staff turnover the community health teams have a skill mix gap. Chief Nurse Advisor Primary and Integrated Care and Nurse Consultant Primary and Integrated Care plan to look at each community health team’s skill mix and identify key staff for development. The service needs to have succession plans in place for the senior nurses who are nearing retirement.

(c) Nursing Pipeline and Education Appendix 1 provides a national snapshot of outcomes for the mid-2017 new Graduates (NETP intake) profile, and recruitment processes, supplied via the national Strategic Workforce group at DHSS/TAS.

National Nursing State exam results Dec 2017 indicated a high failure rate from the Bachelor of Nursing Pacific programme at Manukau Institute of Technology. Of the 12 Pacific students, six had confirmed RN roles at CMH. Meetings between Counties Nursing, Pacific Development Unit and MIT are in place with the aim to support the cohort of students and preventing any reoccurrence.

New Nurse Practitioners in New Zealand information is now available on the Ministry of Health website. The information sheet is designed specifically for employers, and includes sources of funding available as well as links to further information and stories of nurse practitioners at work. The info sheet was written with the support of the Health Workforce New Zealand (HWNZ) Nursing Workforce Governance/Advisory Group. http://www.health.govt.nz/system/files/documents/pages/nurse-practitioners-in-new-zealand.pdf

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http://www.health.govt.nz/system/files/documents/pages/nurse-practitioners-in-new-zealand.pdf


HWNZ has made some changes to postgraduate nursing funding for 2018 to further increase flexibility. The amount of funding remains the same.

In late 2017, the Ministry of Health advised that our application for funding to support enhanced Pacific Workforce initiatives had been successful. In 2018, this will enable 20 trainees to receive Pacific support and mentoring, including: • Linking to the ‘Programme Working and Achieving Together’ intention to support further

regional development and promotion, • With support from the CM Health Professional Development and Recognition Coordinator,

Director of Nursing and Director of Midwifery: • New Graduates Nursing (within NETP programme) - utilising the Pan-Pacific Nurses

Association. • Midwifery New to Practice - utilising the Pasifika Midwives Aotearoa (PMWA).

• Development of a Physiotherapy Graduates wrap-around programme - utilising Eti Televave, a Physiotherapist at CM Health.

Community Nursing The Chief Nurse Advisor Primary and Integrated Care has met with Clinical Nurse Specialists employed within Medicine who have roles across the localities. The purpose was to explore the intent of the employment of the additional roles and what has developed. The roles were provided to support development of skills and knowledge for nurses working in the primary and community services, to support clinical care to people with long term conditions. The Clinical Nurse Specialists employed are working in Diabetes, Cardiovascular, Chronic Kidney Disease, Sleep Apnoea, Gout and Infectious Diseases/Dermatology. To assist with the development of practice nurses in Mangere/Otara, a summer series of clinical updates is being planned for March/April 2018. If successful this will be rolled out to more localities. Midwifery (a) Midwifery Strategic Advisory Group - Immigration Essential Skills List

An action from the national Midwifery Strategic Advisory Group workforce plan was to submit to reinstate Midwifery on the Immigration Essential Skills in demand list. On Friday 15 December 2017, the Ministry of Business, Innovation and Employment (MBIE) completed its annual review and Midwifery has been replaced on the Immediate Skill Shortage List (ISSL). If an occupation is on the shortage list, work visa applications for positions are not subject to an individual labour market test. A labour market test means that an employer must demonstrate that no suitable New Zealanders are available to fill or be trained for each individual position. This will assist in overseas recruitment while we are growing our own midwifery workforce. The three Auckland District Health Boards (DHB’s) are currently investigating a joint overseas recruitment drive.

(b) Midwifery Graduate Programme CM Health currently has 23 midwifery graduates in the 15 month programme with three more commencing at the end of January 2018. There are 11 self-employed graduates. Intakes occur three times a year with the main intake occurring in April/May. Recruitment has commenced for the April 2018 intake and there are 69 third year students from the Auckland University of Technology (AUT) sitting the National Midwifery exam in March 2018. The three Auckland DHB’s have an agreement to interview and offer positions simultaneously.

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Allied Health As the ‘shoulder’ waitlist is currently a problem waitlist for orthopaedics with only one shoulder surgeon (Mr Coleman) to meet the demand, a first specialist assessment role was initiated by orthopaedics and physiotherapy and has been successfully appointed, with a March 2018 commencement. This role will initially work alongside Mr Coleman and build to a point where the physiotherapist is triaging the patients completely and referring on only the ones that would benefit from surgery. The position is 0.4 FTE to start with, but likely will grow to double that. It will also progress to a second stream of patients, where the Physiotherapist is solely responsible for the post-op follow up for appropriate patients. That is where there are no orthopaedic/surgical concerns, meaning the surgeon more often than not will not need to see the patient in the first 4 months post-surgery, reducing the need for unnecessary surgical appointments for the patient. The role will contribute to providing an effective secondary and tertiary physiotherapy clinical service for musculoskeletal outpatients in the sub specialty area of Shoulders, including ACC injuries, within the Acute Allied Health Team. This position will provide an opportunity to develop assessment/intervention skills along with professional development and research opportunities within the Orthopaedic service. The position will be based at Manukau Super Clinic and may involve clinics at Middlemore Hospital and other localities across the Counties Manukau Area. The Orthopaedic outpatient team have links to the musculoskeletal physiotherapy team, who are both committed to ongoing education and continuing professional development. The role will be professionally supported by, the Associate Director of Physiotherapy, a Section Head Physiotherapist, and work alongside an Orthopaedic Consultant and the wider Orthopaedic team. Patient Experience Inpatient Experience Report Efforts to boost participation and email collection for both the National Survey and Inpatient survey continue, with email collection by area being monitored on a monthly basis. Ria Byron, Improvement Advisor, Patient Experience in Ko Awatea, has been awarded the Beryl Institute “Patient Experience Leadership Certificate”. This follows completion of all 15 Body of Knowledge courses and an exam reflecting a sustained commitment to leadership of Patient Experience. There were a total of 19.8% discharges with email addresses in December 2017 compared with 24.3% the previous month. This corresponded to a 14% response rate. All wards are now expected to achieve 80% discharges each month with a view to positively impacting the overall response rate.

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Volunteer Service A work programme is underway focused on strengthening the processes of recruitment and improving the experience and retention of volunteers. Volunteers are undertaking a variety of activities that support both patient and staff experience. The Volunteer Coordinator has resigned from the position and recruitment to replace them is underway. The Manukau Super Clinic Shuttle Service The Northern Shuttle Service route for patients was resumed on 10 July 2017. However it is challenging maintaining this service using only volunteers who are not always available. Given this, there is no immediate plan to re-establish the Southern Shuttle Service route, and the Northern Shuttle has had to be reduced. A longer term and more sustainable plan is needed and has been proposed by the Acting MSC Service Manager which is being considered by the General Manager. The Manukau Super Clinic Mailroom Like the shuttle service, sending of clinic letters to patients has been entirely dependent on the volunteer workforce however with a recent decline in the volunteer numbers at MSC this is not a sustainable model. Alternative options are being explored to ensure the longer term sustainability of this service. The immediate risk is being managed within existing resources and a business plan for the longer term management is being considered. Fundamentals of Care – Peer Review During December, the first Fundamentals of Care peer-review process was piloted and conducted in 36 inpatient wards and units. The Chief Nurse, Clinical Nurse Directors (CNDs), Directors of Midwifery and Nursing and Chief Nurse Advisor provided primary review leadership. The review teams also included Nurse Educators, Associate Directors Allied Health and cultural health teams to conduct the review in a supportive and consistent way with Charge Nurse/Midwife Managers. Ko Awatea teams provided co-ordination and the Research and Evaluation team is currently undertaking data analysis. To ensure there is inter-rater reliability, all reviewers attended a training session. Charge Nurse/Midwife Managers had a 1-2 hour meeting with the lead reviewer on the unit/ward to go through ward management arrangements, best practice standards and evidence etc. In addition, five patients per ward were interviewed, (1 Maori, 1 Pacific, 1 Asian and 2 Pakeha patients; by a Nurse Educator and Associate Directors of Allied Health, Maori Health team staff). Staff experience and observation of practice and the environment is also collected during the review. Ko Awatea are currently analysing the responses and data, with results expected in early 2018 to inform further development.

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Quality and Improvement National Patient Deterioration Programme The Health Quality & Safety Commission has commenced a national patient deterioration programme, which aims to reduce harm from failures to recognise and respond to acute physical deterioration of adult inpatients. As part of the programme, an anonymous survey was undertaken, asking clinicians about their experiences of recognising acute physical deterioration, escalating care, responders, working with patient, family and whaanau, and caring for deteriorating patients who may be approaching the end of life. Certification Update The next Certification audit is 7–9 February 2018 which will be focused on progress with corrective actions. Attached in Appendix 2 is an update on the Corrective Actions that will be reviewed. Good progress has been made with all corrective actions and we expect a number of them to be closed following the audit. Three of these corrective actions have been described in further detail: (a) Complaint Review Update

The review of CM Health’s feedback and complaint process resulted in the development of Feedback Central, a centralised team comprised of existing redistributed organisational resources from SAPs and the Directorate of Patient Care. This team will be able to work flexibly across the organisation to address coordination, timeliness and expertise gaps that exist with Complaint and Adverse Event management. It is proposed that the Clinical Quality and Risk Managers (CQRMs) have a dotted line to the Head of Feedback and Adverse Events for Complaint and Adverse Event management. The Position Descriptions for the CQRM’s, and SAP’s team members transferring, have been reviewed to align to the business need. We received some useful feedback during the consultation process with staff and as a result have agreed: • That the Head of Feedback and Adverse Events role be increased from 0.4 FTE to fulltime • That the Consumer Liaison Officer roles be increased from 1.65 FTE to 2 FTE • That the 0.8 FTE Clinical Quality Specialty Nurse role should remain within SAPs and not

transfer to Feedback Central. A workshop with staff will occur on 24 January at which these changes will be discussed as will the draft CQRM job descriptions. We anticipate being able to recruit and implement the structure in February. This will resolve the issues that lead to the Certification corrective action in April 2016. The need to improve the Risk Management System software was highlighted in the above complaint review so monitoring and reporting can be strengthened and a concept paper (to replace the system) has been developed.

(b) Controlled Documents

Prior to Christmas Health Alliance released its final report on the audit into CM Health’s controlled documents – specifically Policies and Guidelines. It recommended a number of improvements to ensure controlled documents were up to date and accessible as well as recommending improved reporting and data integrity (refer Appendix 3). Having up to date and accessible controlled documents has also been a corrective action from our Certification audits in recent years so to a certain extent some of the issues were known and had work plans in progress. However it was helpful to have an objective and independent review of the controlled document system and in particular it improved our understanding of the issues and how they interrelated with one another.

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A Quality Improvement Plan has been developed which addresses the findings of the audit, as well as taking the opportunity to make other system related improvements. Please refer to the attached plan in Appendix 4.

(c) Corrective Action Database

Not being able to track the completion of corrective actions from complaints and incidents was a corrective action from our April 2016 Certification audit. We have developed a Corrective Action Database, with reporting functions, utilising the Daptive software. It is now possible to report on due and overdue corrective actions by service and Division (for incidents). The Chief Medical Officer manages an excel spreadsheet to monitor and coordinate the Health and Disability Commissioner (HDC) complaint recommendations however it is limited in its reporting ability and it is likely that Daptive could be adapted to cater for the complaint corrective action monitoring. This will be explored in the New Year. Monitoring the completion of corrective actions will be the responsibility of Feedback Central once established.

(d) Plan of Care Following thorough testing, implementation of the Plan of Care (a corrective action) documentation package which includes a Patient Handover form, Patient Information on Admission form, Daily Assessment and Plan of Care document and Discharge Planning Checklist, has progressed well across the medical and surgical wards. Education on the Plan of Care documentation package and requirements has been conducted with the Charge Nurse Managers, nurse educators and clinical staff of 11 wards during November and December with three wards remaining. The feedback from staff has been mostly positive as they have appreciated the streamlining of the documentation, consistency across areas and reduced time to complete the admission process. There has also been an improvement in the content of clinical documentation. An example from one ward shows that prior to implementation of the Plan of Care documents, the ward achieved 53 per cent for their documentation audit and post implementation they achieved 81 per cent which indicates a 28 per cent improvement. The audit results are shared with the each ward to provide evidence of what they are doing well and areas for improvement.

ARHOP, Women’s Health and Kidz First have been involved in discussions about how the Plan of Care documents could be utilised and adapted for their areas and audit tool modified in order to gather baseline information from these areas. The Plan of Care project subject matter expert left the organisation in early January 2018 so key contacts have been identified in each area to maintain the momentum of the project. For ongoing monitoring purposes, five questions on key aspects of the Plan of Care documentation will be incorporated into the Care Compass (point of care measure for safety) Documentation Audit.

Technology Enabled Care (a) Clinical Documentation Programme: e-Vitals

The introduction of e-vitals to more wards has commenced. As the rollout continues, additional clinical coaches are being deployed to support staff adopting the new systems.

(b) New “Point of Care’ Devices and IT Systems

The introduction of new “Point of Care’ devices and IT systems are increasingly visible on wards and units. A report on the forty Windows10 tablet trialled has been circulated by the Health Together Technology team. The report outlines the 4-week trial outcomes, and provides responses to the issues raised during the trial, as well as a clear description of the device mix utilised and the rationale for this.

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(c) e-Portfolio From January, all nursing professional development portfolios are submitted electronically. Training for nurses to learn how to access and set up their e-Portfolio is being provided, via drop-in sessions that support this transition, and also enhance access via KA Learn to other learning opportunities.

