hospital advisory committee (hac) meeting · 7/31/2019 · environmental sciences, auckland...

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING

Wednesday 31 July 2019 2.00pm

AGENDA

VENUE Waitematā District Health Board Boardroom Level 1, Shea Tce Takapuna

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Waitematā DHB Hospital Advisory Committee Meeting 31/07/19

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 31 July 2019

Venue: Waitematā DHB Boardroom, Level 1, 15 Shea Terrace, Takapuna Time: 2.00pm

Committee Members James Le Fevre – Committee Chair Sandra Coney – Deputy Committee Chair Judy McGregor – WDHB Board Chair Max Abbott – WDHB Board Member Edward Benson-Cooper – WDHB Board Member Kylie Clegg – WDHB Deputy Chair Warren Flaunty – WDHB Board Member Matire Harwood – WDHB Board Member Brian Neeson – WDHB Board Member Morris Pita – WDHB Board Member Allison Roe – WDHB Board Member

WDHB Management Dale Bramley – Chief Executive Officer Robert Paine – Chief Financial Officer and Head of Corporate Services Andrew Brant – Deputy Chief Executive Officer and Chief Medical Officer Jocelyn Peach – Director of Nursing and Midwifery Cath Cronin – Director of Hospital Services Joanne Brown – Funding and Development Manager, Hospitals Tamzin Brott – Director of Allied Health Fiona McCarthy – Director Human Resources Peta Molloy – Acting Board Secretary

APOLOGIES:

AGENDA

DISCLOSURE OF INTERESTS Does any member have an interest they have not previously disclosed?

Does any member have an interest that might give rise to a conflict of interest with a matter on the agenda?

PART I – Items to be considered in public meeting

All recommendations/resolutions are subject to approval of the Board.

1. AGENDA ORDER AND TIMING

2. CONFIRMATION OF MINUTES

2.00pm 2.1 Confirmation of Minutes of Hospital Advisory Committee Meeting (19/06/19) Actions Arising from previous meetings

3. PROVIDER REPORT

2.05pm

3.1 Provider Arm Performance Report – May 2019

3.1.1 Executive Summary 3.1.2 Human Resources

3.1.3 Acute and Emergency Medicine Division 3.1.4 Specialty Medicine and Health of Older People Services 3.1.5 Child, Women and Family Services 3.1.6 Specialist Mental Health and Addiction Services

3.1.7 Surgical and Ambulatory Services/Elective Surgery Centre 3.1.8 Diagnostic Services 3.1.9 Clinical Support Services

4. CORPORATE REPORTS

3.00pm 3.10pm 3.20pm

4.1 Clinical Leaders’ Report 4.2 Quality Report 4.3 Human Resources Report

5. INFORMATION ITEMS

3.30pm 6. RESOLUTION TO EXCLUDE THE PUBLIC

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Waitematā District Health Board

Hospital Advisory Committee Member Attendance Schedule 2019

Attended the meeting x Absent * Attended part of the meeting only # Absent on Board business ^ Leave of absence

NAME FEB MAR MAY JUN AUG SEP OCT DEC

James Le Fevre (Committee Chair)

Max Abbott ×

Edward Benson Cooper ×

Kylie Clegg

Sandra Coney ×

Warren Flaunty

Matire Harwood × × × ×

Judy McGregor

Brian Neeson ×

Morris Pita × × × ×

Allison Roe × ×

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REGISTER OF INTERESTS


Board/Committee Member Involvements with other organisations Last Updated

Judy McGregor (Board Chair)

Associate Dean Post Graduate - Faculty of Culture and Society, AUT Member - AUT’s Academic board New Zealand Law Foundation Fund Recipient Consultant - Asia Pacific Forum of National Human Rights Institutions Media Commentator - NZ Herald Patron - Auckland Women’s Centre Life Member - Hauturu Little Barrier Island Supporters’ Trust

28/03/19

Max Abbott Pro Vice-Chancellor (North Shore) and Dean - Faculty of Health and Environmental Sciences, Auckland University of Technology Patron - Raeburn House Advisor - Health Workforce New Zealand Board Member - AUT Millennium Ownership Trust Chair - Social Services Online Trust Board member - Rotary National Science and Technology Forum Trust

19/03/14

Edward Benson-Cooper Chiropractor - Milford, Auckland (with private practice commitments) Edward has three (different) family members who hold the following positions:

Family member - FRANZCR. Specialist at Mercy Radiology. Chairman for Intra Limited. Director of Mercy Radiology Group. Director of Mercy Breast Clinic Family member - Radiology registrar in Auckland Radiology Regional Training Scheme Family member - FANZCA FCICM. Intensive Care specialist at the Department of Critical Care Medicine and Anaesthetist at Mercy Hospital

25/03/19

Kylie Clegg (Deputy Chair) Trustee - Well Foundation Director - Auckland Transport Director - Sport New Zealand Trustee and Beneficiary - Mickyla Trust Trustee and Beneficiary, M&K Investments Trust (includes shareholdings in a number of listed companies, but less than 1% of shares of these companies, includes shareholdings in MC Capital Limited, HSCP1 Limited, MC Securities Limited, HSCP2 Limited, Next Minute Holdings Limited). Orion Health has commercial contracts with Waitematā District Health Board and healthAlliance. Director of High Performance Sport New Zealand Limited Board member, Counties Manukau District Health Board Shareholder – Genesis Energy Ltd

10/07/19

Sandra Coney Member - Waitakere Ranges Local Board, Auckland Council Patron - Women’s Health Action Trust Member - Portage Licensing Trust Member - West Auckland Trusts Services

15/12/16

Warren Flaunty Member - Henderson–Massey Local Board Auckland Council Trustee (Vice President) - Waitakere Licensing Trust Shareholder - EBOS Group Shareholder - Green Cross Health Director - Life Pharmacy Northwest Chair - Three Harbours Health Foundation Director - Trusts Community Foundation Ltd Trustee – Hospice West Auckland (past role) Shareholder - Genesis Energy

12/09/18

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REGISTER OF INTERESTS


Board/Committee Member Involvements with other organisations Last Updated

Dr Matire Harwood Senior Lecturer - Auckland University Director - Ngarongoa Limited, which is contractor providing services to National Hauora Coalition GP at Papakura Marae Health Clinic Advisory Committee Member - State Foundation NZ (Māori Health) Member Te Ora, Māori Medical Practitioners Step-daughter is a surgical registrar at Waitematā DHB

10/05/18

James Le Fevre Emergency Physician - Auckland Adults Emergency Department Trustee - Three Harbours Foundation Member - Medical Protection Society Member - Northern Regional Clinical Practice Committee Shareholder - Pacific Edge Ltd DHB Representative (Auckland and Waitematā DHBs) - Air Ambulance Co-design Procurement Governance Board (past role) James’ wife is an employee of the Waitematā DHB, Department of Anaesthesia and Perioperative Medicine and a Medico-Legal Advisor for the Medical Protection Society Board Member - Auckland District Health Board (past role) Shareholder - Genesis Energy

21/11/18

Brian Neeson Member - Upper Harbour Local Board Member - Human Rights Review Tribunal Member - Auckland District Licensing Committee Managing Director - BK & VS Neeson Limited Managing Director - Apollo Property Investments Limited Property Development Consultant Chair – Wilson Home Committee of Management (past role)

19/12/18

Morris Pita Owner/operator - Shea Pita and Associates Limited. Shareholder - Turuki Pharmacy Limited Shareholder and Director of Healthcare Applications Limited. In December 2018 this company won an RFP with Waitematā DHB for provision of the Emergency Q software service to reduce overcrowding in the ED and the company is currently (as at 27 March 2019) in the final stages of negotiation for a potential contract for service at both North Shore and Waitakere EDs. Morris’ wife is a:

Board member - Northland District Health Board Board member - Auckland District Health Board Director - Healthcare Applications Limited Director - Shea Pita & Associates

10/07/19

Allison Roe Chairperson - Matakana Coast Trail Trust Member - Rodney Local Board, Auckland Council Member - Wilson Home Committee of Management (past role)

22/08/18

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Conflicts of Interest Quick Reference Guide Under the NZ Public Health and Disability Act 2000, a member of a DHB Board who is interested in a transaction of the DHB must, as soon as practicable after the relevant facts have come to the member’s knowledge, disclose the nature of the interest to the Board. A Board member is interested in a transaction of a DHB if the member is:

a party to, or will derive a financial benefit from, the transaction; or

has a financial interest in another party to the transaction; or

is a director, member, official, partner, or trustee of another party to, or person who will or may derive a financial benefit from, the transaction, not being a party that is (i) the Crown; or (ii) a publicly-owned health and disability organisation; or (iii) a body that is wholly owned by 1 or more publicly-owned health and disability organisations; or

is the parent, child, spouse or partner of another party to, or person who will or may derive a financial benefit from, the transaction; or

is otherwise directly or indirectly interested in the transaction. If the interest is so remote or insignificant that it cannot reasonably be regarded as likely to influence the Board member in carrying out responsibilities, then he or she may not be “interested in the transaction”. The Board should generally make this decision, not the individual concerned. A board member who makes a disclosure as outlined above must not:

take part in any deliberation or decision of the Board relating to the transaction; or

be included in the quorum required for any such deliberation or decision; or

sign any document relating to the entry into a transaction or the initiation of the transaction. The disclosure must be recorded in the minutes of the next meeting and entered into the interest register. The member can take part in deliberations (but not any decision) of the Board in relation to the transaction if a majority of other members of the Board permit the member to do so. If this occurs, the minutes of the meeting must record the permission given and the majority’s reasons for doing so, along with what the member said during any deliberation of the Board relating to the transaction concerned. Board members are expected to avoid using their official positions for personal gain, or solicit or accept gifts, rewards or benefits which might be perceived as inducement and which could compromise the Board’s integrity. IMPORTANT Note that the best course, when there is any doubt, is to raise such matters of interest in the first instance with the Chair who will determine an appropriate course of action. Ensure the nature of the interest is disclosed, not just the existence of the interest. Note: This sheet provides summary information only. 2

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2.1 Minutes of the Hospital Advisory Committee meeting held on 19 June 2019

Recommendation: That the draft minutes of the Hospital Advisory Committee meeting held on 19 June 2019 be approved.

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Draft Minutes of the meeting of the Waitematā District Health Board

Hospital Advisory Committee

Wednesday 19 June 2019

held at Waitematā District Health Board Boardroom, Level 1, 15 Shea Terrace, Takapuna,

commencing at 1.39 p.m.

PART I – Items considered in public meeting COMMITTEE MEMBERS PRESENT

James Le Fevre (Committee Chair) Judy McGregor (Board Chair) Max Abbott Edward Benson-Cooper Kylie Clegg (Deputy Board Chair) (from 2.12pm, item 3.1) Sandra Coney Warren Flaunty Brian Neeson Allison Roe

ALSO PRESENT

Andrew Brant (Deputy Chief Executive Officer and Chief Medical Officer) Cath Cronin (Director of Hospital Services) Jocelyn Peach (Director of Nursing and Midwifery) Fiona McCarthy (Director Human Resources) Tamzin Brott (Director of Allied Health) Lorraine Bailey (IDF Performance Manager) Peta Molloy (Acting Board Secretary) (Staff members who attended for a particular item are named at the start of the minute for that item.)

PUBLIC AND MEDIA REPRESENTATIVES PRESENT

There were no members of the public or media present. WELCOME

The Committee Chair welcomed those present. APOLOGIES

Apologies were received and accepted from Matire Harwood and Morris Pita. DISCLOSURE OF INTERESTS

There were no additions to the Interests Register. There were no interests declared that might give conflict with a matter on the open agenda.

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1. AGENDA ORDER AND TIMING Items were taken in the same order as listed in the agenda.

2. COMMITTEE MINUTES

2.1 Confirmation of the Minutes of the Hospital Advisory Committee Meeting held on 08

May 2019 (agenda pages 8 - 16)

Resolution (Moved Allison Roe/Seconded Warren Flaunty) That the Minutes of the Hospital Advisory Committee meeting held on 08 May 2019 be approved. Carried Actions Arising (agenda pages 17) The actions were noted. No issues were raised.

3. PROVIDER ARM PERFORMANCE REPORT 3.1 Provider Arm Performance Report – March 2019 (agenda pages 18 - 82)

Executive Summary/Overview

Andrew Brant summarised the executive summary and overview. Matters covered in discussion and response to questions included:

That there had been a number of people presenting with influenza at the DHBs hospitals, however, it was not a particularly strong strain. The number of presentations was not higher than the previous year.

That the Faster Cancer Treatment graph (page 27 of the agenda) shows a drop in the Māori population; it was noted that this figure is n <20 and that one or two people no longer receiving treatment will show a significant drop. It was noted that the forecast for the month will be 91%.

With regard to the financial performance table, the difference for allied health with a positive to budget and how that relates to other services is turnover and vacancies.

Human Resources

In response to a question, Fiona McCarthy advised that approximately 62% of staff had received the influenza vaccination. This is not expected to increase due to vaccine availability.

Acute and Emergency Medicine Division

Gerard de Jong (Division Head Acute and Emergency Medicine), Alex Boersma (General Manager) and Melody-Rose Mitchell (Acting Associate Director of Nursing) were present for this item.

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Alex Boersma introduced the report. Matters covered in discussion and response to questions included:

That the scorecard shows the turnover rate remains high.

The ‘patients seen’ graph for North Shore Hospital has been duplicated in the report and the graph for ‘patients seen’ at Waitakere Hospital omitted; the graph shows an improvement in the North Shore Hospital data.

Chest pain clinic wait times under six weeks continue to improve with 63% against a target of 80% met in May; the target is expected to be reached in July.

ECHO wait times under 12 weeks has seen a downward trend. Resources are being used appropriately. The waiting list has decreased from approximately 3,000 to approximately 2,000. The decrease is partly due to increase in resource.

Specialty Medicine and Health of Older People Division

Dr John Scott (Head of Division), Brian Millen (General Manager) and Melody-Rose Mitchell is the Acting Associate Director of Nursing Acute and Emergency Medicine and Specialty Medicine and Health of Older People were present for this item. John Scott introduced the report. Matters covered in discussion and response to questions included:

Noting the highlight of the month (page 48 of the agenda) ‘Innovation in practice – Telehealth Outpatient Physiotherapy’; the group education sessions have been acceptable and people are happy to take part. Travel times can be an issue and video conference options are being investigated. In response to a question about how this idea was developed, it was noted that four services from different divisions took part in a pilot led by i3. The initial idea came about due to personal experience from the person leading it. A briefing on the programme and its initiation will be presented to the Committee at a later date.

Brian Millen summarised the key issue ‘lower than anticipated volumes for fracture liaison services. John Scott noted that future fractures can be reduced by as much as half with treatment in people who have had a first fragility fracture. The best intervention for lower level people at risk is an in home strength and training programme; uptake for this had not been as high as hoped. In response to a comment regarding taking medication in these instances and potential side effects, John Scott said that the programme is not about medication. The programme is run in close partnership with a patients GP, who primarily initiate treatment, and provides options for patients. It was suggested and agreed that a fracture liaison nurse present to the Committee at a later date.

Child, Women and Family Services

Stephanie Doe (General Manager) and Emma Farmer, Head of Division Midwifery) were present for this item. An apology was received from Dr Meia Schmidt-Uili. Emma Farmer summarised the highlight of the month reported ‘Completion of the Pregnancy and Parenting Improvement Plan’. Stephanie Doe noted that oral health and dental therapy vacancies remain high, with 14.5 current vacancies. There has been a lot of internal movement across

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teams; the three main reasons for leaving the service are: retirement, moving out of the area or moving to a private practice. In response to a question about retention of staff, Stephanie advise that a lot of work had been done and feedback received showed a lot of support was provided, but not for long enough. It was also noted that new graduates want to maintain a dual scope and the DHB is looking at how to support therapists in maintaining hygiene skills, to address this options of private/public roles are being offered. A site visit for Board members to a mobile dental unit will be arranged. Matters covered in discussion and response to questions included:

That the Pregnancy, Parenting Improvement Plan includes immunisation advice.

That in the past year there were 13 babies Oranga Tamariki care; of which nine babies were Māori (four transitioned to whānau care), two pacific babies (one into whānau and one into non-whānau foster) and two European babies. It was noted that all of these cases were planned, with a process followed. The DHB has well developed child protection systems in place, with appropriate training for staff. The DHB has a very positive relationship with Oranga Tamariki and communicate regularly with them.

Specialist Mental Health and Addiction Services

Dr Susanna Galea-Singer (Director and Head of Division), Pam Lightbown (General Manager) and Alex Craig (Head of Division Nursing) were present for this section of

the report.

Alex Craig introduced the report and summarised the highlight of the month reported ‘Ngā Poutama Oranga Hinengaro – An HQSC Quality in Context Survey’. Susanna Galea-Singer noted the update provided on Zero Seclusion. At a recent national Zero Seclusion forum in Christchurch, the DHB team was awarded the best –co-design and consumer participation project. The Committee Chair congratulated those involved.

Matters covered in discussion and response to questions included:

The recent tragic events at He Puna Waiora were noted; reviews are underway, including on the function of the unit. There is also regular contact with the families involved.

With regards to length of time a client may be a resident in the DHBs service, it was noted that this can be related to general housing issues. There are options including respite beds in the community and step-down beds.

Noting that there is movement and generalised concern in the area of mental health for a firmer stance on substance abuse such as alcohol, as well as gambling, obesity and the like.

The region is undertaking a deep dive on population health with three priorities. The first of these is the stabilisation of ARPHS. The second is a series of risk factors including drugs, alcohol, tobacco, mental health promotion in earlier years. The third is the determinants of health. The work is progressing well.

Surgical and Ambulatory Services

This section as considered before Speciality Medicine and Health of Older People.

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Debbie Eastwood (General Manager) and Michael Rodgers (Chief of Surgery) were present for this item. Michael Rodgers introduced the report. Matters covered in discussion and response to questions included:

Noting the positive change made by the orthogeriatrician model of care, led by a dynamic individual, Dr Min Yee Seow.

There is a large amount of work going into time to surgery for neck of femur fracture.

Noting the update provided on support and developing theatre culture.

That the utilisation metrics are positive. It was also noted that a list can be impacted by someone who calls in unwell and that this is not a system failure. This data can now be shown on Qlik; the Committee Chair suggested that a presentation be given on this, including how other hospitals record this information.

The Committee Chair acknowledged the balance scorecard.

In response to a question about theatre utilisation across the region and nationally, Michael Rodgers noted that there is a national metric (called DAP) which removes any turnaround time from the numerator as well as start and finish. It was noted that the measure can be difficult to measure as there are times when ten cases could be completed in a day and other times when one case will take a full day. A more detailed report around the metrics will be provided to the Committee at a later date.

3.2 Provider Arm Performance Report – April 2019 (agenda pages 82 - 92)

The report was noted. 4. CORPORATE REPORTS

4.1 Clinical Leaders’ Report (agenda pages 93 - 105)

Dr Andrew Brant (Chief Medical Officer and Deputy Chief Executive Officer), Tamzin Brott (Director of Allied Health, Scientific and Technical Professions) and Dr Jocelyn Peach (Director of Nursing and Midwifery; Emergency Systems Planner) were present for this item. Medical Staff

Andrew Brant noted the presentation scheduled on Friday 21st June from Heather Gunter.

Allied Health, Scientific and Technical Professions

Tamzin Brott summarised this section of the report. The Committee Chair acknowledged the Laboratory staff achievements celebrated and the Committee agreed to send a thank you letter. Nursing and Midwifery

Jocelyn Peach summarised this section of the report. In response to a query about the clinical monitoring and management data for Patient and Whanau Centre Care Standards (page 103 of the agenda), Jocelyn Peach

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noted that the scores had been low since monitoring commenced and that it is audited weekly. In response to question about the CCDM (Care Capacity Demand Management) update provided, it was noted that it was too soon to note Union expectation in this area.

4.2 Quality Report (agenda pages 106 - 339)

Penny Andrew (Clinical Lead, Quality), Jacky Bush (Quality and Risk Manager) and David Price (Director of Patient Experience) presented this report. Jacky introduced the report, noting the updates reported around infection, prevention and control, measles, influenza vaccines, falls and pressure injuries and the Learning from Adverse Events week. In response to a query Jocelyn Peach advised that the ‘lavender round’ is an assessment and monitoring round to ensure a proper care plan is in place. With regards to the influenza vaccination rate, it was noted that there is a ‘roving’ vaccinator and that processes are in place to target certain groups needing to be vaccinated. The shortage of vaccine stocks was also noted. David Price summarised the Patient and Whanau Centred Care section of the report. He noted that the inaugural meeting of the Consumer Council is scheduled to be held on Wednesday 3rd July from 2pm to 4pm. Board members are welcome to attend. Matters covered in discussion and response to questions included:

That the Committee can be provided with visibility of complaint trends; the information is available by division and trends over time. This will also be provided as it relates to SAC 3 and 4 information.

Penny Andrew summarised the i3 report provided to the Committee. The success with the PROMS programme was highlighted, this will be presented to the Board later in the year. The Board Chair acknowledged the CIO award presented to the Leapfrog team.

4.3 Human Resources Report (agenda pages 340-345)

Fiona McCarthy (Director HR) presented this item, she noted two new workforce development initiatives underway. The first is accelerating the cohort for 2020, with 14 final year students. Secondly, in relation to the update provided on Māori nursing students, work is underway with AUT for a joint appointment into the nursing school.

5. INFORMATION PAPERS

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There were no information papers. 6. RESOLUTION TO EXCLUDE THE PUBLIC (agenda page 346)

Resolution (Moved Warren Flaunty/Seconded Allison Roe) That, in accordance with the provisions of Schedule 3, Sections 32 and 33, 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

1. Confirmation of Public Excluded Minutes – Hospital Advisory Committee Meeting of 08/05/19

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, S.32 (a)]

Confirmation of Minutes As per resolution(s) to exclude the public from the open section of the minutes of the above meeting, in terms of the NZPH&D Act.

2. Quality 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.


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 S.9 (2) (a)]

3. Human Resources Report



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 S.9 (2) (a)]

Negotiations

The disclosure of information would not be in the public interest because of the greater need to enable the board to carry on, without prejudice

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or disadvantage, negotiations.

[Official Information Act 1982 S.9 (2) (j)]

Carried

The open session of the meeting concluded at 3.46 p.m. SIGNED AS A CORRECT RECORD OF THE WAITEMATĀ DISTRICT HEALTH BOARD HOSPITAL ADVISORY COMMITTEE MEETING OF 19 JUNE 2019 COMMITTEE CHAIR

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Actions Arising and Carried Forward from

Meetings of the Hospital Advisory Committee

as at 24 July 2019

Meeting Agenda Ref

Topic Person Responsible

Expected Report Back

Comment

05/12/18 3.1 Provider Arm Performance Report A semi-regular report to come to HAC highlighting services that are considered vulnerable.

Cath Cronin

Noted for action.

05/12/18 3.1.6 Specialist Mental Health and Addiction Services That indicators in addition to performance against the shorter stays in ED target be developed to ensure that any inequities between patients with acute mental health presentations and acute medical/surgical presentations are captured.

Susanna Galea-Singer

13/02/19 3.1 Provider Arm Performance Report

- Mobile dental clinics – check to

be made that clinic locations are well chosen.

- Obtain information from ACC on number of lime scooter accidents (for advice to HAC – but also forward as soon as available to Kylie Clegg)

Stephanie Doe

Cath Cronin

mid-2019

Review of locations is underway – an extensive process.

As per email of 22.03.19 (in house response). Request is also with ACC (response awaited).

19/06/19 3.1 Provider Arm Performance Report

- Telehealth Outpatient Physiotherapy: presentation to the Committee at a future meeting on the programme and its initiation

Brian Millen

- Fracture Liaison Services:

Committee to be provided a further update on the volumes for fracture liaison services

Fracture liaison nurse to present to the Committee at a future meeting,

Brian Millen

- Mobile dental unit: site visit to be arranged for Board members

Stephanie Doe / Peta Molloy

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Meeting Agenda Ref

Topic Person Responsible

Expected Report Back

Comment

- Utilisation Metrics: presentation to the Committee at a future meeting on utilisation metrics, including how other hospitals record this information.

Michael Rodgers

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3.1 Provider Arm Performance Report – May 2019

Recommendation:

That the report be received.

Prepared by: Robert Paine (Chief Financial Officer and Head of Corporate Services) and Cath Cronin (Director of Hospital Services)

This report summarises the Provider Arm performance for May 2019.

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Table of Contents

Glossary

How to interpret the scorecards

Provider Arm Performance Report – May 2019

Executive Summary / Overview

Scorecard – All services

Health Targets

Elective Performance Indicators

Strategic Initiatives

Financial Performance

Human Resources

Divisional Reports

Acute and Emergency Medicine Division



Specialist Mental Health & Addiction Services

Surgical and Ambulatory Services

Elective Surgery Centre

Diagnostic Services

Clinical Support Services

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Glossary

ACC - Accident Compensation Commission ADU - Assessment and Diagnostic Unit ARDS - Auckland Regional Dental Service ASA - American Society of Anaesthesiologists AT&R - Assessment Treatment and Rehab CADS - Community Alcohol, Drug and Addictions Service CT - Computerised Tomography CTO - Community Treatment Order CWF - Child, Women and Family service DHB - District Health Board DNA - Did not attend ECHO - Echocardiogram ECIB - Elective Capacity Inpatient Beds ED - Emergency Department ESC - Elective Surgery Centre ESPI - Elective Services Performance Indicators EOA - Equity of Access FTE - Full Time Equivalent GP - General Practitioner HCA - Health Care Assistant HDU - High Dependency Unit ICU - Intensive Care Unit KMU - Kingsley Mortimer Unit LOS - Length of Stay MECA - Multi-Employer Collective Agreement MHSOA - Mental Health Service for Older Adults MoH - Ministry of Health MRI - Magnetic Resonance Imaging NSH - North Shore Hospital NZNO - New Zealand Nurses Organisation ORL - Otorhinolaryngology (ear, nose, and throat) RMO - Registered Medical Officer S&A - Surgical and Ambulatory Services SLA - Service Level Agreement SCBU - Special care baby unit SMHA - Specialist Mental Health & Addiction Services SMHOPS - Specialty Medicine and Health of Older People Services SMO - Senior Medical Officer WIES - Weighted Inlier Equivalent Separations YTD - Year to Date

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How to interpret the scorecards Traffic lights For each measure, the traffic light indicates whether the actual performance is on target or not for the reporting period (or previous reporting period if data are not available as indicated by the grey bold italic font).

Measure descriptionTraffic light

Trend indicator

Actual Target Trend

Better help for smokers to quit - hospitalised 98% 95%

Measure descriptionTrend

indicatorTraffic light

The colour of the traffic lights aligns with the Annual Plan:

Traffic light Criteria: Relative variance actual vs. target Interpretation

On target or better Achieved

95-99.9% achieved 0.1–5% away from target Substantially Achieved

90-94.9%*achieved 5.1–10% away from target AND improvement from last month

Not achieved, but progress made

<94.9% achieved 5.1–10% away from target, AND no improvement, OR >10% away from target

Not Achieved

Trend indicators A trend line and a trend indicator are reported against each measure. Trend lines represent the actual data available for the latest 12-months period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. The small data range may result in small variations appearing to be large. Note that YTD measures (e.g., WIES volumes, revenue) are cumulative by definition. As a result their trend line will always show an upward trend that resets at the beginning of the new financial year. The line direction is not necessarily reflective of positive performance. To assess the performance trend, use the trend indicator as described below. The trend indicator criteria and interpretation rules:

Trend indicator

Rules Interpretation

p Current > Previous month (or reporting period) performance Improvement

q Current < Previous month (or reporting period) performance Decline

Current = Previous month (or reporting period) performance Stable

By default, the performance criteria is the actual:target ratio. However, in some exceptions (e.g., when target is 0 and when performance can be negative (e.g., net result) the performance reflects the actual. Look up for scorecard-specific guidelines are available at the bottom of each scorecard:

1. Most Actuals and targets are reported for the reported month/quarter (see scorecard header).

2. Actuals and targets in grey bold italics are for the most recent reporting period available where data is missing or delayed.

3. Trend lines represent the data available for the latest 12-months period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. Small data range may

result small variations perceived to be large.

a. ESPI traffic lights follow the MoH criteria for funding penalties:

ESPI 2: the traffic light will be green if no patient is waiting, blue if greater than 0 patients and less than or equal to 10 patients or less than 0.39%, and red if 0.4% or higher.

ESPI 5: the traffic light will be green if no patient is waiting, blue if greater than 0 patients and less than or equal to 10 patients or less than 0.99% and red if 1% or higher.

Key notes

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Provider Arm Performance Report

The Provider Arm performance is on track for the last quarter of Financial Year 2018/19. Each division has provided quality care within expected timeframes in most areas and working to retrieve any outlying areas such as ESPI 2 and 5. The ED target has been maintained while experiencing increasing presentations at Waitakere Hospital (WTH) and surges in presentations at certain times of the day at both EDs. The faster cancer treatment times are 90% within 62 days for the month of June. All the indicators give us a reassuring measure that patients are receiving care within expected timeframes or have pro-active plans in place to recover.

Executive Summary/Overview

Highlight of the month SOS: Self-referral On Symptom for outpatient follow up Outpatient clinics complete more than 20,000 outpatient appointments each month. The majority (70%) of outpatient appointments are face-to-face follow up appointments. General Surgery, Orthopaedic and Otolaryngology surgical specialties account for a quarter of our follow up appointments. The aim is to reduce unnecessary follow ups by providing patients unlikely to require an outpatient

follow-up with the opportunity to self-refer for General Surgery, Orthopaedic and Otolaryngology

follow -up appointments. Self-Referral on Symptom (SOS) provides an alternative to booking a clinic

follow-up appointment for patients unlikely to need specialist doctor follow up.

Between April 2018 and March 2019, there were 1,633 SOS cards were issued across General

Surgery, Orthopaedics and Otolaryngology. The majority of patients (90%) did not go on to have a

follow up appointment and were discharged from the service. This means that between April 2018

and March 2019 Waitematā DHB freed up 1,366 outpatient follow up appointments which is

equivalent to approximately 85 clinics. All three specialties also experienced reductions in the

number of did not attend appointments. The combination of appointments freed up and decrease in

did not attend rates has enabled Services to see patients who were waiting for follow up

appointments without increasing clinician workload.

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Key Issue of the Month Waitematā DHB’s plan to recover ESPI 2 and 5 across the specialties Waitematā is compliant for ESPI 1 in all specialties and compliant for ESPI 2 general surgery, orthopaedics, gynaecology, urology, all medical specialities and cardiology and the expectation is this will continue. ORL will be compliant for ESPI 2 by March 2020. All patients are being tracked closely including phone contact and all priority patients are treated within expected timelines. Cardiology and general surgery are compliant for ESPI 5 treatment times. Across the other ESPI 5 specialties all services are focused on their non-compliant volumes as service specific work continues to regain compliance. Seasonal impacts have altered forecasts from the June report and we note the risk that we have minimal flexibility within our current resources to add additional clinic or theatre sessions. The DHB plans to manage access and demand within current resources. Our aim is to have all services compliant by November 2019 with the exception of Orthopaedics who will be compliant by March 2020. All patients with a high clinical priority and high suspicion of cancer are treated with expected timeframes. The risks that will impact achievement of ESPI compliance are surgical and orthopaedic acute demand and acute medicine acute demand.

Financial Performance Summary The Provider Arm result for the month ended May 2019 was unfavourable by $3.729m. The result has been impacted YTD by the NZNO and Resident Doctors Association industrial action and winter acute demand pressures that resulted in the displacing of some elective surgery.

Scorecard – All services

Actual Target Trend Elective Volumes Actual Target TrendShorter Waits in ED 95% 95% Provider Arm - Overall 100% 100% p

Faster cancer treatment (62 days) 87% 90% p

Waiting Times

ESPI 2 - % patients waiting > 4 months for FSA Non-Compliant

ESPI 5 - % patients not treated w/n 4 months Non-CompliantESPI 1 - OP Referrals processed w/n 10 days Compliant

Patient Experience Actual Target Trend

Complaint Average Response Time 14 days ≤14 days q Patient Flow

Net Promoter Score FFT 76 65 p Outpatient DNA rate (FSA + FUs) - Total 7% ≤10%

Outpatient DNA rate (FSA + FUs) - Māori 15% ≤10% q

Improving Outcomes Outpatient DNA rate (FSA + FUs) - Pacific 14% ≤10% q

Better help for smokers to quit - hospitalised 99% 95% Average Length of Stay - Electives 1.36 days 1.59 days ####

Average Length of Stay - Acutes 2.62 days 2.25 days ####

Quality & Safety Trend

Older patients assessed for falling risk 96% 90% q

Rate of falls with major harm 0.1 ≤2 p

Good hand hygiene practice 89% 80% Financial Result (YTD) Actual Target Trend

S. aureus infection rate 0.0 ≤0.25 p Revenue 874,876 k 860,823 k p

Occasions insertion bundle used 100% 95% Expense 915,091 k 888,986 k q

Pressure injuries grade 3&4 0 0 p Net Surplus/Deficit -40,215 k -28,163 k q

Capital Expenditure (% Annual budget) #N/A

HR/Staff Experience Trend

Sick leave rate 3.3% ≤3.4% Contracts (YTD)

Turnover rate - external 12% ≤14% p Elective WIES Volumes 15,933 17,636 q

Vacancies - % 6% ≤8% Acute WIES Volumes 60,350 60,713 p

Performance indicators: Trend indicators:

Achieved/ On track Substantially Achieved but off target p Performance improved compared to previous month

Not Achieved but progress made Not Achieved/ Off track q Performance declined compared to previous month

Performance was maintained

a. December data not yet available.

Waitematā DHB Monthly Performance Scorecard

ALL ServicesMay 2019

2018/19

Contact:

Victora Child - Reporting Analyst, Planning & Health Intelligence Team: [email protected]

Planning, Funding and Health Outcomes, Waitematā DHB



3. Trend lines represent the data available for the latest 12-month period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. A small data range may result in small variations

appearing to be large.

Health Targets

How to read

Value for Money

Best Care

Service Delivery

A question?

Key notes

How to read

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Strategic Initiatives Variance Report Deliverable/Action On Track

Cancer Services

1. Develop a work plan for Māori and Pacific Cancer Nurse Coordinators to further

support improved cancer outcomes (EOA) – July 2018

2. Work with primary care to provide education and support to implement the prostate cancer decision support tool – ongoing.

3. With the Northern Cancer Network (NCN),review current resourcing and provision of survivorship care – as determined by NCN

4. Further develop the local delivery of oncology plan; introduce local delivery of zoledronic acid infusions for breast cancer patients – August 2018

5. Evaluate the live outcome process in the melanoma MDM (Minimal Deviation Melanoma) and plan to pilot in further MDMs – Evaluate by August 2018, pilot planned for October 2018

Access to Elective Services

6. Implement patient-focused booking for scheduling first specialist assessment (FSA) appointments across all services within Elective Services – May 2019

7. Develop processes, systems and implementation plan for scheduling follow-up appointments using the patient-focused booking process by 2019/20; implement initially within Medical Services – June 2019

8. Implement perioperative nurse-led coordination and management of all procedure/theatre bookings for Elective Services, including improved coordination of patient flow with clinical guidance and oversight. This will include management of high acuity, high complexity patients, in support of better access to earlier intervention for Māori and Pacific Populations (EOA) – March 2019

9. Alignment of all Waitematā DHB services to the Elective Patient Access Policy and Guidelines to ensure our standards, key requirements and processes are adhered by for the delivery of planned care – February 2019

Areas off track for month and remedial plans

All areas on track.

Scorecard Variance Report Health Targets Faster Cancer Treatment (62 days) Faster Cancer Treatment result is 87% against a target of 90%. The cancer team is focussed to achieve the faster cancer treatment times. The target was achieved in June this will be tracked closely and maintained on an on-going basis.

Predicted Cases Compliant Breaches Compliance

July 35 32 3 91.4%

August 40 36 4 90%

September 40 36 4 90%

October 40 36 4 90%

November 40 36 4 90%

December 40 36 4 90%

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Service Delivery Outpatient DNA rate This area continues to be a focus for all services in 2019 with ongoing rollout of patient focussed booking. Value for Money Variance Report Financial result The Provider Arm result for the month is in line with the consolidated DHBs year-end forecast to meet budget. Contracts Elective WIES Surgical production is returning to plan to meet discharge volumes. The Provider Arm is also reviewing coding to ensure optimal revenue is achieved by 30 June.

Health Targets Faster Cancer Treatment

Faster Cancer Treatments Māori Population

The key reason for the dramatic drop is timing. These figures are 3-month rolling figures and the four breaches in a 12 month period have occurred in this current 3 month rolling period. That, combined with the numbers of Maori patients in the 62-day reporting being very small, means there can be large swings in percentages with a single breach.

From 1 January 2019 - 31 May 2019, there were 10 Maori patients eligible for 62-day reporting. Six were compliant and four breached due to capacity issues. This gives a 60% achievement against a target of 90%.

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In contrast, our 12 month rolling data for Maori is less susceptible to percentage swings as the numbers are larger and the time period evens out breaches that occur in clusters. For the 12 months from 1 June 2018 to 31 May 2019, we are tracking at 85.1% for Maori (23 patients compliant out of 27). We analyse all breaches (Maori and non-Maori) individually. The four breaches in this three month period, were from four different tumour streams ( Head and Neck, Urology, Upper GI and Lung) and occurred for four different reasons (a delay to diagnostic, one delay to FSA, one delay to a follow-up clinic and one delay for treatment at Auckland DHB). As an additional note, our 31-day data for Maori (days from decision to treat to first treatment) from the 12 months until 30 April 2019 is 94.4% (NRA April Regional Report). This covers 107 patients. Shorter Stays in EDs

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Inpatient Events admitted through ED

ED / ADU Presentations

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Improved Access to Elective Surgery

Note: Changes were made to the electives health target for 2015/2016

Percentage Change ED and Elective Volumes

May 2019 Month Volumes % Change (last year) YTD Volumes % Change (last year)

ED/ADU Volumes 11,346 6% 120,482 1%

Elective Volumes 1434 5% 12217 -8.1%

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Elective Performance Indicators Zero patients waiting over 4 months

Summary (May 19)

Speciality Non Compliance %

ESPI 2 - Patients waiting longer than the required timeframe for their first specialist assessment (FSA).

4.56%

ESPI 5 - Patients given a commitment to treatment but not treated within the required timeframe.

3.47%

ESPI Specialty Compliant Non Compliant Non Compliant

ESPI 2 Anaesthesiology 73 - 0.00%

Cardiology 1,201 - 0.00%

Dermatology 167 - 0.00%

Diabetes 83 - 0.00%

Endocrinology 298 - 0.00%

Gastro-Enterology 840 - 0.00%

General Medicine 198 - 0.00%

General Surgery 1,778 7 0.39%

Gynaecology 900 6 0.66%

Haematology 205 - 0.00%

Infectious Diseases 51 - 0.00%

Neurovascular 56 - 0.00%

Orthopaedic 1,836 - 0.00%

Otorhinolaryngology 1,600 538 25.16%

Paediatric MED 900 - 0.00%

Renal Medicine 254 - 0.00%

Respiratory Medicine 635 - 0.00%

Rheumatology 171 - 0.00%

Urology 652 17 2.54%

Total 11,898 568 4.56%

ESPI 5 Cardiology 158 - 0.00%

General Surgery 1,779 5 0.28%

Gynaecology 592 42 6.62%

Orthopaedic 1,044 74 6.62%

Otorhinolaryngology 459 14 2.96%

Urology 338 22 6.11%

Total 4,370 157 3.47%

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90% of outpatient referrals acknowledged and processed within 10 days

ESPI 1 (May 19)

Specialty Compliance %

Anaesthesiology 100.00%

Cardiology 97.35%

Dermatology 99.46%

Diabetes 97.66%

Endocrinology 99.04%

Gastro-Enterology 98.68%

General Medicine 97.40%

General Surgery 96.76%

Gynaecology 99.82%

Haematology 100.00%

Infectious Diseases 98.92%

Neurovascular 96.23%

Orthopaedic 97.98%

Otorhinolaryngology 99.78%

Paediatric MED 98.71%

Renal Medicine 98.68%

Respiratory Medicine 98.73%

Rheumatology 99.46%

Urology 99.75%

Total 98.59%

Legend

ESPI 1 Green if 100%, Yellow if between 90% and 99.9%, and Red if 90% or less.

ESPI 2 Green if 0 patients, Yellow if greater than 0 patients and less than or equal to 10 patients or less than 0.39%, and Red if 0.4% or higher.

ESPI 5 Green if 0 patients, Yellow if greater than 0 patients and less than or equal to 10 patients or less than 0.99%, and Red if 1% or higher

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Discharges by Specialty

Cumulative Bed Days saved through Hospital Initiatives

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Predicted versus Actual Bed Days

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Financial Performance

($000’s)

Actual Budget Variance Actual Budget Variance Budget

REVENUE* Government and Crown Agency 77,651 75,902 1,749 847,932 833,854 14,078 909,648

Other Income 3,089 2,515 573 26,944 26,969 (25) 29,462

Total Revenue 80,740 78,417 2,323 874,876 860,823 14,053 939,110

EXPENDITURE

Personnel

Medical 18,539 17,259 (1,280) 182,052 177,885 (4,166) 194,170

Nursing 24,488 22,380 (2,108) 239,015 225,286 (13,729) 243,593

Allied Health 11,216 11,159 (56) 110,229 109,570 (659) 119,212

Support 1,952 1,816 (136) 20,005 19,002 (1,003) 20,729

Management / Administration 6,325 6,238 (87) 65,490 63,571 (1,918) 69,051

Outsourced Personnel 1,739 1,156 (583) 17,212 11,882 (5,330) 12,955

64,258 60,007 (4,250) 634,002 607,196 (26,806) 659,710

Other Expenditure

Outsourced Services 5,167 4,649 (518) 53,094 51,948 (1,146) 56,555

Clinical Supplies 12,104 11,120 (984) 117,349 115,560 (1,790) 126,343

Infrastructure & Non-Clinical Supplies 10,195 9,897 (298) 110,645 114,282 3,637 118,202

27,466 25,665 (1,801) 281,089 281,789 701 301,100

Total Expenditure 91,724 85,672 (6,051) 915,091 888,986 (26,105) 960,810

Cost Net of Other Revenue (10,984) (7,255) (3,729) (40,215) (28,163) (12,052) (21,700)* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.

Waitemata DHB Statement of Financial Performance

MONTH YEAR TO DATE FULL YEAR

Provider - May 2019

Comment on major financial variances The overall result for Provider is $3.729m unfavourable for May and $12.052m unfavourable for the YTD. Revenue ($2.323m favourable for May, $14.053m favourable YTD) The favourable revenue variance includes MECA timing benefits offset by expenses, and revenue from PHARMAC rebates that are now accounted for as revenue relating to the new Ministry Combined Pharmaceutical Budget (CPB) strategy. Up until December 2018 the rebates had been accounted for and budgeted as an offset in pharmaceutical expenditure. From January onwards the rebate has been accounted for as revenue (unbudgeted). Expenditure ($6.051m unfavourable for May, $26.105m unfavourable YTD)

Personnel ($26.806m unfavourable YTD) Personnel costs are anticipated to track unfavourably to budget this year due to MECA impacts partially offset by additional funding support from the MoH, and additional FTE appointments approved after the formation of the annual plan necessitated in order to maintain safe clinical services, which are funded with additional revenue. Active management of vacancies and leave continues to be a focus for the Provider. Other Expenditure ($701k favourable)

Outsourced Services ($1.146m unfavourable)

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Outsourced colonoscopy and gastroscopy volumes were reduced due to contracted volumes with suppliers. Clinical Supplies ($1.790m unfavourable) The unfavourable variance was due to mobility aids rental volume being consistently high, MHSOA respite volume and acuity and district nursing patient’s volume demands. A project to reduce mobility aids costs will begin implementation in July 2019. The unfavourable variance was also contributed to by medical gases in Facilities. Infrastructure and Non-Clinical Supplies ($3.637m favourable) The unfavourable variance was due to unrealised expenditure reduction initiatives that will not be delivered this year.

($000’s)


CONTRIBUTION

Surgical and Ambulatory (14,936) (14,227) (709) (158,017) (156,860) (1,157) (172,381)

Acute and Emergency (12,685) (11,603) (1,081) (132,173) (126,984) (5,189) (140,839)

Specialty Medicine and HOPS (7,522) (7,200) (321) (81,944) (78,537) (3,407) (86,843)

Child Women and Family (8,124) (7,562) (562) (80,327) (79,503) (824) (87,597)

Specialist Mental Health and Addiction (11,102) (10,562) (540) (120,649) (118,500) (2,149) (131,023)

Elective Surgery Centre (2,644) (2,586) (58) (25,309) (25,490) 180 (27,976)

Corporate and Provider Support 46,029 46,486 (457) 558,204 557,710 494 624,959

Net Surplus/Deficit (10,984) (7,255) (3,729) (40,215) (28,163) (12,052) (21,700)



Provider - May 2019

Comment on major variances by Provider Service The overall result for Provider was $3.729m unfavourable for May and $12.052m unfavourable for the YTD. Surgical and Ambulatory Services ($1.157m unfavourable YTD) While tracking close to budget overall the service continues to benefit financially from additional revenues from orthopaedic ACC cases, and lower volumes due to the impact of industrial action and acute bed encroachment from medical services. Offsetting this, additional costs have been incurred with over-allocations of registrars, outsourced skin lesions, and unplanned repairs and maintenance costs. The service is facing cost pressures in the remaining months to ensure ESPI compliance, plans to deliver to plan on outsourced MRI and ultrasound scans, and unbudgeted outsourced costs to meet interventional radiology demands that exceed internal capacity. Acute and Emergency Medicine ($5.189m unfavourable YTD) The unfavourable variance was due to premium cover costs for medical staff, additional sessions to shorten the patient waiting list, RMO strike cover cost by SMOs, extra beds and resources required to meet high winter demand and high watch costs. Specialty Medicine and HOPS ($3.407m unfavourable YTD) The unfavourable variance was due to increased patient watches in the KMU, increased demands in District Nursing, and increased demand for mobility aids.

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Child, Women and Family Services ($0.824m unfavourable YTD) The unfavourable result YTD was the result of on-going patient demand driven cost increases across predominately Maternity (antenatal assessments and caesarean section activity) and Neonatal services involving use of external staffing resource and overtime to cover vacancies and roster gaps, cleaning outsourced costs, patient food and to a lesser extent increased maintenance costs in the mobile dental units and fixed dental facilities. These cost increases have been partly mitigated by service wide vacancies and an improved revenue position. Specialist Mental Health and Addiction Services ($2.149m unfavourable YTD) The unfavourable result YTD was due to the use of locums to cover medical vacancies and increasingly ‘acute’ caseloads. This is particularly the case in the Rodney region, both for adult and child and youth specialist psychiatrists. There remains a difficulty recruiting to nursing vacancies, again specifically in more specialist areas such as child and youth as well as intellectual disability. Also, vacancies in both the adult inpatient units and forensics are covered with overtime rates which are paid at a premium. Elective Surgery Centre (ESC) ($0.180m favourable YTD) Three factors have reduced the capacity to deliver to plan and resulted in the favourable financial variance YTD; industrial action, acute bed encroachment at NSH impacting ESC, and the holiday closure. This has resulted in lower costs. Offsetting this, the service has realised higher than budgeted non-volume related clinical supplies, e.g. repairs and maintenance, and minor purchases. Corporate and Provider Arm Support Services ($0.494m favourable YTD) Revenue is favourable $10.723m due to additional revenue from MoH for Care Capacity and Demand Management (CCDM), Capital Charge and MECA settlements, along with additional cost recoveries and includes additional interest income $434k and back-dated SLA in Primary Health Care Nursing for vaccination program at Auckland DHB $307k. Also contributing were favourable personnel costs due to vacancies along with risk pool provisions $431k; this was offset with unfavourable variances driven primarily by a delay in implementing some of the financial sustainability initiatives and unfavourable expenditure in Facilities outsourced maintenance and consultants costs $1.395m. Overall the cost overspends in Facilities have improved and the financial result has remained closer to breakeven over the past five months.

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Human Resources Method of calculation of graphs:

1. Overtime Rate: The sum of overtime hours worked over the period divided by worked hours over the period.

2. Sick Leave Rate (days): The sum of sick leave hours over the period divided by total hours over the period.

3. Annual Leave balance days: Count of staff with 0-76+ days equivalent 8 hour days accumulated leave entitlement.

4. Voluntary Turnover Rate: Count of ALL staff resignations in the last 12 months. This data excludes RMOs, casuals, and involuntary reasons for leaving such as redundancy, dismissal and medical grounds.

Sick Leave Sick leave has increased in May, with the organisational result is just above the upper tolerance level at 3.6%. The increase in sick leave has continued into June with a likely contributor being seasonal winter illness. CWF Division and SMHA have reported the highest variances above target and tolerance level. CWF have experienced an increase in sick leave across the majority of their services indicating seasonal winter illness. Sick leave levels in SMHA have seen a moderate 0.8% increase across all services indicating a similar reason. As mentioned the trend continues into June and a deeper dive into the drivers and the best way to support services and staff is underway. It is pleasing to see the staff uptake of the influenza vaccination at 65.5% with the vaccination continuing to be offered to staff in high risk areas. Robust on-going reporting and monitoring continues across all services to give visibility to instances and patterns of leave to ensure appropriate responses to intermittent high leave absences and long term sickness.

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Overtime The positive downwards trend in overtime rates has continued into May. SMHA have achieved a decreased rate over the last quarter which reflects recent success with recruitment campaigns.

Annual Leave Leave balances in the 0-25 and 75+ days brackets are slightly increased in comparison to May 2018 but overall leave remains relatively consistent. The average leave days per person in May 2018 and 2019 was 20 days, but improves with June 2018 average days at 20 and June 2019 at 19.

Annual Leave May 2019 Leave Bal 0-25 days

Leave Bal 25-50 days

Leave Bal 50-75 days

Leave Bal 75 days +

S&A 833 325 77 28 ESC 87 16 1 - CWF 957 152 20 14 Hospital Operations 439 141 20 0 Facilities & Development 32 13 3 - Corporate 328 103 13 5 Acute & Emergency Medicine 938 322 72 33 Director of Hospital Services 222 51 6 1 Elective & Outpatient Services 57 21 2 - SMHA 1068 280 26 2 Specialty Medicine and HOPS 765 205 32 13 WDHB Governance and Funding 82 16 4 3

Total 5808 1645 276 99

Comparison – May 2018 5465 1676 286 89

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Staff Turnover Turnover is sitting on the lower tolerance level for this reporting period and continues into June. On-going monitoring continues in all services and deeper analysis undertaken where identified.

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Divisional Reports

Acute and Emergency Medicine Division Service Overview This division is responsible for the provision of General, Acute and Emergency Medical services. The division includes the departments of General Medicine, Assessment and Diagnostic Unit (ADU), Emergency Medicine, Cardiology, Medical wards and Hyperbaric Medicine. The service is managed by Dr Gerard de Jong, Division Head Acute and Emergency Medicine and Alex Boersma, General Manager. The Associate Director of Nursing Medicine is Melody-Rose Mitchell. The Clinical Directors are Dr Hamish Hart for General Medicine, Dr Willem Landman for Emergency Care, Dr Tony Scott for Cardiology, Dr Hasan Bhally and Dr Hugh de Lautour for North Shore Hospital ADU and Dr Chris Sames for Hyperbaric Medicine.

Highlight of the Month ADU Presentations at NSH The total number of patients presenting to the ADU, YTD in the current financial year 2018/19 is projected to be below that of 2017/18 and will be close to the number of presentations in 2016/17. This is despite a continued growth in population and demographic changes within the population.

The reduction in presentations is the result of a number of strategies that have been implemented in the ADU. Senior decision making at the front door – The ADU is staffed 08:00 to 20:00 Monday to Friday with SMOs responsible for the flow throughout the department, and with a focus on discharging patients as appropriate. Acute GP referral phone –SMOs consistently hold the GP phone from 8:00am-8:00pm, Monday to Friday. By doing this, they are able to provide advice to GPs, thereby avoiding presentations to hospital. They can also identify patients that are suitable to be seen in the Acute General Medicine clinic as well as patients that can be treated via the Primary Options for Acute Care (POAC) scheme. It is estimated that between 6-7 patients daily are deferred from the ADU via the GP phone daily. This equates to approximately 1,500 deferred presentations per annum. The Acute General Medicine clinic was set up in January 2019 and is available for outpatients four days a week. To the end of June 2019, 186 patients have been seen in this clinic. Patients are referred to the clinic via the Acute GP referral phone and they are seen and assessed in outpatients, rather than the ADU. Acute and Emergency are working on increasing the number of patients referred to the acute clinic and anticipate that over 500 patients could be deferred annually.

2016/17 Baseline

2017/18 2018/19 (partial year to end May

2019)

Total number of medical patients presenting to ADU NSH

16,884 18,175 15,276 (projected to be 16,665)

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Chest Pain pathway – changes to the chest pain pathway mean that 78% of low risk chest pain patients are now discharged from ED, compared to 62% in the old model. Five hundred eighty nine more patients were discharged home from ED in the last 12 months (average of 49 per month). These patients were historically transferred to General Medicine and the ADU. Acute and Emergency are in the process of implementing a number of other strategies with the aim of further reducing the number of presentations to the ADU and ultimately, admissions to hospital.

Key Issues Safety and Security in the ED at Waitematā DHB Background Waitematā DHB is committed to the provision of a safe environment, free of occupational violence and aggression. The Waitematā DHB ED Security Task Force was established to develop a framework for the prevention and management of clinical aggression and to review the training needs within the EDs. The review found there was a low level of awareness and an inconsistent use of de-escalation and personal restraint procedures amongst the ED clinical and security staff. Over the last 12 months, the following training programme have been implemented across the emergency and security departments to address this deficit. Staff Training implemented over the last 12 months

Intervention Started Duration No of staff trained

Essentials of Safety and Security

Introduction to Safety and Security at Waitematā DHB

December 2018 30 minutes 232

Restraint Minimisation and Safe Practice e-modules

Currently in development

eCALM October 2018

30 minutes 717

Extended CALM Workshop

March 2019 4 hours 529

Advanced Safety and Security

Management of Actual and Potential Aggression (MAPA) Foundation

June 2019 2 days 60

MAPA Foundation August 2019 1 day 0

MAPA Advanced Proposed September 2019

2 days 0

The Management of Actual and Potential Aggression (MAPA) training commenced in June 2019. This course is for identified clinical and security roles that are either part of code orange or work in a service where there is increased exposure to potentially aggressive situations. It is designed to provide staff with the skills to identify behaviour that indicates an escalation toward aggressive and violent behaviour and to take appropriate measures to avoid, decelerate and/or de-escalate a

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potential crisis situation. The ED Clinical Nurse Managers and the Associate Clinical Charge Nurses (ACCN) were the first groups to complete this foundation course. Feedback from staff that have been on the course is detailed below:

“I feel more confident in my own skills and my ability to help with holds if necessary.”

“Have learnt a lot from it and will help me in what I do.”

“I was able to apply theory to practice, was also able to build relationships with members of Code Orange Team. Great emphasis of non-physical de-escalation techniques.”

“I gained skill and methods to apply and deal with low, medium and high risk situations with safety and security perspective.”

“I feel more confident to manage critical situations and engage in verbal de-escalation.”

“I will utilize the MAPA principles to ensure a team approach in the ED between ED ACCN and security for the safety and well-being of a patient in crisis.”

“The instructors were excellent in their enthusiasm and knowledge in teaching the course. They made us feel relaxed and made the days fun. Best course I have attended for years. A small group was excellent to be a part of and easier learning.”

CALM Training This is considered the basic requirement to work in ED. This course is designed to enable staff to be able to utilise effective communication strategies and remain safe when faced with challenging situations. The training includes developing an understanding of the cycle of escalation and the role that communication plays in the de-escalation of a distressed person. The relationship between least restrictive interventions and the decision making process are explored. The course consists of an eLearning module and a 4 hour workshop. All ED staff have attended the eLearning CALM module and all new staff will attend as part of their orientation to ED. The extended CALM workshop training began in February 2019 and to date over 500 staff have attended. Next Steps Over the last year a significant number of staff have been trained in de-escalation and the management of patients with behaviours of concern. The next stage of this programme is the advanced MAPA training course and the development of training package for HCAs within ED/ADU responsible for the close observation of patients.

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Scorecard – Acute and Emergency Medicine Division

Actual Target Trend Waiting Times Actual Target Trenda. Shorter Waits in ED 96% 95% General Medicine - % seen w/in 120 mins 81% 85% q

Elective coronary angiography w/in 90 days 95% 95% q

b. Angiography for ACS w/in 72 hours 80% 70% p

c. Chest pain clinic wait time under 6 weeks 53% 80% p

Patient Experience Actual Target Trend c. O/P Transthoracic Echo wait time under 12 weeks 17% 95% q

Complaint Average Response Time 8 days ≤14 days q

Net Promoter Score FFT 70 65 q Patient Flow

Elective Discharge Volumes (Cardiology) 95% 100% q

Improving Outcomes Outpatient DNA rate 7% ≤10% q

PCI w/in 120 minutes (STEMI patients) 83% 80% q Patients with EDS on discharge 88% 85% q

Better help for smokers to quit - hospitalised 100% 95% p Average Length of Stay - Acutes 2.50 days <2.12 days ####

Quality & Safety


Rate of falls with major harm 0.03 ≤2 p Financial Result (YTD) Actual Target Trend

Good hand hygiene practice 84% 80% q Revenue 3,704 k 3,283 k p

Pressure injuries grade 3&4 1 0 Expense 135,877 k 130,266 k q

Net Surplus/Deficit -132,173 k -126,984 k q

HR/Staff Experience Capital Expenditure (% Annual budget) #N/A

Sick leave rate 3.1% ≤3.4%

Turnover rate - external 18% ≤14% p Contracts (YTD)

Vacancies - % 6% ≤8% q Elective WIES Volumes 1,033 1,099 p

Acute WIES Volumes 33,570 33,132 p





b. Quarterly, Mar 19

c. Apr data, May n/a yet

Contact:




Acute and Emergency MedicineMay 2019

2018/19



3. Trend lines represent the data available for the latest 12-month period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. A small data range may result in small variations appearing to

be large.

a. Data for Medicine overall

Health Targets

How to read

Value for Money

Best Care

Service Delivery

A question?

Key notes

How to read

Scorecard Variance Report Best Care Pressure injuries grade 3 and 4 – 1 against a target of 0 During the month of May 2019, there was one Stage 3/4 unstageable Hospital Acquired Pressure Injury reported. This was on Ward 11. Acute and Emergency continue to focus on the Pressure Injury Prevention Action Plan which is being rolled out across the medical wards. This Action Plan aligns with the Waitematā DHB Pressure Injury Management Workgroups Action Plan. All Pressure Injury (Stage 3/4 unstageable) incidents are discussed at the Divisional Quality Meeting and investigations are presented to the Adverse Events Committee.

(Source: RiskPro)

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Turnover rate – External 17.7% against a target of ≤14% The external turnover rate has been declining since December (19.4%) now sitting at 17.7%,a 1% decrease from the March figure of 18.7%. Whilst it is declining slowly and still above the DHB target of 14%, the downward trend is a positive sign that things are continuing to improve. The internal turnover rate has seen a significant increase from 14.3% (March 2019) to 22.4% (May 2019), however, this figure is largely distorted due to the movement of a number of incumbents who now fall under the recently appointed Operations Manager – ED WTH. The internal turnover rate remains largely static otherwise. All leavers in the month of May were Registered Nurses with the exception of one HCA.

Of the 10 voluntary leavers in May 2019, four left to go overseas, four to take up another role in the public health sector, one incumbent left due to ill health and the other incumbent resigned without disclosing a reason. Of the 10 voluntary leavers, one was an HCA from the Wards and nine were Registered Nurses (five from ADU, two from ED and two from the wards).

Service Delivery Chest pain clinic wait times under 6 weeks – 53% against a target of 80%

Performance against the chest pain clinic wait times is continuing to improve, with 52% seen within 6 weeks in April and 63% seen within six weeks in May. Acute and Emergency have implemented a process to review all the referrals to the chest pain services to ensure that only appropriate patients are seen in this clinic. Waitematā DHB receives significantly higher referrals for the chest pain service than the other DHBs in the region. In addition, resources have been realigned to meet this demand.