Integration and Locality Development Mental Health continues to embed localities-based primary mental health services, and this is receiving excellent feedback from Primary Care providers. Beachlands Medical Practice is very proud of their achievements with mental health liaison, with integration led by a CM Health Clinical Nurse Specialist, Jo Dickens, at Beachlands. Mental Health The new Acute Adult Mental Health Inpatient Unit build is progressing well. Regular staff tours are held to begin to familiarise staff with the size and scale of this building. The design will give up to six different options for managing space with swing doors; will enable staff to ensure those who are most vulnerable are able to be cared for in a safe environment. The proposal for change regarding Mental Health Integration was released to staff and unions in late 2017 for discussion and feedback. This is a large proposed change, which affects all staff working in Community Mental Health teams. These proposed changes are in line with census and demographic information about our current population. It proposes a fifth community team, to better serve Clendon and Takanini. In addition, the proposal suggests an increase in 2x FTE Clinical Nurse Specialists for Infant Child and Youth. This is a hard to recruit area, and having more clinical expertise may support retention for novice practitioners to develop. Regional Pacific Development Unit The Regional Pacific Development Unit has had seven countries approved by Ministry of Foreign Affairs and Trade (MFAT) to commence the INFANTS (a Neonatal Education Development programme). There are excellent CM Health good candidates ready to train as trainers, and the CND for Kidz First is planning a one week training programme for our Trainers in February. Community Nursing A need for a quality framework has been identified for community health teams with reoccurring themes in complaints and incidents of more communication, coordination of care, and lack of consistency in the care team. Support has been obtained from the General Managers of the localities for progression of this project. The National Health Service in 2016 developed a quality framework for district nurses. This framework will be explored to identify if it can be translated to our context. A project brief is in development with support from Ko Awatea. The ‘acute beds stay’ system level measure action group continues to meet fortnightly to progress the programme of work and coordinate the activity of all the groups. Continued development of earlier supported discharge for people with Cellulitis to be supported by community health team for completion of intravenous antibiotics and home visits to assess person, provide health education on keeping well and follow up to support completion of treatment. Eastern Locality has indicated they have the resources available to trial this approach.

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Midwifery (a) Women’s Health and Newborn Annual Report 2016-2017 – Feedback from Ministry of Health

The CM Health Women’s Health and Newborn Annual Report 2016-2017 was submitted to the National Maternity Monitoring Group, Ministry of Health on 1 September 2017. This year’s annual report expanded to involve the Gynaecology Department and saw the Newborn section include projects specifically focused on improving care for neonates, along with NNU statistics.

In December, CM Health received feedback on the Annual Report from the National Maternity Monitoring Group congratulating CM Health on the positive coverage of the previous year’s activities reflecting the commitment to the women and whaanau in our area.

(b) Safe Sleep Day

Safe Sleep Day was on 1 December 2017 promoting the safe sleep messages to remind whaanau and staff of the protection that these actions provide to prevent sudden unexpected death in infancy(SUDI). The day was celebrated by staff wearing Safe Sleep Day t-shirts; excellent displays set up on the wards and all babies in Counties Manukau Health facilities were gifted with their own Safe Sleep onesies. CM Health has achieved a 30% reduction in SUDI since 2010.

(c) Electronic Caesarean Section (CS) Booking Pathway Update

Women’s Health has been working to streamline the booking process for elective CS and align it with other CM Heath elective procedures. The previous process relied on phone calls to book and relied on the oversight of different clinicians. To ensure consistency, women centred care and clear prioritisation a clear pathway has been agreed on.

The new pathway commenced on 4 December 2017 and this involves an obstetric electronic referral via MCIS identifying gestation CS required. The woman is then placed on CS wait list via the Maternity Administration team. The Coordinator of elective CS, which is a new role, phones woman three-four weeks prior and negotiates and confirms date for surgery and a letter confirming the date, blood forms, and relevant information is posted no later than two weeks prior to CS. The Coordinator will be responsible for managing the booking process and will liaise with the personnel involved.

This process has been worked on adjacent to and part of the Living our Values Project of the Maternity Wards.

Allied Health (a) Occupational therapy

One of the senior Occupational Therapists and triage clinician in Community Central has developed a system to manage the Occupational Therapy waitlist in the community. Information is added directly onto Google Maps. Therefore on the map at the beginning of each day all new referrals from the previous day will have been added to existing waitlisted clients. The advantage of this method is that when you click on a mapped referral you will have the option to view the property in Google Maps. This might be helpful when looking at issues around external access. The map can be updated relatively quickly when waitlisted clients have been seen. This additional intelligence around what the waitlist looks like in terms of location and complexity will make a difference to everyone and make a seemingly impossible task “doable.” The hope is that once tackling the waitlist using this system we will have a far more sustainable and proactive way of keeping on top of the workload. In terms of the patient experience this should result in reduced wait time and a more efficient professional service with better equity across the bases with all the teams using the same system and central triage having the over-arching view.

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Leadership Nursing There was concerted effort by nursing staff and teams across all areas, to provide considered feedback to a number of proposals for organisational changes in 2018, including the Ko Awatea new direction, creation of a “Feedback Central function”, development of Allied Health Leadership and service reconfigurations in mental health, renal medicine and to support ongoing Maternity developments. A number of these changes will affect staff reporting and team structures into 2018. Negotiation continues for renewal of the NZNO Nursing and Midwifery MECA. NZNO conducted membership meetings between 20 November and 8 December 2017. NZNO has now formally advised that the DHB offer to settle the NZNO Nursing and Midwifery MECA has been rejected. NZNO have confirmed they are prepared to enter mediation in late January 18 in an attempt to progress this bargaining. In the interim the union will be surveying their membership to reconfirm their mandate before bargaining recommences. Joint meetings with the University of Auckland School of Medicine and Health Sciences, and CM Health senior leadership team have been recommenced with the aim of a more formal partnership. MIT has confirmed a new academic structure commencing in 2018. The existing structure of seven Faculties has been replaced by 3 campuses, each with satellite sites. The faculty leadership structures have been replaced by new positions. As a result, the Faculty of Nursing and Health Studies is under the General Manager for the Manukau Campus, and will be headed by a Director of Practice Nursing, Sandra Wilkinson. The graduation ceremony of national Pacific postgraduate programme (ANIVA) coordinated by the Ministry of Health , Health Workforce NZ with Pacific Perspectives Ltd and Whitiera was held in Manukau. Of the 18 (nursing 16 and midwives 2) graduating the majority were from Counties. The key note speakers were the Honourable Jenny Salesa Associate Minister of Health Education & Housing and Denise Kivell DON. Community Nursing The Chief Nurse Advisor Primary and Integrated Care has been asked to be Nurse Clinical Lead for the regional closed system device procurement for administration of anti-neoplastic medications. A selection of products to be trialled and evaluated is underway. As Chair of Nurse Executive New Zealand, the Chief Nurse Advisor Primary and Integrated Care attended the National Nurses Organisation meeting held on 1 December. The National Nurses Organisation provides opportunity for collaboration between National Nursing Organisations to support the profession across education, Maori Nursing Organisations, Nursing Council, New Zealand Nurses Organisation and College of Nurses Aotearoa. The Chief Nurse Advisory Primary and Integrated care is also Chair of Nurse Executives New Zealand. This national group of nurse leaders and Health and Disability Services across New Zealand held their meeting on 8 December. In 2018 the meeting will be held in Christchurch, Wellington and Auckland. All meetings will be held over two days and will allow greater use of local speakers and support nursing leaders development through inclusion of more associate members. Allied Health One of CM Health senior social workers has been seconded to a part time position with the School of Counselling, Human Services and Social Work, University of Auckland (UoA). This is the first for a DHB and UoA partnership. It is a 3-semester secondment, beginning February 2018 and running to July 2019 and the social worker will lecture on social work assessment skills with a health focus, as well as working with older people.

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Patient Safety Pressure Injuries Since July 2017, we have been unable to report monthly pressure injuries data due to issues with the pressure injury Access database. Various actions to remediate the Access database were unsuccessful. As such, the wound care coaches tested using the Care Compass database to enter their audit data as an alternative option. This test went well with 20 areas entering their data and it seems reasonable for Care Compass to be an interim solution for the pressure injury audits in conjunction with eVitals. In January 2018, a staff member on non-clinical duties will assist in entering the pressure injury audit data from July to December that has been unable to be entered on the Access database into the Care Compass database. The reporting side of Care Compass is being refined in consultation with Ko Awatea in order for the Charge Nurses to have visibility of their ward-level data and to enable a service, division and organisational view. Patient Safety Week The theme of last year's national Patient Safety Week, held on 6-10 November 2017, was ‘Let’s Talk Medicines' encouraging patients to understand and ask questions about their medicine; and to encourage health professionals to follow AI2DET/health literacy principles1. The following three patient questions were the focus of ‘Let’s Talk Medicine’: • What is my medicine called? • What is it for? • When and how should I take it? Highlights of the week included the engagement from the majority of the clinical areas with the medication safety theme. The Patient Safety Team visited clinical areas between 6-10 November to view the visual showcases as part of the competition to demonstrate how an area was communicating key aspects of medication safety to their patients. The creativity displayed was impressive and some of the areas will continue to use what they had developed as part of the week as an on-going resource (ie: Te Rawhiti, Ward 31, Discharge Lounge). The clinical areas appreciated having Executive Leadership Team members as part of the visits during the week. Photographs from the Patient Safety Week clinical area visits are available on Paanui: Patient Safety Photographs of Displays.

First prize in the competition went to Te Rawhiti Community Mental Health Clinic. The team designed and implemented many medication safety related items showcasing their creativity including an owl made from medication packages placed in reception stating ‘be wise and know about your medicines’, a medication passport which was co-designed with patients, a ‘top 20 medications’ sheet in easy to understand terminology using evidence-based information, as well as a clothesline with mediation related questions pegged on in the clinic waiting area.

In second place, The Spinal Unit team embraced the ‘Let’s talk medicines’ theme of the week with an excellent demonstration of multidisciplinary team engagement. They had developed a ‘medicines to know before you go’ and top 10 medications resource that was being used.

1 AI2DET: Acknowledge, Introduce, Identify, Duration, Enquire and effective communication, Thank you. Health literacy principles: Step 1 - Find out what people know; Step 2 - Build health literacy skills and

knowledge; Step 3 - Check you were clear (and, if not, go back to Step 2).

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https://cmhealth.hanz.health.nz/Patient%20Safety/Patient%20Safety%20Week%202017/Pages/Photographs-of-Entries.aspx

https://cmhealth.hanz.health.nz/Patient%20Safety/Patient%20Safety%20Week%202017/Pages/Photographs-of-Entries.aspx


Third place went to Ward 31 for their creative, engaging display on stroke which will be used as an on-going resource. All staff were involved in the creation of this resource. They also developed a patient pamphlet with stroke-related medications and stroke risk factors. The Paanui/Patient Safety Week 2017 page had 823 visitors, the Facebook post had 7307 views and the ‘questions are the answer’ video was watched 3493 times during the week. Watch the video: Patient Safety Week 2017 on Vimeo.

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https://vimeo.com/241069420


Appendix 1

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Appendix 2 April 2016 Certification Corrective Actions December 2017 update

HDSS Standard MoH Finding MoH Corrective Action Executive Owner

Operational Lead

Update (summary) End date

Corrective Actions that are anticipated to be unresolved by the February Certification Audit Medicine Management 1.3.12.1

Prescriptions do not always meet best practice and regulatory requirements such as: - indications for use and maximum doses for prn medications are not documented - prescriptions are not consistently individually dated - the date, time and signature for discontinued medications is not consistently documented - sample signatures and registration numbers are not always recorded for prescribers - oxygen is not always charted - VTE assessments are not completed Franklin Hospital - The documentation of indications for use of PRN’s is inconsistent.

Ensure that medicine records are sufficiently detailed to consistently include dose limits, indications for prn medicines, dating and signing when medications are discontinued, individual dating of medications when prescribed. Ensure that sample signatures and prescriber numbers as well as venous thromboembolism risk assessments are documented. Franklin Hospital - Ensure an indication for use for all PRN medications is documented in the residents medication chart.

Chief Medical Officer

Clinical Head Medication Safety Group E Prescribing Lead Medical Education Fellow Operations Manager Franklin/Pukekohe Hospitals Chair VTE Committee

E Prescribing will ultimately resolve the majority of issues of prescribing and documentation issues. Testing is underway with a pilot planned for April 2018 and a business case will be developed for implementation developed after that starting in ARHOP.

• Consideration was given to introducing a stamp signature but ultimately this was decided against as not being practical. The Certification Audit findings were highlighted by Education Fellow to RMO’s.

A VTE audit and ‘shoulder tap’ survey was undertaken with doctors to identify barriers to documentation. As a result: • the VTE Prevention Policy has been updated to reflect the current required

practice with documentation of VTE risk within the clinical notes. • Reference to documenting in the Medication Chart has been removed,

since this section is not routinely utilised for documentation of VTE risk. • A Sticker has been developed and is being trialled in Orthopaedics,

including the ED patients coming into Orthopaedics. This has potential to be utilised more widely across the organisation.

• Plastics are undertaking an in-depth retrospective audit of VTE Assessments on patients with recent leg injuries looking at completion over the 24 hour period. This will also capture whether there are variations in practice between HO, RMO, SMO’s.

Franklin Memorial has worked with both the nurses and medical team on the ward to ensure that they are aware of the requirements to document the indications for use for PRN medication. This is now part of charting process. They have put in place a regular audit process for monitoring this.

Pilot in Apr 18 Complete Complete Complete Complete March 2018 February 2018 Complete

Complaints Management 1.1.13.1

Examples of feedback received from Middlemore Central and the complaints database indicates that not all complaints are being included in the system, the response is not timely and allocation of responsibility around who will address the complaint is not clear. Reports sighted do not record all the necessary response times required under the Code of Rights, however, the total time to resolution is normally recorded and has improved over the past year (from 25 working days to 12 days in November 2015). There is no central system to follow up recommendations and their implementation, particularly where

Ensure the complaints management system includes all complaints and demonstrate the management of complaints within expected timeframes.