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The Service will be trialling a nurse-led screening process for these patients to ensure that the referrals are appropriately managed. Outpatient Transthoracic ECHO wait times under 12 weeks – 17% against a target of 95% Outpatient transthoracic performance in terms of waiting time and throughput is measured on a monthly basis in the Northern Region through the following KPIs:

Outpatient Transthoracic % under 12 weeks

Count of Outpatient Transthoracic (no of procedures done in the month)

Median Wait times (weeks) Outpatient Transthoracic

95th Percentile Wait time (weeks) Outpatient Transthoracic

Outpatient Transthoracic % under 12 weeks Outpatient Transthoracic performance is currently measured as the % of patients treated in under twelve weeks. Performance against this indicator has deteriorated over the last nine months as we have been treating more priority three patients from the waiting list. Although we have reduced the overall number of patients on the waiting list, and we have improved the waiting time for P3 patients, this has not been reflected in this KPI. There are currently approximately 1,500 patients in the outpatient ECHO Cardiology waiting list at Waitematā DHB. This is a significant reduction from the 3,000 patients that were on the waiting list at the beginning of 2017. On average, we receive 430 to 450 outpatient ECHO referrals per month. Thirty six percent are received from within Cardiology, 34% from General Medicine and 16% are GP referrals, direct to ECHO. The remaining ECHOs are received from Surgery, oncology, mental health and other hospital departments. All out-patients referrals received by the ECHO service are triaged by one of two SMOs and they are graded as per clinical priority. They are graded as P1 – to be done immediately, P2 to be done within 8 weeks and P3. Referrals that do not meet the agreed criteria for outpatient ECHOs are declined. The ECHO service at Waitematā DHB provides a service to both NSH and WTH. There are nine sonographers at Waitematā DHB and at NSH there are four echo rooms, three in the cardiology procedures department and one in Coronary Care Unit (CCU). The ECHO room in CCU is

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used for inpatients only. At WTH there are two ECHO rooms. The ECHO service provides an acute inpatient ECHO service, treating approximately 60 inpatients at NSH and 25 inpatients at WTH per week. In addition, there are four weekly stress ECHO lists and one Transoesophageal Echocardiography (TOE) list. This leaves approximately 110 ECHO slots available for outpatient ECHOs per week which is approximately 440 per month. Outpatient Transthoracic performance is currently measured as the % of patients treated in under twelve weeks. Performance against this indicator has deteriorated over the last nine months as we have been treating more priority three patients from the waiting list. Although we have reduced the overall number of patients on the waiting list and we have improved the waiting time for P3 patients this has not been reflected in this KPI.

Strategic Initiatives Variance Report

Deliverable/Action On Track

Shorter stays in ED

1. Implement a review of all ‘stranded’ patients, i.e. those with a length of stay >10 days in general medicine – June 2019.

2. Develop and plan to improve access to acute outpatient clinics from the ADU: next day for general medicine and access to subspecialty outpatient clinics in a timely manner for acute patients – June 2019.

3. Ensure diversity in our work force to represent our patient population (EOA) – June 2019


All areas on track.

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Financial Results - Acute and Emergency Medicine

($000’s)


REVENUE* Government and Crown Agency 263 251 11 2,980 2,766 214 3,017

Other Income 74 44 31 725 517 208 561

Total Revenue 337 295 42 3,704 3,283 422 3,578

EXPENDITURE

Personnel

Medical 4,240 3,836 (404) 47,553 45,982 (1,571) 50,004

Nursing 6,157 5,753 (405) 61,783 59,076 (2,706) 66,916

Allied Health 213 222 9 2,336 2,432 96 2,653

Support 0 0 0 0 0 0 0

Management / Administration 466 451 (15) 5,534 5,417 (117) 5,872

Outsourced Personnel 118 76 (41) 1,396 873 (523) 949

11,194 10,338 (856) 118,602 113,780 (4,821) 126,393

Other Expenditure

Outsourced Services 32 38 6 368 420 52 458

Clinical Supplies 1,390 1,219 (170) 12,929 12,820 (109) 14,010

Infrastructure & Non-Clinical Supplies 405 303 (102) 3,979 3,247 (732) 3,556

1,827 1,560 (267) 17,276 16,486 (790) 18,024

Total Expenditure 13,022 11,899 (1,123) 135,877 130,266 (5,611) 144,417

Cost Net of Other Revenue (12,685) (11,603) (1,081) (132,173) (126,984) (5,189) (140,839)* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.



Acute & Emergency Medicine - May 2019

Comment on major financial variances The overall result for Acute and Emergency was $1,081k unfavourable for May and $5,189k unfavourable for the YTD. Revenue ($42k favourable for May, $422k favourable YTD) The favourable variance for May and YTD was due to revenue received from non-residents and University of Auckland teaching. Expenditure ($1,123k unfavourable for May, $5,611k unfavourable YTD) The unfavourable variance for May and YTD was due to premium cover cost for medical staff, additional beds and resources used to meet high winter demand, actual medical beds utilisation, vacancies and turnover for covered areas. In addition, increased orientation costs for new graduates, RMO strike cover cost, cardiology SMO back-pay, security watch cost for NSH ED have also added an extra cost pressure. Personnel ($4,821k unfavourable YTD) Medical ($1,571k unfavourable YTD) The unfavourable variance was due to extended sick leave in ED over the winter period for 2018, additional session by an ED SMOs to cover vacant shifts, cardiology SMO to reduce the patient waiting list, SMO back pay and RMO strike cover cost by SMOs.

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Nursing ($2,706k unfavourable YTD) The unfavourable variance was due to high staffing level for winter demand, high over time in ED due to lack of experienced ED nurse for cover, high orientation costs, external agency used to cover unfilled positions and not fully budgeted cost commitment for watches and ADU observation beds. Allied Health ($96k favourable YTD) The favourable variance was due to vacancies. Support and Management/Administration ($117k unfavourable YTD) The unfavourable variance was due to high penal cost for ED administration staff. Outsourced Personnel ($523k unfavourable YTD) The unfavourable variance was due to outsourced nursing expenditure for watches demand and locums for ED Other Expenditure ($790k unfavourable YTD) Clinical Supplies ($109k unfavourable YTD) The unfavourable variance was due to high Implantable cardioverter defibrillator (ICD) implant procedure and high catheter and balloon cost from the cardiology vascular unit. Infrastructure and Non-Clinical Supplies ($732k unfavourable YTD) The unfavourable variance was due to high security watch cost and unrealised savings, which was allocated in the budget to encourage savings within the whole division.

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Service Overview This Division is responsible for the provision of medical sub-specialty and health of older people services. This includes respiratory, renal, endocrinology, stroke, dermatology, haematology, diabetes, rheumatology, infectious diseases, medical oncology, neurology, gastroenterology, smoke-free, fracture liaison services and Older Adults and Home Health, which in turn includes palliative care, geriatric medicine, district nursing, EDARS (early discharge and rehabilitation service), needs assessment and service coordination, the specialist gerontology nursing service Nga Kaitiaki Kaumatua, Mental Health Services for Older Adults, and the AT&R wards. The division also includes the Medicine patient service centre. Allied Health provides clinical support (inpatient, outpatient and community) across the Acute and Emergency Medicine Division, Specialty Medicine and Health of Older People Division and Surgical and Ambulatory Service and reports to the General Manager Specialty Medicine and Health of Older People.

The service is managed by Dr John Scott, Head of Division, and Brian Millen, General Manager. Melody-Rose Mitchell is the Acting Associate Director of Nursing Acute and Emergency Medicine and Specialty Medicine and Health of Older People. The Clinical Directors are Dr Cheryl Johnson for Geriatric Medicine, Dr Sachin Jauhari for Psychiatry for the Older Adult, Dr Moira Camilleri for Palliative Care, Dr Stephen Burmeister for Gastroenterology, Dr Simon Young for Diabetes/Endocrinology, Dr Janak De Zoysa for Renal, Dr Megan Cornere for Respiratory, Dr Ross Henderson for Haematology, Dr Blair Wood for Dermatology and Dr Michael Corkill for Rheumatology.

Highlights of the Month Implementing Electronic notes (E-notes) on Wards 15 and 14 Progress notes are the main communication/information tool between different disciplines involved in the care of patients. They aim to capture the ‘story’ of the patient’s hospital journey from admission to discharge and are seen as a way for staff to obtain an understanding of the patient history while supporting holistic care. Medico-legally, they are the official “record of care” provided by the DHB. In most hospital settings around the world, progress notes are hand written entries onto a paper form that collectively make up a patients’ clinical record. Some of the inherent challenges with paper notes include illegible handwriting and signatures, single use access and the fact that access is limited to the ward environment. Paper notes can be damaged or go missing. Secondary analysis for auditing or case review is restrictive and time-consuming.

Transitioning progress notes to an electronic platform is widely regarded as a key component of high-quality and effective health care systems of the future.

As part of a collaborative venture led by David Ryan and involving Waitematā DHB’s Health Information Group and staff on Ward 15, ‘E-notes’ has been developed to allow clinicians to capture progress note entries directly into clinical portal. The system, which was developed in-house by the Health Information Group as part of the DHB’s Leapfrog Program, allows progress notes to be immediately available for all clinical staff to view via the patient’s chart.

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E-notes were designed in consultation with ward clinical staff, and education and training was provided to all staff prior to and during the trial. This enabled the project and ward teams to identify issues and make improvements which allowed the platform to evolve in a fluid way.

Of note, all Waitematā DHB wards already possess the physical infrastructure – computers on wheels, reliable Wi-Fi, and other electronic systems, as well as a high degree of staff literacy and comfort with electronic medical records of many types. This greatly helped facilitate the transition. They were successfully trialled on Ward 15 starting from 1 April 2019. They offer the following advantages over hardcopy documents:

Patient notes being accessible from any computer in the organisation, previous time in

motion audits have shown clinicians waste considerable time searching for patient notes

The ability for multiple users to read and write notes concurrently – no need to wait for the

notes folder to become available

Time-saving features, including pre-populated templates, text-expansion for commonly

typed phrases, and the ability to import from external systems (e.g. Patientrack and Éclair)

All entries are 100% legible and auditable, and all users have their contact details easily

visible in the system

Reduced storage needs of hardcopy clinical documents and folders, both on the ward, and

for clinical records

Increased sustainability due to a reduction in paper and printing costs

Documentation for previous admissions is available immediately rather than having to wait

for clinical records.

Templates have been developed with and to support clinicians with documenting in E-notes (as below)

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The feedback from staff has been very positive. Comments have included:

“Staff have really loved using e-notes. It is easy to use. We can access the clinical file without

having to wait for someone to finish with it. We can read what has been written and see

what others have recommended or done.” – Ward 15 Charge Nurse Manager

“We heard about it from ward 15 staff and couldn’t wait for it to come to our ward. We have

our templates and some of our forms in e-notes. We are working on other forms to go into

it.” – Ward 14 Registered Nurse

“I am able to read progress entries while off site at a remote location or at home. I was able

to document a discussion with the coroner after a patient’s death which would not normally

have been possible as usually the physical file would have left the ward.” – Ward 15 SMO

“David (i3 project lead) and his team were really supportive and available to us.” – Ward 14

Registered Nurse

Waitematā DHB uses approximately 760,000 double-sided clinical notes pages each year, and it is

hoped this initiative will reduce this to zero once fully rolled out. The initiative has since been rolled

out to Ward 15 and is scheduled to be implemented on general medical wards in the coming

months.

Key Issue Hospital Palliative Care Team Waitematā DHB employs a small inpatient palliative care team, with two SMOs, a registrar, and five specialist nurses. The team provides specialist care to people in both our hospitals, primarily in the general medical and general surgical wards, but patients in all services can at times require their input. Although sometimes perceived as a service for cancer patients in the last phase of life, Palliative Care has an increasingly broader scope as a service with expert skills in symptom control for many life limiting conditions, and provides essential care and advice well before the terminal phase of an illness has begun.

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The team liaises closely with community based palliative care services, which are run by the Hospice service providers in the Waitematā area: Hospice West Auckland, and Harbour Hospice (which provides services to North Shore, Hibiscus Coast and Warkworth). Although the community hospice service is closely identified with inpatient hospice units, most care in fact is provided in people’s homes and most patients spend only a short time, if any, in the inpatient units. Recent changes to community hospice configuration combined with the increasing busyness of our acute hospitals have presented a challenge for our inpatient palliative care service. Hospice West Auckland closed its inpatient beds in 2018 and Hospice North Shore plans a major rebuild later this year which will impact the availability of inpatient beds. For the hospital palliative care service this means a greater challenge to accommodate people after discharge as the option of transfer to hospice for care of imminently dying patients is constrained compared to the usual state, and this constraint will worsen later this year. In addition, the increase in admissions and decrease in LoS in our inpatient wards has impacts on Palliative Care, as on every inpatient service. Admissions under general medicine, for example, grew by 8% in the 2017/18 financial year, and LoS reduced. These changes have meant that the Palliative Care team has had to adapt its way of working. A vacant SMO position has been filled and will bring much needed support to the clinical director, Dr Camilleri. The team have presented at nursing and medical forums, and are encouraging in-patient teams to refer to Palliative care as early as possible after the need for their input is identified. Further communication is planned. Earlier referral means staff have as much time as possible to identify the goals of care, and for those patients who are not imminently dying will allow for what is often complex discharge planning to occur in an unhurried and considerate timeframe as practically possible. Inevitably, decisions made in hospital around the care of dying patients are complex and are often stressful and emotionally charged for patients, their families and staff. The Palliative Care team hope that an increased emphasis on outreach and early involvement with ward based teams will enable them to be giving input as soon as possible and allow decisions around future care to be as considered and compassionate as possible.

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Scorecard – Specialty Medicine and Health of Older People Services

Patient Experience Actual Target Trend Waiting Times Actual Target Trend

Complaint Average Response Time 14 days ≤14 days p Urgent diagnostic colonoscopy w/in 14 days 100% 90% p

Net Promoter Score FFT 76 65 q Diagnostic colonoscopy w/in 42 days 48% 70% q

Surveillance colonoscopy w/in 84 days 53% 70% p

Improving Outcomes

b. Patients admitted to stroke unit 69% 80% q Patient Flowb. Acute Stroke to rehab w/in 7 days 64% 80% q Outpatient DNA rate 6% ≤10%

a. InterRAI assessments - LTHSS clients 99% 95% p Patients with EDS on discharge 90% 85% p

Better help for smokers to quit - hospitalised 100% 95% p Average Length of Stay - AT&R 16 days <19 days ####

Quality & Safety

Older patients assessed for falling risk 100% 90% p

Rate of falls with major harm 0 ≤2 Financial Result (YTD) Actual Target Trend

Good hand hygiene practice 91% 80% p Revenue 7,792 k 8,384 k p

Pressure injuries grade 3&4 0 0 Expense 89,736 k 86,921 k q


HR/Staff Experience Capital Expenditure (% Annual budget) #N/ASick leave rate 3.1% ≤3.4% p

Turnover rate - external 14% ≤14% p Contracts (YTD)

Vacancies - % 4% ≤8% p Elective WIES Volumes 459 417 p

Acute WIES Volumes 2,169 1,977 q





b. April data, May n/a yet

Contact:




Specialty Medicine and Health of Older PeopleMay 2019

2018/19





a. Quarterly Dec 18 latest data

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Scorecard Variance Report Patients admitted to stroke unit – 69% against a target of 80% 69% equates to 42 out of the 60 eligible patients admitted to a stroke ward in April. A clinical review of the patients that were not admitted to a stroke ward identified that four patients were incorrectly coded as having had a stroke, four were end of life care, two were incidental findings (one was discharged the same day and the other was already on an AT&R ward), and six were either not referred to the stroke team for review, or were referred, reviewed and discharged the same day. One patient was unable to be admitted to a stroke ward due to no availability of beds. Acute Stroke to rehab within seven days – 64% against a target of 80% A clinical review of the eight patients that did not transfer to rehabilitation within seven days identified that two were discharged directly to our Early Discharge and Rehabilitation Service (EDARS), and five were considered too medically unwell to transfer. Service Delivery Diagnostic colonoscopy within 42 days – 48% against a target of 70% The endoscopy service did not achieve the MoH target for diagnostic colonoscopy and surveillance colonoscopy (70% within 84 days) in May 2019. However there has been an improvement from the result in February of 38.7% for diagnostic and 38.9% for surveillance colonoscopy. An increase in the inflow of patients over April and May in Diagnostic colonoscopy compared to the same period last year remains a challenge. The recovery plan which includes regular review and optimisation of session utilisation and DNA rate remains in place. An additional Gastroenterology Fellow joined the team in June increasing internal capacity for 2019/20. Outsourced volumes have also been increased in 2019/20 to meet forecast demand.

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Surveillance colonoscopy within 84 days – 53% against a target of 70% As above Compliance with patient safety checks in Adult Mental Health Ward Seventeen clinical notes were randomly audited throughout from 1-31 May. The need for safety checks was correctly documented in all cases and all current risk assessments were up to date.

Strategic Initiatives Variance Report

Deliverable/Action On Track

Stranded Patients

1. Implement a review of all ‘stranded’ patients, i.e. those with a length of stay >20 (i.e. ‘stranded’) in AT&R – June 2019.

Fracture Liaison

2. Identify and address barriers to older people being referred to and using the Fracture Liaison Service (FLS) – June 2019.


All areas on track.

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Financial Results – Specialty Medicine and Health of Older People

($000’s)


REVENUE* Government and Crown Agency 782 667 115 7,197 7,349 (153) 8,022

Other Income 118 94 24 596 1,034 (439) 1,128

Total Revenue 900 761 138 7,792 8,384 (591) 9,150

EXPENDITURE

Personnel

Medical 1,799 1,711 (89) 20,423 20,023 (400) 21,765

Nursing 2,598 2,504 (94) 26,876 25,591 (1,285) 29,227

Allied Health 1,736 1,786 50 19,218 19,325 108 21,083

Support 0 0 0 0 0 0 0

Management / Administration 388 417 29 4,922 5,077 155 5,502

Outsourced Personnel 31 49 17 901 534 (368) 582

6,553 6,467 (86) 72,340 70,549 (1,791) 78,159

Other Expenditure

Outsourced Services 316 349 34 3,744 4,014 270 4,363

Clinical Supplies 1,274 981 (293) 11,307 10,526 (782) 11,476


1,868 1,495 (374) 17,396 16,371 (1,025) 17,835

Total Expenditure 8,421 7,962 (460) 89,736 86,921 (2,816) 95,993

Cost Net of Other Revenue (7,522) (7,200) (321) (81,944) (78,537) (3,407) (86,843)* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.



Specialty Medicine and HOPS - May 2019

Comment on major financial variances The overall result for Specialty Medicine and Health of Older People was $321k unfavourable for May and $3,407k unfavourable for the YTD. Revenue ($138k favourable for May, $591k unfavourable YTD) The unfavourable variance YTD to May was due to Hepatitis bulk funded revenue of $340k not being received. Expenditure ($460k unfavourable for May, $2,816k unfavourable YTD)

Personnel ($1,791k unfavourable YTD) Medical ($400k unfavourable YTD) The unfavourable variance was due to unbudgeted sabbatical leave and premium rate paid to cover costs (approximately $320k). In addition rotation of RMO staff resulted in increased costs of $104k. Nursing ($1,285k unfavourable YTD) The unfavourable variance was due to the following:

KMU model of care changes requiring more patient watches which are not full budgeted $527k

Watches demand was covered by overtime which was paid at an additional cost of $74k

District Nursing volume demand increased resulting in overtime and cover at an additional cost of $180k.

Nurse Endoscopic cost approximately $128k.

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Allied Health ($108k favourable YTD) The favourable variance was due to EDARs return to operational leave variance of $128k which is offset by savings from Allied Health staff vacancies. This area is under recruited. Support and Management/Administration ($155k favourable YTD) The favourable variance is due to an operations manager vacancy in MHSOA which has now been recruited to. Outsourced Personnel ($368k unfavourable YTD) The unfavourable variance was due to outsourced nursing to cover the KMU watches and other unplanned nursing leave. Outsourced locum to cover medical vacancies and leave. Other Expenditure ($1,025k unfavourable YTD)

Outsourced Services ($270k favourable YTD) Outsourced colonoscopy and gastroscopy volumes were reduced due to contracted volumes with suppliers. Clinical Supplies ($782k unfavourable YTD) The unfavourable variance was due to Mobility Aids rental volume being consistently high, MHSOA respite volume and acuity and District Nursing patients volume demands. Infrastructure and Non-Clinical Supplies ($513k unfavourable YTD)

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Service Overview This Division is responsible for the provision of maternity, obstetrics, gynaecology and paediatric medicine services for our community, for the regional Out of Home Children’s Respite Service, the Auckland Regional Dental Service (ARDS), and the national Child Rehabilitation Service. Services are provided within our hospitals, including births, outpatient clinics and gynaecology surgery, and within our community, e.g. community midwifery, mobile/transportable dental clinics and the Wilson Centre. The service is managed by Dr Meia Schmidt-Uili, Division Head and Stephanie Doe, General Manager. Head of Division Nursing is Marianne Cameron, Head of Division Midwifery is Emma Farmer and Head of Division Allied Health is Susan Peters. The Clinical Directors are Dr Sathananthan Kanagaratnam for ARDS, Dr Christopher Peterson for Child Health and Dr Diana Ackerman for Women’s Health.

Highlight of the Month Better, best, brilliant – Implementation of the Outreach Fluoride Varnish Programme ARDS is systematically implementing a programme of topical fluoride application to pre-schoolers in early childhood education centres across metropolitan Auckland. The programme is specifically targeted to early childhood centres with high numbers of Māori and/or Pacific pre-schoolers. It aims to improve long term oral health outcomes and reduce inequities, as topically applied fluoride varnish has been shown to arrest and potentially reverse early enamel carious lesions. The programme was initially piloted in 2018 in four Kohanga Reo and two Pacific Language Nests on the North Shore (where ARDS had pre-existing relationships with staff). It has now been rolled out to 39 early childhood centres across Auckland – eight within Waitematā DHB (planning is underway for a further roll out in eight additional centres), 16 in Auckland DHB and 15 in Counties Manukau Health. The programme has provided an opportunity to enrol children not previously known to the service, complete ‘lift the lip’ (screening) examinations and facilitate appointments for children who have not previously been seen or are overdue for examinations. All children also receive a toothbrush and oral health promotion pack. There is opportunity to engage with whānau to address any issues or concerns and also promote oral health. All participating early childhood centres are visited every six months to ensure children receive regular preventive therapy. Opportunities to bring a mobile clinic into the centres is currently being explored – this will enable children, who may not otherwise be able to attend appointments, to receive oral health examinations and treatments at their early childhood centre.

Key Issue Maintaining patient flow in acute paediatrics at WTH One of the challenges faced by Child Health is responding to the seasonal demand for acute paediatric care. During the winter months, as many as thirteen children can be admitted and discharged from the 33 bed Rangatira Ward per day. Given this, maintaining effective patient flow to

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ensure that children are treated in the most appropriate environment as quickly as possible and supporting timely discharge home are key priorities for the service.

The service has developed a range of strategies in order to support patient flow include:

Prioritising early discharges of children in the ward round.

Proactively identifying and reviewing of children who are potentially well enough for discharge throughout the day.

Paediatric medical staff making early clinical decisions (within four hours of ED admission) as to whether the child will be admitted.

Paediatric medical staff working collaboratively with their ED colleagues to see children presenting with medical concerns in a timely manner.

Introducing a flow coordinator in Rangatira Ward, seven days a week between 1.00 – 9.00pm (the busiest time for paediatric presentations). The flow co-ordinator is responsible for identifying potential admissions from ED to Rangatira and working collaboratively with ED staff to ensure effective and timely patient flow.

Managing inter-hospital patient transfers through conversations between the on-call paediatrician and Rangatira shift co-ordinator.

Scorecard – Child, Women and Family Services

Actual Target Trend Elective Volumes Actual Target TrendShorter Waits in ED 94% 95% p Provider Arm - Overall 100% 100% p

CWF Services 79% 100% q

Waiting Times

Gateway referrals waiting over 8 weeks 17 5 p

Patient Experience Actual Target Trend

Complaint Average Response Time 9 days ≤14 days q Patient Flow

Net Promoter Score FFT 74 65 p Outpatient DNA rate 10% ≤10% q

Theatre utilisation Gynaecology 80% 85% q

Improving Outcomes Patients with EDS on discharge 91% 85% q

Exclusive breastfeeding on discharge 76% 75% p Oral Health - chair utilisation 11 11 p

Women smokefree at delivery 97% 95% p Average Length of Stay - Paediatrics 1.34 days <1.24 days ####

Better help for smokers to quit - hospitalised 92% 95% q Average Length of Stay - SCBU 10.75 days <10.4 days ####

a. Oral health - % infants enrolled by 1 year 82% 95% p

a. Oral health - exam arrears 0-12 yr 34% ≤10%

Financial Result (YTD) Actual Target Trend

Quality and Safety Revenue 6,520 k 6,436 k q

Good hand hygiene practice 91% 80% p Expense 86,847 k 85,939 k q


HR/Staff Experience Trend Capital Expenditure (% Annual budget) #N/A

Sick leave rate 3.7% ≤3.4% q

Turnover rate - external 11% ≤14% Contracts (YTD)

Vacancies - % 7% ≤8% q Gynaecology Elective WIES (excl ESC) 854 1,103 p

Gynaecology Acute WIES 1,217 1,343 q

Maternity WIES 6,946 7,210 q

Paediatrics WIES 1,733 1,744 q

Neonatal WIES 2,161 2,084 p





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Child Women and Family Services and Elective Surgical CentreMay 2019

2018/19





a. Oral health data - Total WDHB, ADHB and CMDHB, DHB of service not domicile

Health Targets

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Scorecard Variance Report Best Care Oral health - % infants enrolled by one year – 82% against a target of 95% There continues to be steady progress towards achieving the target. Work is currently underway to align the automated enrolment process with the methodology used for the National Immunisation Register. This will further improve performance.

Oral health - exam arrears 0-12 years – 34% against a target of ≤10% Arrears remain high at 34%. Systematic review of all children in arrears, by wait time, is currently underway. Initiatives to reduce arrears include: the introduction of centralised booking and scheduling; on-going recruitment of dental/oral health therapists; improved chair utilisation practices; the development of outreach services; and centralised rostering.

Sick leave rate – 3.7% against a target of ≤3.4% The sick leave rate continues to be slightly above target in ARDS (3.9%) and Women’s Health (3.7%).

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Service Delivery Elective Volumes – 79% against a target of 100% Gynaecology has not achieved the elective WIES volume target to date – but improvement has been seen over the last month. While WIES elective volumes are running below target, YTD the service has achieved 96% of the surgical health target. Gateway referrals waiting over 8 weeks – 17 against a target of 5 There has been further improvement in the number of children waiting over eight weeks for a Gateway assessment.

Theatre utilisation gynaecology – 80% against a target of 85% There has been an improvement in theatre utilisation from last month. Performance against the target excludes day of surgery cancellations. When comparing utilisation based on first patient ready to last patient out, as a proportion of the scheduled theatre session time, the utilisation rate is currently 85%.

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Value for Money Gynaecology Elective WIES – 854 against a target of 1,103 Gynaecology remains below the elective target, as WIES target was overstated for the 2018/19 financial year. Gynaecology Acute WIES – 1,029 against a target of 1,099 Gynaecology acute WIES performance to date has been impacted by variable acute demand over the financial year.


Support to Quit Smoking

1. Employ a Midwife Smokefree Coordinator to improve the quality of ABC and smoking cessation support for pregnant women and their whanau – June 2019

Child Wellbeing

2. Fully implement the fluoride varnish programme for pre-schoolers – June 2019

3. Trial a tool to identify unmet health needs in new entrants – June 2019


All areas on track

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Financial Results - Child, Women and Family Services

($000’s)


REVENUE* Government and Crown Agency 579 662 (83) 5,419 5,636 (217) 6,298

Other Income 122 92 30 1,101 800 300 893

Total Revenue 701 754 (53) 6,520 6,436 84 7,190

EXPENDITURE

Personnel

Medical 1,784 1,469 (315) 17,793 17,726 (68) 19,278

Nursing 3,210 3,051 (160) 28,529 27,200 (1,329) 30,766

Allied Health 2,120 2,347 227 23,448 25,040 1,592 27,324

Support 24 25 2 247 282 35 307

Management / Administration 372 385 13 4,172 4,400 228 4,780

Outsourced Personnel 212 109 (103) 1,640 1,198 (442) 1,306

7,722 7,386 (336) 75,829 75,845 16 83,762

Other Expenditure

Outsourced Services 35 47 12 526 514 (12) 561

Clinical Supplies 554 537 (18) 5,785 5,753 (32) 6,290


1,103 930 (173) 11,018 10,094 (924) 11,025

Total Expenditure 8,825 8,316 (509) 86,847 85,939 (908) 94,787

Cost Net of Other Revenue (8,124) (7,562) (562) (80,327) (79,503) (824) (87,597)* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.



Child Women and Family - May 2019

Comment on major financial variances The overall result for CWF was $562k unfavourable for May and $824k unfavourable for the YTD. Revenue ($53k unfavourable for May, $84k favourable YTD) The unfavourable variance for May was due to a one off adjustment in Colposcopy funding whilst the YTD favourable position has been driven by back dated ACC claiming and new service level agreements. Funding pressures remain in Colposcopy (volume delivery) and Child Respite services (contract pricing change). Expenditure ($509k unfavourable for May, $908k unfavourable YTD) The unfavourable variance for May was due to the cover costs related to the Junior Doctor strike, backdated allowance claiming, reduced annual leave impact, midwifery staffing pressures and patient demand across the neonatal units. The YTD unfavourable position was driven by the above mentioned cost pressures along with patient supplies, cleaning, motor vehicle and facility repairs and maintenance. Service vacancies have been the dominant cost mitigating factor throughout the year. Personnel ($16k favourable YTD) Medical ($68k unfavourable YTD) The unfavourable variance was due to a combination of SMO and Registrar vacancies being offset by higher costs to cover the roster gaps along with pressures associated with the series of Resident Doctors Association strike action. The service continues to actively recruit to vacant positions.

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Elective Gynaecology activity has been impacted by staffing gaps with volume delivery at 77% of contracted to date. Nursing ($1,329k unfavourable YTD) The unfavourable variance was due to increased caesarean section and antenatal assessment demand across Maternity Services. Workforce shortages has made managing maternity rosters challenging. The recently established mixed midwife/nurse model is working well and recent success in attracting new graduates has provided partial cost mitigation. Neonatal inpatient wards are also experiencing increased patient demand which is placing additional pressure on nursing budgets. Maternity inpatients are tracking at 97% of contracted WIES while Neonatal services are at 104% of contracted WIES targets. Allied Health ($1,592k favourable YTD) The favourable variance was due to ongoing therapist, therapy assistant and health promotion vacancies across ARDS. Work continues on developing the scope of practise for therapy staff as part of the service staff retention strategy. Support and Management/Administration ($263k favourable YTD) The favourable variance was due to service vacancies. Outsourced Personnel ($442k unfavourable YTD) The unfavourable variance was due to medical locum and external nursing cover for service vacancies where internal cover options are not available. Other Expenditure ($924k unfavourable YTD) Clinical Supplies ($32k unfavourable YTD) The unfavourable variance was due to patient demand for neonatal and community child nursing services enteral feeding supplies, respiratory products, mobility aids and continence and hygiene supplies. Infrastructure and Non-Clinical Supplies ($880k unfavourable YTD) The unfavourable variance was due to an increase in motor vehicle registration and maintenance costs, maintenance of dental facilities and equipment, patient food and groceries, back dated cleaning.

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Specialist Mental Health & Addiction Services

Service Overview This service is responsible for the provision of specialist community and inpatient mental health services to Waitematā residents. This includes child, youth and family mental health services, adult mental health services including two acute adult in-patient units, community alcohol, drug and other addiction services across the Auckland metro region, Whītiki Maurea providing mental health services to Waitematā residents and addiction services across metro-Auckland, Pasifika Peoples mental health services and regional forensic services that deliver services to the five prisons across the northern region as well as eight in-patient villas and a regional medium secure Intellectual Disability unit including an intellectual disability offenders liaison service. The group is led by Dr Susanna Galea-Singer (Director and Head of Division) and Pam Lightbown (General Manager). The Head of Division Nursing is Alex Craig and the Clinical Directors are Dr Greg Finucane for Adult, Dr Frances Agnew for Whitiki Maurea and Takanga A Fohe, Dr Jeremy Skipworth for Forensics, Dr Emma Schwarcz for CADS, and Dr Mirsad Begic for Child, Youth and Family.

Highlight of the Month Individual Placement and Support (IPS) Trial IPS Prototype Background The Individual Placement and Support model is an evidence-based employment service that serves to co-locate employment specialists within existing mental health clinical teams. Robust international evidence exists regarding IPS and the strong relationship it has with positive health and employment gains with mental health clients. The IPS implementation trial commenced July 1st 2019. This is funded based on a successful prototype phase which closed on 30th June 2019. Three providers Workwise, Emerge Aotearoa and Ember will embed employment specialists within Waitematā DHB Adult Mental Health Services (MHS) clinical teams, West, North and Rodney, as well as Moko and Isa lei. The trial will look to recruit to a total of 500 participants. The aims of the trial are to:

Implement good fidelity IPS services for clients of Waitematā DHB Community Mental Health Teams and monitor engagement and outcomes,

Engage with the Ministry of Social Development’s (MSD) evaluation of the Trial to assess its fidelity, efficacy and cultural appropriateness in a New Zealand context.

The trial will target people who access Waitematā DHB’s Adult MHS and also aims to reduce disparities for Māori who are over represented within unemployment and health (including mental health) statistics. The trial is funded by the MSD and is expected to reduce benefit use. IPS Prototype phase results: Between June 2018 and May 2019, 76 people have participated in the prototype phase. Recruitment has been targeted towards Māori as exploring the cultural acceptability and responsiveness of the IPS approach for Māori was a key aim of the evaluation (50% of the participants are Māori, n=38). Twenty two people have either secured jobs or have been supported to remain in their employment, the majority of which are full-time. While the main focus of the prototype stage was not to assess the impact of the service on employment, these results are encouraging. Formal employment

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outcomes will be assessed at the one year stage which is yet to be reached by any participants. For the group who have accessed IPS to date:

75% are receiving benefit support (n= 57; 75% ‘Job Seeker’ and 25% ‘Supported Living’)

25% were in employment and seeking assistance to remain in employment or were looking to change jobs.

Of those receiving benefit support on entry and getting jobs (n=17) 41% were Māori (n=7).

Many people have been out of work for significant periods. Length of time out of work was recorded for 15 of the 17 people receiving benefit support on entry, six had been unemployed for less than one year, four people for between 1-2 years and five people for greater than 3 years.

Whitiki Maurea Award Whitiki Maurea is very proud of Stella Williams, who recently won the Te Kauae Raro Māori Nursing and Midwifery Award, for Waitematā DHB Māori Registered Nurse of the Year, 2019. Stella won the award in recognition of the work she is doing with cultural supervision for our New Entry to Speciality Practice (NESP) programme. Stella has been involved in the design and delivery of Whai Arataki, which is the bi-cultural learning component of NESP. Stella’s aim is to support the groups understanding of Te Ao Māori within the context of their own values and beliefs. This involves facilitating reflective practice upon the previous month’s kaupapa and examples of how this was integrated into practice which will support practitioners to be more responsive to Māori.

Key Issues Quality Care in Adult Mental Health Inpatient Units Programme - Progress Update Summary Following on from the two recent deaths in He Puna Waiora acute inpatient unit, a Quality Improvement programme in Adult Mental Health inpatient units has been initiated. The programme involves a number of work-streams:

1. Clinical leadership and Clinical Governance; 2. Patient safety – Safe Environment; 3. Patient safety – Safe Care; 4. Service user, Whanau Co-design and Experience; 5. Staff experience; 6. Workforce planning; 7. Acute Adult Mental Health Services Model of Care.

Any recommendations from the He Puna Waiora review and adverse event investigations will be adopted into this programme of improvement.

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Scorecard – Specialist Mental Health & Addiction Services

Actual Target Trend Waiting Times (latest available) Actual Target Trend

Shorter Waits in ED 80% 80% pa. Adult (20-64) <3 weeks 83% 80%

a. CADS (0-19) <3 weeks 91% 80%

a. CADS (20-64) <3 weeks 96% 80%

CYF <3 weeks 100% 95%

Patient Experience Actual Target Trend a. Forensic (20-64) <3 weeks 87% 90% p

Complaint Average Response Time 18 days ≤14 days p Prison inpatient waiting list 1 0

Improving Outcomes b. Patient Flow

Better help for smokers to quit 97% 95% Bed Occupancy - Adult Acute 100% 80-90%

Seclusion use Forensics - Episodes 16 ≤14 q Bed Occupancy - CADS Detox 88% 80-90%

Seclusion use Adult - Episodes 2 ≤5 Bed Occupancy - Forensics Acute&Rehab 100% 80-90%

Adult Inpatient Unit AWOL (clients) 1 ≤1 q Bed Occupancy - ID 84% 80-90%

Forensic Unit AWOL (clients) 0 ≤1

c. CTO - Māori (Rate per 100,000) 293 ≤274 Community Care

Therapeutic Observations - High Care/ICU 99% 95% p Preadmission community care - adult 77% 75% q

Post discharge community care - adult 87% 90% p

a. MH Access Rates 0-19 years (Total) 3.91% 3.49% p

a. MH Access Rates 0-19 years (Māori) 5.41% 4.70% p Clinical contact directly with consumer - adult 84% 80% q

a. MH Access Rates 20-64 years (Total) 3.65% 3.43% p Clinical contact directly with consumer- CADS 91% 80%

a. MH Access Rates 20-64 years (Māori) 8.76% 7.80% p Clinical contact directly with consumer - CYF 89% 80%

Clinical contact directly with consumer - Forensic 69% 80% q

HR/Staff Experience

Sick leave rate 3.6% ≤3.4% Whanau contacts per service user - adults 39% 70%

Turnover rate - external 11% ≤14% p Whanau contacts per service user - child 100% 80%

Vacancies - % 7% ≤8% Whanau contacts per service user - youth 100% 80%

Financial Result (YTD) Actual Target Trend

Revenue 7,776 k 5,275 k p

Expense 128,425 k 123,775 k q


Capital Expenditure (% Annual budget) #N/APerformance indicators: Trend indicators:




Contact:




Specialist Mental Health and Addiction ServicesMay 2019

2018/19



3. Trend lines represent the data available for the latest 12-month period. All trend lines use auto-adjusted scales: the vertical scale is adjusted to the data minimum-maximum range being represented. A small data range may result in small variations appearing to be

large.

a. Reported approx 3 months in arrears (Feb data). c. Quarterly data Sep 18

b. Rolling 3 month indicator

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Health Targets

Scorecard Variance Report Best Care Complaint Average Response Time – 18 days against a target of <14 days The longer response times in May can be attributed to delayed investigations where staff were covering multiple roles, awaiting the completion of a Human Resources process, and service user availability for a meeting to resolve the complaint. Over the last twelve months SMHA had a median complaint response time of 13.2 days, which is below the target of 14 days. Seclusion use Forensics – Episodes – 16 against a target of <14 The 16 events breakdown into 11 episodes attributable to nine distinct service users. The service continues work on the zero seclusion project.

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CTO - Māori (Rate per 100,000) – 293 against a target of <274 The target in the scorecard represents a year-end target. A project group is currently working with the Māori health gain team to evaluate and reduce the number of Māori on the Mental Health Act: section 29 community treatment orders relative to other ethnicities. This project is using a Model for Improvement methodology which has involved engaging psychiatrists into the aims and methodology. This has been a slow process due to availability. We have continued this work into our 2019/20 Annual Plan. Sick leave rate – 3.6% against a target of <3.4% SMHA continue to work at reducing this including discussions and developing management plans for staff with low sick leave balances and general reminder to all staff on the importance of maintaining adequate sick leave balances and support that is available (e.g. Employee Assistance Programme and Occupational Health). Service Delivery Prison Inpatient Waiting List – 1 against a target of 0

In May 2019 there was one individual on the Prison Inpatient Waiting List who waited more than six weeks. The individual’s prolonged wait for admission reflects the on-going imbalance between acute forensic psychiatry inpatient beds and the acute mental health needs of the prisoners in the Northern region. The mental health care needs of this individual continue to be addressed by the forensic prison team. Bed Occupancy – Adult Acute – 100% against a target of 80-90% Inpatient beds continue to remain at high in occupancy at a rate of around 100% the majority of the time. Twice daily bed management meetings continue to highlight alternative to admission and alternative options within the community with more intensive support by community services and NGO partners as required on discharge.

Bed Occupancy – Forensics Acute and Rehabilitation – 100% against a target of 80-90%

The Mason Clinic has experienced high demand across the service in the last reporting period: medium secure Intellectual Disability and Mental Health units have regularly been over numbers and minimum secure units are at capacity. SMHA are working hard to get back to more manageable inpatient volumes, but a lack of community discharge options for step down beds and high prison acuity are presenting barriers to this.

Clinical contact directly with consumer – Forensic – 69% against a target of 80% This result is attributable to a number of factors for example patients not attending groups due to flu symptoms, annual leave and vacancies. The service is reviewing face to face contact recording within the service to see if any improvements can be made. Whanau contacts per service user – Adults – 39% against a target of 70% Contact with Whanau is the National key performance indicator (KPI) focus for 2019. The National group have indicated that there is likely to be adjustments to how this KPI is measured. Currently, it is only face to face contacts with the client present. However, family are often contacted via phone due to difficulty attending appointments because of, for example, work. These occasions are not captured in the KPI. The National KPI data provides the following examples in relation to where Waitematā DHB is against national average.

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Participate in the Health Quality and Safety Commission Project (HQSC)

1. Participate in the HQSC project commencing June 2018 with the aim to improve service transitions to primary care through ensuring 95% of transition plans/discharge letters contain a follow-up plan (with a copy sent to the person concerned); this activity is supported across all services, including kaupapa Māori and Pacific mental health addiction services (EOA) – June 2019.

2. Participate in the HQSC project commencing March 2019 that aims to reduce the occurrence of serious adverse events through ensuring learnings are introduced into clinical practice in a responsive manner, including Māori and Pacific representation in the adverse event investigation and recommendation process (EOA) – June 2019.

3. Minimise restrictive care through engagement in HQSC Zero Seclusion project activities, with the aspirational goal of eliminating seclusion in inpatient units and a focus on the regional forensic services, which has a high prevalence of Māori patients (EOA) – June 2019.

Supporting Parents Healthy Children

4. Implement adequate systems to identify parents across all services - June 2019.


4. A change to all services’ clinical forms is required for this system to be fully in place. Forensic services have made changes to their clinical form and a roll-out has begun. There has been a delay in the implementation into Te Ātea Marino (Māori addictions team) where the clinical forms are undergoing a wider review. Once the required changes have been made the same format will be adopted by Tupu (Pasifika addictions team). This work is expected be completed within the next three months.

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Financial Results – Specialist Mental Health & Addictions Services

($000’s)


REVENUE* Government and Crown Agency 478 291 187 4,930 3,197 1,733 3,488

Other Income 320 209 112 2,847 2,078 768 2,287

Total Revenue 798 499 299 7,776 5,275 2,501 5,775

EXPENDITURE

Personnel

Medical 2,284 2,275 (9) 26,062 26,629 568 28,935

Nursing 5,274 4,953 (321) 55,619 52,783 (2,836) 59,670

Allied Health 2,500 2,465 (35) 28,380 28,826 446 31,290

Support 124 134 10 1,465 1,498 33 1,626


Outsourced Personnel 306 92 (214) 3,094 1,092 (2,002) 1,191

10,978 10,389 (588) 120,095 116,262 (3,833) 128,612

Other Expenditure

Outsourced Services 10 7 (3) 168 70 (98) 77

Clinical Supplies 149 136 (12) 1,062 1,498 436 1,635

Infrastructure & Non-Clinical Supplies 765 529 (236) 7,100 5,945 (1,155) 6,474

923 672 (251) 8,330 7,513 (817) 8,186





Specialist Mental Health and Addiction - May 2019

Comment on major financial variances The overall result for SMHA was $540k unfavourable for May and $2,149k unfavourable for the YTD. Revenue ($299k favourable for May, $2,501k favourable YTD) The favourable variance for May was due to revenue for two contract variations for two acutely unwell intellectually disabled patients as well as high court billing. The YTD variance was due to these intellectual disability variation contracts worth $1,369k, as well as court billing revenue volumes being higher than forecasted worth $428k. The Incredible Years contract in Child and Youth is worth $165k YTD, and the University of Auckland revenue received for our doctors providing teaching services is worth $127k YTD. Expenditure ($839k unfavourable for May, $4,650k unfavourable YTD) The unfavourable variances for May was partly due to strike costs, very low leave uptake for Allied and nursing. Variances in May and YTD continue due to the use of locums to cover medical vacancies, nursing overtime to cover nursing vacancies and patient acuity which are paid at a premium. Personnel ($3,833k unfavourable YTD) Medical ($568k favourable YTD) The favourable variance was due to vacancies, 9.6 FTE in May and an average of 9.2 FTE YTD.

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Nursing ($2,836k unfavourable YTD) The unfavourable variance was due to 69.1 FTE nursing vacancies in May and an average of 86 FTE YTD, valued at $799k. This was offset by overtime ($1,434k) and casual spend ($308k), as well as pricing including allowances ($1,170k). Allied Health ($446k favourable YTD) The favourable variance was due to 53.6 FTE Allied vacancies in May, and 51.2 FTE YTD, valued at $307k, as well as pricing including allowances of $88k. Outsourced Personnel ($2,002k unfavourable YTD) The unfavourable variance was due to the use of locums to cover medical vacancies for 5.0 FTE in May and 0.7 FTE to help cover the acute caseload in Rodney, paid at a 30% premium ($1,740k). The variance was also due to an increase in court reports being outsourced due to volume increases ($287k). Other Expenditure ($817k unfavourable YTD) Outsourced Services ($98k unfavourable YTD) The unfavourable variance was due to clinical and research services provided by Auckland University of Technology. Clinical Supplies ($436k favourable YTD) This favourable variance was due to underspend in the Mental Health flexifunds worth $342k including specifically in forensics worth $181k. Infrastructure and Non-Clinical Supplies ($1,155k unfavourable YTD) The unfavourable variance was due to unallocated savings ($570k), not expected to be recovered this year as well as maintenance ($137k) and the Health and Quality Safety Commission regional programme ($142k).

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Surgical and Ambulatory Services/Elective Surgical Centre

Service Overview The Surgical and Ambulatory Services provide elective and acute surgery to our community encompassing surgical specialties such as general surgery, orthopaedics, otorhinolaryngology and urology, and includes outpatient, audiology, clinics, operating theatres and pre and post-operative wards. ICU and radiology services are with this service. The service is managed by Dr Michael Rodgers (Chief of Surgery), Debbie Eastwood (General Manager) and Kate Gilmour (Associate Director of Nursing). The Elective Surgery Centre provides elective surgical services to our community, managed by Dr Bill Farrington (Clinical Director). Currently the ESC Operations Manager role is vacant.

Highlight of the Month Outreach 24/7 NSH commenced in June Having ICU Outreach 24/7 has provided an increase in the support to junior nursing and medical staff after hours clinically at the bedside improving patient safety. Having an increase in senior nurse availability at night to support nursing decision making and address clinical concerns enables proactive out of hours decision making. It also provides the ability to provide additional support to recently discharged ICU/HDU patients to the wards. There is now the opportunity to provide teaching/coaching for permanent night staff who often missed Monday to Friday office hours-based teachings. Going forward Critical Care Outreach (CCOT) will be present on all resuscitation calls at NSH 24/7. It is well documented in the literature that prompt intervention will reduce long-term morbidity and reduce length of hospital stay. This service has been well received by the wards and here are a few comments received from our clinical staff:

“We have had a positive reduction in workload and stress overnight for our ICU coordinators

since commencement of Outreach 24/7. Previously we were often asked to provide advice

without having been able to physically review the patient. Outreach 24/7 has allowed us to

focus on our role and patients in the ICU.”

“Knowing that there is timely expert assessment of the deteriorating patient overnight

supporting the nursing and medical staff who can often be unavailable as they are on

another ward, theatre, ED .“

“I now have quick access to expert support for my deteriorating patients.”

“Better communication between wards, registrars and ICU medical team.”

“Being coached and supported on how to manage unwell patients.”

Key Issues Recruiting Surgical Pathology Laboratory Staff Anatomical (surgical) pathology includes the laboratory disciplines of histology and cytology. The surgical pathology department is a stand-alone unit and does not share technician/scientist staff with clinical laboratory, for reasons that the training and skills are different.

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In surgical pathology, the daily laboratory duties are manual and people dependent, with little automation. This makes the department very dependent on skilled scientists/technicians. However, the training schemes for histology gradually decreased to the extent that there is only one histology paper during the Bachelor of Medical Laboratory Science degree and no cytology component at all. Cytology, as a discipline, has also changed due to decreased demand for cytotechnologists. This is due to the change of primary cervical screening from cytology to Human Papillomaviruses (HPV) testing. This has resulted in a loss of scientific staff and the eventual cutting of cytology training. However, the demand for non-gynaecology cytology has increased due to the clinicians’ drive for diagnoses with less invasive techniques, leading to increased numbers of Endoscopic Bronchial ultrasound and Endoscopic ultrasound guided Fine Needle Aspirate biopsies. Surgical pathology also attends to a large number of CT guided biopsies. The most urgent reason for difficulty in attracting laboratory staff is location together with salary. Auckland is an expensive city to live in and lab staff are moving out to regional laboratories. As evidenced by our recent response to vacant posts, the Department had to employ junior staff that need intense training. This equates to releasing a senior scientist to train and up-skill the juniors, which in the short term, results in staff shortage and backlog in work flow. It is hoped that in time, there will be adequate resourcing for scientific laboratory staff with enough skills to run an efficient, high quality laboratory.

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Scorecard - Surgical and Ambulatory and Elective Surgical Centre

Actual Target Trend Elective Volumes Actual Target Trend

Shorter Waits in ED 95% 95% q Provider Arm - Overall 100% 100% p

Surgical and Ambulatory Services 86% 100% q

Elective Surgical Centre - ESC (YTD) 95% 100%

Elective Surgical Centre - ESC (month) 97% 100% q

Waiting Times

Patient Experience Actual Target Trend % of CT scans done within 6 weeks 74% 95% p

Complaint Average Response Time 19 days ≤14 days q % of MRI scans done within 6 weeks 81% 90% p

b. Complaint Average Response Time - ESC 7 days ≤14 days % of US scans done within 6 weeks 76% 75% q

Net Promoter Score FFT - S&A 76 65 p

Patient Flow

Improving Outcomes Outpatient DNA rate (S&A) 8% ≤10% q

Better help for smokers to quit - hospitalised 99% 95% q Theatre utilisation - NSH 91% 85% p

a. #NOF patients to theatre w/in 48 hrs 100% 85% Theatre utilisation - WTH 85% 85% p

Skin Abscess - median LOS hrs 29 ≤24 p Theatre utilisation - ESC 89% 85% q

Laproscopic Cholecystectomy - median LOS hrs 113 ≤48 p Patients with EDS on discharge 90% 85% q

Laparoscopic Appendicectomy - median LOS hrs 45 ≤36 q Average Length of Stay - Acutes ####

Average Length of Stay - Electives ####

Quality & Safety Average Length of Stay - Electives - ESC ####


Occasions insertion bundle used 100% 95%

Good hand hygiene practice 90% 80%

ICU - rate of CLAB per 1000 line days 0.66 ≤1 p Financial Result (YTD) Actual Target Trend

Revenue 8,463 k 7,568 k q

HR/Staff Experience Expense 191,790 k 189,919 k q

Sick leave rate 3% ≤3.4% Net Surplus/Deficit -183,327 k -182,350 k q

Sick leave rate - ESC 4.9% ≤3.4% q Capital Expenditure (% Annual budget) #N/A

Turnover rate - external 10% ≤14% Contracts (YTD)

Turnover rate ESC - external 7% ≤14% p Elective WIES Volumes - S&A 6,461 8,028 q

Vacancies - % 6% ≤8% p Elective WIES Volumes - ESC 5,788 6,068 p

Acute WIES Volumes - S&A 13,436 14,073 q





b. Sep 17 data - no complaints since

Contact:




Surgical and Ambulatory Service / Elective Surgery CentreMay 2019

2018/19





a. Apr 19, coding dependent

Health Targets

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Scorecard Variance Report Complaint Average Response Time – 19 days against a target of ≤14 days The average days to close complaints in May was impacted by:

Multiple complex complaints for General Surgery requiring clinical and surgical dates booking to effectively resolve them,

Skin Abscess Median LoS – 29 hours against a target of ≤24 hours Laparoscopic Cholecystectomy Median LoS – 113 hours against a target of ≤48 hours Laparoscopic Appendicectomy Median LoS – 45 hours against a target of ≤36 hours a) Abscess Pathway: abscess drainage for acute ASA 1 and 2 (low risk) patients. Aim: LoS ≤ 24

hours

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(i) Baseline patients (between 7 May 2019 to 6 June 2019): patients with an acute abscess treated via traditional pathway, Median LoS = 31 hours.

(ii) Abscess Pathway (Minor Procedures List in the Procedure Room): a total of 21 abscess

patients have had surgery via Minor Procedures List between 7 May 2019 to 6 June 2019 (these include the 17 inpatients, two acute arranged patients and two fast track patients). The Median LoS = 28 hours

a. Two patients treated via the abscess pathway (Minor Procedures List) were treated as

acute arranged (seen in ED, discharged home and returned for day case surgery). Median LoS = 7 hours

b. Two patients treated via the abscess pathway (Minor Procedures List) were treated as fast track patients (surgery on day of admission). Median LoS = 11 hours

c. Seventeen patients treated via the abscess pathway (Minor Procedures List) were treated as procedure room inpatients (admitted as inpatients, surgery done in procedure room). Median LoS = 40 hours

d. Overall, all acute ASA 1 and 2 patients for abscess drainage had a Median LoS of 27.4 hours when filtered for May 2019.

(i)

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Comments:

The number of patients that went through the acute arranged or fast tracked pathway has decreased when compared to previous months.

Surgical registrars changed over on June 10th and further work required for orientating the Minor Procedures List.

Between 7 May 2019 to 6 June 2019, 10 Minor Procedures List were scheduled of which three lists were cancelled due to staffing shortages or reprioritisation of the procedure room.

Appendicitis Pathway for acute ASA 1 and 2 (low risk) patients. Aim: LoS ≤ 36 hours

Median LoS for ASA 1 and 2 patients along appendicitis pathway during April 2019 is 42.8 hours

Comments:

Improvement work currently is centred in sustaining criteria led discharges (CLD)

Work in place reviewing online content for nursing CLD competency assessment

High level plan in place for CLD to be incorporated into orientation for all surgical nurses.

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Cholecystitis (inflamed gallbladder) Pathway for acute ASA 1 and 2 (low risk) patients. Aim: LoS ≤ 48 hours

Median LoS for ASA 1 and 2 patients on the cholecystitis pathway during April 2019 is 100.1 hours.

Comments: Focused gallbladder ultrasound scans continue to be monitored. The training content and diagnostic worksheet has been modified after review of the first 20 scans. The group will continue to review scans until the group is satisfied with the quality of bedside scans and consistency between bedside and formal scan before initiating audit.

Sick leave rate ESC – 4.9% against a target of ≤3.4% The Clinical Nurse Manager of the Cullen Ward has completed a number of sick leave review meetings and providing support to staff as required. Service Delivery

S&A – 86% against a target of 100%

Percentage against target

Jul 18

Aug 18

Sept 18

Oct 18

Nov 18

Dec 18

Jan 19

Feb 19

Mar 19

Apr 19

May 19

S&A Volumes (YTD) 80% 76% 76% 80% 83% 86% 86% 85% 86% 87% 86%

ESC Volumes (Month)

85% 92% 83% 98% 97% 76% 98% 96% 100% 100% 95%

ESC Volumes (YTD) 85% 90% 88% 91% 93% 91% 92% 92% 94% 95% 97%

As noted in the table above there has been a steady improvement in the YTD performance for ESC. The overall YTD S&A volumes are steady. However, the winter impact continues to be a challenge to mitigate along with the reduction in elective orthopaedic lists to manage acute demand, SMO vacancy/unplanned leave and industrial action. % of CT scans done within six weeks – 74% against a target of 95% CT continues to make gradual improvements. The arrival of the new NSH CT scanner will provide increased capacity and allow for streaming of acute and elective workflows to improve efficiency. Technician staffing remains a constraint, an issue that affects the region.

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% of MRI scans done within six weeks – 81% against a target of 90% MRI continues to make improvements that exceed previous forecasts. Continuation of this positive trend will see a return to compliance before November 2019.

Month end CT MRI

May 2019 71% 72%

June 2019 72% 78%

July 2019 74% 86%

August 2019 74% 89%

September 2019 76% 91%

October 2019 79%

November 2019 82%

December 2019 85%

January 2020 88%

February 2020 91%

March 2020 95%

Forecast improvement against MoH targets for CT and MRI. Value for Money Elective WIES Volumes – S&A – 6,461 against a target of 8,028 The elective WIES volumes for S&A are approximately 15% below target across the four sub-specialties; ORL, Urology, General Surgery and Orthopaedics. There are a number of contributing factors that have impacted on the elective program and the shortfall in actual WIES performance against target: • NZNO strike • Continuing RDA strikes • Acute winter workload • Surgeon resignations • Surgeon availability/locums • Surgeon illness/special leave/sabbatical • Acute volumes impacting on electives • Mix of elective cases due to the factors above.


Access to Elective Services

1. Implement perioperative nurse-led coordination and management of all procedure/theatre bookings for Elective Services, including improved coordination of patient flow with clinical guidance and oversight. This will include management of high acuity, high complexity patients, in support of better access to earlier intervention for Māori and Pacific populations (EOA) – June 2019


1. There are now four Perioperative nurse coordinator (PNC) leads for the following sub-specialties: Orthopaedics, Urology, ORL and Gynaecology. Whilst supporting the management of high acuity and high complexity patients is underway and a core component of the role, more work needs to be done to provide of better access to earlier intervention for Māori and Pacific populations.

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Financial Results - Surgical and Ambulatory and Elective Surgical Centre Combined

($000’s)



Other Income 95 81 13 746 750 (4) 831

Total Revenue 746 706 40 8,463 7,568 895 8,274

EXPENDITURE

Personnel

Medical 5,796 5,359 (437) 63,250 62,404 (846) 67,922

Nursing 4,345 4,202 (143) 43,087 42,895 (192) 48,647

Allied Health 1,334 1,286 (49) 14,990 14,535 (455) 15,794

Support 189 212 23 2,248 2,488 240 2,701


Outsourced Personnel 726 622 (104) 7,014 6,418 (596) 6,952

12,926 12,198 (728) 136,602 134,730 (1,872) 148,524

Other Expenditure

Outsourced Services 806 712 (94) 7,025 6,957 (67) 7,588

Clinical Supplies 4,184 4,275 91 43,819 44,305 487 48,254


5,400 5,322 (78) 55,187 55,189 1 60,108


Cost Net of Other Revenue (17,580) (16,814) (767) (183,327) (182,350) (976) (200,357)* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.



S&A and ESC Combined - May 2019

Comment on major financial variances The overall result for S&A and ESC was $767k unfavourable for May and $976k unfavourable for the YTD. S&A continued to track close to budget YTD, less than 1% variance. Overall, the service has benefited financially from additional revenue from orthopaedic ACC cases and SLA income from other DHBs. On the cost side, lower volumes due to the impact of industrial action and acute bed encroachment from medical services earlier in the year, as well as lower than planned production, has had a positive impact on personnel costs and clinical supply costs. Offsetting these benefits there were additional costs incurred with over-allocations of registrars, locums to cover vacancies, skin lesion outsourcing and unplanned repairs and maintenance costs. There are also unbudgeted outsourced costs to meet Interventional Radiology demands that exceed internal capacity. ESC was favourable YTD. This was driven by lower than budgeted package of care costs, encroachment on ESC beds by NSH patients during the winter acute spike as well as the additional week of closure over the Christmas period. Refer to below commentary for a detailed overview for S&A and ESC performance against budget.

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Surgical and Ambulatory – S&A

($000’s)



Other Income 95 81 13 746 750 (4) 831

Total Revenue 746 706 40 8,463 7,568 895 8,274

EXPENDITURE

Personnel

Medical 5,793 5,357 (436) 63,222 62,382 (840) 67,897

Nursing 3,813 3,687 (126) 37,741 37,522 (219) 42,559

Allied Health 1,334 1,285 (49) 14,990 14,532 (458) 15,790

Support 181 204 23 2,164 2,401 236 2,606


Outsourced Personnel (220) (300) (80) (1,878) (2,722) (844) (2,967)

11,421 10,735 (686) 122,097 119,936 (2,161) 132,210

Other Expenditure

Outsourced Services 783 693 (90) 6,775 6,745 (31) 7,356

Clinical Supplies 3,149 3,254 106 34,076 34,738 662 37,824


4,261 4,198 (63) 44,383 44,492 109 48,445





S&A - May 2019

Comment on major financial variances The overall result for S&A was $709k unfavourable for May and $1,157k unfavourable for the YTD. Revenue ($40k favourable for May, $895k favourable YTD) The favourable variance for May was due to the unbudgeted revenue streams from services provided to other DHBs and catch up on audiology revenue of $82k. The YTD favourable variance includes a $179k upside in ACC revenue with another significant benefit of $388k for the provision of theatres and staff to Auckland DHB Ophthalmology and Auckland DHB Dental at WTH. The balance was due to the additional SLA revenue from other DHBs. Expenditure ($749k unfavourable for May, $2,052k unfavourable YTD) The result for May was above budget in the key personnel categories but other expenditure was in line with budget. The YTD unfavourable Personnel variance was due to RMO costs and the use of locums and bureau nurses to cover vacancies. Personnel ($2,161k unfavourable YTD) Medical ($840k unfavourable YTD) The unfavourable variance was due to higher than budget RMO mix in the current run, as well as the RMO over-allocations in General Surgery, and in ICU for the first six months. There were higher than budgeted SMO costs in Orthopaedics and General Surgery which were partly offset by vacancies in ORL, Anaesthesia and Radiology. The last NZRDA strike was a part of the Medical variance for May.