Director of Patient Care

Quality Assurance Manager Director Patient Safety and Quality Assurance

A review of Feedback process has been completed and recommendations agreed to by ELT (for further consultation). Logging and coordination of complaints will be centralised under Feedback Central. ‘Work arounds’ are in place to minimise risk until implementation occurs.

March 2018

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Operational Lead


there are cross sector involvement and learnings. (Refer also criterion 1.2.3.8).

Quality And Risk Management Systems 1.2.3.3

Not all policies and procedures are current not being reviewed on a regular and timely basis.

Policies and procedures are current and reviewed at regular intervals as defined in policy.

Clinical Governance Group

Controlled Document Committee

The overdue rate is now 26% (up from a low of 18%). Data integrity issues persist making accurate reporting problematic and not trusted by stakeholders. These issues, amongst others, were highlighted in a recent Health Alliance audit report. A work plan has been developed in response to audit findings as has a Procedure document which will provide more guidance to the development and updating of controlled documents. The Clinical Governance Group approved the Procedure for publication at their December Meeting and has also reviewed the work plan.

• Work plan completed

Change were needed to the Terms of Reference to give the Controlled Document Committee the authority to ‘approve’ the development of new controlled documents thus ensuring correct process is being followed. This should in time improve quality and limit numbers of new documents (and therefore reduce overtime the updating workload). A process and Controlled Document Initiation Form has been developed to facilitate the change.

• Implementation of the changed process

Complete July 2018 Complete March 2018


An inconsistent approach to follow-through of recommendations following the development of corrective action plans is evident. It is difficult to track that these have all been completed as and when required and that the actions plans developed have addressed the issues raised.

All corrective actions as a result of events and complaints are implemented as and when required and there is a systematic approach to ensure completion and that the recommendations have in fact addressed the issues raised.



A Corrective Action Database has been developed for Adverse Events which will also include complaints once Feedback Central is established. The last year’s data has been inputted and report parameters developed. A Corrective Action Spreadsheet already exists for HDC complaints and is currently managed and coordinated by the CMO’s Office. Responsibility for this will be moved to Feedback Central (a central team responsible for coordinating and improving the quality of incidents and complaints) which is a proposed structure under consultation. Responsibility for tracking and monitoring Corrective Action monitoring is an explicit responsibility for Feedback Central and resource has been allocated to undertake this.

March 2018 Complete

Human Resource Management 1.2.7.5

Records of mandatory training requirements are neither complete nor accurate in the examples reviewed. Mandatory and other levels of training are still being defined. Performance appraisals are significantly overdue in some areas. Franklin Hospital - It is not clear what training staff have attended in 2016, with the 2015 programme showing not all staff complete mandatory training.

Implement a comprehensive system to identify, plan, manage, and record ongoing staff education. Ensure performance appraisals are completed on a regular basis within the timeframes defined by the organisation. Franklin Hospital - Ensure a system is in place to accurately capture compliance with mandatory training requirements.

Director Hospital Services Director Human Resource

Building Capability Lead Group Manager HR Operations Manager Pukekohe/Franklin Hospitals

Staff Education: The CMH Statutory Training Policy was issued in January 2017and sets out the requirements for the organisation. Testing for transition from OneStaff to Leader occurred in mid-September 2017 as planned however this proved to not be an appropriate platform. Modifications have been made to KA Learn to now include a unique employee identifier, which will assist with linking records and reporting, however it is not a complete solution.

• A business case is being developed to determine a medium and longer term solution to data capturing and reporting problem

• Implementation of business solution if approved

The Restraint Minimisation and Safe Practice Group have developed an E Learning package to address the training needs of staff around assessment and documentation of bed rail use. The E Learning package will be part of the Mandatory Patient Safety training programme. A supporting Bedrail Guideline and Decision Guide has been developed and published.

Complete March 2018 February 2019 Complete March 2019 March 2018 June 2019

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Operational Lead


• Staff training completed

Performance Appraisals: In March 2016 we established recording and reporting through manager KIOSK. However this is not a complete solution and a business case is being developed to establish a more effective solution going forward.

• Implementation of business solution if approved

Service Provision Requirements 1.3.3.3

Service provision is not always provided within a timeframe that safely meets the needs of the patients. The current process of managing inpatients awaiting surgery in acute theatres is causing repeated cancelations and delays that are resulting in nutritional deficits, patient distress and a negative effect on the flow of patients through the organisation. The process around transferring emergency obstetric patients to the operating theatre within a time frame that safely meets the patient needs is not consistent.

Ensure patients’ needs are identified and provided for in a timely manner.

Director of Hospital Services

SAPs Jacqui Wynne-Jones WH Thelma Thompson/Michelle NB

The “Categorisation of Urgency for Caesarean Section and “How to Arrange the Procedure” guideline was rolled out on 1/5/17 and communicated with staff over the 2 weeks prior. An audit was undertaken to measure compliance: 85% of category 1 caesareans were called using the 888 process (a good result).

• A follow up audit will be conducted in 12 Months.

SAPS have set a goal of 3.8 days admission to discharge. There is a trend with increasing high acute volumes each month impacting on flow, since the appointment of an acute flow coordinator in September2017 there has been an improvement There is regular reporting to the Director of Hospital Services and theatre hours are monitored in relation to Dot Days (over capacity).

• The need for additional theatres is recognised and the feasibility of this is being investigated. The Master Plan identifies the site remedial issues including theatre and this work is prioritised.

Complete February 2019 Tbc

Assessment 1.3.4.2

Individual goals/desired outcomes/needs, including cultural and spiritual needs are not consistently documented throughout most service streams as a basis for care planning and service delivery.

Individualised goals/needs/desired outcomes are sought and documented as a basis for care planning and delivery. Franklin Hospital - Ensure all interRAI assessments and reviews are completed within required timeframes.


Lead CND Surgical Operations Manager for Pukekohe & Franklin Hospitals

See 1.3.5.2 for Plan of Care project. Note a number of Assessments have been included in E Vitals initiative which is being progressively rolled out eg FBC, which will in time reduce the documentation issues.

• Plan of Care implementation complete (dependant on replacing PoC resource)

Franklin: The Programme Manager for HOP met with the Service Manager Franklin Memorial Hospital to verify progress attained by the Facility in implementing the specific elements of the required corrective action. The Facility provided evidence they are completing interRAI assessments as per the contractual requirements. The Facility verified they have 3 staff who are interRAI trained who are able to ensure that each Resident has an initial interRAI assessment within 21 days of admission and each Resident has reassessed every 6 months or sooner if their health needs change.

A whiteboard has been set up and the Residents interRai initial assessment and reassessment are allocated to a specific Registered Nurse who has the responsibility to ensure the assessment and care plans are current. This information was provided to the Ministry of Health who accepted this aspect of the CAR as closed.

December 2018 Complete Complete

Planning 1.3.5.2

Care plans are not patient focussed, do not proactively guide practice and are not always used to promote continuity of service delivery and do not always reflect involvement of the patient. Evidence of

Ensure the information from all relevant assessment sources is documented in detail to support an ongoing plan of care to meet the patients’ needs and goals. Care


Lead CND Surgical CND MHS WH KF Director

The Assessment, Planning and Evaluation CAR’s have been rolled into the Plan of Care project which has focused on a revised format which captures Patient goals more explicitly, and requires the updating of the risk assessments every shift. Ultimately it will sit within E Vitals and has been developed with this in mind for ease of eventual transfer. The Plan of Care process includes AIE documentation

Complete

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Operational Lead


patient assessments is not always reflected in the care plan. Early warning signs and relapse prevention plans are not evident in Tiaho Mai.

plans are developed that guide practice and support the patient, with the involvement of the patient. Early warning signs and relapse prevention is part of the care plan for patients in the mental health service.

Midwifery/CND ARHOP Service Manager

format (Assessment/Intervention/Evaluation) which is both streamlined and focused.

• The pilot of the PoC and AIE t (Medical and Surgical) is underway • Gynae and Kidz Kirst will complete a baseline audit using the PoC audit

tool to check performance, and confirm whether the current work programme underway (Clinical Pathways, Variance project) will deliver the expected benefits/resolve problems or whether there is leverage to be obtained from the PoC format and approach.

• ARHOP are interested in trialling PoC format however greater emphasis on Allied Health interventions will be needed in the current format.

• Organisation wide implementation of PoC (subject to replacement of PoC Lead)

MHS report that EWS plans are developed in the community as patients are generally too unwell to participate in their development when inpatients which is why EWS do not appear in the inpatient files.

February 2018 April 2018 December 2018 Complete

Evaluation 1.3.8.2

The evaluation of interventions and the response to treatment is inconsistently documented.

Ensure evaluation tools are completed and inform the care planning process


Lead CND Surgery

See 1.3.5.2 December 2018

Facility Specifications 1.4.2.6

In the Tiaho Mai mental health service patients are not provided with safe and accessible external areas that meet their needs.

Ensure patients can access a safe outdoor courtyard area.


GM/CD MHS CND MHS

Will be resolved with new build and issue was improved as a result of the temporary relocation while the rebuild is underway.

• Phase one completed • Unit fully operational and decant complete

June 2018 December 2018

The following Corrective Actions anticipated to be closed by the February Certification Audit

Service Provider Availability 1.2.8.1 Moderate

Service provider levels and skill mix is not adequately addressed in three service areas, including the orthopaedic service for patients being transferred from the ICU to the ward, and prior to transfer to the spinal unit. The recruitment process is long and protracted in some cases causing gaps in rostering and unnecessary use of casual/bureau staff.

Ensure staffing levels and skill mix meet requirements for patient safety, including for patients with spinal injuries being transferred from ICU to the ward. The current recruitment process is reviewed to ensure all possible delays are reduced.

Director Hospital Services Director HR

MMC Governance Group Michelle MJ Talent Acquisition Manager

A Spinal Cord Injury Unit has been established in Orthopaedics with a Associate Charge Nurse who links into ICU and we believe that the issue identified at Certification is resolved. Management of workload focus has been on the CCDM coordinator now in post and supporting the wards to capture data, and then development of useful reporting. Currently there are some challenges with getting meaningful AWM reports for review, and the matching of the acuity score to the established roster model. There is also a focus on getting a dashboard - that will integrate the various metrics of CCDM framework. There has been a 'budgeted shift' for FY17/18 in Medical wards to include the HCA use for patient watches into the ward FTE establishment, with the intention this will reduce the draw from bureau for these watches (particularly use of external HCA), and enable HCAs to be deployed in other work shifts. The daily Middlemore Central operational meetings with CNMs and services continue to review the shift staffing levels, and allocate bureau/ redeployment of staff available to best manage risks. Internal Bureau recruitment action

Resolved pending MoH approval

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Operational Lead


continues, and has increased the available pool of HCA, however it is more challenging to attract registered staff. The electronic on boarding process has streamlined the process. The pipeline management of the recruitment process has been reviewed and improved with average length of time to recruit reduced from 119.9 days to 56.6 (for nursing) and we believe the issues apparent at the Certification visit in April have been resolved.

Transition, Exit, Discharge, Or Transfer 1.3.10.2 Moderate

Discharge planning is not always planned, coordinated or documented. Discharge is at times a reactive process driven by the hospital’s need for a bed rather than a patient focussed proactive activity. For one patient with complex medical needs, the transfer from the intensive care unit to the orthopaedic ward was not well planned and did not provide the level of care and support required to manage associated risks.

Ensure discharge and transfer planning is documented, timely and minimises the risks associated with discharge and/or transfer.

Director Hospital Services

MMC Governance Group

A work-stream is underway with Inpatient services working with community based services and GP Liaison to proactively identify potential discharges that can be “pulled” by the community. Several initiatives are being trialled including:

• The sharing between DHB and community of a report of all patients with a length of stay greater than 7 days by locality. These patients may be known by the community and discharge preparations set in place.

• District Nursing attend the 1030 Charge Nurse meeting asking the Charge Nurses if they have patients who could go home with support – this is to prompt ongoing review of patients rather than waiting until time of discharge.

• Goal discharge dates are being entered into IPMS (in some services), into Concerto and a daily report is prepared which will facilitate proactive discharge preparation, potentially by the night staff of patients who could go to the Discharge Lounge early.

• Measures of success would show an increase of discharges either to home or to the Discharge Lounge by 1100 hours with a target of 30%. Also an increase of patients for Re-ablement.

• Improvements to the medical roster enhancing discharging at the weekend.

There are now 2 Patient Flow Nurses, one in Surgical Services and one in Medicine. Part of their role in managing the smooth flow of the patient through the system is to identify daily those patients who are likely for discharge the following day. The patients are prepared for early transfer to the Discharge Lounge in the morning where their discharge process can be facilitated. Goal discharge date has been added to the new Plan of Care form (Medical and Surgical areas). A Discharge Checklist is being developed which will further streamline the discharge process and improve quality.


090



Operational Lead


Facility Specifications 1.4.2.4 Moderate

The physical environment is not always managed in a manner which ensures consumer safety is maintained. (Dirty/Clean flow in some wards, some reuse of single use items noted)

Implement consistent processes which ensure the physical environment minimises the risk of harm to patients including management of waste, storage and maintenance of equipment, facilities and supplies, temperature control of facilities and prevention of infection.


Infection Control TL Facilities Lead tbc

The reuse of single use items has been included in the Safe Environment Checklist. The Clean/Dirty Flow is checked in Leadership Walkarounds and has been included in the Safe Environment Audit (Certification). A new Waste Management Policy has been implemented. Temperature, appropriate storage of equipment are monitored via the H+S Checklist.


Independence, Personal Privacy, Dignity, And Respect 1.1.3.6 Low

The unit doors to the Tiaho Mai mental health unit are locked restricting the freedom of movement of informal patients.

Ensure Tiaho Mai does not restrict the movement of informal patients.


GM/CD Mental Health CND MHS

Good progress with rebuild and development of a new model of care has occurred to support the less restricted environment. Meanwhile the temporary relocation of patients during the rebuild enabled greater and more appropriate freedom.