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Nursing ($219k unfavourable YTD) Ongoing favourable variances that arose due to the NZNO strike in July and ongoing vacancies for senior nurses and registered nurses created were offset by increased costs in enrolled nurses $217k and internal bureau nurses, $888k. Ongoing difficulty in recruiting to HCA vacancies across the surgical wards has resulted in a below budget spend of $620k. Allied Health ($458k unfavourable YTD) The unfavourable variance continued due to expected vacancy impacts. Support and Management/Administration ($201k favourable YTD) The favourable variance was due to vacancies in Sterile Supply for which recruitment is an ongoing issue. Outsourced Personnel ($844k unfavourable YTD) The unfavourable variance was due to the lower than budgeted SMO package of care recharges from S&A to ESC arising from lower elective volumes at ESC and the use of locums in Anaesthesia and Surgical Services and for one month in Advanced Interventional Radiology. External bureau nurse expenditure in theatres and wards to cover vacancies, unplanned leave and sick leave also contributed to the unfavourable variance. Other Expenditure ($109k favourable YTD) Outsourced Services ($31k unfavourable YTD) Outsourced services are in line with budget YTD. There continued to be a positive variance against budget from Radiology for the outsourcing of MRI and Ultrasound scans, although this was offset in part by the need to outsource Advanced Interventional radiology procedures due to limited internal capacity. The demand for outsourced skin lesion surgeries continued to be significantly higher than expected, $227k above budget. Clinical Supplies ($662k favourable YTD) The YTD positive variance was due to a number of key factors. The outsourcing of Radiology procedures has reduced the need for the related clinical supplies. The impact of the strikes, acute orthopaedic demand and medical bed encroachment has impacted the theatre production plan which has created a positive variance in implants and prostheses. Infrastructure and Non-Clinical Supplies ($522k unfavourable YTD) The YTD variance was due to unrealised expenditure reduction initiatives, not expected to be recovered this year.

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Elective Surgical Centre - ESC

($000’s)


REVENUE* Government and Crown Agency 0 0 0 0 0 0 0

Other Income 0 0 0 0 0 0 0

Total Revenue 0 0 0 0 0 0 0

EXPENDITURE

Personnel

Medical 2 2 (0) 28 23 (5) 25

Nursing 532 515 (17) 5,346 5,373 27 6,089

Allied Health 0 0 (0) 0 4 3 4

Support 8 8 (1) 84 87 3 95

Management / Administration 15 15 (1) 156 168 11 182

Outsourced Personnel 947 923 (24) 8,891 9,139 248 9,919

1,505 1,463 (43) 14,505 14,794 288 16,314

Other Expenditure

Outsourced Services 24 19 (4) 249 213 (36) 232

Clinical Supplies 1,035 1,021 (14) 9,743 9,567 (176) 10,430

Infrastructure & Non-Clinical Supplies 80 84 4 812 916 104 1,000

1,139 1,124 (15) 10,804 10,696 (108) 11,662

Total Expenditure 2,644 2,586 (58) 25,309 25,490 180 27,976

Cost Net of Other Revenue (2,644) (2,586) (58) (25,309) (25,490) 180 (27,976)* Government and Crown Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue.



ESC - May 2019

Comment on major financial variances The overall result for ESC was $58k unfavourable for May and $180k favourable for the YTD. Three factors reduced the capacity to deliver to plan: industrial action, acute bed encroachment at NSH impacting ESC, and the holiday closure. This resulted in lower personnel costs. Personnel ($288k favourable YTD) Nursing ($27k favourable YTD) In addition to the reasons mentioned above, vacancies in the Cullen Ward during the year contributed to the favourable variance. Outsourced Personnel ($248k favourable YTD) The favourable variance was due to the lower than budgeted package of care charges from SMOs and Anaesthesia recharges from S&A to ESC, both arising from lower elective volumes.

Other Expenditure ($108k unfavourable YTD) Outsourced Services ($36k unfavourable YTD) The unfavourable variance was due to higher than budgeted volumes outsourced to Auckland Breast Centre Services.

Clinical Supplies ($176k unfavourable YTD)

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The case mix of procedures at ESC has resulted in a higher spend on implants/prostheses, laparoscopic equipment as well as monitoring equipment costs. YTD ESC did more knee procedures than the production plan. There are also unbudgeted costs relating to repairs and maintenance and minor equipment. Infrastructure and Non-Clinical Supplies ($104k favourable YTD) The favourable variance was due to savings in Laundry offset by higher patient meal costs.

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Diagnostic Services

Service Overview This division is responsible for the provision of Pharmacy, Laboratories and Radiology. The service is managed by Dr Jonathan Wallace General Manager and Head of Division. The Operation Managers and Clinical Directors are Marilyn Crawley for Pharmacy, Lee-Ann Weiss and Dr Matt Rogers (Clinical Director) for Laboratories and Wilhelmina Mentz and Dr Hament Pandya (Clinical Director) for Radiology.

Highlight of the Month

Successful Compressed SENSE trial in Radiology Compressed SENSE is a new software technique that dramatically increases MRI image processing speed and reduces scanning time. We have been trialling this software from 6 May 2019. Results have been impressive, with reduced scanning times and improved patient experience. A final report will be issued shortly. We expect to recommend adopting this software permanently, which will effectively increase the scanning capacity of existing MRI machines.

Key Issue

Radiology demand management: Choosing Wisely Work is underway to implement appropriate Choosing Wisely guidelines for radiology in the hospital setting. This will ensure more consistent application of best practice algorithms for deciding whether to perform diagnostic imaging. This is expected to have an impact on reducing demand growth. We aim to implement these guidelines via our electronic eOrders system, which will integrate scores and calculators to guide clinicians when ordering scans. Areas for improvement include abdominal X-rays and CT head scans for trauma in the ED. Progress will be monitored using our Radiology Explorer in Qlik Sense.

Screenshot of Qlik Radiology Explorer

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Clinical Support Services

Service Overview This division is responsible for the provision of Clinical Support Services Division includes Food Services, Security, Traffic and Fleet , Clinical Engineering, Clinical Support Services, Contact Centre Collaboration. The service is managed by Dr Jonathan Wallace General Manager and Head of Division. The Operation Managers are Barbara Schwalger for Clinical Support Services, Bill MacDougall for Clinical Engineering, Chris Webb for Security, Traffic and Fleet , Teresa Stanbrook for Food Services and Matthew O’Connor for Contact Centre.

Highlight of the Month

Commendations for security and traffic team members from public and staff Over the past few months we have received numerous notes of recognition for our security and traffic staff. Both of these teams can operate in challenging circumstances. Common in the recognition was an appreciation of the professionalism shown, reflecting a strong team culture.

Key Issue

ECIB consultations The Division is participating in the consultation process underway to discuss the operational aspects of the new ECIB building. Key topics for discussion are the food service model, orderly and cleaning support and workflow, and clinical engineering requirements for equipment support and maintenance.

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4.1 Clinical Leaders’ Report

Recommendation:

That the report be received. Prepared by: Dr Andrew Brant (Chief Medical Officer and Deputy Chief Executive Officer), Dr Jocelyn Peach (Director of Nursing and Midwifery; Emergency Systems Planner), and Tamzin Brott (Director of Allied Health, Scientific and Technical Professions)

Medical Staff Accreditation of Waitematā DHB for prevocational medical training The Medical Council of New Zealand (MCNZ) considered our accreditation report (dated April 2019) at its meeting held on 11 and 12 June 2019. The Council determined that Waitematā DHB be accredited for the remaining balance of its accreditation period to 31 December 2021, with no further reporting requirements. The Council’s decision was that it was satisfied Waitematā DHB has met the outstanding required actions on its accreditation. Royal Australasian College of Physicians (RACP) Basic Training Accreditation report The formal RACP Accreditation report for Medicine was received during the March 2019 visit. Waitematā DHB gained the maximum possible accreditation of five years duration for North Shore Hospital, which was also achieved for Waitakere Hospital last year. RACP Clinical Examination Results Waitematā DHB had 23 individuals sit for this examination with an overall pass rate of 19/23 (or 83%). This is higher than that the NZ pass rate. Quality and Risks The Quality and Risk team continues to focus on the development and delivery of training. The Lead Investigator training sessions have now commenced and have been well received. The Northern Region has previously identified a gap with regard to practical Adverse Event Investigation training. In order to share the Waitematā DHB training tools, colleagues from Auckland DHB, Northland DHB and Counties Manukau Health Quality Teams were invited to attend the session on 16th July 2019. All DHBs took up this offer and sent two delegates each. The vacancies within the Quality and Patient Safety Leads Team have now been successfully recruited. The final new staff member is due to join the team at the end of August 2019. This means that all Divisions will have a dedicated and permanent Quality and Patient Safety Lead to support them. Work has commenced on the project to upgrade the current incident reporting system (Risk MonitorPro), which will become unsupported in January 2020. As both Waitematā DHB and Counties Manukau Health need to upgrade their systems we are working jointly on the upgrade project to realise any possible time and cost benefits.

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Registrar Orientation Registrar orientation took place in June, attendance was difficult to achieve, but those who attended found the sessions useful. Lumber punctures, chest drains, joint aspiration, paracentesis and rectal examination skills sessions were delivered. Other sessions included an overview of Gen Med and introductions to the Med Specialties.

Skills sessions during Registrar orientation

Medication safety Prescribing and therapeutics teaching is integrated across all medical student and prevocational programmes. This includes formal workshop and clinical pharmacist attachments. The feedback shows that 100% of respondents have improved confidence in prescribing on a paper chart and 80% of respondents reporting improved knowledge of how to avoid making medication errors. An abstract for a poster has been submitted at the 2019 prevocational education forum in Canberra.

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Community Based Attachments (CBAs) Director HR, Clinical Education and Training Unit (CETU) and Northern Regional Alliance (NRA) are working with Mental Health Services and the Health Outcomes Team to develop additional CBAs. We hope to have nine of the required fifteen CBAs in place by November 2019, leaving six remaining CBAs required to meet the 2020 MCNZ target. RMOs in Clinical Governance Naomi Heap and Dr Jonathan Wallace continue to run the RMO in Clinical Governance (CG) programme. Three RMOs are ongoing with their projects in the second quarter (Feb 2019 – May 2019). Three RMOs have been allocated for the third quarter. NRA has been advised of issues with RMOs being rostered to ward duties on project days. The programme will move to Wednesdays as of the fourth quarter to facilitate rostering. Projects this quarter: Dr Agatha Kim and Dr Andrew Pan – Auckland audit Dr Michael Hutchinson (working with George Shand) – Integrating Clinical Governance into the PGY1 house officer programme Medical Education Fellows Two of the current medical Education Fellows have applied to enrol in General Practitioner Education Program (GPEP) which will commence in December if their applications are successful. Continuance of these roles will need to be considered given that recruitment will need to align to the NRA led RMO recruitment to enable interested candidates to apply, before they apply for and accept registrar positions. The following is an overview of the work currently being undertaken by the Medical Education Fellows:

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Key projects for Dr Ellen Miller • Delivers Medical Students and Trainee Intern (TI) teaching

• Peer mentoring programme

• Student remediation and pastoral care

• Co-investigator in the Wellbeing@work research

• Implementing compassion rounds (Schwartz Rounds) for medical students

• Co-investigator research on Pharmacist led teaching for first year clinical students

• Co-investigator research on the benefits of multidisciplinary prescribing training for final year

medical students

• Interviewed for GP training scheme.

Key projects for Dr George Shand: • Delivers PGY1 formal teaching

• Waitematā lead for electronic Death Documents – designed two guides that are now included

in the death packs

• Provided educational sessions to assist in the NZ Early Warning Score (NZEWS) roll-out

• Working with Rosie Andrickson and i3 to transition Clinical Decision Support (CeDS) onto smart

phones

• Undertaking a Certificate in Clinical Education at the University of Auckland

• Undertaking the NHS Quality Improvement Learning programme

• Assisting in a multi-centre research project looking into doctors’ understanding and trust in

artificial intelligence. Survey sent out 7th May.

• Working to establish ‘teach the teacher’ sessions in House Officer orientation

• Advocating for the purchase of a linear ultrasound probe by the medical department

• Assisting with the RMOs in Clinical Governance programme

• Investigating opportunities for virtual reality in PGY1 teaching.

Key projects for DR Kate Richardson: • Delivers PGY2 programme

• Leading discussions about wellbeing enhancement for PGY1/2s

• Integrating patient experience and co-design into PGY2 programme

• Working with Vanessa Duthie to run the Awi Ora Maori House Officer support programme

• Has been accepted in the Master of Health Leadership postgraduate course offered through

The University of Auckland (to be completed part-time).

• Interviewed for GP training scheme.

Laparoscopic training resources Entry level Laparoscopic training is being set up and will be held at Whenua Pupuke. The LapSim equipment and teaching tasks are being developed and will be used for the first time in July. Capex has been approved for LapSim training boxes, all items have been ordered and the skills training tasks have been made. This is work done in collaboration with Tracey Purdy from the Elective Surgery Centre. This training equipment connects to work being done by Obstetrics and Gynaecology (O&G) to set up advanced training equipment for LapSim and a surgical mesh project that is being developed by i3.

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Nursing and Midwifery and Emergency Planning Systems Nurses, Midwives and Health Care Assistants account for 43% of the total DHB workforce. Pressure Injury Prevention Management [PIPM]: Two nurses (0.6 for North Shore and 0.4 for Waitakere) have been seconded to participate in the PIPM programme. A plan for their work has been agreed. Work is underway to ensure that patients are followed up to improve assessment, ensure care planning and reduce incidence. There is heightened frontline awareness and vigilance of pressure injury identification and initiation of prevention/treatment. Reporting of progress against targets is currently presented in the Quality report to this committee. Workforce planning, professional development and recognition for the future service needs Recruitment of new graduate nurses for the September intake has been challenging. At present there are 11 positions still to fill, which may be resolved when the national pool opens. Other District Health Boards are in a similar position. The national Directors of Nursing group are working on a framework to better understand the national supply of nurses and coordinate initiatives with the various agencies to achieve consistent supply and influence the preparation of the workforce of the future. Twenty-four nurses were acknowledged at RN Level 4 expert from the April 2019 Professional Development and Recognition Panel process. The contribution these nurses make to improve clinical practice and patient safety is worth noting. While their work is hidden within their teams, they are demonstrating clinical leadership at its best. Initiatives to support safe staffing and healthy workplaces Work continues to implement the requirements of the Care Capacity and Demand Management (CCDM) programme. As reported previously there are three streams of work: General medical, surgical and child health with New Zealand Nurses Organisation (NZNO) which is achieving in all components. Work will start in August with midwives and Midwifery Employee Representation and Advisory Service (MERAS) and nursing and allied health with the Public Service Association (PSA). Waitematā DHB is achieving all milestones according to the agreed plan with the Safe Staffing Healthy Workplace executive and the Ministry of Health. The Trendcare database upgrade has been delayed and we plan to complete this essential requirement within the month. Emergency Systems Planning Plan updates for community sites are being progressed, including learning from recent contained incidents. Preparation is underway for future external audit requirements to assure the readiness of the systems and processes for response. This includes review of contingency plans that will be essential with the planned building programmes over future months.

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Allied Health, Scientific and Technical Professions Forty-two (42) professions, accounting for 24% of the Waitematā DHB workforce. Everyone Matters, With Compassion, Connected and Better, Best, Brilliant Friends and Family Test – Allied Health – June 2019

Comments received in June 2019 include:

“It has given me a new lease of life. I was struggling to walk 50m, now I can walk half an hour,

visit parks etc with walker and 02. I found them all (people) extremely good in helping me.”

“The support offered to make me stay in the apartment and not having to move to a Rest Home.”

“Very happy to have been included on an 8-week exercise programme for pulmonary rehab. Has

taught me a good ex regime and has been good to experience this with a group. All the

therapists are great, friendly and very informative.”

“Physio ‘S’ is very professional and follows through very empathetic and is an asset to the team.”

“Excellent exercises from very friendly and competent professionals.”

“Very helpful and staff very caring.”

“Fantastic treatment as an in-patient and outpatient.”

Recruitment and retention of Māori and Pacifica workforce Four allied health professions (Oral Health, Dietetics, Occupational Therapy and Physiotherapy) are in focus, with work plans in place locally, regionally and nationally in order to recruit and retain Māori and Pacifica clinicians reflecting the communities we serve. We continue to connect undergraduate students who identify as Māori and Pacifica to the Waitematā DHB scholarship programme and the cultural and peer support that we offer them throughout their undergraduate programme, and beyond as new graduates. Current Māori and Pacifica staff across those priority professions and staff required to reflect the working population as at June 2019 are:

MALT PRIORITY AH PROFESSIONS May 2019

Maori in current

workforce*

% of Maori in current workforce

Number of Maori to

reflect working

population

Additional Maori

required

Recruited last 12

months

Terminated last 12

months

Oral Health Therapist 17 10.18% 15 0 3 -5

Dietitian 2 4.00% 5 3 0 -3

Occupational Therapist 3 1.92% 14 11 1 -4

Physiotherapist 7 6.14% 10 3 4 -1

Total AH Priority Professions

29 5.95% 44 15 8 -13

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PALT PRIORITY AH PROFESSIONS May 2019

Pacific in current

workforce*

% of Pacific in current

workforce

Number of Pacific to

reflect working

population

Additional Pacific

required

Recruited last 12

months

Terminated last 12

months

Oral Health Therapist 14 8.38% 12 0 2 -1

Dietitian 0 0.00% 4 4 0 0

Occupational Therapist 3 1.92% 11 8 1 0

Physiotherapist 4 3.51% 8 4 0 -3

Total AH Priority Professions

21 4.31% 35 14 3 -4

Reasons for leaving Waitematā DHB, across all allied health scientific and technical professions for Māori and Pacifica, continues to be to leave the district, leaving for personal reasons and leaving to go to another job in public health. On-going work is being undertaken to more fully understand those that choose not to disclose why they are leaving via choosing personal reasons, including offering exit interviews with the Director of Allied Health Scientific and Technical Professions. Get up, Get dressed, Get moving (#EndPJparalysis, #last1000days) As part of this year’s international #EndPJparalysis social movement campaign, which is about encouraging patients to get up, dressed and moving to reduce the risk of deconditioning while in hospital, we arranged resources, led a number of events and took part in an online Global Summit. The following is an outline of key events led by Waitematā DHB. Master Class and Grand Round - Make patient time the most important currency in healthcare. We were thrilled to host Professor Brian Dolan (OBE, FRSA, MSc(Oxon), MSc(Nurs), RMN, RGN), founder of the #EndPJparalysis and #Last1000days social movements on 2 July 2019. With a psychiatric and emergency care nursing background, as well as academic general practice, Brian currently holds the role of Director of Health Service 360 UK and Director of Service Improvement at Canterbury DHB. Alongside these roles Brian provides leadership programs, coaching and consulting on improving patient flow and whole of systems improvement in New Zealand, Australia and the United Kingdom. Brian has published over 70 papers, and is the author/editor of seven books. Brian is a Fellow of the Royal Society of Arts, an Honorary Professor of Leadership in Healthcare at the University of Salford, and is Visiting Professor of Nursing at the Oxford Institute of Nursing, Midwifery and Allied Health Research. In June last year, Brian was voted one of the 20 most influential people in the 70-year history of the NHS, and in the 2019 Queen’s New Year’s Honours List, Brian was awarded an OBE in ‘For Services to Nursing and Emergency Care’. Sixty people across multiple professions (allied health, nursing, medicine) attended a three-hour Master Class with Brian on 2 July 2019, with a focus on making patient time the most important currency in healthcare. Key aspects of the Master Class were:

Why time is the key currency in healthcare.

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Taking responsibility for things you can influence.

Red2Green Days and making it SAFER (Senior review, All patients have an expected date of discharge, Flow of patients, Early discharge, Review).

Taking action on patient time.

Following the Master Class, Brian presented at Grand Round in Whenua Pupuke, with an almost full house and 45 off-site groups around New Zealand linking in via videoconferencing and zoom including all remaining 19 DHBs, the Chief Allied Health Professions Office at the Ministry of Health, Northern Regional Alliance, Royal District Nursing Service, St Johns Ambulance, Waitakere Health Link MetLife Care, Harbour Sport, Laura Fergusson Rehabilitation and ABI Rehabilitation. The Grand Round was a consolidated version of the Master Class, touching on key points, linking how valuing patient’s time leads to sustainable, evidence based change, and better patient outcomes including reduction in deconditioning, falls and pressure injuries and length of stay.

Independence Day! - Get up, Get dressed, Get moving On 4 July 2019 at North Shore Hospital we joined our national colleagues celebrating Independence Day, promoting our 3G programme, get up, get dressed, get moving (#getupgetdressedgetmoving) in the main foyer. The same celebrations occurred in Rodney the day prior and at Waitakere Hospital on 5 July 2019. As the lead #EndPJparalysis DHB we produced, with assistance from our communications

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team, some amazing resources (https://www.waitematadhb.govt.nz/news/posts/endpjparalysis/), including patient information sheets in Maori, Korean and Chinese and meal tray mats reminding people to stay active, which were shared nationally (and internationally) to encourage other DHBs to take part. We had an amazing response to the campaign with staff, patients and visitors taking part in quizzes and using photo frames to share the message via multiple social media platforms.

Global Summit – Waitematā DHB representing New Zealand on the global stage! On 10 July 2019 the #EndPJparalysis team, Sharon Russell (Professional and Clinical Leader Physiotherapy), Elaine Docherty (Gerontology Nurse Specialist) and Renee Kong (Project Manager, i3 - Institute for Innovation and Improvement), presented the Waitematā DHB journey, “Using Social Movement: The 3G Programme” as part of the 72 hour virtual Global #EndPJparalysis Summit, representing Waitematā DHB and New Zealand on the global stage. The virtual summit followed time zones around the world, starting in New Zealand at 1100hrs on 10 July 2019, then moving to Australia, England, Ireland, Wales, Netherlands, Canada and the United States of America before rotating back to the southern hemisphere for a final round of the world before ending 1100hrs 13 July 2019. We were privileged to be presenting alongside esteemed colleagues from Johns Hopkins Medicine, Cleveland Clinic, Mayo Clinic, Alfred Health, and Alberta Health Services among others.

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https://www.waitematadhb.govt.nz/news/posts/endpjparalysis/


(Professional and Clinical Leader Physiotherapy), Elaine Docherty (Gerontology Nurse Specialist), Tamzin Brott (Director Allied Health Scientific and Technical Professions), Professor Brian Dolan (OBE), and Renee Kong (Project Manager, i3 - Institute for Innovation and Improvement)

Regional Vulnerable Adults Study Day On 10 June 2019 Waitematā DHB hosted our first Vulnerable Adults study day for any staff working with Vulnerable Adults from the metro DHBs and staff from the community. Convened by Petra Fowler (Waitematā DHB Vulnerable Adults Coordinator), over 100 participants attended the training covering topics such as, legal implication of the Crimes Amendment Act, the role of the Banking Ombudsman when dealing with financial abuse, Capacity Assessments among others. Guest speakers included Sandra Mechen (Legal Advisor) and Dr Alan Jenner on behalf of Waitematā DHB. We were honored to host Nicola Sladden (Banking Ombudsman) and Tina Mitchell (Deputy Banking Ombudsman) to share with us how their roles can assist when dealing with financial abuse, scams and banks. Senior Sergeant Wendy Pickering (New Zealand Police) informed us on the positive changes the new Whāngaia Ngā Pā Harakeke (http://www.mt.org.nz/find-help/whangaia-nga-pa-harakeke/) police approach to family harm is creating, while Joseph Jang (Elder Abuse and Neglect Prevention Service Social Worker Age Concern) gave a very informative presentation on the role of Power of Attorney when dealing with finances. Cathy Leigh and Sizani Ngonyamo from Home-based Care Service provider Vision West informed us about the experiences of caregivers when dealing with Vulnerable Adults.

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http://www.mt.org.nz/find-help/whangaia-nga-pa-harakeke/

http://www.mt.org.nz/find-help/whangaia-nga-pa-harakeke/


Feedback was extremely positive, with all presenters being very much appreciated by the attendees, and many requests to repeat the study day next year. Focus on leadership - growing our own – Allied Health Leadership Workshop with Dr Rosalie Boyce Earlier in the year we collaborated with our metro DHB colleagues, holding workshops and master classes with current and emerging allied health leaders lead by Dr Rosalie Boyce. Rosalie is internationally recognised for her expertise in allied health management and leadership, with her PhD in health services management focused on a comparative study of different models of organising allied health services in complex health care settings. Alongside her PhD, Rosalie holds an additional four university degrees, has authored over 100 papers in academic and professional outlets and is a Fellow of the Australasian College of Health Service Management. In 2016 Rosalie was awarded the International Allied Health Award for Excellence by the International Chief Health Professions Officers (ICHPO) network for outstanding lifetime contribution to international allied health development and in the following year, 2017, awarded Australia’s inaugural National Allied Health Inspiration Award. The workshop explored how traditional professional agendas can be repurposed into strategic agendas that add value to allied health’s contribution. Content included:

Current thinking on allied health governance models.

Allied Health leadership in a matrix and divisional stream structures.

Leadership communication styles for impact and outcomes.

Strengthening allied health’s service identity as a value-adding strategy.

Allied health pathways to leadership. Across the three metro DHBs 24 current leaders attended two Master Classes, and 120 current and emerging leaders attended two workshops with representation from Waitematā from a wide range of services (Auckland Regional Dental Service (ARDS), Child Development, Adult Physical Health, Mental Health and Corporate Services) and professions/roles (occupational therapy, physiotherapy, speech-language therapy, dietetics, social work, oral health therapists, alcohol and drug clinicians, psychologists, clinical leaders, professional leaders and team leaders). Feedback was extremely positive and a local community of practice has been set up to continue to consolidate the learnings across the DHB.

94


4.2 Quality Report (May and June 2019)

Recommendation:

That the report be received.

Prepared by: Dr Penny Andrew (Clinical Lead, Quality), Stacey Hurrell (Corporate Compliance Manager) and David Price (Director of Patient Experience)

Contents 1. Health Quality and Safety Markers

2. HQSC QSM Dashboard

3. DHB Quality Indicator Trends –October 2018

4. Key Quality Indicators

5. Improvement Active Projects Report

6. Safe Care

7. Patient and Whānau Centred Care

95


Acronyms

Acronym Definition Acronym Definition

ADU Assessment and Diagnostic Unit KPI Key Performance Indicator

AMS Antimicrobial Stewardship LOS Length of Stay

CAUTI Catheter Associated Urinary Tract Infection

MACE Major Adverse Cardiac Events

CDI (C.diff)

Clostridium difficile (C.difficile) infection

MALT Maori Alliance Leadership Team

CGB Clinical Governance Board MRSA Methicillin Resistant Staphlococcus aureus

CLAB Central Line Associated Bacteraemia MRO Micro Resistant Organism

CCOT Critical Care Outreach Team MSU Mid-Stream urine

CeDSS Clinical e-Decision Support N/A Not Applicable

CPP Chronic Pelvic Pain NPS Net Promoter Score

ESC Elective Surgery Centre OBD Occupied Bed Day

ePA Electronic Prescribing and Administration

PACE Pathway for Acute Care of the Elderly

eMR E-Medicine Reconciliation PDP Patient Deterioration Programme

ED Emergency Department PERSy Patient Experience Reporting System

EDARS Early Discharge and Rehabilitation Services

PICC Peripherally Inserted Central Catheter

ELT Executive Leadership Team PROM Patient Reported Outcome Measure

ETT Exercise Tolerance Test PWCCS Patient Whānau Centre Care Standards

FFT Friends and Family Test QI Quality Improvement

FHC Front of House Coordinator QSM Quality and Safety Markers

FY Financial Year SAB Saureus bacteraemia

HABSI Hospital Acquired Blood Stream Infection

SAC Severity Assessment Code

HCAI Health-care associated infection S&A Surgical and Ambulatory

HDU High Dependency Unit SAQ Safety Attitude Questionnaire

HH Hand Hygiene SCBU Special Care Baby Unit

HOPE Health Outcomes Prediction Engineering

SMART Specific, Measurable, Achievable, Reliable and Time bound

HQSC Health Quality and Safety Commission SMT Senior Management Team

HRT Health Round Table TBA To Be Advised

ICU Intensive Care Unit TRAMS Tracheostomy Review and Management Service

IORT Intraoperative Radiotherapy UTI Urinary Tract Infection

IP&C Infection, Prevention and Control WTK Waitakere Hospital

ISBAR Identify, Situation, Background, Assessment, Recommendation

XPs Extended Properties

IT Information Technology YTD Year to date

IVL Intravenous luer

96


1. Health Quality and Safety Markers

The Quality and Safety Markers (QSMs) are used by the Health Quality and Safety Commission to evaluate the success of its national patient safety campaign, Open for better care, and determine whether the desired changes in practice and reductions in harm and cost have occurred. The markers focus on the four areas of harm covered by the campaign:

1. falls

2. healthcare associated infections (hand hygiene, central line associated bacteraemia and surgical site infection)

3. perioperative harm

4. medication safety

5. pressure injuries (data collection commenced July 2018)

6. deteriorating patient (data collection commenced July 2018)

7. patient experience

For each area of harm there are a set of process and outcome markers. The process markers show whether the desired changes in practice have occurred at a local level (e.g. giving older patients a falls risk assessment and developing a care plan for them). The outcome markers focus on harm and cost that can be avoided. Process markers at the DHB level show the actual level of performance, compared with a threshold for expected performance:

90% of older patients are given a falls risk assessment

90% of older patients at risk of falling have an appropriate individualised care plan

90% compliance with procedures for inserting central line catheters in ICU (insertion and maintenance bundle compliance)

80% compliance with good hand hygiene practice

Surgical Site Infections rate per 100 procedures [target has not been set by HQSC)

100% primary hip and knee replacements antibiotic given 0-60 minutes before ‘knife to skin’ *first incision]

95% primary hip and knee replacements right antibiotic in the right dose - Cefazolin 2g or more

100% of audits where all components of the surgical safety checklist were reviewed

100% of audits with surgical safety checklist engagement scores of five or higher

>50 observational audits are carried out for each part of the surgical checklist

Number of DVT/PE cases per quarter (target has not been set by HQSC)

Percentage of patients aged 65 years and over (55 and over for Māori and Pacific people) where electronic medicine reconciliation was undertaken within 72hrs [of

admission] (target has not been set by HQSC)

Percentage of patients aged 65 years and over (55 and over for Māori and Pacific people) where electronic medicine reconciliation was undertaken within 24hrs [of

admission] (target has not been set by HQSC)

Percentage of patients aged 65 years and over (55 and over for Māori and Pacific people) where electronic medicine reconciliation was included within as part of the

discharge summary (target has not been set by HQSC)

Percentage of patients with a documented sedation score(target has not been set by HQSC)

Percentage of patients with documented bowel function monitored (target has not been set by HQSC)

97

http://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/quality-and-safety-markers/falls/baseline/

http://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/quality-and-safety-markers/hand-hygiene/baseline/

http://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/quality-and-safety-markers/CLAB/baseline/

http://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/quality-and-safety-markers/perioperative-harm/baseline/


Percentage of patient with uncontrolled pain(target has not been set by HQSC)

Percentage of patients with documented opioid related adverse events(target has not been set by HQSC)

Percentage of patients with a hospital acquired pressure injury (target has not been set by HQSC)

Percentage of patients audited for pressure injury risk who received a score (target has not been set by HQSC)

Percentage of patients with the correct pressure injury care plan implemented (target has not been set by HQSC)

Percentage of wards using the NZ early warning score (target has not been set by HQSC)

Percentage of audited patients with an early warning score calculated correctly for the most recent set of vital signs (target has not been set by HQSC)

Percentage of audited patients that triggered an escalation of care and received the appropriate response to that escalation as per the DHB’s agreed escalation

pathway (target has not been set by HQSC)

Number of in-hospital cardiopulmonary arrests in adult inpatient wards, units or departments (target has not been set by HQSC)

Number of rapid response escalations (target has not been set by HQSC)

Score of 8.5 per domain - improvement in national patient experience survey response results over time

Maintain and improve national patient experience survey response rate over time

The future timetable for Health Quality and Safety Commission Quality Safety Marker (QSM) reporting in 2019 is:

Period covered Publication date (indicative)

Q2 2019 (Apr-Jun 19) 30/09/2019

Q3 2019 (Jul-Sep 19) 13/12/2019

98


2. Health Quality and Safety Commission QSM Dashboard

Quality Safety Markers (QSM) Target Q2

2017 Q3

2017 Q4

2017 Q1

2018 Q2

2018 Q3

2018 Q4

2018 Q1

2019 Q2

2019

Last Quarter Change

Falls

% older patients assessed for falls risk.

90% 95% 99% 97% 96% 95% 98% 96% 98% 97%

% older patients assessed as significant risk of falling with an individualised care plan.

90% 96% 100% 95% 95% 98% 97% 96% 94% 99%

Health Care Associated Infections

Hand Hygiene

(HH) % of compliant HH moments. 80% 86% 87% 88% 89% 90% 89% 89% 89% 90%

CLAB

% occasions insertion bundle used in ICU.

90% 100% 99% 100% 99% 99% 98% 100% 99% 100%

% occasions maintenance bundle used in ICU (not currently an HQSC Target).

90% 98% 91% 96% 95% 91% 96% 97% 92% 96%

Surgical Site

Infections

Surgical Site Infections rate per 100 procedures [target has not been set by HQSC. National Q4 2018 rate 1.0 infections per 100 ops).

HQSC has not defined a target

1.2 0.3 0.7 0.9 0.7 0.0 0.0 1.6* 0.4*

Cumulative rate 1.0 (From Jul 13) *Preliminary

100% primary hip and knee replacements antibiotic given 0 -60 minutes before ‘knife to skin’ [first incision].

100% 90% 96% 96% 98% 95% 97% 97%

HQSC SSI data lags by two

quarters

95% primary hip and knee replacements right antibiotic in the right dose - Cefazolin 2g or more.

90% 97% 97% 97% 96% 97% 99% 98%

100% of primary hip and knee replacements will have alcohol based skin preparation.

100% 99% 100% 98% 94% 100% 98% 100%

100% of primary and knee replacements will have surgical antimicrobial prophylaxis discontinued with 24 hours post-operatively.

100% 94% 96% 100% 100% 100% 100% 100%

eMedRec

% of patients aged 65 years and over (55 and over for Māori and Pacific people) where electronic

TBD Orion working nationally on version of SQL script for testing/validation -

99



2017 Q3

2017 Q4

2017 Q1

2018 Q2

2018 Q3

2018 Q4

2018 Q1

2019 Q2

2019

Last Quarter Change

Medication Safety

reconciliation was undertaken -within 72hrs [of admission]

% of patients aged 65 years and over (55 and over for Māori and Pacific people) where electronic reconciliation was undertaken within 24hrs [of admission]


% of patients aged 65 years and over (55 and over for Māori and Pacific people) where electronic reconciliation was included within as part of the discharge summary


Opioids

% of patients with a documented sedation score

TBD

Until Privacy Impact Assessment is completed by HQSC for Waitematā DHBs data we will provide aggregated data

only

85% 72% 76%

% of patients with documented bowel function monitored

TBD 10% 4% 3%

% of patient with uncontrolled pain

TBD 30% 18% 8%

% of patients with documented opioid related adverse events

TBD HQSC collates this data -

Patient Deterioration

% of eligible wards using the NZ Early Warning System (EWS)

TBD TBA TBA

% of audited patients with an EWS score calculated correctly for the most recent set of vital sign

TBD TBA TBA

% of audited patients that triggered an escalation of care and received appropriate response to that escalation as per DHB agreed escalation pathway

TBD TBA TBA

Number of in-hospital cardiopulmonary arrests in adult inpatient wards, units or

TBD Reporting Commenced Q1

2018 7 22 32 17 15 16

100



2017 Q3

2017 Q4

2017 Q1

2018 Q2

2018 Q3

2018 Q4

2018 Q1

2019 Q2

2019

Last Quarter Change

departments

Number of rapid response escalations

TBD -

Pressure Injuries

% of patients audited for pressure injury risk who received a score

90% Reporting commenced Q3 2018 88% 86% 85% 86%

% of patients with the correct pressure injury care plan implemented

90% Reporting commenced Q3 2018 71% 96% 68% 68%

% of patients audited with a hospital acquired pressure injury

TBD Reporting commenced Q3 2018 1.6% 2.4% 0.6% 1.0%

Meets or exceeds the target

Within 5% of the target

More than 5% away from target

Positive increase

No change

Positive Decrease

Negative Increase

Negative Decrease

101


Quality Safety Markers Target

Q2 2017

Q3 2017

Q4 2017

Q1 2018

Q2 2018

Q3 2018

Q4 2018

Q1 2019

Last Quarter Change

Peri-Operative Care

Surgical Safety

Uptake: % of audits where all components were reviewed.

100%

Sign In

100% 100% 98% 98% 98% 100% 100% 98%

Time Out

100% 100% 100% 97% 100% 98% 98% 100%

Sign Out

100% 92% 100% 98% 98% 100% 98%

Engagement: % of audits with engagement scores of five or higher.

95%

Sign In

75% 94% 84% 93% 85% 96% 88% 89%

Time Out

89% 84% 89% 90% 92% 94% 94% 100%

Sign Out

83% 94% 95% 95% 100% 92% 98%

Observations: number of observational audits carried out for each part of the surgical checklist (Minimum of 50 observations per quarter).

≥ 50

Sign In

52 51 57 56 56 52 51 57

Time Out

53 56 54 64 61 51 53 53

Sign Out

49 52 52 55 56 52 50 51

Data not published by the HQSC if audits were <50

Less than 75%

More than 75%

Target Achieved

102


3. DHB Quality Indicator Trends

Hospital Diagnosis Standardised Mortality Ratio (HDxSMR) The HDxSMR is expressed as a ratio and seeks to compare actual deaths occurring in hospital (or in hospital and following hospital admission), with a predicted number of deaths based on the types of patients admitted to the hospital. The HDxSMR is a new HRT mortality methodology introduced in November 2016 (see Key Quality Indicator ‘Mortality’ below for further description of the new HRT mortality methodology).

Hospital Diagnosis Standardised Mortality Ratio (HDxSMR) Waitematā DHB’s HDxSMR (combined NSH + WTH ) Q3 FY2018/2019 = 87.2

113.6

97.4 92.4

106.3 106.5 103.1 103.1 100.9 109.3

84.5 91.8

107.5 100.5

93.4 89.2 85.4 87.6

74.9 76.6 84.4 81.5

74.8

87.2

20.0

40.0

60.0

80.0

100.0

120.0

140.0

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

WDHB Hospital Diagnosis Standardised Mortality Ratio

HDxSMR

103


North Shore Hospital

HDxSMR (12 months: Jan – Dec 2018) 89 Episodes 68,538 Deaths 624 Expected Deaths 703.4 Combined HRT HDxSMR for Jan – Dec 2018 81 NZ HDxSMR for Jan – Dec 2018 101 Network HDxSMR 82

Waitakere Hospital

HDxSMR (12 months: Jan – Dec 2018) 66 Episodes 33,864 Deaths 198 Expected Deaths 301.4 Combined HRT HDxSMR for Jan – Dec 2018 81 NZ HDxSMR for Jan – Dec 2018 101 Network HDxSMR 82

104


Falls Pressure Injuries

UCL 6.100

X 4.641

LCL 3.182

2.65

3.15

3.65

4.15

4.65

5.15

5.65

6.15

6.65

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Falls per 1,000 Bed Days Jan 2017 - Jun 2019

UCL 2.028

X 1.437

LCL 0.846

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

2.20

2.40

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Pressure Injuries per 1,000 Beds Days Jan 2017-Jun 2019

UCL 0.326

X 0.113

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Falls - Major Harm Per 1,000 Bed Days Jan 2017 - Jun 2019

UCL 0.169

X 0.055

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

0.20

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

Dec

-18

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Stage 3, 4 and Unstageable Pressure Injuries per 1,000 Beds Days Jan 2017 - Jun 2019

105


Hospital Acquired Blood Stream Infections (HABSI)

HABSI is defined as a bloodstream infection attributable to hospital where acute or rehabilitation care is provided, if the infection was not incubating on admission. Typically bacteraemia diagnosed after 48 hours of admission, on readmission, related to a device, or within 30 days of a procedure (if no alternate source identified) is categorised as a HABSI. There is no recognised national benchmarking 'acceptable' rate or target for HABSI.

Period HABSI Rate

May 2019 0.25

June 2019 0.17

Q1 2019 0.24

Q2 2019 0.23

2019 YTD 0.24

Source May (6) June (4)

CAUTI 2 -

IV Luer - 1

Other 3 3

Unknown 1 -

Central Line Associated Bacteraemia (CLAB) Patients with a central venous line are at risk of a blood stream infection (CLAB). Patients with a CLAB experience more complications, increased length of stay, and increased mortality; and each case costs approximate $20,000 - $54,000. CLAB infections are largely preventable using a standardised procedure for insertion and maintaining lines (insertion and maintenance bundles of care). NSH’s ICUs compliance with standard procedure and rates of CLAB are Health Quality and Safety Markers. Comment Rate of CLAB/1,000 line days: May 2019 rate was 0.66 and June 2019 was 0.65/1,000 line days the target for this is <1 per 1,000 line days. ICU/HDU 181 “CLAB Free” days as at 30 June 2019 (* restarted as of 01/01/2019). The National target is >90% compliance for insertion and maintenance bundles use.

Period Insertion Bundle Maintenance Bundle

May 2019 100% 96%

June 2019 100% 98%

Q1 2019 99% 94%

Q2 2019 100% 96%

2019 YTD 100% 95%

Staph Aureus Blood Stream Infections The rate of S.aureus bacteraemia (SAB) infections attributed to healthcare is the national outcome measure for hand hygiene compliance. The SAB rate is based on HHNZ‘s definition to maintain consistency in DHB reporting. This is a ‘days between’ control chart and, therefore, the clustering of data points below the mean (Ẋ) represents events occurring close in time or an increased relative frequency of events. Comment The length of time between infections is increasing which may reflect improved compliance with hand hygiene practices. Waitematā DHB’s SAB rate remains consistently below the national average (0.11-0.13 per 1,000 bed days) with an approximate average of one SAB per month.

Period SAB Rate

May 2019 0.04

June 2019 0.13

Q1 2019 0.03

Q2 2019 0.10

2019 YTD 0.07

UCL 0.520

CL 0.248

0.00

0.10

0.20

0.30

0.40

0.50

0.60

Rat

e p

er

1,0

00

Be

d D

ays

Hospital Acquired Blood Stream Infections Jan 2017 - Jun 2019

UCL 0.817 X 0.788 LCL 0.760

0.60

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

Rat

e p

er

1,0

00

Be

d D

ays

Central Line Associated Bacteraemia (CLAB) Jan 2017 - Jun 2019

UCL 84.1

X 25.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

S. Aureus Blood Stream Infections Days In Between Infections

(Jan 2017 - Jun 2019)

106


4. Key Quality Indicators

4.1 Hospital Acquired Blood Stream Infections (HABSI)

Target Measure Prev.

Report Period

Current Report Period Commentary

0 Total # of infections

6 (Apr)

6 (May)

4 (Jun)

HABSI is defined as a bloodstream infection attributable to hospital where acute or rehabilitation care is provided, if the infection was not incubating on admission. Typically bacteraemia diagnosed after 48 hours of admission, on readmission, related to a device, or within 30 days of procedure (if no alternate source identified) is categorised as a HABSI. There is no recognised national benchmark ‘acceptable’ rate or target for HABSI.

Mean rates of HABSI/1,000 occupied bed days over the last five years are:

Year Rate N=

2014 0.32 79

2015 0.33 79

2016 0.35 89

2017 0.25 67

2018 0.26 70

2019 Q1/Q2 0.21 28

0.00 # of infections per 1,000 occupied bed days

0.27 (Apr)

0.25 (May)

0.17 (Jun)

HABSI Analysis May 2019

Source Total Area Organism Comments

CAUTI 2

Muriwai Ward Serratia maracens

A patient admitted following a dense stroke and required a urinary catheter to manage continence issues; a trial removal of the catheter was unsuccessful and required reinsertion. The urinary catheter was clinically appropriate for this patient.

Ward 10 Pseudomonas aeruginosa

A patient was admitted with urinary retention and required a urinary catheter to manage this issue; a trial removal of the catheter was unsuccessful and required reinsertion. The urinary catheter was clinically appropriate for this patient.

Other 3

Ward 11 E coli All three cases were patients who had developed non- catheter associated

urinary infections (urosepsis) Muriwai Ward E coli

Ward 14 ESBL E Coli

1 ICU/HDU Enterococcus faecium A patient with a severe cryptogenic organising pneumonia

1 required admission

to ICU for further management. The patient died from respiratory failure unrelated to the HABSI.

1 Cryptogenic organizing pneumonia (COP) is a form of idiopathic interstitial pneumonia characterized by lung inflammation and scarring that obstructs the small airways and air sacs of the lungs (alveoli). Signs and symptoms may include flu-like symptoms such as cough, fever, malaise, fatigue and weight loss

107



Report Period


HABSI Analysis June 2019

Source Total Area Organism Comments

IV Luer 1 Ward 6 Staph Aureus

A patient developed a Staph aureus bacteraemia (SAB) five days post insertion of an intravenous luer; the HABSI was avoidable. The luer had been left in for 144hrs (six days); DHB policy indicates a 72hrs (3days) maximum dwell time with appropriate extenuating clinical circumstances allowing a 96hr dwell time if the site in free of infection. Additionally it was noted that the IV luer did not have appropriate documentation of insertion nor review and maintenance.

Other 3

Muriwai Ward Staph Aureus A patient developed a Staph aureus bacteraemia (SAB) of which the source of the infection is unclear.

Two cases were related to patients who had developed non- catheter associated urinary infections (urosepsis)

Ward 8 E coli

Anawhata Ward ESBL E coli

4.2 Hand Hygiene (HH) Compliance


Report Period


>80% % rate of compliance with five Hand Hygiene Moments

89% (Apr)

90% (May)

90% (Jun)

Hand Hygiene Results by Division Q2 2019

Division Correct

Moments Total

Moments Compliance

Acute & Emergency Medicine 3,975 4,519 88%

Child Women & Family 1771 1944 91%

Specialty Mental Health + Addictions 534 554 96%

Specialist Medicine + Health of Older People 1,969 2,176 90%

Surgical & Ambulatory 4,380 4,892 90%

Total 12,629 14,085 90%

108



Report Period


Hand Hygiene Results by Division June 2019

Division Correct

Moments Total

Moments Compliance

Acute & Emergency Medicine 1369 1512 91%



Specialist Medicine + Health of Older People 659 729 90%


Total 4,083 4,516 90%

Hand Hygiene Results by Division May 2019

Division Correct

Moments Total

Moments Compliance

Acute & Emergency Medicine 1275 1512 84%



Specialist Medicine + Health of Older People 678 748 91%


Total 4,220 4,760 89%

The Hand Hygiene Reports for May and June 2019 is attached - Appendices 1 and 2

0 Total # of Hospital Acquired SAB infections

3 (Apr)

1 (May)

3 (Jun)

Staph Aureus Blood Stream Infections

Year Staph Aureus Rate per 1,000 Bed Days

2017 0.07

2018 0.05

2019 (Q1/Q2) 0.07

The Infection, Prevention and Control Committee’s Executive Reports for May and June 2019 are attached – Appendices 3 and 4

0 # of Hospital Acquired SAB infections per 1,000 bed days

0.14 (Apr)

0.04 (May)

0.13 (Jun)

109



Report Period


4.3 Surgical Site Infections

Target Measure Previous Report Period

Current Report Period

Commentary

TBA - 0.0% (SSI Rate Q3 Jul – Sep 2018)

0.0% (SSI Rate Q4 Oct – Dec 2018)

Surgical Site Infections (SSIs) – in scope procedures for SSI are primary and revision hip and knee arthroplasty at either North Shore Hospital or the Elective Surgery Centre (ESC) in accordance with the National Surgical Infection Improvement Programme.

Waitematā DHBs cumulative rate (July 2013 – December 2019) is 0.9/100 procedures; National cumulative rate for the same period is 1.0/100 procedures.

Preliminary Q1 2019 data indicates that we have had four SSIs two deep and two superficial infections (rate 1.6/100 procedures). The cause of each of these SSIs is yet to be determined. The deep SSI identified in March isolated Staph aureus which is the first since the introduction of Staph decolonisation bundle in November 2017; one case was a left total hip revision (Elective Surgery Centre) and the other a right total knee revision (NSH Theatre).

Preliminary Q2 2019 rate was 0.6/100 procedures; this one SSI was superficial

The National average SSI rate was 1.0/100 procedures (Q4 2018). Reporting of the national SSI rate is delayed by

0.13 0.12

0.14 0.13 0.13

0.12 0.13

0.11

0.18

0.1

0.13 0.13

0.06 0.04

0.07 0.09

0.10

0.14

0.07

0.02

0.05 0.03

0.09

0.06 0.06

0.03

0.10

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0.2

Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018 Q1 2019 Q2 2019

Healthcare Associated S.aureus Bacteraemia (2015-2018) Waitemata DHB rate per 1,000 bed days vs. National Rate

National Rate Waitemata DHB Rate

110




Commentary

two quarters

SSIs per 100 operations (Q1 2015 –Q1 2019)

Quarter Q1

2016 Q2 Q3 Q4

Q1 2017

Q2 Q3 Q4 Q1

2018 Q2 Q3 Q4

Q1 2019

Q2

Procedures 299 340 311 267 274 331 288 303 217 304 240 229 261 250

#SSIs 1 1 6 4 6 4 1 2 2 2 0 0 4 1

Waitematā ’s Rate

0.3 0.3 1.9 1.5 2.2 1.2 0.3 0.7 0.9 0.7 0.0 0.0 1.6 * 0.4*

National Rate 1.2 0.7 1.2 1.0 1.1 0.8 0.6 1.3 0.7 0.9 0.9 1.0 TBC TBC

*Preliminary Result Number of SSI per quarter by classification (Q1 2015 – Q1 2019)

Quarter Q1

2016 Q2 Q3 Q4

Q1 2017

Q2 Q3 Q4 Q1

2018 Q2 Q3 Q4 Q1 Q1

Superficial hip 0 0 2 0 3 0 0 0 1 0 0 0 1 1

Deep hip 1 0 2 3 2 3 1 0 0 0 0 0 1 0

Superficial knee 0 1 2 0 0 1 0 1 1 2 1 0 1 0

Deep knee 0 0 0 1 1 0 0 1 0 0 0 0 1 0

Total SSIs 1 1 6 4 6 4 1 2 2 2 1 0 4 1

4.4 Central Line Associated Bacteraemias (CLAB)



Commentary

<1 # of CLAB infections per 1,000 line days (ICU)

0.67 (Apr)

0.66 (May)

0.65 (Jun)

Central Line Associated Bacteraemia (CLAB) Patients with a central venous line are at risk of a blood stream infection (CLAB). Patients with a CLAB experience more complications, increased length of stay, and increased mortality; and each case costs approximate $20,000 - $54,000. CLAB infections are largely preventable using a standardised procedure for insertion and maintaining lines (insertion and maintenance bundles of care). NSH’s ICUs compliance with standard procedure and rates of CLAB are Health Quality and Safety Markers.

111




Commentary

>98% % bundle compliance at insertion (ICU)

100% (Apr)

100% (May)

100% (Jun)

The ICU is currently 181 days CLAB Free as at 30 June 2019 – count restarted 01/01/2019

Central lines are inserted in the operating theatre and maintenance of the lines on the wards is followed up by theatre, ICU and the Infection Prevention and Control team staff supporting ward staff.

The total number of central lines (centrally and peripherally) inserted in May = 36, June = 29

CLAB rates at Waitematā DHB remain low and most wards have very long CLAB free periods due to both good compliance and infrequency of patients with central lines.

>98% % bundle compliance maintenance (ICU)

94% (Apr)

96% (May)

98% (Jun)

4.5 Falls with Harm


Report Period


Commentary

Total number (#) of falls 130

(Apr) 146

(May) 143

(Jun) 55% reduction in patients sustaining major harm from falls for Q1/Q2 2019

(N=17) in comparison to the same period in 2018 (N=31)

Measures for Falls 2016 2017 2018 2019 (YTD)

Total number of falls 1552 1687 1698 828

Number of falls per 1,000 OBD 4.4 4.7 4.7 4.6

% patients 75 years and over (55 years and over Maori and Pacific) assessed for the risk of falling (average)

98% 96% 96% 98%

% patients 75 years and over (55 years and over Māori and Pacific) assessed for the risk of falling within eight hours of admission

85% 82% 78% 80%

% patients 75 years and over (55 years and over Maori and Pacific) assessed as being at sufficient risk of falling have an individualised care plan in place (average)

89% 96% 98% 97%

Total number of falls where an injury has occurred (including Major Harm)

393 428 435 239

<5.0 Number of falls per 1,000 Occupied Bed Days (OBD)

4.4 (Apr)

4.7 (May)

4.5 (Jun)

Total number of multi-fallers 16

(Apr) 16

(May) 14

(Jun)

>90% % patients 75 years and over (55 years and over Māori and Pacific) assessed for the risk of falling

97% (Apr)

96% (May)

99% (Jun)

>90% % patients 75 years and over (55 years and over Māori and Pacific) assessed for the risk of falling within eight hours of admission

83% (Apr)

79% (May)

81% (May)

>90% % patients 75 years and over (55 years and over Māori and Pacific) assessed as being at sufficient risk of falling have an individualised care plan in place

99% (Apr)

99% (May)

99% (Jun)

Total number of falls where an injury has occurred (including Major Harm)

39 (Apr)

45 (May)

36 (Jun)

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Report Period


Commentary

Number of falls where an injury has occurred (including Major Harm) per 1,000 Occupied bed day

1.3 (Apr)

1.4 (May)

1.1 (Jun)

Number of falls where an injury has occurred (including Major Harm) per 1,000 Occupied bed day

1.1 1.2 1.2 1.3

Total number of falls with major harm (SAC 1 and 2)

41 40 44 17

Number of falls with major harm per 1,000 OBD

0.12 0.11 0.12 0.09

Total number of fractured neck of femurs (NOF) as a result of a fall while in hospital

11 11 10 6

Total number of falls with major harm (SAC 1 and 2)

4 (Apr)

2 (May)

3 (Jun)

Number of falls with major harm per 1,000 Occupied bed day

0.14 (Apr)

0.06 (May)

0.09 (Jun)

<1 Total number of reported fractured neck of femurs (NOF) as a result of a fall while in hospital (included in the major falls with harm rate)

1 (Apr)

2 (May)

2 (Jun)

<1 Total number of coded fractured neck of femurs (NOF) as a result of a fall while in hospital

4.6 Peri-Operative Harm – surgical safety checklist

Target Measure Previous Report

Period Current

Report Period Commentary

100% Uptake: % of audits where all three components of the Surgical Safety Checklist were reviewed. 100% 100%

Please see the Quality QSM Dashboard for trends.

95% Engagement: % of audits with engagement scores of five or higher. 92% 98%

≥ 50 Observations: number of observational audits carried out for each part of the surgical checklist (Minimum of 50 observations per quarter).

Sign in 51

Sign in 57

Time Out 53

Time Out 53

Sign Out 50

(Oct –Dec 2018)

Sign Out 51

(Jan – Mar 2019)

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4.7 Pressure Injuries


Report Period


Commentary

100% % patients risk assessed within specified time frame (eight hours)

77% (Apr)

78% (May)

80% (Jun)

20% reduction in confirmed hospital acquired Stage 3, 4 and unstageable pressure injuries for Q1/Q2 2019 (N=4) in comparison to the same period in 2018 (N=20)

Measures for Pressure Injuries 2016 2017 2018 2019 (YTD)

% patients risk assessed within specified time frame (average)

75% 72% 68% 78%

% patients audited who received a score (average)

92% 88% 86% 87%

% patients with the correct care plans implemented (Average)

95% 95% 74% 68%

Number of patients with reported confirmed pressure injuries (Incident Reporting System – Risk MonitorPRO)

384 563 549 206

Number of confirmed pressure injuries per 1,000 Bed Days

1.1 1.6 0.7 0.1

Number of reported confirmed Stage 3, 4 or unstageable pressure injuries (Incident Reporting System – Risk MonitorPRO)

23 20 29 4

Number of confirmed Stage 3, 4 or unstageable pressure injuries per 1,000 Bed days

0.06 0.06 0.08 0.02

100% % patients audited who received a score

85% (Apr)

86% (May)

88% (May)

100% % patients with the correct care plans implemented

69% (Apr)

73% (May)

69% (Jun)

Number of patients with reported confirmed pressure injuries (Incident Reporting System – Risk MonitorPRO)

37 (Apr)

33 (May)

29 (Jun)

Number of confirmed pressure injuries per 1,000 Bed Days

1.2 (Apr)

1.1 (May)

0.9 (Jun)

0

Number of reported confirmed Stage 3, 4 or unstageable pressure injuries (Incident Reporting System – Risk MonitorPRO)

1 (Apr)

1 (May)

1 (Jun)

Number of confirmed Stage 3, 4 or unstageable pressure injuries per 1,000 Bed days

0.03 (Apr)

0.03 (May)

0.03 (Jun)

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4.8 E-Medicine Reconciliation (eMR), ePrescribing and Administration (ePA)



Commentary

100% % patients with eMR completed within 24 hours on admission and discharge

87% - Electronic Medicines Reconciliation (eMR/eMedRec) eMedRec is live in 919 acute beds across North Shore and Waitakere Hospitals. Our completion rates for inpatients sit between 85-95% of all ward patients having an eMedRec form completed by a pharmacist during their admission (in areas where eMedRec available). The rollout of eMedRec has now been completed to all planned areas. Maternity, and the Emergency departments been enabled for limited use in selected, complex paediatric patients.

WDHB has been working with HQSC and other eMedRec stakeholder DHBs to agree on nationally appropriate quality and safety markers (QSMs) around the Med Rec process. Updated QSMs had been proposed and reports were under development but the HQSC value of reporting QSMs for eMedRec given the low uptake of the software among other DHBs with only six DHBs currently using it. Feedback was provided by stakeholders and the HQSC Medication Safety Expert Advisory Group’s (MSEAG) recommended that QSMs for Med Rec should be kept. The new QSM development remains on hold. Electronic Prescribing and Administration (ePA) MedChart Performance: healthAlliance (hA) has agreed to move the remaining MedChart servers to the new Virtual Farm as there was some performance improvement when some servers were moved across. We are waiting for this to be scheduled by hA. iPad Freezing: Freezing of iPads is still occurring; we have put many hours into manually upgrading the entire fleet to iOS12 which provides performance improvements for older devices. A new wireless network called TWA has been stood up which is more like NorthAir than SWA2. We are waiting for some iPads to be connected to this new network so we can test whether this resolves the freezing issue.

115


4.9 Complaint Responsiveness



Commentary

<15 days

Average time to respond to complaints in the reporting month

13 (Apr)

14 (May)

10 (Jun)

The average days to respond have gradually decreased over the last four years and services across the DHB are working diligently to ensure they meet the target of <15 calendar days to respond.

Year Average Days to Respond

2015 18

2016 19

2017 15

2018 14

2019 YTD 13

Average Days to Close by Division for May 2019

YearDivis Division Average Days to Respond

Acute and Emergency Medicine 8

Child Women and Family 9

Specialist Mental Health and Addiction 18

Specialty Medicine and Health of Older People 14

Surgical and Ambulatory 19

Average Days to Close by Division for June 2019







Average Days to Close by Division for 2019 (YTD)







116


4.10 Hospital Mortality

Key Quality Indicators



Commentary

Mortality (death rate)

<100 Hospital Standardised Mortality Ratio (HDxSMR)

81.5

(Q1 FY 18/19)

74.8

(Q2 FY 18/19)

See latest data under Section 3, DHB Quality Indicators Dashboard

117


5. Improvement Team Active Projects Report

Innovation and Improvement Project Team: Active Projects Report

June 2019 000‘000 Overall Status

Project Name Project Summary Sponsor(s) PM Resource Budget Forecast Variance

This Period

Last Period

Phase

Organisation wide / Multiple Divisions

Patient Deterioration Programme (PDP)

An organisation and national programme to improve the management of the clinically deteriorating patient. The Programme has 3 main streams: (1) Recognition and response systems; (2) Kōrero mai: Patient, family and whānau escalation (3) Shared goals of care

Andrew Brant Jos Peach Penny Andrew

Jeanette Bell N/A N/A

1. a. PDP: Recognition and Response Systems - Adult Andrew Brant Jos Peach Penny Andrew

Sue French N/A N/A Executing

b. PDP: Recognition and Response Systems – Maternity National Maternal Early Warning System

Andrew Brant Jos Peach Penny Andrew

Sue French N/A N/A Initiating

2. PDP: Kōrero mai: Patient, family and whānau escalation David Price Jeanette Bell N/A N/A Closing

3. PDP: Shared Goals of Care TBA Jeanette Bell N/A N/A Scoping

Survive Sepsis Improvement Collaborative

A quality improvement project that aims to reduce inpatient sepsis mortality to <15% by September 2017

Dr Penny Andrew Dr David Grayson Dr Matt Rogers Shirley Ross Kate Gilmour

Kelly Bohot Kelly Fraher Renee Kong

N/A N/A Closing

Leapfrog (refer to Leapfrog project update)

Data Discovery Project: Implement and ensure use of QlikSense Business Intelligence tool across Waitematā DHB

Penny Andrew Renee Kong $1.2m 0% Closing

Outpatients Dale Bramley & Robyn Whittaker

Kelly Bohot N/A N/A Executing

PROMs Programme Establish a system for developing, collecting and utilising patient reported outcome measures (PROMs) to inform patient experience and outcome improvements in clinical practice and health care delivery planning

Jay O’Brien Mustafa Shaabany

N/A N/A Planning

Smartpage Extend the use of Smartpage messaging system for calls to House

Officers during business hours (Mon-Fri 08:00 – 16:00) by

deploying DHB-managed smartphones with the Smartpage app

installed to all House Officers who currently have a pager.