Quality And Risk Management Systems 1.2.3.9 Low

Several deficiencies in the current risk management system have been identified with a plan developed and a new risk manager employed to address this. At the time of audit these have yet to be implemented.

Work to address the current deficiencies in the risk management system is implemented as planned to ensure a robust system is in place and understood by those staff involved.

Director of Strategy

Risk Manager A Risk Champion model has been implemented so there is a role with clear accountability at Divisional level for the identification, management, monitoring and reporting of risk. A Risk Champion Forum has also been developed. New reporting format developed making risk more easily monitored and managed. The Risk Policy has been reviewed and strengthened.


Human Resource Management 1.2.7.2 Low

Completion of departmental credentialing is variable, with some areas well overdue. General medicine is overdue by five years. Areas such as Ophthalmology have been completed but other areas e.g. general medicine. Senior staff also report some long term vacancies in some specialty areas put additional pressure on completion of credentialing.

Complete credentialing and maintain currency in accordance with organisational requirements.


Chief Medical Officer Deputy CMO, CD Medicine

Credentialing is monitored by the CMO Office. The Credentialing Policy was updated earlier in the year to clarify process and get leverage off the good practice occurring in Surgical Services. Good progress made with planning and scheduling with most current.


Planned Activities 1.3.7.1 Low

No activities are provided at Tiaho Mai to develop and maintain strengths that are meaningful to the consumer.

Resource and develop the activity programme that has been developed. Individual care plans reflect the inclusion of activities meaningful for the patient.


GM/CD Mental Health

Activities completed by patients are reported monthly by the OT’s. At the time of this CAR MHS had a long standing vacancy which is now resolved


Nutrition, Safe Food, And Fluid Management 1.3.13.2 Low

Examples of patients not receiving food suitable to meet their specific needs were identified, including easy access to drinks and snacks in the mental health unit. As the organisation is transitioning to a new menu ordering system through electronic technology, there is a risk that patients will not receive the correct diet.

Patients with special dietary needs have these consistently identified and met.


Manager Food Service and Fleet GM MHS

The early issues identified with the electronic ordering system have mainly been overcome with the roll out of the new TMMI screen. Ward food service staff are managing their role in the system with greater compliance, remaining system issues have been identified in the TMMI/Saffron interface and have robust manual ‘work arounds’ in place until these are resolved. A project is underway to produce an eLearning module on the subject of correct meal and diet code ordering at ward level to encourage nursing staff to complete and have a greater understanding of correct ordering. Meanwhile the Food Manager monitors satisfaction surveys and incident reports and compiles a report that goes to


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Operational Lead


CND’s and CN’s. MHS have a beverage bays where patients can make tea and coffee and access snacks from a fridge (apples, yogurts etc). Staff also regularly review patient feedback on this.


Numerous examples were sighted of patient food fridges not being monitored to ensure food is stored appropriately and at the correct temperature. Several were not clean and food was not labelled nor stored safely. These findings are supported in a recent audit.

All patient food is stored safely within fridges in patient ward areas, at the correct temperature, correctly labelled and dated.


Director of Nursing Manager OSHH

Health and Safety Reps have included a check of patient fridge temperatures in their 2 monthly checklists. The last result August showed improved compliance. Attach result (33/36).



Operational Lead

Update (summary) Progress

Corrective Actions that are anticipated to be unresolved by the February Certification Audit

Medicine Management 1.3.12.1

Prescriptions do not always meet best practice and regulatory requirements such as: - indications for use and maximum doses for prn medications are not documented - prescriptions are not consistently individually dated - the date, time and signature for discontinued medications is not consistently documented - sample signatures and registration numbers are not always recorded for prescribers - oxygen is not always charted - VTE assessments are not completed Franklin Hospital - The documentation of indications for use of PRN’s is inconsistent.

Ensure that medicine records are sufficiently detailed to consistently include dose limits, indications for prn medicines, dating and signing when medications are discontinued, individual dating of medications when prescribed. Ensure that sample signatures and prescriber numbers as well as venous thromboembolism risk assessments are documented. Franklin Hospital - Ensure an indication for use for all PRN medications is documented in the residents medication chart.


Clinical Head Medication Safety Group E Prescribing Lead Medical Education Fellow Operations Manager Franklin/Pukekohe Hospitals Chair VTE Committee

E Prescribing will ultimately resolve the majority of issues of prescribing and documentation issues. Testing is underway with a pilot planned for April 2018 and a business case will be developed for implementation developed after that starting in ARHOP. Consideration was given to introducing a stamp signature but ultimately this was decided against as not being practical. Audit findings were highlighted by Education Fellow to RMO’s. A VTE audit and ‘shoulder tap’ survey was undertaken with doctors to identify barriers to documentation. As a result the VTE Prevention Policy has been updated to reflect the current required practice with documentation of VTE risk within the clinical notes. Reference to documenting in the Medication Chart has been removed, since this section is not routinely utilised for documentation of VTE risk. A Sticker has been developed and is being trialled in Orthopaedics, including the ED patients coming into Orthopaedics. This has potential to be utilised more widely across the organisation. Plastics are undertaking an in-depth retrospective audit of VTE Assessments on patients with recent leg injuries looking at completion over the 24 hour period. This will also capture whether there are variations in practice between HO, RMO, SMO’s. Franklin Memorial has worked with both the nurses and medical team on the ward to ensure that they are aware of the requirements to document the indications for use for PRN medication. This is now part of charting process. They have put in place a regular audit process for monitoring this.

Slow

Complaints Management 1.1.13.1

Examples of feedback received from Middlemore Central and the complaints database indicates that not all complaints are being included in the system, the response is not timely and allocation of responsibility around who will address the

Ensure the complaints management system includes all complaints and demonstrate the management of complaints within expected timeframes.


Quality Assurance Manager Director Patient Safety and Quality

A review of Feedback process has been completed and recommendations agreed to by ELT (for further consultation). Logging and coordination of complaints will be centralised under Feedback Central. ‘Work arounds’ are in place to minimise risk until implementation occurs.

Slow

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Operational Lead


complaint is not clear. Reports sighted do not record all the necessary response times required under the Code of Rights, however, the total time to resolution is normally recorded and has improved over the past year (from 25 working days to 12 days in November 2015). There is no central system to follow up recommendations and their implementation, particularly where there are cross sector involvement and learnings. (Refer also criterion 1.2.3.8).

Assurance


Not all policies and procedures are current not being reviewed on a regular and timely basis.

Policies and procedures are current and reviewed at regular intervals as defined in policy.

Clinical Governance Group

Controlled Document Committee

Recently change were made to ToR for Controlled Document Committee to ‘approve’ the development of new controlled documents to ensure correct process is being followed which should improve quality and limit numbers of new documents (and therefore reduce overtime the updating workload). The overdue rate is now 26% (up from a low of 18%). Data integrity issues persist making accurate reporting problematic and not trusted by stakeholders. These issues, amongst others, were highlighted in an Health Alliance audit report. A work plan has been developed in response to audit findings as has a Procedure document which will provide more guidance to the development and updating of controlled documents. Clinical Governance Group approved the Procedure for publication at their December Meeting and has also reviewed the work plan. The work plan will resolve the issues identified in the audit.

Slow


An inconsistent approach to follow-through of recommendations following the development of corrective action plans is evident. It is difficult to track that these have all been completed as and when required and that the actions plans developed have addressed the issues raised.

All corrective actions as a result of events and complaints are implemented as and when required and there is a systematic approach to ensure completion and that the recommendations have in fact addressed the issues raised.



A Corrective Action Spreadsheet exists for HDC complaints and is currently managed and coordinated by the CMO’s Office. Responsibility for this will be moved to Feedback Central (a central team responsible for coordinating and improving the quality of incidents and complaints) which is a proposed structure under consultation. A Corrective Action Database has been developed for Adverse Events which will also include complaints once Feedback Central is established. The last year’s data has been inputted and report parameters developed. Responsibility for tracking and monitoring Corrective Action monitoring is an explicit responsibility for Feedback Central and resource has been allocated to undertake this. Weakness will be the lack of reporting.

Slow

Human Resource Management 1.2.7.5

Records of mandatory training requirements are neither complete nor accurate in the examples reviewed. Mandatory and other levels of training are still being defined. Performance appraisals are significantly overdue in some areas. Franklin Hospital - It is not clear what training staff have attended in 2016, with

Implement a comprehensive system to identify, plan, manage, and record ongoing staff education. Ensure performance appraisals are completed on a regular basis within the timeframes defined by the organisation. Franklin Hospital - Ensure a system

Director Hospital Services Director Human Resource

Building Capability Lead Group Manager HR Operations Manager Pukekohe/Fra

Staff Education: The CMH Statutory Training Policy was issued in January 2017and sets out the requirements for the organisation. Testing for transition from OneStaff to Leader occurred in mid-September as planned however this proved to not be an appropriate platform. Modifications have been made to KA Learn to now include a unique employee identifier, which will assist with linking records and reporting. A business case is under development to determine a medium and longer term solution to data capturing and reporting problem. The Restraint Minimisation and Safe Practice Group have developed an E

Slow

093



Operational Lead


the 2015 programme showing not all staff complete mandatory training.

is in place to accurately capture compliance with mandatory training requirements.

nklin Hospitals

Learning package to address the training needs of staff around assessment and documentation of bed rail use. A supporting Bedrail Guideline and Decision has been developed. The package will be implemented by mid-January 2018. The E Learning package will be part of the Mandatory Patient Safety training programme which staff will progress through over the year. Performance Appraisal: In March 2016 we established recording and reporting through manager KIOSK. This has created a higher level of visibility, which allows for reporting to be visible to the direct line manager and their manager, which should support greater accountability. CM Health is developing a business case to establish a more effective solution going forward.

Service Provision Requirements 1.3.3.3

Service provision is not always provided within a timeframe that safely meets the needs of the patients. The current process of managing inpatients awaiting surgery in acute theatres is causing repeated cancelations and delays that are resulting in nutritional deficits, patient distress and a negative effect on the flow of patients through the organisation. The process around transferring emergency obstetric patients to the operating theatre within a time frame that safely meets the patient needs is not consistent.

Ensure patients’ needs are identified and provided for in a timely manner.


SAPs Jacqui Wynne-Jones WH Thelma Thompson/Michelle NB

The “Categorisation of Urgency for Caesarean Section and “How to Arrange the Procedure” guideline was rolled out on 1/5/17 and communicated with staff over the 2 weeks prior. An audit was undertaken to measure compliance: 85% of category 1 caesareans were called using the 888 process. A follow up audit will be conducted in 12 Months. SAPS have set a goal of 3.8 days admission to discharge. There is a trend with increasing high acute volumes each month impacting on flow. However since the appointment of an acute flow coordinator in September we have already seen a difference so are expecting to see further improvement this month. There is regular reporting to the Director of Hospital Services and theatre hours are monitored in relation to Dot Days (over capacity). The need for additional theatres is recognised and the feasibility of this is being investigated. The Master Plan identifies the site remedial issues including theatre and this work is prioritised.

Slow

Assessment 1.3.4.2

Individual goals/desired outcomes/needs, including cultural and spiritual needs are not consistently documented throughout most service streams as a basis for care planning and service delivery.

Individualised goals/needs/desired outcomes are sought and documented as a basis for care planning and delivery. Franklin Hospital - Ensure all interRAI assessments and reviews are completed within required timeframes.


Lead CND Surgical Operations Manager for Pukekohe & Franklin Hospitals

See 1.3.5.2 for Plan of Care project. Note a number of Assessments have been included in E Vitals initiative which is being progressively rolled out eg FBC, which will in time reduce the documentation issues.

Franklin: The Programme Manager for HOP met with the Service Manager Franklin Memorial Hospital to verify progress attained by the Facility in implementing the specific elements of the required corrective action. The Facility provided evidence they are completing interRAI assessments as per the contractual requirements. The Facility verified they have 3 staff who are interRAI trained who are able to ensure that each Resident has an initial interRAI assessment within 21 days of admission and each Resident has reassessed every 6 months or sooner if their health needs change.

A whiteboard has been set up and the Residents interRai initial assessment and reassessment are allocated to a specific Registered Nurse who has the responsibility to ensure the assessment and care plans are current. This information was provided to the Ministry of Health who accepted this aspect of the CAR as closed.

Slow

Planning 1.3.5.2 Care plans are not patient focussed, do not proactively guide practice and are not

Ensure the information from all relevant assessment sources is

Director of Lead CND Surgical

The Assessment, Planning and Evaluation CAR’s have been rolled into the Plan of Care project which has focused on a revised format which captures Patient goals

Slow

094



Operational Lead


always used to promote continuity of service delivery and do not always reflect involvement of the patient. Evidence of patient assessments is not always reflected in the care plan. Early warning signs and relapse prevention plans are not evident in Tiaho Mai.

documented in detail to support an ongoing plan of care to meet the patients’ needs and goals. Care plans are developed that guide practice and support the patient, with the involvement of the patient. Early warning signs and relapse prevention is part of the care plan for patients in the mental health service.

Patient Care CND MHS WH KF Director Midwifery/CND ARHOP Service Manager

more explicitly, and requires the updating of the risk assessments every shift. Ultimately it will sit within E Vitals and has been developed with this in mind for ease of eventual transfer. The Plan of Care process includes AIE documentation format (Assessment/Intervention/Evaluation) which is both streamlined and focused. The pilot of the PoC and AIE was successful and the wider role out (Medical and Surgical) is underway (estimated completed date 18 December 2017). Gynae and Kidz Kirst will complete a baseline audit using the PoC audit tool to check performance, and confirm whether the current work programme underway (Clinical Pathways, Variance project) will deliver the expected benefits/resolve problems or whether there is leverage to be obtained from the PoC format and approach. ARHOP are interested in trialling PoC format however greater emphasis on Allied Health interventions will be needed in the current format. A presentation to CN’s planned by the PoC Lead. MHS report that EWS plans are developed in the community as patients are generally too unwell to participate in their development when inpatients which is why EWS do not appear in the inpatient files.