Penny Andrew Stuart Bloomfield

Dina Emmanuel

$50k (opex) phase 2

0% Executing

118


Then extend to all RMOs (House Officers + Registrars).

IC-Net Optimisation Optimise the use of ICNet, a software solution for infection

surveillance and management in the Waitematā DHB

environment

Matthew Rogers, Stuart Bloomfield

Barbara Corning-Davis

N/A N/A

Closing

Improve “unapproved” clinical letters backlog

Reduce unapproved clinical letters backlog to meet the KPI of 5 days for P1 documents and 10 days for P2 documents from the time letters being transcribed and ready for approval by the author

Lara Hopley Dina Emmanuel

N/A N/A Closing

Radiology Service Care Transformation

Develop Care Transformation Programme to ensure high quality, high value service addressing: demand and outsourcing; patient flow; service utilisation; evidence-based care and elimination of unnecessary procedures (Choosing Wisely); patient experience and staff experience

Cath Cronin Robert Paine

Renee Kong Laura Broome

N/A N/A Executing

Acute Pain Service Review Review Acute Pain Service, with possible re-design. Current referral demand and workload not fitting within current model

Lydia Gow N/A N/A Scoping

Wound Maap Test Test Wound Maap wound analytic app to understand benefits for wound assessment and monitoring.

Jos Peach Kate Gilmour

Kelly Bohot Scoping

Surgical

General Surgery Clinical Pathways (appendicitis, laparoscopic cholecystectomy, abscesses)

Improve general surgery patient experience: reduce length of stay, variation and cost of care

Richard Harman Kate Macfarlane

Lisa Sue N/A N/A

Executing

Conversion of Short-Stay to Surgical ADU

Convert the Short Stay Ward into a Surgical ADU (surgical specialties + gynae) to facilitate the introduction of acute clinical pathways for surgery, smooth RMO workflow, and potentially free up space in the current ADU for medical patients + pathways

Michael Rodgers Debbie Eastwood

Kelly Fraher N/A N/A Scoping

Surgical Implant Tracking Develop a system to track surgical implants. The aim is to capture product information at point of entry into Waitematā DHB and assign a unique Waitematā DHB identifier in bar code format that can be captured and linked to a patient at point of care (in theatre) and beyond

Michael Rodgers Mustafa Shaabany

N/A N/A Initiating

Medical

TransforMed Improve the experience of acute medical inpatients by eliminating unnecessary waiting, reducing deconditioning, improving flow, and providing team-based care through four workstreams:

Cath Cronin Alex Boersma Gerard de Jong John Scott

Kelly Bohot Kelly Fraher Renee Kong

N/A N/A Executing

119


- Inpatient Wards: eliminate unnecessary patient waits + implement SAFER bundles of care

- ADU: improve flow, earlier access to senior doctor + diagnostics

- PACE: early identification and care of frail elderly - Medical Model: home-based wards and collaborative,

MDT ward service

Chest Pain Pathway Review Complete a review of the chest pain pathway including: - Review of local and international literature - Audit of ETTs and patient outcomes

Jonathan Christiansen Laura Chapman, Kate Allan

Kelly Bohot N/A N/A Closing

Choosing Wisely-Optimise Abdominal X-ray (AXR) requests in Emergency Department

Abdominal X-ray has long been regarded as overused, with low diagnostic yield in the Emergency Department. The aim is to refine the e-ordering process by adopting Choosing Wisely approach to refine the list of indications “Indication list” for patients requiring abdominal X-ray with the view of reducing the unnecessary X-ray orders that does not add value and in some occasions can cause harm to the patient.

Willem Landman Amanda Holgate

Dina Emmanuel

N/A N/A Executing

OptimisED+ Providing best care by continuous improvement

Review, Identify opportunities and implement further improvements in the Emergency Department, to consistently deliver best emergency care by optimising ED staffing, capacity-demand matching, and leadership structures and roles.

Cath Cronin Willem Landman

Dina Emmanuel

N/A N/A Executing

Rapid Cardiac Screening Clinic Model of Care

Develop a model of care for a new rapid cardiac screening (RCS) clinic model of care. Develop a business case to introduce a new model of care that will include - Improved, timely access to initial outpatient cardiology

evaluation - Improved screening process to allow risk stratification

that enables early intervention for higher acuity patients

- Identification and elimination of unwarranted tests and investigations

Patrick Gladding Alex Boersma

Lisa Sue Kelly Bohot

N/A N/A Scoping

Endoscopy Service Care Transformation

Undertake a review of international models of care for endoscopy services

Cath Cronin Robert Paine

Delwyn Armstrong Penny Andrew

N/A N/A Planning

Cardiology Outpatient Triaging and Grading

Review and improve the process for triaging cardiology outpatient referrals to the Cardiology Service to ensure more timely access to the service, appropriate prioritisation, and identification of patients who require specialist assessment

Tony Scott Alex Boersma Linda Flay

Kelly Bohot

N/A N/A Initiating

120


Child Woman and Family

Urogynaecology Service Develop a local service for women requiring management of urogynaecological conditions; Stress Urinary Incontinence (SUI) and Pelvic Organ Prolapse (POP) and management of complications associated with previously implanted surgical mesh as a treatment type. Development of a business case will include care for women in Waitematā and the Northern Regions with SUI or POP, and those affected by complications secondary to treatment of these conditions where mesh was used

Cath Cronin

Sue French N/A N/A Initiating

Mental Health and Addiction Services

Mental Health and Addiction (MHA) National Quality Improvement Programme

Support the development and delivery of the national MHA quality improvement programme, Whakapai i ngā mahi hauora hinengaro waranga hoki, at Waitematā DHB. The programme aims to improve the quality and safety of mental health and

addiction services and the experience of care for consumers

Susanna Galea Laura Broome and Barbara Corning-Davis

N/A N/A Phase 1: Executing Phase 2: Planning next phase

Acute Mental Health Services Quality Improvement Programme

Support the development of a quality improvement programme for the acute mental inpatient units and related community services in response to recent client incidents (deaths in inpatient units and community)

Susanna Galea Pam Lightbrown

Laura Broome Barbara Corning-Davis Jay O’Brien

N/A Phase 1: planning

Mission Home Ground Sarah Masson, Planning Funding & Outcomes’ Request for business analyst/process mapping for development of a 10 bed medical detox floor at Waitematā DHB and 15 bed social detox floor for ADHB, to be operational by October 2020. Proposed start date mid-November

Sarah Masson Laura Broome

N/A N/A Closing

Community

Safety in Practice Programme Waitematā DHB’s Safety in Practice (SiP) Programme aims to promote a safety and improvement culture within community teams including general practice (GP), pharmacy and urgent care teams, within the Auckland region. The programme is adapted from the Scottish Patient Safety Programme in Primary Care. The i3 provides quality improvement and project management support to the programme.

Tim Wood Stuart Jenkins

Sue French N/A N/A Executing

Ear Nurse Service Process Improvement

Improve Ear nursing service (ENS) by identifying the required nursing FTE to maintain a sustainable workforce. Define and implement more efficient streamlined processes and clear parameters to enhance patient outcomes.

Marianne Cameron Michele Kooiman

Dina Emmanuel

N/A N/A Executing

121


District Nursing Service Review

Review and work to improve DN service across West, North and Rodney.

Jos Peach Brian Millen

Lydia Gow Kelly Bohot

N/A N/A Planning

Other Work In Progress Overview Involvement Sponsor(s) PM Resource Comment

ECIB Design Support Support for ECIB Programme Support being provided for: - Spatial design of ideal ward and

other spaces in ECIB - Design of models of care

including data analytics and options analysis

Andrew Brant Cath Cronin Michael Rodgers

Robyn Whittaker Delwyn Armstrong Jay O’Brien Penny Andrew

Commenced

Innovation Partnership Develop, test and refine mobile app review process

Research and develop a process including a review questionnaire to screen apps based on business/clinical relevance, quality, functionality and security

Stuart Bloomfield Robyn Whittaker

Kelly Bohot Ongoing

Quality Improvement Training

Overview Involvement Sponsor(s) PM Resource Comment

Tier 2 project-based QI Training Programme

Teach QI skills to hospital and community staff and mentor each to deliver a QI project

Content development and delivery Ongoing mentorship

Penny Andrew Barbara Corning-Davis

Ongoing

Mental Health and Addiction (MHA) Quality Improvement Programme

As above As above Susanna Galea Laura Broome and Barbara Corning-Davis

Planning

Safety in Practice As above As above Tim Wood Stuart Jenkins (ADHB/WDHB) Lisa Eskildsen Diana Phone

Sue French Ongoing

RMO Clinical Governance Training

QI training involving project-based learning in the workplace with QI coaching

Content development and delivery Andrew Brant Penny Andrew Naomi Heap Ian Wallace

Jonathan Wallace

Ongoing

Management Foundations Teach QI skills to 22 participants and mentor each to deliver a QI project


Sue Christie Barbara Corning-Davis

Ongoing

Waimarino Clinic QI Workshop

Teach QI skills to 12 participants and mentor each to deliver a QI project


Tony McGeady Philippa Cope

Barbara Corning-Davis

Ongoing

Te Whanau o Waipareira Teach QI skills to 11 participants and mentor each to deliver a QI project


Penny Andrew Barbara Corning-Davis

Ongoing

Aged Residential Care and Teach QI skills to 28 participants and Content development and delivery Penny Andrew Barbara Ongoing

122


Hospice Providers mentor each to deliver a QI project Ongoing mentorship Corning-Davis

HQSC-Sponsored Quality Improvement Advisor Training

HQSC is sponsoring two i3 Project Managers to complete the Improvement Advisor (IA) Training Programme. The programme involves experience based learning with each IA trainee working on a project during the programme. HQSC’s focus this year is on improving QI capacity in aged residential care.

Two i3 Project Managers are completing the programme. Kelly Fraher is working with an aged residential care facility and ED to explore the use of telehealth Jeannette Bell is working with an aged residential care facility and the DHB’s pressure injury steering group designing a collaborative pressure injury QI programme between the DHB and the facility

Penny Andrew Willem Landman Jos Peach

Kelly Fraher Jeannette Bell

Scoping

Support Requests

Current Support Requests

Project Name Sponsor / Requestor

Description Request received

Scoping Completed Approved date

Assigned to Comment

Organisation-wide/Multiple Divisions

eProgress Notes roll-out Stuart Bloomfield David Ryan

Project management support for the roll out of eProgress notes across the acute wards at NSH and WTH during June and July 2019.

May 2019 June 2019 Lydia Gow Roll out with i3 PM support on the wards to commence late June 2019

eOrders: support with training and change management in ED/ADU

Robyn Whittaker Michael Sheehan

Project management support for the implementation of eOrders Phase 2 – training and change management in ED/ADU

February 2019

Review of clinical monitoring across the DHB

Most of the monitoring equipment is outdated. The purpose of the review is to scope options for a new system addressing existing shortcomings; develop a replacement strategy; write a business case to replace the equipment

February 2019 Not progressed Closed

Further development of the skin service model of care

Cath Cronin Debbie Eastwood Michael Rodgers Richard Martin (Clinical Lead)

Support for the Operations Manager and Clinical Lead to: -Set up a clinical governance structure for the skin service -Bring all the stakeholders together

September 2018

Not progressed Closed

123


to discuss service development -Review contracts for GPs within the scheme including the process for appointment -Review GP pay rates (this is a regional piece of work) -Review the service specification so a procurement process can be completed -Review resources across the service and bring them together into one service (GP, General Surgery + ORL) -Streamline the referrals flows and allocation process – current duplication -Further develop Qlik scorecard for the Skin Service

Staff security Cath Cronin Prepare an overview of where we are at with security from an operational and Health and Safety view following the work of a Security Review Programme developed by a service project manager in 2016/17. The work is spread over the operational team, Occupational Health team, and Health and Safety team. Develop a proposal for one service to lead and own this work, with responsibility for keeping a full oversight and accountability for the programme.

September 2018

Not progressed Closed

Dysphagia and older adults in inpatient setting

Adverse Event Committee

The adverse event committee have reviewed two cases where patients with dysphagia were provided high risk foods resulting in request to understand current processes and whether any opportunities for improvement exist.

May 2019

Carolyn Czepanski Scoping assigned and commenced May 2019

124


Child Women and Family Service

Maternity Nurse Call Evaluation

Robyn Whittaker Undertake an evaluation of the trial of the use of cell phones for patients in the maternity ward at NSH as a nurse call system. The evaluation will help inform a decision whether or not to implement at NSH and WTH

April 2019 Carolyn Czepanski and Kelly Bohot

Evaluation commenced May 2019

Surgical

Gynaecology Theatre informed consent process for sensitive examinations

Cath Cronin Diana Ackerman

Project management support to improve the process of informed consent for patients undergoing sensitive examinations in the gynaecology theatre

May 2019 20 May 201 Lisa Sue Scoping has commenced, further work to be completed to understand current process and issues

Meeting the community’s need for equitable elective surgery

Michael Rodgers How can the surgical triage tools and thresholds for elective surgery tell us whether we are being equitable between and within specialties?

May 2018 Not progressed Closed

NSH Operating Theatres: Improving the function of and culture

Michael Rodgers Debbie Eastwood

Work with the theatre teams (by profession, by area etc.) collaboratively on how we can improve the way theatres function linked to how staff work together

28 August 2018

Carlene Lawes, i3 public health physician is supporting Chief of Surgery with literature review and research

PACE model of graded assertiveness

Daniel Fung Proposal to implement PACE model of graded assertiveness – a tool to empower staff to speak up in situations where patient safety is potentially compromised

18 June 2019 Scoping commenced

Surgical pathology stock management

Neville Angelo Request to review how we manage stock in Surgical Pathology with a view to eliminating waste

21 June 2019

Medical

QI Support for Renal Medicine Service Improvement

Andy Salmon QI specialist to support/review programme of quality work in the renal service. We require some strategic oversight/focus, as well as guidance on resources we might draw on for key individual projects.

April 2019 Support being provided by i3’s Person Centred Care team (Jay O’Brien) including introduction of PROMs

125


Integrated rehab model of care

Jessie McArthur Develop a new model of care and business case for integrated rehab. ACC require a model to be adopted by 2022. Work in progress with leadership from John Scott, Brian Millen and Cheryl Johnson.

24 June 2019

Sub-cutaneous injections in the community

Jay O’Brien Henry Chan, consultant haematologist, has received a grant to trial giving sub-cutaneous injections in the community for patients with multiple myeloma. Request for PM support.

12 July 2019

Closed since last report

Project/Work/Request Sponsor/Requestor Overview Outcome Close out / summary report location

Mission Home Ground Sarah Masson, Planning Funding & Outcomes

Request for business analyst/process mapping for development of a 10 bed medical detox floor at Waitematā DHB and 15 bed social detox floor for ADHB, to be operational by October 2020. Proposed start date mid-November

Process Map of CADS inpatient unit (IPU) at Pitman House from admission, through to treatment and discharge from the IPU was completed with input from clinical staff from the IPU and Pitman House.

G:drive/Institute i3/Project Management /Closed/Mission Homeground

126


Patient Deterioration Programme (PDP) Progress Summary

Sponsors: Andrew Brant, Jos Peach, Penny Andrew

Project Manager: Jeanette Bell

Phase: Scoping - Executing - Closing

Opportunity / Problem Statement: Our processes and systems to support safe, consistent, effective 24 hour care for the clinically deteriorating patient are not always adequate, presenting an on-going risk to patient safety. Local and national scoping has identified a number of improvement opportunities and initiatives to further develop and strengthen our management of the deteriorating patient. Waitematā DHB has identified a local programme of work to consider as well as participation in the Health Safety and Quality Commission (HQSC) national and regional patient deterioration programme (July 2016 to June 2021). Objective / Aim: To introduce a patient deterioration programme to promote a structured and systematic approach towards improving the management of deteriorating patients at Waitematā DHB.

Project Risks:

Large scale of programme and change

Need to keep large number of stakeholders informed

Clinician availability, staff engagement

Potential for local and national priorities and timelines to differ

Impact of other service and staffing changes on project timelines and plans Project Issues:

Next Steps:

Continue monitoring and supporting New Zealand Early Warning System (NZEWS) changes

Publish and refine Patient Deterioration Dashboard

Complete Kōrero Mai closure report and transfer business as usual to Patient Experience team

Set up Shared Goals of Care working group

Support Maternity with planning MEWS

Publish EWS audit results

Status Update:

Monthly Executive Sponsor meetings and regular updates to CGB and Provider SMT scheduled Recognition and Response Systems (see separate progress summary reports) a. Adult - National vital signs chart and early warning system implemented Monday 6 both sites

Unresolved Smartpage issues.

Monitoring for practice issues and follow up further education planned b. Maternity - National Maternity Early Warning System (MEWS)

Working group meeting and using HQSC framework for planning c. Mental Health - National adult vital signs chart and early warning system (not started) Kōrero mai: Patient, family and Whānau Escalation (see separate progress summary report)

20 calls since November

Implemented in all inpatient areas except mental health

Post implementation staff and patient/whānau awareness survey completed in May, awareness campaign planned for late August

Transition to business as usual under the Patient Experience Team near completion Shared Goals of Care

Waitematā DHB working with HQSC as 1 of 2 test DHB’s for new national Shared Goals of Care principles, tools and resource – Setting up working group. Ward 3 and 15 identified as pilot wards

Measurement

Quarterly HQSC quality safety markers reporting

Deteriorating dashboard to be published in Qlik Sense this week – working with clinical teams to refine. QlikSense app called NZEWS Live available for hourly monitoring of EWS activity

Weekly charge nurse manager led Early Warning Score (EWS) auditing commenced in May. Publication in QlikSense expected this week

Timeline

Milestone Status Completion

Recognition and Response Systems - Implementation of National Vital Signs Chart & Early Warning Score (adult)

Executing Implemented 6 May 2019

TBC

Recognition and Response Systems - Implementation of National Vital Signs Chart & Early Warning Score (maternity)

Scoping May 2019 start

TBC

Kōrero mai: Patient, family and Whānau Escalation Co-design

Closing BAU complete

June 2019 (was Dec 2018)

Shared Goals of Care Scoping In progress Sept 2020

Budget Spend to Date Forecast to Complete Variance Scope Timeline Budget

Capex $ N/A N/A $0 On track Delayed N/A

Opex $ N/A N/A $0

127


PDP Work Stream 1: Recognition and Response Systems - Adult

Clinical Leads: Jonathan Casement

Project Manager: Sue French

Phase: Executing

Opportunity / Problem Statement:

Ensuring deteriorating patients receive appropriate and timely care is essential to meeting the aim of safe, effective, quality patient care. Early recognition and response to clinical deterioration can minimise and reverse the severity of deterioration and the level of intervention required to stabilise a patient’s condition and can reduce patient harm, morbidity and mortality, hospital length of stay and associated health costs. Evidence demonstrates that patients exhibit many signs and symptoms of deterioration for a reasonable period of time before cardiac arrest or unplanned admission to intensive care occurs. Evaluation of our current systems indicates that there is inconsistent processes and pathways and an absence of processes and mechanisms to support safe, consistent, effective 24 hour care for the deteriorating patient

Objective / Aim:

Develop and deploy a robust strategy for the implementation of a Waitematā Recognition and Response program that will reduce the harm associated with unrecognised deterioration and its subsequent delayed treatment for all adult in-patient (excluding maternity) care areas.

Project Risks:

Engagement from existing clinical teams

Human resource resistance to organisation wide change process

Resource requirements (clinical staff ) for potential changes to escalation and response systems and delivery of education

Project Issues:

Technical issues with SmarPage, In-patient, Clinical Whiteboard, Trendcare and Capacity-At-A-Glance Board occurred secondary to eVitals changes

Next Steps:

Report June audit outcomes

Status Update:

Following SmartPage features remain unresolved: automated ‘urgency’ selection, screen display colours, combining scores and displaying scores with modifications, and cross site paging function. SmartPage lead working on these. Resolution date to be confirmed

SmartPage working group continue to seek a solution for contacting registrars

Education group closed; strategy and actions confirmed for all levels of medical, nursing and allied staff education for the future confirmed by each group

Specific education for Waitakere Hospital nursing staff to improve execution of escalation plan between 22:30-0700 in planning

Orthopaedic group working on a solution to address issue of limited registrar availability to respond to Red and Blue zones

Timeline

Milestone Status Estimated Completion Date

Initiating Complete September 2017

Planning Complete July 2018

Executing Complete 6 May 2019

Closure Pending TBC


Capex $ N/A N/A $0 On track Delayed N/A

Opex $ N/A N/A $0

128


PDP Work Stream 1: Recognition and Response Systems - Maternity Progress Summary



Phase: Initiating

Opportunity / Problem Statement: Recent international and national reviews of maternal morbidity have highlighted opportunities to improve systems for recognising and responding to deteriorating maternity inpatients. The Health Quality Safety Commission (HQSC) has developed a nationally consistent, standardised approach to recognising and respond to acute deterioration of pregnant or recently pregnant (up to 42 days later) inpatient women. The HQSC is asking all hospitals to prepare for and implement this system by March 2020. The aim of MEWS is to reduce:

Harm through using a consistent process nationally

Duplication of effort across multiple DHB’s

Number of pregnant and recently pregnant women admitted to Intensive Care

The length of stay of pregnant and recently pregnant women in Intensive Care, high dependency and maternity units

Objective / Aim: To transition from Waitemata Maternity Early Warning Score to New Zealand Early Warning System (MEWS) and deliver a Waitematā mandatory escalation pathway to all areas where pregnant or recently pregnant women(up to 42 days later) are admitted, by March 2020

Project Risks:

Work stream will require across service engagement

Clinician availability


Human resource resistance to organisation wide change process Project Issues:

Apple Operating System upgrade is causing frequent loss of connectivity for users. Clinical Users are disengaging with digital system with preference for paper notes recording of vital signs

Potential technical issues with Smartpage, In-patient Snap, Clinical Whiteboard, Trendcare and Capacity-At-A-Glance secondary to eVitals changes

Next Steps:

Complete current state report

Complete Project charter

Confirm vital sign frequency with stakeholders

Working group established, meeting series commenced

Project lead confirmed; Dr Diana Ackerman (obstetric), Emma Farmer (Midwifery)

Development of project charter commenced

Leapfrog programme manager confirmed funding for MEWS development in eVitals

Work commenced to define current state

Work commenced to understand impact of new ipad operating system issues on user.

Working group exploring regional mandatory escalation pathways for applicability to Waitematā

Timeline


Initiating In progress July 19

Planning Pending August 19

Executing Not started TBC

Closure Not started TBC


Capex $ N/A N/A $0 TBA N/A

Opex $ N/A N/A $0

129



Capex $ N/A N/A $0

June 2019 (was Dec 18)

N/A Opex $ N/A N/A $0

PDP Work Stream 2: Kōrero mai: Patient, Family and Whānau Escalation

Progress Summary

Sponsor: David Price


Phase: Closing

Opportunity / Problem Statement: Staff inaction in the face of patient or family/whānau reports of patient deterioration is considered an adverse event. Sadly, case studies in New Zealand identify that lack of follow up by staff following such reports have led to poor patient outcomes and/or death. The Health and Disability Commissioner has identified that communication between patients, families and medical teams is a key point of concern in approximately 42 per cent of complaints. It is thought that an escalation process for patients, family and whānau will help reduce adverse events occurring in response to reports of patient deterioration. There is no such system currently in place at Waitematā DHB. The Health Quality and Safety Commission (HQSC) sponsored Waitematā DHB as one of four national sites to co-design a patient, family and whānau escalation system (Kōrero Mai). Objective / Aim: To co-design a patient, family and whānau escalation system for deteriorating patients with consumers, family, whānau and staff at Waitematā DHB

Project Risks: Nil at present Project Issues: Closure timeline delayed to allow full transition to business as usual and to

allow for post implementation evaluation

Next Steps:

Complete transition of service to business as usual under the Patient Experience Team

Post survey awareness campaign

Project close out report

Scope potential for service in Mental Health

Status Update:

Kōrero mai telephone service live across both hospital sites from 19 November 2018 in inpatient settings and phone line staffed by Waitematā Central

Patient experience team now manage service. I3 project management support until transition complete.

20 calls since November 2018. No calls for acute physical deterioration

Special Care Baby Units and Maternity now included, Mental Health service yet to be scoped.

Post implementation staff and consumer awareness surveys completed. Plan for awareness campaign in progress

Timeline


Initiating Complete 29 August 2017

Planning Complete 31 October 2017

Executing Complete

14 June 2018 (Co-design process) 19 November 2018 (DHB roll out)

Closure (of HQSC co-design project) and transfer to business as usual

In progress June 2019 (was Dec 18)

130


PDP Work Stream 3: Shared Goals of Care Progress Summary



Phase: Scoping

Opportunity / Problem Statement: Unwanted or unwarranted treatments at the end of life can contribute to suffering for patients, families and whānau, moral distress for clinicians, and unnecessary expenditure for the health system. Planning and managing end of life decision making and care can be challenging for clinicians and is often not adequately addressed, placing acutely deteriorating patients at risk of unwanted or unwarranted treatment, particularly at the end of life. Objective / Aim: To develop a consistent organisational approach to determining, communicating and documenting shared goals of care for adult inpatients to ensure all adult inpatients have patient centred clinically appropriate care plans in the event of acute deterioration and at the end of life.

Project Risks:

Work stream will require across service engagement


Clinician availability, staff engagement

Potential for scope creep as work overlaps into community and to multiple specialties Project Issues:

HQSC using national Advance Care Planning Programme (ACP) to meet some Shared Goals of Care objectives. Waitematā DHB is not taking part in full national ACP programme so will not have access to this resource and will have to find an alternative approach to meet objectives

Next Steps:

Establish working group

Identify project lead

Develop project charter and plan

Arrange workshop visit from HQSC

Meet with programme leads to establish work stream leads, plan working group and work stream content once additional scoping complete

Status Update:

Scoping document presented to PDP Executive Sponsor Group August 2018

Advance Care Planning (ACP) discussion document submitted to ELT in September 2018 with DHB decision not to join national Advanced Care Planning programme confirmed

Waitematā DHB to work with HQSC as one of two national test sites for the nationally developed Shared Goals of Care principles, tools and resources. Mid Central DHB is the other site

Setting up working group

Timeline


Initiating Scoping

Planning Not started

Execution Not started

Close Not started Pilot: December 2019 –Jan 2020 September 2020 (HQSC time line)


Capex $ N/A N/A $0 TBA N/A

Opex $ N/A N/A $0

131


Survive Sepsis Improvement Collaborative - Progress Summary

Sponsor: Dr Penny Andrew, Dr David Grayson, Shirley Ross, Kate Gilmore and Dr Matt Rogers

Project Manager: Kelly Bohot

Phase: Closing

Problem Statement: Sepsis poses significant morbidity and mortality risks to our patients, and with every hour delay to treatment there is an 8% increase in mortality. Waitematā DHB does not reliably recognise and treat patients with sepsis in a timely manner. Aim: To reduce the rate of inpatient sepsis mortality to less than 15% by August 31, 2017.

Project Issues: Further validation of data required. There are issues with specificity and sensitivity of the data which uses multiple sources (eVitals, laboratory, clinical notes and coded data). Further work is needed to develop a reliable sepsis data dashboard. An expert group (Dr Matt Rogers, Dr Hasan Bhallay; Dr Nick Gow, and Kirsten Bondesio is working with the i3 team to further develop the dashboard. We are also learning from work completed at Waikato DHB and Imperial College Health Partners, London.

Next Steps: Work stream 1: Best Practice Guidelines Adult guideline Nil Maternity guidelines

Complete publication process Paediatric guidelines Nil Work stream 4: Measurement and Evaluation

Project Implementation Review document in progress

Review dashboard and identify outstanding actions

Explore options to validate sepsis screening tool

Status Update: Work stream 1: Best Practice Guidelines

- Maternity guidelines agreed and signed off by Antimicrobial Stewardship Committee and Pharmacy Committee. Awaiting publication.

Work stream 2: Improvement Activities Work stream 3: Clinical education programme Work stream 4: Measurement and Evaluation

Coding system w updated on 1 July 2019. Initial review indicates no changes to sepsis codes.

Qlik Sense app further developed following consultation with Waikato DHB, New Zealand Sepsis Trust and Imperial College. Now includes both Macpherson 3 and Imperial College sepsis definition coding sets

Meeting with sepsis project clinical leads on 26.07.2019 to review dashboard changes with a view to completing phase 1 of sepsis improvement collaborative and identifying goals for potential phase 2

-

Project Timeline

Activities Status Timeline

Publish adult guidelines Complete January 2018

Complete maternity guidelines Complete January 2018

Identify resource for paediatric workstream Complete January 2018

Develop test and analyse Qlik data In progress TBA

Complete Project Implementation Review In progress TBA


Capex $ N/A N/A $0 On track Extend N/A

Opex $ N/A N/A $0

132


Patient Reported Outcome Measures (PROMs) Progress Summary

Sponsor: Jay O’Brien

Project Manager: Mustafa Shaabany

Phase: Planning


Data collection for patient reported and clinician assessed outcome measures and patient experience of service is currently fragmented, requires extensive resources and lacks transparency for clinical providers and service funder and planners. The lack of an efficient data capture system limits the capacity to make improvements in real time for patients and whānau.

Objective / Aim:

Develop a reliable, systematic PROMs data collection and reporting system.

Triangulate patient reported outcomes (PROMs), patient experience, clinical outcomes data and health economics analysis to provide a meaningful and reliable dataset for clinicians about an individual patient’s potential to achieve improved quality of life throughout their condition and treatment.

Provide reliable PROMs data for population health analysis and improvement. To create a synthesis between PROMs, PERSy and the HOPE project (health outcome prediction engine in stroke) for greater efficiency and improvement opportunities for service providers and end user application.

Project Risks:

Cost/acquisition of electronic devices and licence fees for individual services to carry out surveying with patients – there is no budget in the services or HIG/i3

Risk of other people seeing patient information if it is sent to patients via email – mitigated via validation process with patients consenting to use email

Project Issues:

Nil

Next Steps:

Develop a communications plan to assist on-boarding of services

Complete patient interviews to test acceptability and utility of PROMs from a consumer perspective in Septoplasty, Renal, Urogynaecology and Orthopaedics

Status Update: Plan to test sending surveys to the patient’s email address – in progress

Service PROMs merge with EQ-5D - in progress

IPOS-Renal survey design - in progress

Further updates of PROMS website completed in response to feedback

Online playbook (checklist for staff wanting to start PROMs collection and use) testing - completed

Online playbook feedback website updates - in progress

Electronic version of EQ-5D has been submitted to EuroQol for approval

Timeline


Initiating Completed June 2018

Planning Current August 2019

Executing Pending September 2019

Closure Pending December 2019


Capex $ N/A N/A $0 On track On Track N/A

Opex $ N/A N/A $0

133



Capex $ TBA N/A $0 On track On track N/A

Opex $ TBA $50k TBA

SmartPage- Clinical- Progress Summary Sponsor: Penny Andrew/Stuart Bloomfield

Project Manager: Dina Emmanuel

Phase: Executing

Opportunity / Problem Statement: The primary communication method, during the day, between the ward doctors and others is alphanumeric pagers. Pagers have limited ability to share information effectively and efficiently. Smartpage is a smart mobile and web-based clinical messaging and mobile task management system that has been used after hours (4pm-8am) by ward nurses, Duty nurse managers, Smartpage Coordinators, and house surgeons (RMOs) since 2013. The system is overwhelmingly endorsed by the RMOs and other users, and the RMOs and other users have consistently requested Smartpage be made available to them over all shifts (24/7). An extended trial in 2013-14 reported significant time savings and improved communication, with up to 15-20 minutes of time saved every hour. Recent quality improvement programmes, in particular TransforMed and the Deteriorating Patient Programme, have highlighted the need for better communication and RMO task management across all shifts, both of which can be improved significantly by the use of Smartpage. Objective / Aim: To extend the use of Smartpage messaging system for calls to HOs during business hours (Mon-Fri 08:00 – 16:00)

by deploying approximately DHB-managed smartphones with the Smartpage app installed to all House Officers

who currently have a pager. Following that, extend to all RMOs (House Officers + Registrars).