Evaluation 1.3.8.2

The evaluation of interventions and the response to treatment is inconsistently documented.

Ensure evaluation tools are completed and inform the care planning process


Lead CND Surgery

See 1.3.5.2 Slow

Facility Specifications 1.4.2.6

In the Tiaho Mai mental health service patients are not provided with safe and accessible external areas that meet their needs.

Ensure patients can access a safe outdoor courtyard area.


GM/CD MHS CND MHS

Will be resolved with new build and issue was improved as a result of the temporary relocation while the rebuild is underway.

Slow

The following Corrective Actions anticipated to be closed by the February Certification Audit

Service Provider Availability 1.2.8.1 Moderate

Service provider levels and skill mix is not adequately addressed in three service areas, including the orthopaedic service for patients being transferred from the ICU to the ward, and prior to transfer to the spinal unit. The recruitment process is long and protracted in some cases causing gaps in rostering and unnecessary use of casual/bureau staff.

Ensure staffing levels and skill mix meet requirements for patient safety, including for patients with spinal injuries being transferred from ICU to the ward. The current recruitment process is reviewed to ensure all possible delays are reduced.

Director Hospital Services Director HR

MMC Governance Group Michelle MJ Talent Acquisition Manager

A Spinal Cord Injury Unit has been established in Orthopaedics with a Associate Charge Nurse who links into ICU and we believe that the issue identified at Certification is resolved. Management of workload focus has been on the CCDM coordinator now in post and supporting the wards to capture data, and then development of useful reporting. Currently there are some challenges with getting meaningful AWM reports for review, and the matching of the acuity score to the established roster model. There is also a focus on getting a dashboard - that will integrate the various metrics of CCDM framework. There has been a 'budgeted shift' for FY17/18 in Medical wards to include the HCA use for patient watches into the ward FTE establishment, with the intention this will reduce the draw from bureau for these watches (particularly use of external HCA), and enable HCAs to be deployed in other work shifts. The daily Middlemore Central operational meetings with CNMs and services

Good

095



Operational Lead


continue to review the shift staffing levels, and allocate bureau/ redeployment of staff available to best manage risks. Internal Bureau recruitment action continues, and has increased the available pool of HCA, however it is more challenging to attract registered staff. The electronic on boarding process has streamlined the process. The pipeline management of the recruitment process has been reviewed and improved with average length of time to recruit reduced from 119.9 days to 56.6 (for nursing) and we believe the issues apparent at the Certification visit in April have been resolved.

Transition, Exit, Discharge, Or Transfer 1.3.10.2 Moderate

Discharge planning is not always planned, coordinated or documented. Discharge is at times a reactive process driven by the hospital’s need for a bed rather than a patient focussed proactive activity. For one patient with complex medical needs, the transfer from the intensive care unit to the orthopaedic ward was not well planned and did not provide the level of care and support required to manage associated risks.

Ensure discharge and transfer planning is documented, timely and minimises the risks associated with discharge and/or transfer.


MMC Governance Group

A work-stream is underway with Inpatient services working with community based services and GP Liaison to proactively identify potential discharges that can be “pulled” by the community. Several initiatives are being trialled including:

• The sharing between DHB and community of a report of all patients with a length of stay greater than 7 days by locality. These patients may be known by the community and discharge preparations set in place.

• District Nursing attend the 1030 Charge Nurse meeting asking the Charge Nurses if they have patients who could go home with support – this is to prompt ongoing review of patients rather than waiting until time of discharge.

• Goal discharge dates are being entered into IPMS (in some services), into Concerto and a daily report is prepared which will facilitate proactive discharge preparation, potentially by the night staff of patients who could go to the Discharge Lounge early.

• Measures of success would show an increase of discharges either to home or to the Discharge Lounge by 1100 hours with a target of 30%. Also an increase of patients for Re-ablement.

• Improvements to the medical roster enhancing discharging at the weekend.

There are now 2 Patient Flow Nurses, one in Surgical Services and one in Medicine. Part of their role in managing the smooth flow of the patient through the system is to identify daily those patients who are likely for discharge the following day. The patients are prepared for early transfer to the Discharge Lounge in the morning where their discharge process can be facilitated. Goal discharge date has been added to the new Plan of Care form (Medical and Surgical areas). A Discharge Checklist is being developed which will further streamline the discharge process and improve quality.

Good

096



Operational Lead


Facility Specifications 1.4.2.4 Moderate

The physical environment is not always managed in a manner which ensures consumer safety is maintained. (Dirty/Clean flow in some wards, some reuse of single use items noted)

Implement consistent processes which ensure the physical environment minimises the risk of harm to patients including management of waste, storage and maintenance of equipment, facilities and supplies, temperature control of facilities and prevention of infection.


Infection Control TL Facilities Lead tbc

The reuse of single use items has been included in the Safe Environment Checklist. The Clean/Dirty Flow is checked in Leadership Walkarounds and has been included in the Safe Environment Audit (Certification). A new Waste Management Policy has been implemented. Temperature, appropriate storage of equipment are monitored via the H+S Checklist.

Good

Independence, Personal Privacy, Dignity, And Respect 1.1.3.6 Low

The unit doors to the Tiaho Mai mental health unit are locked restricting the freedom of movement of informal patients.

Ensure Tiaho Mai does not restrict the movement of informal patients.


GM/CD Mental Health CND MHS

Good progress with rebuild and development of a new model of care has occurred to support the less restricted environment. Meanwhile the temporary relocation of patients during the rebuild enabled greater and more appropriate freedom.

Good

Quality And Risk Management Systems 1.2.3.9 Low

Several deficiencies in the current risk management system have been identified with a plan developed and a new risk manager employed to address this. At the time of audit these have yet to be implemented.

Work to address the current deficiencies in the risk management system is implemented as planned to ensure a robust system is in place and understood by those staff involved.

Director of Strategy

Risk Manager A Risk Champion model has been implemented so there is a role with clear accountability at Divisional level for the identification, management, monitoring and reporting of risk. A Risk Champion Forum has also been developed. New reporting format developed making risk more easily monitored and managed. The Risk Policy has been reviewed and strengthened.

Good

Human Resource Management 1.2.7.2 Low

Completion of departmental credentialing is variable, with some areas well overdue. General medicine is overdue by five years. Areas such as Ophthalmology have been completed but other areas e.g. general medicine. Senior staff also report some long term vacancies in some specialty areas put additional pressure on completion of credentialing.

Complete credentialing and maintain currency in accordance with organisational requirements.


Chief Medical Officer Deputy CMO, CD Medicine

Credentialing is monitored by the CMO Office. The Credentialing Policy was updated earlier in the year to clarify process and get leverage off the good practice occurring in Surgical Services. Good progress made with planning and scheduling with most current.

Good

Planned Activities 1.3.7.1 Low

No activities are provided at Tiaho Mai to develop and maintain strengths that are meaningful to the consumer.

Resource and develop the activity programme that has been developed. Individual care plans reflect the inclusion of activities meaningful for the patient.


GM/CD Mental Health

Activities completed by patients are reported monthly by the OT’s. At the time of this CAR MHS had a long standing vacancy which is now resolved

Good

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Operational Lead



Examples of patients not receiving food suitable to meet their specific needs were identified, including easy access to drinks and snacks in the mental health unit. As the organisation is transitioning to a new menu ordering system through electronic technology, there is a risk that patients will not receive the correct diet.

Patients with special dietary needs have these consistently identified and met.


Manager Food Service and Fleet GM MHS

The early issues identified with the electronic ordering system have mainly been overcome with the roll out of the new TMMI screen. Ward food service staff are managing their role in the system with greater compliance, remaining system issues have been identified in the TMMI/Saffron interface and have robust manual ‘work arounds’ in place until these are resolved. A project is underway to produce an eLearning module on the subject of correct meal and diet code ordering at ward level to encourage nursing staff to complete and have a greater understanding of correct ordering. Meanwhile the Food Manager monitors satisfaction surveys and incident reports and compiles a report that goes to CND’s and CN’s. MHS have a beverage bays where patients can make tea and coffee and access snacks from a fridge (apples, yogurts etc). Staff also regularly review patient feedback on this.

Good


Numerous examples were sighted of patient food fridges not being monitored to ensure food is stored appropriately and at the correct temperature. Several were not clean and food was not labelled nor stored safely. These findings are supported in a recent audit.

All patient food is stored safely within fridges in patient ward areas, at the correct temperature, correctly labelled and dated.


Director of Nursing Manager OSHH

Health and Safety Reps have included a check of patient fridge temperatures in their 2 monthly checklists. The last result August showed improved compliance. Attach result (33/36).

Good

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Appendix 3 21 November 2017 To: Mashouda Chuttur Cc: Jenny Parr, Graham Manning, Sarah Thirlwall From: Jo Rankine Chair Controlled Document Committee RE: Findings from the audit of controlled documents Thank you for the opportunity to respond to the draft audit findings. We commend you on your thoroughness and quality improvement focus. However it would be helpful to include input from a broader range of users (Owners, LDC’s, Authors, and Approvers) in your next audit to ensure all issues/barriers are identified and evidence can be triangulated. The ‘people dimension’ of the controlled document process is complex. The risk that having overdue controlled documents poses has been added to the organisational risk register. We are developing a project brief to assist with the actions relating to data integrity and training issues. The findings and recommendations have formed the basis of the Controlled Document Committee’s (CDC) 2018 Work Plan. However I should note that a number of items were already underway so we expect to complete several of them well before the March/April 2018 completion date specified in your report. Please note the CDC has taken a team approach to the ownership of the actions below therefore both the Chair and the Corporate Managers names are listed jointly. However the CDC Work Plan does have identified operational leads. Finding 1 • We will undertake an audit of Documentation Directory in early 2018. • The options to implement footer restrictions that is compatible with the automated system

used for updating metadata fields will be raised with the Objective Corporation Limited (OCL). We will also investigate how to accommodate, or convert old document format versions as well as raising other issues as identified. An ‘error report’ is under development so as to identify issues and use as a feedback tool to stakeholders (including OCL). Additionally we propose boosting our CDC membership to include all Local Document Controllers (LDC’s) so we can strengthen their engagement and accountability. We lack dedicated training resources so are revising our training model (currently 1 : 1) to better target and support those involved in the creation and review of documents. An E Learning Module and online manual will be developed which will improve performance quality and enable less resource intensive training. Owner: Chair/Corporate Records Manager.

Finding 2 • The CDC has a governance responsibility and as such is not in a position to follow up with

Owners to ‘take necessary action to have the policies and Guidelines updated’. The best tool for improving performance and compliance is by ensuring there are accurate and appropriate reports being provided to stakeholders (including Owners and General Managers). Accordingly we have under development a revised report format and dissemination plan which will improve visibility of issues (via an error report) and the overdue/due status of controlled documents. Additionally the development of divisional KPI’s and a Procedure document (publication December 2017) will improve the ability of the business to support/performance manage where needed.

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• There are a variety of issues that users of Objective and the Documentation Directory experience that cause frustrations, ‘work arounds’ and ultimately impact on data quality and timeliness. An upgrade to Objective is planned for 2018 which is more accessible for users and supports workflow. A review of the Documentation Directory is planned as is ensuring staff are appropriately trained on how to locate controlled documents. Owner: Chair/Corporate Records Manager.

Finding 3 • The Policy is being updated to ensure all links are operational and the document is

appropriately cross referenced. Owner: Chair/Corporate Records Manager.

• The recently developed Procedure document (publication December 2017) describes the

creation and review process in detail. Additionally we will be developing an online manual and E Learning Manual to support users. Owner: Chair/Corporate Records Manager.

Finding 4 • The recently developed Procedure includes criteria for determining who can be a

Document Owner. Owner: Chair/Corporate Records Manager.

Finding 5 • Roles and responsibilities of all staff have been described in the new Procedure referred to

above (note roles and responsibilities are typically outlined in Procedure rather than Policy documents in CM Health). Owner: Chair/Corporate Records Manager.

Finding 6 • The newly developed Procedure describes who can be an Approver, and the purpose of the

approver’s role. We are also updating the list of approving Committees. Owner: Chair/Corporate Records Manager.

Finding 7 • The development of a Disposal and Archiving Policy is included in the CDC 2018 Work Plan. • The tagging of ‘retired and superseded’ documents will be included in training via the

online manual and E Learning Module. Owner: Chair/Corporate Records Manager.

Finding 8 • An automated report solution (with revised format and narrative) is under development,

providing specific reporting and pipeline reminders by divisions and services, to LDCa, Owners, and General Managers.

• The development of Divisional KPI’s will be proposed and discussed with the Clinical Governance Group.

• The Chair of the Clinical Governance Group will be invited to a CDC meeting to discuss issues, reporting, and support needed. Owner: Chair/Corporate Records Manager.

Finding 9 • Having a senior staff member holding the LDC role will assist with pipeline management

and relationship management with Owners. A proposal to include the Local Document Controller role into the job descriptions of Clinical Quality and Risk Managers is under consultation. Note these people are already CDC members. In Divisions that do not have

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senior Quality staff the Procedure states that the responsibility should default to a senior role.

• The proposed changes to the training model and Procedure will enable users to operate the system with confidence and competence. Owner: Chair/Corporate Records Manager.

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Appendix 4

Controlled Document Committee Work Plan October 2017 – June 2018 (draft) Activity Rationale Lead Status Timeframe 1 Publish new PPG Procedure

Clarifies staff accountability and supports correct procedure - improving performance Addresses hA audit finding

Jane, Jo, Sandhya

Approved needing supporting comms for publication

January 2018

3 Update current PPG policy so aligned with draft procedure and all links are active

Clarifies staff accountability and supports correct procedure, improving performance. Addresses hA audit finding

Jane, Jo, Sandhya

Completed December 2017

4 Review and agree report query/parameters

Clarifies the fields being reporting which will assist with the interpretation of reports and improve stakeholder trust and confidence

Graham, Sandhya, Jane

In progress February 2018

5 Develop and implement a report format with enhanced narrative for a wider stakeholder group including:

• Owners • LDC’s • Approving

Committees • GM’s/CD Group • Executive

Improves stakeholder visibility of issues/emerging issues. Improves accountability Improves stakeholder trust in the system and process Addresses hA audit finding

Graham, Sandhya, Jane


6 Develop additional reports to monitor the following:

• Retired documents • Newly published

documents • Error reports

Improves stakeholder visibility of issues/emerging issues Facilitates targeted feedback and training to users to improve data integrity and performance Improves stakeholder trust in the system and process

Graham, Sandhya


7 Include all LDC’s as CDC members (Corporate can have rotating member)

Improves engagement of LDCs and maintains their competency Improves control and accountability for LDC performance

Jo In progress January 2018

8 Recommend that controlled document/LDC responsibilities rest with a senior person (the CQRM in clinical areas)

Improves LDC mandate and performance of system. Improves accountability Addresses hA audit finding

Jo In progress December 2017

9 Develop and recommend a KPI for overdue documents to CGG and HMT

Improves accountability and performance (reduces overdue) Addresses hA audit finding

Jo Not started January 2018

10 Develop an Archival and Disposal Policy

Improves performance and reporting Addresses hA audit finding Addresses standards

Graham In progress June 2018

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Activity Rationale Lead Status Timeframe 11 Include ‘how to access the

Documentation Directory” in the Pink Palace training (5 mins)

Supports appropriate and autonomous use of the system Addresses hA audit finding

Graham, Sandhya

Not started January 2018

12 Audit the Documentation Directory to verify currency of documents available

Addresses hA audit finding Reduces risk of gaps or incorrect PPG’s being accessed

Graham Sandhya

Not started February 2018

13 Review and refresh training materials and model used for training LDC’s

• E Learning module • Online manual giving

step by step guidance • ‘Tips and Handy Hints’

folder in Documentation Directory

Improves LDC performance and autonomy Improves performance Addresses hA audit finding

Sandhya, Jo

In progress March 2018

15 Implement new process requiring CDC approval for newly created PPG’s

Supports appropriate development and process. Manages growing number of PPGs. Addresses hA audit finding

Jo, Mary, Sandhya

In progress December 2017

17 Update list of Approved Committees

Improves performance Addresses hA audit finding

Sandhya In progress February 2018

18 Support implementation of Version 10 Objective

Improves performance and stakeholder trust and confidence

Graham, Sandhya

Not started tbc

19 Add the risk to the organisation of having overdue PPG’s to the Risk Register

Provides visibility of the risk and management

Jo, Jane, Graham

Complete November 2017

20 Clarify the management process for other ‘Controlled Documents’ such as Clinical Forms and Patient Education/Information materials

Supports correct procedure and closes a gap and area of potential risk

Jo In progress February 2018

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Human Resources (HR) Regular reporting items HR metrics are provided to outline performance for Annual Leave Balances, Sick Leave and Turnover rates. Below are the 12 month trend graphs to November 2017.

7%8%9%

10%11%12%13%14%15%

Percentage of CMDHB Workforce with Annual Leave Balances > 2 Years' Equivalent (Hospital Directorate Only)

> 2 Years > 2 Years LY UCL Average LCL

0%

4%

8%

12%

16%

20%

Annual Leave Paid as Percentage of Total Paid Hours December 2016 to November 2017

AL Paid % AL Paid % LY UCL Average LCL

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0%

1%

2%

3%

4%

5%

6%

Sick Leave as Percentage of Total Paid Hours (Hospital Directorate Only)

Sick Leave Sick Leave LY UCL Average LCL

0%

5%

10%

15%

20%

Annualised CMDHB Voluntary Turnover (Hospital Directorate Only)

Turnover Turnover LY UCL Average LCL

12.9%

16.5%

9.5% 11.4% 11.1% 12.0% 12.3%

10.0%

-2%

3%

8%

13%

18%

Voluntary Turnover by Occupational Group December 2016 - November 2017

Turnover CMDHB Average Previous Year Previous Month

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0 10 20 30 40 50 60 70 80

Dec'16

Jan'17

Feb'17

Mar'17

Apr'17

May'17

Jun'17

Jul'17

Aug'17

Sep'17

Oct'17

Nov'17

Voluntary Employee Turnover by Reason for Leaving

December 2016 to November 2017

Personal To go overseas Another job in public health Left districtResigned Retired Job outside of health Job in Private healthEducation Job dissatisfaction Unpaid work

57% 21%

13%

6% 4%

Total FTE Hired November 2017

Nursing

Allied Health

Admin/Management

Medical

Non Clinical Support

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Counties Manukau District Health Board Hospital Advisory Committee

Q1 2017/18 Non-Financial Summary Report

Recommendation It is recommended that the Hospital Advisory Committee: Receive the Q1 2017/18 Non-Financial Summary Report. Note this report was endorsed by the Executive Leadership Team on 28 November 2017. Prepared and submitted by Kitty Neill, Planning Advisor on behalf of Margie Apa, Director Population Health, Strategy and Investments. Glossary CVDRA –Cardiovascular Risk Assessment ED – Emergency Department FCT – Faster Cancer Treatment OIS – Outreach Immunisation Service WCTO – Well Child Tamariki Ora Purpose To provide a summary picture of how we are progressing against our planned commitments outlined in the 2017/18 CM Health Annual Plan. Significant Achievements Overall, we have performed well in meeting our commitments outlined in our 2017/18 Annual Plan for Q1. In summary:

• Raising Healthy Kids Health Target – CM Health was one of just three DHBs to achieve 100% against this health target (Waitemata and Auckland DHBs also achieved results of 100%). This means that 100% of children in Counties Manukau who were identified as obese in their Before School Check (B4 School Check) were being referred to a health professional for a clinical assessment and family based nutrition, activity and lifestyle interventions.

• Smokefree Health Targets- Performance against the Maternity Smokefree Health Target has improved by 3.1% since last quarter with Q1 results of 93% for Maaori and 94% for the total population (data not broken down to other ethnicities). To note is that in Q4 2016/17 CM Health achieved the highest number of pregnant women (who had set a quit date) who were smokefree at four weeks nationally.

The Primary Care Smokefree Health Target has also been met for the total population (90%) with Maaori and Pacific results at 88% and 89% respectively.

• Faster Cancer Treatment (FCT)- The FCT Health Target has been achieved with a Q1 result of 94%. To note is that as of 1 July 2017, the FCT target has increased from 85% to 90%; however, the target definition has also changed. Previously, breaches could be attributed to patient choice, clinical consideration, or capacity constraints. As of 1 July 2017, only those relating to capacity constraints are counted as breaches. Accordingly, we have achieved this target with 12 of the 191 patients in the health target cohort having breached the 62 day timeframe due to capacity constraints.

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• Colonoscopy - All three colonoscopy targets (urgent (14 days), diagnostic (42 days) and surveillance (84 days)) have been achieved this quarter for the first time since Q1 2016/17.

Key Issues

Not all targets have been met due to differing factors:

• Emergency Department (ED) 6 hour Health Target – The 6 hour ED Health Target was again not met in Q1 with a final result of 88%. Although volumes dropped in September by 1.7% when compared year-on –year, year-to-date volumes remained higher at 3.8% compared to September 2016.

The hospital was unable to reach the 6 hour target for a variety of factors including high consistent surge presentation rates and consistently high hospital occupancy. Individual monthly results for Q1 were: July 84%, August 89% and September 92%. To note is that current Q2 performance for October is at 92%.

A range of initiatives are underway to address underlying system challenges and manage demand including: increasing staff to optimize capacity at the Manukau Super Clinic, cancelling outpatient appointments, utilising areas that can accommodate additional beds, and many staff providing additional cover out of hours. Long term, consideration is being given to ensuring there is sufficient capacity available next winter.

Key impacts of the additional efforts required to meet ED volumes, and the ED Health Target, include: increased staffing costs particularly for increased numbers of watches (usually Healthcare Assistants) and overtime payments, an increased nurse-to-patient ratio required to ensure safety in an environment of high patient volumes, and the continued stress and additional workload impacts for staff.

• CVDRA rates for Maaori Men aged 35 to 44 years - The CVDRA rate for Maaori men aged 35-44 for Q1 is 72%, well below the 90% target. There has been very little movement in the assessment rate for this population group over the last year, with results ranging between 72.1% and 73.3%.

A number of initiatives to increase coverage in this typically “hard to engage” population group are underway (see discussion at PP20 below), supported by increased More Heart and Diabetes Checks funding from the MOH in 2017/18.

• Immunisation Health Target – the Immunisation at 8 Month Health Target has not been met with an end of year result of 94% for the total population and 89% for Maaori. Likewise, the immunisation at two and five year targets have not been met with equity gaps for Maaori babies also persisting for these age groups.

To try and address low Maaori coverage rates, Maaori babies and infants are prioritised for Outreach Immunisation Services (OIS).

• Flu vaccination rates in people aged 65 and over – At 46% flu vaccination coverage is below the 75% target. See discussion at PP21 for detail of current activity to increase coverage.

• Stroke services – In Q4 2016/17 only 20 of 45 (44%) patients admitted with acute stroke were transferred to inpatient rehab within 7 days of acute admission, against a target of 80% (target reported one quarter in arrears). As noted in previous reports, CM Health has identified a high number of patients under the age of 65 with severe strokes and high levels of impairment. This is due to more patients with minor strokes being discharged directly home from the acute ward. This further increases the average dependency of patients in the rehabilitation ward, impacting on bed availability and patient flow. Some of these patients were staying in excess of 40 days at the inpatient stroke rehab ward. See discussion at PP20 for mitigation strategies. Note that most recent October data suggests that stroke volumes have reduced, and those presenting to ED with stroke appear to have lighter symptoms resulting in less transfers to the rehabilitation ward.

• Rheumatic fever - 50 cases of rheumatic fever were identified by the MOH from the National Minimum dataset in the year ended Q1 2017/18 giving a rate of 9.2/100,000. This has increased from 8.1/100,000 for the 2016 calendar year and is above the 2017/18 target of 4.5/100,000. Reasons for

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this increase are unclear although it is suspected to be a result of increasingly difficult circumstances for whaanau in Counties Manukau. See discussion at PP28 for ongoing efforts to reduce rheumatic fever rates.

CM Health 2017/18 Quarter 1 Health Target Snapshot

* Due to issues with the Maternity Clinical Information System (MCIS), results for the maternity smokefree target were not available in Q3 2016/17. The issue has now been resolved.

Primary Maternity

Quarter 2, 2016/17 96% 108% 74% 94% 89% 89% 62%

Quarter 3, 2016/17 95% 107% 75% 94% 89% Not available* 91%

Quarter 4, 2016/17 92% 107% 78% 94% 92% 90% 98%

Quarter 1, 2017/18 88% 99.6% 94% 94% 90% 94% 100%

Achieved

National target 95% 100% 90% 95% 90% 90% 95%

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CM Health 2017/18 Quarter 1 Summary Progress Report

Dashboard Key

Yellow = Outstanding Green = Target Achieved Orange = Partially Achieved Red = Not Achieved

Priority Indicator Frequency

of reporting

Current Target

Performance – 2017/18 Quarter 1 Commentary / Interpretation

Total Maaori Pacific Other Asian

National Health Targets

Cancer Percentage of patients receiving their first cancer treatment (or other management within 62 days of being referred with a high suspicion of cancer and a need to be seen within two weeks

Quarterly 90%

94% The FCT target has been achieved with a Q1 result of 94%. As of 1 July 2017 only 62 day breaches due to capacity constraints are counted as breaches against this target. Accordingly we have achieved this target with 12 of the 191 patients in the health target cohort having breached due to capacity constraints. Of the 12 breaches, 5 were due to capacity delays in the treatment end, notably in radiation oncology, which is provided by the tertiary centre. The remaining 7 were capacity related delays such as staffing, resourcing or process issues in the diagnostic (front end) of the pathway, provided by the domicile DHB. Analysis of performance by equity has identified Maaori having a higher number of capacity related breaches. Plans are in place to improve care coordination of Maaori patients, for example the Cancer Nurse Coordinator for Maaori will be the lead point of contact and care coordinator for all Maaori patients entering the high suspicion of cancer lung pathway, identifying individual patients at the point of referral and micromanaging their pathway to first treatment. This will be done in conjunction with the lung tumour stream clinical team. At the end of 3 months performance data will be measured against the 3 months prior to implementing the approach.

Elective Surgery

Volume of elective surgery will increase by at least 4000 discharges per year

Quarterly Increase of 4,000 discharges per year

99.6% The electives health target was narrowly missed in Q1 with a final shortfall of 19 discharges. The shortfall is a result of the high winter pressures on beds, high levels of acute patients and a shortage of anesthetists resulting in a significant number of elective theatre sessions needing to be cancelled. This situation is not expected to continue with CM Health expecting to back on target by the end of Q2.

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Priority Indicator Frequency of reporting

Current Target



Emergency Department Care

Percentage of patients admitted, discharged, or transferred from an ED within six hours

Quarterly 95% 88% The 6 hour ED health target was again not met in Q1 with a final result of 88%. Although volumes dropped in September by 1.7% when compared year-on –year, year-to-date volumes remained higher at 3.8% compared to September 2016. The hospital was unable to reach the 6 hour target for a variety of factors including high consistent surge presentation rates and consistently high hospital occupancy. Individual monthly results for Q1 were: July 84%, August 89% and September 92%. To note is that current Q2 performance for October is at 92%. A range of initiatives are underway to address underlying system challenges and manage demand including: increasing staff to optimize capacity at the Manukau Super Clinic, cancelling outpatient appointments, utilising areas that can accommodate additional beds, and many staff providing additional cover out of hours. Long term, consideration is being given to ensuring there is sufficient capacity available next winter.

Immunisation Percentage of eight months olds who have had their primary course of immunisation on time

Quarterly 95% 94% 89% 95% 92% 98% Results against this health target have remained consistent at 94% for the last year. CM Health was ranked 7th nationally in Q1. The definition of the eight month immunisation health target requires that 95% of all eligible children aged eight months are immunised and that significant progress for the Maaori population group. The coverage target was not met for Maaori (89.4%) however this is an improvement of 0.8% since last quarter (88.6%) and is above the national average for Maaori (87%). A further 23 babies were required to be immunised on time by 30 September 2017 to meet the Q1 target. To try and address low Maaori coverage rates, Maaori babies and infants are prioritised for Outreach Immunisation Services (OIS). The OIS received 495 referrals for 8 month immunisations in Q1, 196 of which were for Maaori babies. Of the 495 referrals to OIS, 136 babies were immunised at their family doctor after follow up and 184 were immunised by OIS.

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Current Target



Smoking (primary)

Percentage of enrolled patients who smoke and were seen by a health practitioner in general practice and were offered brief advice and support to quit smoking

Quarterly 90% 90% 88%

89% 92% 90% The Primary Care Smokefree target has also been met for the total population (90%) with Maaori and Pacific results at 88% and 89% respectively. It is expected that rates of Maaori and Pacific receiving brief advice will improve over the coming three quarters as they did in 2016/17. An ongoing area of focus has been improving ways in which PHOs can provide ABC brief advice to patients who are transient and do not have up to date contact details. In line with the 2017/18 Regional SLM Improvement Plan, a key focus for the Smokefree Advisor – Primary Care is now on increasing the cessation support rates. This is particularly important for patients who are prescribed pharmacotherapy as evidence shows quitting success is much greater if behavioural support is also given.

Smoking (maternity)

Percentage of pregnant women who identify as smokers, at the time of confirmation of pregnancy in general practice or booking with a Lead Maternity Carer, being offered advice and support to quit smoking

Quarterly 90% 94% 93% Performance against the Maternity Smokefree target has improved by 3.1% since last quarter with Q1 results of 93% for Maaori and 94% for the total population (data not broken down to other ethnicities). According to the 100 pregnant smoking women per month estimate, the service received referrals for 54% of the total smoking population with 162 referrals received. This is a 2% increase in referral volumes since last quarter. 78 referrals were received for Maaori women and 62 for Pacific women. Out of the 162 referrals received, 152 (94%) were eligible for the Smokefree incentives programme, the highest to date. In Q1, 31 out of 46 pregnant women who set a quit date the previous quarter were Smokefree at 4 weeks, biochemically validated (67% 4 week quit rate). To note is that in Q4 2016/17 CM Health achieved the highest number of pregnant women Smokefree at 4 weeks nationally.

Raising healthy kids

Percentage of obese children identified in the Before School Check (B4 School Check) programme will be referred to a health professional for a clinical assessment and family based nutrition, activity and lifestyle interventions by December 2017

Quarterly 95% 100% 100% 99% 100% CM Health has met the Raising Healthy Kids health target with a total population result of 100%. The focus is now on the proportion of whaanau who are declining the offer of a referral to a health professional for clinical assessment and family-based nutrition, activity and lifestyle interventions.

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Current Target



The overall rate of referrals being declined in CM Health in Q1 was 33% (an increase from the 24% rate in Q4 2016/17 and well above the national average of 26%). The decline rate for Maaori is 38% (national average 28%) and for Pacific 21% (national average 21%). Activity aimed to reduce the number of declines includes decline notification letters being sent to GPs to notify them with a child has been identified as being >98th centile and the parent/caregiver has declined a referral, quarterly audit of declines, and focus groups to investigate reasons for declines.

MOH Quarterly Reporting Performance Indicators PP7: Improving

mental health services using transition (discharge) planning and employment

Child and Youth Quarterly 95% 97%

PP8: Shorter waits for non-urgent mental health and addiction services for 0-19 year olds - Mental Health (Provider Arm)

<3 weeks Quarterly 80% 75% CMDHB Mental Health Service – Provider Arm has exceeded its waiting time targets for non-urgent referrals in all age groups in Q1 except for the 0-19 and 20-64 age groups seen within 3 weeks. 0-19 Age Group: Though the 0-19 age group (74.5%) is below target, it is higher than both regional (73.0%) and national (70.0%) percentages. Also, it is worthy of note that the corresponding percentages for the 12-19 age group is above the target at 81.7%. Note that the number of unique CMDHB domiciled clients aged 0-19 seen during the year ended 30 June 2017 was 6,611, an increase from the 6,574 unique clients seen in the corresponding period last year. This increase has meant delays for some but overall far more young people are accessing specialist mental health services and almost all are being seen within the expected timeframes. Referrals are triaged and those with the highest need are prioritised and those needing urgent intervention are seen within 48 hours.

<8 weeks Quarterly 95% 95%

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Current Target



The Whole of System / integrated Locality approach including the development of School Based Mental Health service and the alignment of NGO/ Primary Care at intake are amongst plans to further assist with sustainable progress against this target. 20-64 Age Group: 20-64 age group seen within 3 weeks (84.8%) is marginally below target. Note that the number of unique CMDHB domiciled clients aged 20-64 seen during the year ended 30 June 2017 was 12,371, an increase from the 11,920 unique clients seen in the corresponding period last year.

PP8: Shorter waits for non-urgent mental health and addiction services for 0-19 year olds Addiction (NGOs)

<3 weeks Quarterly 80% 95%

<8 weeks Quarterly 95% 97.4%

Long Term Conditions

PP20: Cardiovascular (CVD) health (CVD Risk Assessment – previous health target) Total eligible population

Quarterly 90% 92% 89% 91% 93% 91% Performance this quarter has continued to exceed the 90% target. The overall performance demonstrates that this activity remains embedded in general practice teams despite it no longer being one of the six National Health Targets. To build on this, focus is shifting towards risk factor management for high CVD risk populations (and interventions which promote behaviour change), as part of the SLM and other local work. There are ongoing differences in performance between Maaori and other ethnicities. This has been difficult to shift despite the DHB actively working with PHOs and practices to target activities at Maaori groups. For 2017/18 there is additional More Heart and Diabetes Checks funding provided to specifically support actions for these groups. We will be focusing on potential strategies within the community, as well as in primary care. This also supports the focus of the System Level Measures for Metro Auckland.

PP20: Cardiovascular (CVD) health (CVD Risk Assessment – previous health target) Eligible Maaori men aged 35-44 years

Quarterly 90% 72% The CVDRA rate for Maaori men aged 35-44 for Q1 is 72%, a 1% drop since Q4 2016/17. There has been very little movement in the assessment rate for this population group over the last year, with results ranging between 72.1% and 73.3%. Given that equity of coverage has not been achieved yet, CM Health and PHOs have committed to a

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Current Target



number of actions regarding this measure under the 2017/18 Maaori Health Plan. For example, all of our PHOs provide monthly reporting to their practices regarding this measure. We use prioritised ethnicity reporting for this; with Maaori and Pacific coverage reported at the top of the page. We believe regular feedback and the use of good quality data is integral to meeting this target. PHOs also continue to share innovative ways of thinking in order to reach high risk populations. For example, practices with high numbers of Maaori men aged 35-44 were identified by PHOs and have together (as part of the SLMs) discussed strategies to improve coverage. For example, appointment scanning (if these men are attending with family members), using Test Safe data, and opportunistic screening at urgent care appointments. This activity is supported by the increased More Heart and Diabetes Checks funding referred to above.

PP20 Acute Coronary Syndrome - Percentage of high-risk patients who receive an angiogram within 3 days of admission (‘day of admission’ being ‘Day 0’)

Quarterly 70% 69% 59% 63% 69% 75% Performance has dropped since Q1 2016/17 (Q1 results - Total: 76%, Maaori: 86%, Pacific: 78%) and results for all population groups except Asian are now below target, with a growing equity gap for Maaori and Pacific patients. Feedback from the cardiology service is that this is most likely as a result of Maaori and Pacific patients being more likely to present later (for example after having had three bouts of chest pain rather than one) and with higher rates of co-morbidities and clinical complexity. Plans for a second catheter laboratory (cath lab) remain in progress, which would help to increase capacity and timeliness of angiograms. Any additional cath lab build would however take approximately two years. Consequently, opportunities to create interim capacity in the single cath lab or regional opportunities for utilising any regional capacity (this is very limited) are being explored.

PP20 Acute Coronary Syndrome - Percentage of patients presenting with ACS who undergo coronary angiography who have completion of ANZACS QI ACS and Cath/PCI registry data collection within 30 days

Quarterly 95% 100% 100% 100% 100% 100%

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Current Target



PP20: Stroke - Percentage of potentially eligible stroke patients thrombolysed (result reported one quarter in arrears – Q4 result presented)

Quarterly 8% 11%

PP20: Stroke - Percentage of stroke patients admitted to a stroke unit or organised stroke service with demonstrated stroke pathway (result reported one quarter in arrears – Q4 result presented )

Quarterly 80% 84%

PP20: Stroke – Percentage of patients admitted with acute stroke who are transferred to inpatient rehabilitation services are transferred within 7 days of acute admission (also report % of acute stroke patients transferred to inpatient rehab) (result reported one quarter in arrears – Q4 result presented)

Quarterly 80% 44% In Q4 2016/17 only 20 of 45 patients admitted with acute stroke were transferred to inpatient rehab within 7 days of acute admission. As noted in previous reports, we have identified a high number of patients under the age of 65 with severe strokes and high levels of impairment as supported by Australasian Rehabilitation Outcomes Centre (AROC) outcome data. This is due to more patients with minor strokes being discharged directly home from the acute ward. This further increases the average dependency of patients in the rehabilitation ward, impacting on bed availability and patient flow. Some of these patients were staying in excess of 40 days at the inpatient stroke rehab ward. Mitigation strategies include utilisation of privately-provided residential rehabilitation for those patients requiring an extend rehabilitation stay (60 - 90 days). This would involve a rehabilitation plan being set by CM Health and the provision of rehabilitation by the private provider. We are also pursuing extension of community rehabilitation capacity by engaging a private provider to supplement low-intensity community rehabilitation. This will enable an increase in capacity of early support discharge, or high-intensity community rehabilitation, to allow for increased proportions of patients avoiding an extended inpatient stay.

Immunisation

PP21: Percentage of two year olds who are fully immunised

Quarterly 95% 94% 89% 95% 94% 98% Note that Maaori immunisation coverage for this age group has remained relatively stable over the last year ranging between 89% and 92%.

PP21: Percentage of five year olds who are fully immunised

Quarterly 95% 91% 87% 92% 91% 96% The 95% immunisation target at 5 years has not been met in quarter 1 and coverage is trending down for all population groups except Asian (change for total population: -1%, change for Maaori: -3%).

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Current Target



PP21: Percentage of the population aged 65+ who are immunised against influenza annually (measured at 30 September)

Annual 75% by Sept 2017

46% 40% 45% 47% 46% As at 30 September 2017, Counties Manukau DHB had reached 46.2% coverage for influenza immunisation among those 65 years and older. This is significantly lower than the target of 75%. However, it is acknowledged that 2017/18 is a transition year for this target, having previously been a Maaori health plan indicator. There has been a significant amount of targeted activity occurring over the last quarters to increase coverage including: • A campaign to raise awareness of immunisation

eligibility as part of the Winter Wellness work including a flu vaccination “voucher” for older people accessing secondary care,

• Working with community pharmacies funded to provide vaccination to ensure that they target older people for this programme particularly when older people are engaging with the pharmacy to pick up scripts or seek healthcare advice, and

• Working with PHOs and pharmacies to ensure that systems and processes are used effectively to support this goal. It is likely that not all activity being carried out is recorded on the National Immunisation Register (NIR) currently.

System integration

PP22: Improving system integration

Quarterly

PP22: SLMs Quarterly

Health of Older People

PP23: Implementing the Healthy Ageing Strategy

Quarterly

Mental Health PP25: Prime Minister’s Youth Mental Health Project

Quarterly

PP26: The Mental Health and Addiction Service Development Plan

Quarterly

Child Health PP27: Supporting vulnerable children Quarterly

Rheumatic Fever

PP28: Reducing rheumatic fever Quarterly 4.5 per 100,000 (Total)

Our target for 2016/2017 is 4.5/100,000. We did not meet this target with 50 cases identified by the MOH from the National Minimum dataset. On review of these NHIs it appears 46 of these were actual cases. Using the official number of 50 the rate for CM Health for Q1 2017/18 is 9.2/100,000. This has increased from 8.1/100,000 for the 2016 calendar

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Current Target



year and is above the target of 4.5/100,000. Ongoing efforts to reduce the number of cases include: • Governance and stakeholder engagement:

Monthly progress updates to the Alliance Leadership Group regarding activity in the school based clinics (including provider level data), community engagement activities, Pacific engagement work, case review outcomes and rheumatic fever epidemiology

• Sore throat management: Workforce development training sessions for health workers focused on sore throat management in particular managing classroom case-finding

• Reducing the transmission of Group A Strep throat infections: Kidz First, district nurses (bicillin programme) and the school based programme continue to identify whaanau with children at high risk of rheumatic fever living in crowded housing. Once identified, engagement of the whaanau is undertaken and they are referred to Auckland Wide Healthy Homes Initiative (AWHI);

• Awareness raising: including school specific health promotion activities; and

• Follow up of identified rheumatic fever cases

Improving waiting times for diagnostic services

PP29a: Coronary angiography – within 3 months (90 days)

Monthly 95% 97%

PP29b: CT –within than 6 weeks (42 days)

Monthly 95% 94%

PP29c: MRI – within 6 weeks (42 days) Monthly 85% 64% CM Heath is in the process of planning for additional MRI capacity at the Middlemore site due on stream in Q4 2017/18. Demand continues at a high level and outsourcing is assisting in addressing the difference between demand and the current capacity to produce. We have very recently had 2 MRI trainees sit their final exams and the team is working to capacity. However capacity is limited by the lack of MRI access.

PP29d: Urgent diagnostic colonoscopy – within two weeks (14 days)

Monthly 75% 99%

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Current Target



PP29e: Diagnostic colonoscopy – within six weeks (42 days)

Monthly 65% 71%

PP29f: Surveillance colonoscopy - within twelve weeks (84 days) beyond the planned date

Monthly 65% 86%

Faster Cancer Treatment

PP30: FCT - Length of time taken for patients to receive their first treatment (or other management) for cancer from date to decision-to-treat (31 day indicator)

Quarterly 85% 93%

Better help for smokers to quit (previous health target)

PP31: Percentage of hospital patients who smoke and are seen by a health practitioner in a public hospital are offered brief advice and support to quit smoking

Quarterly 95% 96% 96% 96% 95%

Community Treatment Orders (CTOs)

PP36: Rate of Maaori under the Mental Health Act: section 29 community treatment orders per 100,000

Quarterly Reduction of 10% (baseline of 403/100,000 for Maaori for 2016 calendar year *MOH data)

98/100,000

407/100,000

Note that results are based on PRIMHD data provided by the MOH for the period April 2016 to March 2017. These differ from internal Counties Manukau Health figures based on the DHB Financial (not calendar) year. The Q1 2017/18 DHB data show: Maaori per 100,000 on a section 29 Indefinite to be 141.8; Non-Maaori per 100,000 on a section 29 Indefinite to be 35.8; Total Maaori under a section 29 CTO per 100,000 to be 213.7; Total Non- Maaori under a section 29 CTO per 100,000 to be 54.9. In 2016/17 a detailed review was undertaken of the factors influencing the health disparity for Maaori with regards to the higher rate of compulsory community treatment orders (CTO’s) under the Mental Health Act 1992: Section 29. While focus areas were improved the data illustrated that the ratio of disparity between Maaori and non-Maaori on CTOs has remained stable over the past few years. Also to note is that while the MOH have set a target to reduce CTO rates for Maaori, we are exercising caution in the reduction in the number of Maaori service users on a CTO as done inappropriately this raises significant risks to service users, whaanau and communities. Three areas for improvement were identified in the 2017/18 Action Plan which continue to build upon the focus areas of 2016/17. These are: 1. Implement activity to improve consultation/engagement with whaanau to enhance

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Current Target



service user recovery and ability to be released from a CTO; 2. Automate clinical reporting for Mental Health Act Reviews and data feeds into the Director Area Mental Health Services monthly Dashboard to enable better reporting and monitoring; and 3. Enhance Mental Health Workforce capability in working with Maaori service users and their whaanau.

Improving breastfeeding rates

PP37: Percentage of infants who are exclusively or fully breastfed at three months

Six-monthly 60% 50% 39% 45% Note that this is a new government policy priority for 2017/18. Data reported for January to June 2017, sourced from WCTO data. The national result for all ethnicities was 59%. In addition to inpatient services, there are currently two community-based breastfeeding services in the Counties Manukau district, a funder arm service (Turuki Health Care’s B4Baby Breastfeeding Services) and a provider arm pilot (Te Rito Ora). Both B4Baby and Te Rito Ora are home visiting services specifically targeted to improve breastfeeding rates in Maaori, Pacific and South Asian target populations. The key components of these services are: • In-home antenatal breastfeeding education and

postnatal breastfeeding support • Community lactation consultant service • Peer Supporter Programme • Supporting implementation of Baby Friendly

Community Initiative Accreditation (BFCI) • Phone triage system • Maternal Nutrition – via 1:1 education as well as

MKR cooking classes • Focus on age appropriate introduction of first

foods – provide education session/cooking class

A recent evaluation of the Te Rito Ora service has shown positive improvement in uptake and sustained breastfeeding. Breastfeeding rates at 3 months for mothers who had received Te Rito Ora services being approximately 10% higher than the average CM Health breastfeeding rate at 3 months. These results support the in-home community based model for the Counties Manukau population. Key challenges impacting on lower breastfeeding

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Current Target



rates in Counties Manukau are believed to include: • Potential lack of maintained WCTO

engagement • A lack of health literacy regarding the benefits

of continued breastfeeding • A lack of whaanau and other support to

continue breastfeeding; and • Transiency and hard to reach mothers and

whaanau meaning that uptake of breastfeeding support services is lower.

Specific focus areas to address these challenges are: • Transitioning proved pilots into business as

usual/ permanent service provision • Review of the delivery of complimentary

services • Maintaining and building on the influences

outside of the 2 services i.e. our relationship with LMCs and WCTO providers

Inpatient length of stay

OS3: Inpatient length of stay

Elective LOS Quarterly 1.47 days 1.64 days

Acute LOS Quarterly 2.30 days 2.67 days

Data Quality OS10: NHI and data submitted to National Collections

Quarterly

National Collections Quarterly

PRIMHD Quarterly

Mental Health OP1: Mental health output delivery against plan

Quarterly

Patient Experience

DV4: Improving patient experience - Proportion of patients who have rated CMH overall experience of care and treatment as ‘Very Good’ or ‘Excellent’

Quarterly

CFA B4 School Check Funding Quarterly

CFA Well Child Tamariki Ora Services Quarterly

HS Supporting delivery of the NZ Health Strategy

Quarterly

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Northern Regional Health Plan Quarter 1 Summary Report Key achievements this quarter include:

• Child Health - Auckland, Waitemata and Northland DHBs have agreed to the final business case for the integrated enrolment platform called National Child Health Integrated Enrolment Platform (NCHIP). Counties Manukau Health (CMH) already has a solution in place and will make data on CMH children available to NCHIP but will not invest in the new patform at this stage. Regional approvals for the business case have been completed and 70% of the required capital budget for implementation in 2017/18 has been approved. A Project Manager is being recruited and implementation planning is underway.

• Health of Older People - The Northern Region led the development, review and promotion of several Regional clinical health pathways including Carer Stress, Before Entering Aged Residential Care and Unexpected Deterioration in Older Adults

• Cancer – The Cancer Deep Dive and Head & Neck Review were completed and endorsed by the Cancer Board in September. Implementation planning is now in progress

• CVD – Implementation planning is progressing for the Out-of-Hospital STEMI pathway, which has been developed to improve patient outcomes across the country, as part of the National working group. The network is progressing implementation of the GoodSAM app and a targeted approach for increased awareness and training for CPR across the country in conjunction with increased access to AEDs

• Diabetes - Integrated Mentorship Programme Proposal has been completed and the group is moving its focus to finding funding for a Proof of Concept

• Mental Health and Addictions. The Youth Forensics clinical governance group has reviewed the Model of care for Nga Taiohi and related issues with transfer and discharge that have arisen in the Northern region, to inform the national review of the service planned by the Ministry of Health. The Acute Inpatient Working Group is progressing an analysis of 159 clients that are high users of acute adult inpatient services is underway, including patient journeys to inform the continuum of care for clients with high and complex needs.

• Youth - Chlamydia testing in pregnant women 25 year and under has been chosen as the initial area of focus by the metro DHBs and an SLM Data Panel has been set up to look at how the data will be collected. NDHB has chosen to initially focus on Alcohol-related Emergency Department (ED) presentations for 10-24 year olds. This will allow learning to be shared between Metro Auckland and Northland DHB when they work on the different contributory measures.

• Hepatitis C - Two one-hour presentations were given in a talkback style: the first on Pacific Island Radio by Dr Stephen Gerred (SMO CMDHB), and the second on Chinese Television Channel 29 by Dr Tien Huey and Dr Derek Luo (SMO’s CMDHB) in Mandarin. These served to highlight the disease and the highly efficacious treatment available now to these two large populations in the Northern Region, and wider afield.

• Workforce -NorthlandDHB reported increased recruitment for Maori new graduate nurses based on their recent NETP review with 40% (10 of 25) of new graduates’ intake in September 2017 being Maori. The metro DHBs have maintained the sonographer trainee pipeline with optimum trainee volumes in difficult circumstances for some DHBs; there are 15 trainees in total as at July 2017. A Guide to the Auckland metro DHBs Sonography Training Pathway has been completed and endorsed for local DHB adoption. This provides an agreed standardised pathway for clinical educators and supervisors to maximise the trainees’ learning opportunities matched to the appropriate supervision and training resources.

• Stroke The phased, implementation of the Centralised Stroke Hyperacute After Hours Model of Care, commenced late July, for those people residing in West Auckland. Clot retrieval cases are slowly increasing as capacity builds at ACH. Early indications are outcomes for patients in the Northern Region are exceeding those measured in the meta analysis (following the recent international studies which now underpin best practice). Face-to-face discussions have commenced with the Midland Region on strengthening the pathway for Clot Retrieval.

• Electives - The region has continued to focus on meeting its ESPI and service volume targets, despite significant demand pressures during the winter period.

• Workforce -Northland DHB reported increased recruitment for Maori new graduate nurses based on their recent NETP review with 40% (10 of 25) of new graduates’ intake in September 2017 being Maori. The metro DHBs have maintained the sonographer trainee pipeline with optimum trainee volumes in difficult circumstances for some DHBs; there are 15 trainees in total as at July 2017. A Guide to the Auckland metro DHBs Sonography Training Pathway has been completed and endorsed for local DHB adoption. This provides an agreed standardised pathway for clinical educators and supervisors to maximise the trainees’ learning opportunities matched to the appropriate supervision and training resources.

• Capital and Assets - The Northern Region Long Term Investment Plan is nearing completion. The region has agreed its investment logic, a high level regional service model and is reviewing a range of counterfactual options for a preferred investment pathway. A draft regional investment plan document will be reviewed by key decision making groups during October and November, culminating in a joint DHB Boards workshop during Q2.

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NZ Health Strategy – Regional highlights for the quarter

People - powered • Skin infection prevention resource developed by Early Childhood Centres, Primary Care, Well Child/Tamariki Ora Providers. These groups are now working together to develop the implementation plan for high needs areas.

• ADHB has developed a whanau/family support interview guideline resource to inform recruitment and hiring managers of the whanau/support person role.

Closer to home • Maintenance Herceptin infusion services for breast cancer patients has been made available at North Short Hospital for Waitemata patients who previously had to travel to Auckland City Hospital for this service.

• Stronger engagement with primary care through the inclusion of a primary care clinical director on the Youth Network

Value and high performance

• Waitemata DHB’s Clinical Nurse Specialists and Gastroenterology fellow have been reviewing the known Hepatitis C patients on the DHBs databases to develop management plans for those patients and ensure patients eligible for treatment are engaged

One team • The Northern Region is integrally involved with the other regions and the ambulance services , working to implement the NZ Out-of Hospital STEMI pathway

• Close collaboration between DHBs, central stakeholders and non DHB service providers in developing a Long Term Investment Plan

Smart system • Utilisation of PRIMHD data to collate patient journeys for individuals who are high users of inpatient services to inform service planning for people with high and complex needs

• The e-rReferrals (inter and intra hospital referrals programme) will improve the quality, efficiency and safety of inter specialty referrals across the region

The table below shows progress against the top 10 commitments

On track Some concerns regarding progress to target

Not achieved or declining performance

Commitment Status Notes 1 Achieve and maintain the National Health

Targets National targets were achieved with regard to

‘Improved access to elective surgery’; ‘Raising healthy kids’; ’Better help for smokers to quit - primary’ and ‘Better help for smokers to quit – maternity’. National targets substantially achieved with regard to: • ‘Shorter stays in ED’ (91.6% on target of

95%) • ‘Increased Immunisation’ (achieved 92.8%

against a target of 95%) ‘Faster Cancer Treatment’ achieved 83.1%, to June 2017 (against an increased target for 2017/18 of 90%).

2 Child Health continue to reduce SUDI deaths to < 0.4 SUDI Deaths per 1,000 Maori live births

Refocusing Northern Region SUDI prevention initiatives

3 75% of clients receiving long term Home Based Support Services have an interRAI clinical assessment within the previous 24 months

79.9% of LT HBSS clients have received an interRAI clinical assessment within the previous 24 months (as of June 2017)

4 85% of patients receive their first cancer treatment or other management within 31 days from decision to treat

Note: 1 quarter data lag (Apr-Jun 2017) 88.3%

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Commitment Status Notes 5

Reduce the percentage of trauma patients transferred to more than one hospital for definitive care from the baseline of 23%

Status pending analysis of 2016-17 baseline data

6 80% of patients presenting with ST elevation myocardial infarction (STEMI) referred for percutaneous coronary intervention (PCI) will be treated within 120 minutes1

The Northern Region is slightly below the target this quarter at 78.3%. WDHB exceeded target at 84.1%. CMH and ADHB were slightly below target at 78.6 and 78.3 % respectively and NDHB was significantly below target. The Network continues to work with these DHBs to improve STEMI rates. The Regional Cath Lab review outcomes will also contribute to improvement in this area.

7 80% of diabetes patients to have good or acceptable glycaemic control (HbA1c<64)

The latest report from July 2017 indicated 72.2% of patients have good or acceptable glycaemic control, similar to the previous 6 months.

8 90% of discharges from adult mental health services receive post discharge community care (within 7 days)

Although the target has not been reached as yet, there was a 3% increase in comparison with previous quarter and at 71.8% performance is 6% higher than national average.

9 80% of patients who have a stroke are treated in a stroke unit

80% of stroke patients treated in a dedicated stroke unit for the period Apr-Jun 2017.

10 Reduce unintended teen pregnancies

The Youth KPIs continue to show a reduction in both youth pregnancy and termination of pregnancy over the last 5 years

1 There may be some variation for patients from NDHB due to geographical isolation and dependence on emergency helicopter transport.

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Counties Manukau District Health Board Resolution to Exclude the Public Resolution: That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

2.1 Public Excluded Minutes of 15 November 2017

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes For the reasons given in the previous meeting.

3.1 Patient Experience and Safety Report

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32 (a)]

Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S9(2)(a)]

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