Project Risks: Setting up all phones at House officers and Registrars’ rotation

change over in a timely manner Project Issues: Nil

Next Steps:

Work with the finance team to create one operational RC code (instead of 22 RC codes) that can be used by all services/ departments

Review” roll out options paper” (all roll out options with advantages and disadvantages for each option) with the steering committee

Issue Smartpage phones to after hours on-call registrars (Gen Med, Gen Surg, Ortho, O &G and cardiology) as an interim solution before we roll out to all registrars.

Status Update: The project is structured in phases to roll out Smartpage phones to HO first then registrars: Phase 1 August 18- Smartpage for 100 HO replacing the pagers (HO Quarter 4 final run) Phase 2 Nov 18- Smartpage for 100 HO replacing the pagers (HO new run) Phase 3 June 19- Smartpage to 165 HO (100 HO already have Smartpage +65 without pagers) Phase 4 June 19- Smartpage for registrars Phase 5 Nov 19- Smartpage for all HO at the changeover Phase 6 Jun 20- Smartpage for all registrars at the changeover - Phase 1 and 2 of the project is now complete ( gone live). Getting ready for Phase 3 - Appointed process owner from Waitematā Central. i3 will continue with PM support for the next phases - Work in progress to create one RC code for project operational cost - Confirmed the availability of phase 3 and 4 funding required for additional 150 phones to be given to registrars

and possibility of 60 phones to pharmacists at an approximate cost of $150K (hardware) - Created process map showing all the steps and departmental responsibilities required at each change over - Successful completion of house officers’ rotation change over with volunteers support in May 2019 - Completed options paper ready to share with the steering committee - Operation managers (Gen Med, Gen Surg, Ortho, O & G and Cardiology) approved the go ahead with issuing

after hours on- call registrars with SmartPage phone

Timeline


Initiating Complete April 2018

Planning Complete May 2018

Executing On going June 2019

Closure Not started September 2020

134


ICNet Optimisation Progress Summary Sponsors: Matthew Rodgers, Stuart Bloomfield

Project Manager: Handed over by Arti Chandra to Graham Upton – Infection Prevention & Control, supported by Barbara Corning-Davis (i3)

Phase: Closing

Opportunity / Problem Statement: ICNet (infection control surveillance + management system) went live at Waitematā DHB on 28 March 2018 after two failed starts in April 2017 and November 2017. This is a shared system with ADHB. The system was implemented ‘out of the box’ and needs to be configured in order to deliver the benefits highlighted in the business case. Implementation into the IP&C service is led by IPC Clinical Nurse Specialist, Graham Upton. Objective / Aim: To develop the ICNet functionality for the Infection Prevention and Control (IP&C) team to realise the benefits of : 1) improving patient safety by facilitating earlier identification of patients with

health-care associated infection (HCAI) 2) improving data quality, providing real time quality information and timely

access to clinical knowledge 3) reducing administrative overhead so the IP&C team can focus on infection

prevention best practice

Project Risks: Project Issues:

Medchart interface on hold, pending resources.

Use of iPads for point prevalence audits on hold pending resources.

Status Update:

Candidate has been hired for Infection Prevention and Control Quality Improvement Lead, starting November. A 0.2 FTE contractor has been hired to manage ICNEt system issues in the interim.

Next Steps: (Time boxed for 3 months – 1 June – 31 August 2019) Identify and on-board ICNet Super User (completed)

Support Lab Information System upgrade (August/September)

Timeline


Initiating Complete June 2017

Planning Complete June 2017

Executing (Project handed over to Service January 2018)

Extended May, 2019

Closure Extended June 2019


Nil N/A N/A $0 Extended until December 2019 N/A

135


Chest pain pathway - Progress Summary Sponsor: Jonathan Christiansen & Alex Boersma

Clinical Leads: Laura Chapman & Kate Allan


Phase: Execution

Problem Statement: The purpose of the project is to understand whether our care of patients presenting with chest pain can be improved. The pathway was implemented 3-4 years ago. Since this time there have been new publications about improving care processes for patients with chest pain/acute coronary syndrome. The review of the pathway includes:

Review of national and international literature

Review of local data The following were investigated:

1. Which of our current three risk scores identifies patients a. who are safe to discharge? b. who will have a coronary event <30 or < 180 days from presentation?

2. Is an exercise tolerance test (ETT) useful for low risk patients? 3. Does an ETT have negative or positive predictive value or neither? 4. Is high risk ethnicity a predictor of clinical course? 5. Do demographics alone identify safe for discharge/high risk patients?

Gestalt and Troponin identified as most effective indicators for risk stratification in the Chest Pain Pathway (most effective predictors of a chest pain event in patients with low risk chest pain).

Project Risks: Nil Project Issues:

Need to agree data markers to define patients are on the chest pain pathway for Qlik dashboard. Dataset proposed 18.02.2019.

Patients on the chest pain pathway do not always have an electronically documented risk score available.

Development of chest pain pathway dashboard is on hold as resource required has been allocated to ED capacity and demand dashboard.

Next Steps:

Develop Qlik app to assist ED to monitor chest pain pathway and cardiac outcome data once resource is available again

Status Update: - Qlik dashboard under development


Complete audit and data analysis Complete April 2018

Validate model with additional dataset Complete April 2018

Develop new interim Chest Pain Pathway document

Complete May 2018

Implement interim Chest Pain Pathway document

Complete June 2018

Develop Chest Pain Pathway (New assay) To be confirmed

December 2018

Develop Qlik dashboard In progress May 2019


Capex $ N/A N/A $0 On track On track N/A

Opex $ N/A N/A $0

136


Choosing Wisely-Optimise Abdominal X-ray (AXR) requests in Emergency Department- Progress Summary

Sponsor: Willem Landman/Amanda Holgate


Phase: Executing


Over-requesting AXR with low diagnostic yield causing delays in completing procedures and

exposing patients to unnecessary radiation. There are evidences of over requested AXR causing

delays in processing needed x-ray requests and impacting negatively on demand management

strategies. Patients undergoing AXR are then exposed to further radiation with a CT scan.

Objective / Aim: Adopt Choosing Wisely approach to patients requiring abdominal X-ray with the view of reducing the unnecessary X-ray orders that does not add value and in some occasions can cause harm to the patient.

Project Risks:

Not all clinicians follow the “Adult acute abdominal pain pathway” instead continue ordering AXR unnecessarily

Project Issues:

Nil

Next Steps:

Audit AXR requests and measure the impact of process changes by comparing full 2018 to Jan-June 19 results.

Establish the financial benefits based on the reduction of non-indicated AXR and cost of $130/AXR request

Status Update:

Completed the following tasks: Scoping document

ED-Radiology patient current process map

Collected data for initial capability study

Audit of the collected data and results discussed with the team

Established the percentage of AXR requests (50-60%) that didn’t add value or improve

patient experience

Completed survey (44 responders) to better understand the reasons for ordering an AXR.

Feedback has been graphed and shared with project team and communication poster

created for wider communication. 45% of participants indicated the AXR outcome rarely

alters the management of the patient.

WIP

Establish % of indicated (added value) AXR completed following project work

Initial data indicates 25% improvement

Timeline


Scoping Complete April 2018

Initiating Completed August 2018

Planning Completed August 2018

Executing In progress April 2019

Closure Not started September 2019


Capex $ N/A N/A $0 On track N/A

137




OptimisED+ (plus)- Progress Summary Sponsor: Cath Cronin

Willem Landman


Phase: Planning


Since 2012 Emergency Department-ED has experienced an increased demand and growth in presentation numbers and complexity. This has limited our ability to consistently deliver optimal emergency care which compromises patients and staff safety and wellbeing. Objective / Aim:

Through OptimisED + we will be able to consistently deliver best emergency care by optimising our staffing, capacity-demand matching and leadership structure and roles.

Project Risks:

Unable to execute and implement recommendations resulting in deterioration of the current situation with declining patient and staff safety and wellbeing

Project Issues:

Financial constraints

Environmental constraints (physical areas/space)

Impact of other services on ED

Next Steps:

Arrange “Pit Crew” PDSA third trial

meet with recruitment team to clarify issues with the current recruitment process

Outcome Measures Stream One: Staffing Define adequate staffing numbers and skills to meet 85

th centile demand

Improve staff safety

Better understand the reasons for nurses leaving ED

Review salary and rates over the last 5 years

Identify improvement opportunities for ED recruitment process Stream Two: Capacity and Demand

Short Stay in ED SSED >95%

No inappropriate spaces

Adequate staffing numbers and skill mix to meet 85th

centile demand Stream Three: Leadership structure and roles

Review the current leadership structure throughout our ED Stream Four: Mental Health

Analyse physical areas for mental health patients in ED

Identify ED nurse time spent caring for mental health patients Completed

Second PDSA trial. The new process is aiming to more efficiently and effectively manage patients presented to ED by “Pit Crew” team and swiftly assessing, ordering the required tests and initiating referral/disposition process as required

Time and motion study for nurses in both NSH and WTH

Bench mark patient/nursing ratios for all ED locations WIP

Study the 2nd

PDSA results and plan for the 3rd

trial

Work with the recruitment team to resolve some issues identified in the current nursing recruitment process

Timeline


Scoping Completed Feb 2019

Initiating Completed March 19

Planning Completed March 19

Executing Started October 19

Closure Not started November 19

138


Spend to Date Forecast to Complete Variance

Scope Timeline Budget


Opex $ N/A N/A $0

Community Child and Family Ear Nursing Service Improvement- Progress Summary

Sponsor: Marianne Cameron

Michele Kooiman


Phase: Executing

Opportunity / Problem Statement: The Ear nurse service has no clearly defined designated full time employee (FTE). The processes for service delivery are inconsistent and out-dated The ear nursing service is a non-acute, community-based service delivering ear health assessment and treatment for children aged 3 months to 18 years. The community ear nurse works with all children, prioritising those from identified at risk groups and those for whom barriers create an inequality or gap in access to health services. Objective / Aim: Improve ear nursing service (ENS) by identifying the required nursing FTE to maintain a sustainable workforce (capacity and demand). Define and implement more efficient processes and clear parameters to enhance patient outcomes.

Project Risks: Nil Project Issues: Nil

Next Steps:

Meeting scheduled to review electronic iPM bookings in test environment

Collect data following the agreement on referral source definitions

Measure appointment duration variation for Ear nurses following the implementation of iPMbooking

Status Update: Completed tasks:

Created project charter

Established team working group

Agreed on tasks that need to be completed as part of the project scope

Completed “as is” service delivery process map for both Waitakere and North Shore regions

Identified improvement opportunities

Completed future map

Established community services “Child and family” data explorer. Information viewed via Qlik dashboard

Streamlined referral data entry process. Created guide document with screen shots to assist administrators when creating new referrals in iPM

Administrators can select one of the pre-defined sources when completing referrals in iPM

Streamlined the current process for creating ”presenting referral” and “related referral” at both sites (North and West)

WIP:

Organise a meeting to review outpatient wait list and iPM-booking in test environment

Analyse the current Ear Nursing capacity and demand

Timeline


Initiating Complete October 2018

Planning Complete December 2018

Executing In progress TBA

Closure Not started October 19

139


General Surgery Clinical Pathways

- Progress Summary

Sponsor: Richard Harman, Kate Macfarlane

Project Manager: Lisa Sue (PM support for Angie Hakiwai)

Phase: Executing


The Department of General Surgery has identified an opportunity to quantify ways to improve patient outcomes and experience, and reduce health care costs within General Surgery. The focus of this work is the development and implementation of evidence-based protocols for three presentations – abscess, appendicitis and cholecystitis, which account for approximately two thirds of general surgery acute cases booked for theatre.

Objective / Aim:

To identify and implement solutions to meet target length of stay and improve patient experience and outcomes for patients who undergo simple abscess drainage, appendicectomy, and cholecystectomy procedures, by December 2020

Project Issues:

Diagnostic accuracy audit has not started and the X-Porte Machine loan agreement will expire in September.

Shortages of Operating Theatre nurses or anaesthetists impact on the ability to run a Minor Procedures List.

Next Steps:

Cholecystitis bedside ultrasound scan project:

Working group to meet on 16 July to review study protocol and discuss readiness to commence diagnostic accuracy audit.

Criteria Led Discharge

Rewriting nurse competency assessment.

Provide details of electronic test to Awhina (Learning and Development) to develop.

Status Update:

Diagnosis of simple cholecystitis with bedside ultrasound scans o ED Focused Gallbladder workshop held on July 2

nd.

o Working group reviewed next 35 bedside scans to compare concordance with formal scans. The new diagnostic worksheet has shown improvements in the diagnosis however further work is required to review definitions for concordance.

o Changes in scanning protocol and measurement parameters required. Group decision to focus on improved specificity over sensitivity.

o On-going data collection of bedside scans.

Criteria Led Discharge o Review of the Criteria Led Discharge policy and nurse competency assessment

questions to align with NZEWS.

Acute Arranged Abscesses – Minor Procedures List o On-going monitoring.

Timeline


Initiate Complete September 2017

Plan Complete December 2018

Execute In progress March 2020

Close On track December 2020



Opex $ N/A N/A $0

140


Safety in Practice - Progress Summary Sponsor: Stuart Jenkins

Project Manager: Sue French (Improvement Advisor role)

Phase: Ongoing


Safety in Practice (SiP) is designed to enhance quality improvement capability of general practice (GP) teams within the Auckland region, by focusing on patient safety. In order to achieve this goal, a range of tools and resources (adapted from the Scottish Patient Safety Programme in Primary Care), alongside support from improvement and clinical experts are provided to general practice teams to foster a patient safety culture.

In 2017 a pilot programme for twenty community pharmacies and four acute care clinics to participate in SiP commenced; clinical modules specific to this practice domain were developed and tested.

Objective / Aim:

To develop more reliable practice systems and to promote a safety and improvement culture within general practices and community pharmacies

Project Risks:

Nil noted

Project Issues:

Insufficient resource/mismatch of skills and expertise required to support programme (administration; quality improvement; programme development)

Reduction in improvement advisor capacity for 2019-2020 programme year

Next Steps:

Awaiting outcome of discussions regarding withdrawal of Auckland DHB dedicated improvement advisor hours from the commencement of 2019-2020 Programme year. Discussions with Tim Wood regarding impact and mitigation of this decision pending.

Status Update:

Dr Sarah Hartnal, Urgent Care Consultant from Shore Care commenced role as Strategic Programme Lead June 2019

2018-19 Year 5 closed

2019-2020 Teams are confirmed, contracts process has commenced

2019-20 Quality Improvement learning curriculum and content development near completion

Development of 2019-2020/21 clinical module supporting documents in progress

Timeline


Initiate (SiP year 6 2019-20) In progress July 2019

Plan In progress August 2019

Execute Pending August 2019

Close (Year 6 GP, Year 3 Pharmacy)

On track July 2020



Opex $ N/A N/A $0

141


Rapid Cardiac Screening Clinic Model of Care business case - Progress Summary

Sponsor: Penny Andrew & Robyn Whittaker

Project Manager: Lisa Sue / Kelly Bohot

Phase: Planning

Opportunity / Problem Statement: The initial outpatient evaluation of patients with cardiac symptoms is complicated and an outmoded process that has resulted in long wait times and rapidly rising costs as population demand increases. This situation is unsustainable and requires innovative approaches to improving patients’ experience and efficient use of limited health system resources.

Objective / Aim: Develop a model of care for a new rapid cardiac screening (RCS) clinic model of care An initial business analysis for a new RCS model of care has been completed. A business case is being developed to introduce a new model of care and will include

- Improved, timely access to initial outpatient cardiology evaluation - Improved screening process to allow risk stratification that enables early intervention

for higher acuity patients - Identification and elimination of unwarranted tests and investigations

The model utilises multiple new mobile and rapid screening technologies to accurately risk-stratify patients with undifferentiated cardiac symptoms. These technologies are point-of-care cardiac biomarkers, a 5-minute point-of-care echocardiogram and an AI-based electrocardiogram evaluation – all of these approaches have been locally validated and have a sound evidence base. The RCS clinic has been piloted and found to have a much higher throughput than the traditional cardiology clinic model – this will potentially enable a significant impact on waiting lists. The innovative use of new medical technologies presents an opportunity for a highly valuable collaboration between Waitematā DHB, MedTech CoRE and industry partners. The establishment of formal clinical research collaboration for the RCS has been proposed, with a defined programme of research into cardiac screening, outcomes and integration of new technologies into pathways and decision-making processes.

Project Risks: N/A

Project Issues: N/A

Next Steps:

Developing an ECHO plan with some project management support for data.

Identify initiatives where further project management support required.

Status Update: Rapid cardiac screening clinic work is on hold until external funding approved.

Project management support in echo work: o Creating focused echo lists for left ventricular cases only. Worked with health

information group to create a report to identify this cohort to be booked. o Providing data analysis support for inpatient and outpatient referral

proportions and outcomes.

Timeline


Data analysed Completed 15 March 2019

Defined aim and objectives WIP 13 May 2019 (SRO Extended)


Capex $ N/A N/A $0 Extended N/A

Opex $ N/A N/A $0

142


Mental Health and Addiction (MHA) Quality Improvement Programme (National)

Sponsor: Dr Susanna Galea-Stringer

Project Managers: Laura Broome and Barbara Corning-Davis

Phase:

Opportunity / Problem Statement: Develop and implement Quality Plan for Mental Health and Addiction Services, including Health Quality and Safety Commission (HQSC) National QI Programme Phase 1: Reduction in Seclusion Objective / Aim (Phase 1): The project aims to improve patient experience on inpatient units by reducing the use of seclusion and or restraint. The overall aim is to achieve zero seclusion in adult acute and forensic services He Puna Waiora (Phase 1) Reduce the average number of minutes service users spend in seclusion in He Puna Waiora Acute Unit by 50% (from 466 minutes to 233 minutes) by September 2019 Waiatarau (Phase 1) Reduce the percentage of all restraints experienced by service users admitted to Waiatarau Acute Unit that are prone restraint by 50% (from 23% to 11%) by September 2019 Forensics (Phase1) Reduce the average number of minutes service users spend in seclusion at Mason Clinic by 50% (from 858 minutes to 429 minutes) by September 2019

Project Risks: Waitematā DHB has very low levels of clinical staff trained in QI Methodology

(<0.25%) Project Issues: Nil

Next Steps:

Determine measures, reporting structure, timelines, and working groups for each of the quality plan objectives.

Status Update:

Developing Project Charter with Evelyn McPhillips and Michelle Dawson. Timeline


Storyboard completed

Aims completed

Training Adult inpatient Start first cycle

21 November 2018

Training Forensics Start Mid December 2018



Opex $ N/A N/A $0

143


Tier 2 Quality Improvement Workshops Quality Improvement Programme

Sponsor: Penny Andrew

Project Manager: Barbara Corning-Davis

Phase:

Opportunity / Problem Statement: An understanding of quality improvement and experience in the applying quality improvement tools is essential for systematic, continuous quality improvement and innovation across the organisation. Objectives / Aims: - Develop Tier 1 Quality Improvement (QI) e-learning modules that provide basic, foundation-level QI knowledge that is available through Awhina Learning (Completed). - Develop an experience-based quality improvement training programme available to all staff across the DHB (Tier 2 of the Transforming Care Programme). -Develop a teaching faculty and an alumni network to sustain a culture of continuous quality improvement.

Project Risks: Due to competing clinical duties, low levels of clinical staff uptake of opportunity to learn and apply QI Methodology (Waitematā DHB has very low levels of clinical staff trained in QI Methodology: (<0.25%) Project Issues:

DHB Collaborative between the Auckland region DHBs and the HQSC is on hold due to schedule conflicts. Also, HQSC has already developed a QI tool kit for Aged Residential Care.

Need to continue to expand programme capacity, through mentorship and coaching alumni.

Next Steps: Community QI workshops and ongoing coaching support, in progress. Plan second QI alumni lunch (August 2019).

Status Update:

½ day QI workshop was held for Te Whanau o Waipereira on 4 July. Coaching support for participants is on-going. Follow-up workshop for cohort is scheduled for 12 September.

Other workshops held/planned for this year: o Follow-up workshop at Waimarino Clinic on 25 July. o Hospice and Residential Care Providers (30 enrolled) date: 1 Aug 2019 o NSH – Starting 5 September

Ad hoc quality improvement coaching has been provided on request with QI workshop alumni and others

Timeline


Training at NSH and WTH completed Ongoing

Training in community In progress 2019



Opex $ N/A N/A $0

144



Capex $nil to date N/A N/A $0 On track On track On track

Opex $nil to date N/A N/A $0

Urogynaecology Service Development Sponsor: Cath Cronin


Phase: Initiating

Opportunity / Problem Statement: The treatment of Stress Urinary Incontinence (SUI) and Pelvic Organ Prolapse (POP) with surgical mesh has occurred at Waitematā DHB since 1995 for SUI, and 2000 for POP. The implantation of a mesh mid-ureteral sling (MUS) has become the ‘gold standard’ procedure for SUI surgery. Most mesh devices were launched without clinical trials, meaning complication rates were never established prospectively. For the majority of women surgical treatment with mesh for SUI and POP has led to good long-term results with no complications. However, some women experience complication, and for some women complications have devastating and lifelong consequences. Increasing national and international concern for the failure rate and complications of mesh in these procedures has led to several large-scale reviews and investigations world-wide. The Ministry of Health has asked all District Health Boards (DHB) to stop using surgical mesh in urogynaecological surgery unless they can guarantee that credentialing standards and robust informed consent process are being met. Objective / Aim: To review Waitematā DHB’s urogynaecology services and develop a proposed model of care for the provision of secondary and tertiary urogynaecology services with scope for national delivery of tertiary care for this patient group. The model of care will surgeon credentialing, informed consent and surgical implant tracking processes that meet national and international standards.

Project Risks:

Large scale of programme and change

Potential for local, regional and national priorities and timelines to differ

Human resource resistance to organisation wide change process

Dr Eva Fong on sabbatical January 2020, for 12 weeks Project Issues:

Nil at present

Next Steps:

Cath Cronin and Eva meeting with Northern Region CMO to discuss priorities for region

Gynaecology and Urology Clinical Directors, with Michael Rodgers to present credentialing plans to each group by end of July

Present current work and plans to Mesh Roundtable August 1st

Confirm GP liaison for operational work progression

Obtain consumer feedback on current versions of Informed Consent documents

Submit Strategic Investment Committee paper July 2019

Submit Credentialing Policy to Credentialing Committee July 2019

Status Update:

Peer review from Australia and New York State Hospital complete.

Credentialing model presented to Ministry of Health, confirmation that this is for Waitematā women only, at this stage. Request to share with Mesh Roundtable and further discussion in late July on opportunities

Informed consent document for POP treatment options and Mesh Removal development commenced

Sub working group commenced to develop Operational management processes

Work on going to define nursing roles and needs, including advanced practice role. Suitable candidate from Auckland Hospital identified for Urodynamic study

Working with Portfolio Support Office on documents for submission

Work engagement with Medical Education Unit lead to develop learning outcomes, assessment criteria and e-portfolio commenced

Timeline


Scoping Complete November 2018

Initiating Complete April 2019

Planning In progress October2019

Executing Pending TBC

145




District Nursing Service Review Sponsor: Brian Miller/Jocelyn Peach

Project Manager: Lydia Gow

Phase: Planning

Opportunity / Problem Statement: With an ageing population and a strategic move towards delivering care closer to home, the District Nursing Service is seeing increasing referrals. The Service reports they are struggling to manage their workload, often resulting in overtime and casual labour use. The Service is currently not meeting the Ministry of Health entry criteria for a community nursing service with patients deemed high risk needing to be seen within 8-24 hours of referral. This criteria was met for 47.5% of high risk patients referred to the service in 2018. This is likely to also be influenced by a lack of understanding and accurate utilisation of this risk measure by the service. Anecdotally, nurses are often not able to attend professional supervision and other non-clinical meetings due to workload, and staff experience is poor. The Service feels better care could be given to staff and patients with well-managed workloads. Objective / Aim: To deliver timely patient care, aligned to the Services’ Entry and Transfer of Care criteria for 90% of patients, within allocated district nursing FTE, by October 2019.

Project Risks:

Nil at present Project Issues:

Documentation for new referrals received out-of-hours is currently paper-based and requires administrative staff to register referral onto iPM/Soprano. Adoption of more electronic processes requires a solution to address this ‘air gap’ (potentially Robotic Process Automation). Currently scoping out-of-hours administrative support within the DHB.

Next Steps:

Currently, e-referrals to the DNS are only monitored within office hours. Out-of-hours, only fax referrals are monitored. E-Referrals will be monitored out-of-hours from 23

rd July.

Analysis of Service activity data compared to cover model.

Changes in Soprano to enable tracking and visibility of risk to the Service via Qlik

Status Update:

Airwatch now implemented to all district nurse phones, enabling safe capture and transfer of clinical photographs.

Plan and funding to enable district nurses to be “live” via Citrix whilst in the community approved by the GM/Steering Group. Roll-out across sites over five weeks, starting 05.08.19; support/ training to be delivered by i3 and district nurse super users.

Aim to become paperlight: o The general assessment form, which is used for all new patients, has been transferred from paper

to electronic in Soprano. This is the first of five assessments that will become paperless. o Changing practice for district nurses to refer using DeeR instead of paper referral forms, where

available. o Once live, general paper charts for new referrals will change from 8 forms (10 sheets of paper) to

3 forms (4 pieces of paper). This will reduce to 2 forms after further Soprano form development.

After successful testing, where 88% of new referrals received a first visit within Ministry of Health response criteria (patient-related clinical reasons for delay for remaining 12%), a triage/prioritization process has been implemented across the sites which assesses the new patient’s risk and determines the first face-to-face contact date. This visit date takes into account the upcoming Service demand and staffing.

Cover model being formulated with Finance. Service data and literature being consulted re: workload management models and safe staffing requirements in district nursing services. Travel time data from GPS on North cars and self-reported data from West and Rodney analysed to inform cover model.

HIG is developing a Qlik app for district nursing for utilisation within the project and for on-going use by DNS management.

Timeline


Scoping Complete

Initiating Complete

Planning In progress August 2019

Executing Pending

146





Cardiology triage and grading Sponsor: Alex Boersma

Clinical Lead: Tony Scott


Phase: Planning

Opportunity / Problem Statement: Demand for Cardiology outpatient appointments at Waitemata DHB exceeds current appointment capacity. Referral data indicates demand for first specialist Cardiology appointments for this financial year (FY2018/19) is 31% higher than the last. Our current first specialist appointment demand is greater than other Auckland DHBs and the rest of the New Zealand. The largest growth has been for patients prioritised as priority 2 and priority 3. Priority 1 patients have remained stable which suggests the burden of disease in the community is unchanged. There are national referral guidelines for cardiology in use in other DHBs which are not currently systematically implemented in our cardiology service. There are opportunities to standardise our triage and grading process and expand our modes of delivery (eg nurse led clinics, virtual clinics) to better manage demand and ensure the right patients receive the right advice and care in the right place at the right time. Objective / Aim: tbc

Project Risks:

Nil at present Project Issues:

Nil at present

Next Steps:

Align project to work to better manage demand for ECHOs.

Review improvement priorities with triage and grading group 22 July 2019.

Status Update:

Baseline data complete

Initial meeting with Cardiology triage and grading group complete. Identified some improvement opportunities to test including clinical nurse specialist nurse to review referrals and remove duplicates, follow ups and requests for communication (30% referrals in recent 1 day audit), implement national referral guidelines, develop and test chest pain screening questions, test virtual clinics.

Clinical nurse specialist now in post

Clinical nurse specialist meeting with Cardiologists to observe and better understand triage and grading process.

Timeline


Scoping Complete March 2019

Initiating In progress May 2019

Planning Pending TBC


Closing Pending TBC

147





Surgical Implant Tracking Sponsor: Michael Rodgers

Project Manager: Mustafa Shaabany

Phase: Initiating

Opportunity / Problem Statement: We do not have a reliable, efficient system to track surgical implants; this means we cannot:

track exactly which devices are implanted in which patients

quickly trace and alert individual patients in the event of a product recall Currently:

Data collection for surgical implants is fragmented; in some locations data is stored in an isolated IT system, in others it is documented manually in the physical (paper) patient record

A lack of standardised data results in data gaps, poor visibility, and difficulties connecting patient information and technical details about implants (e.g. implant model no, manufacturer or lot number)

Surgical implant spend is not accurately tracked, which adversely impacts our reporting to the MoH

We lack a local register to collect information about surgeries involving mesh. As a result of world-wide concerns about surgical mesh, the MoH (in Sept 18), directed DHBs to hold and maintain such a register

Objective / Aim: (i) Develop a surgical implant tracking system that will:

Enable fast, efficient and complete identification of patients with implants in the event of a product recall

Allow tracking of implant outcomes (e.g. cost, complications, clinical outcomes) by patient demographics, procedure type and surgeon (ii) Measure the cost of waste and unwarranted variation

Project Risks:

Capturing implant cost details might slow down the progress of the project

The need for development resources might delay or stop the progress of the project

Project Issues: Nil

Next Steps:

Draft end user quick guide

Purchase 28 barcode scanners

Status Update:

Quote to purchase of 28 scanners acquired

Purchase and test of scanner software plugin to break down barcode - completed successfully

Test of retrieving scanned codes from data warehouse - completed successfully

Development of an in-house system in parallel to the committed working solution - in progress

Timeline


Scoping Complete March 2019

Initiating In progress TBC

Planning Pending TBC


148


Radiology Service Care Transformation Sponsors: Cath Cronin, Robert Paine, Penny Andrew

Project Manager: Renee Kong, Laura Broome

Phase: Executing

Objective / Aim: Optimise radiology services by:

- Optimising patient flow and service utilisation - Optimising demand by embedding evidence-based care and eliminating

unnecessary procedures (Choosing Wisely) - Developing robust data to inform current + future service planning including

outsourcing, capacity and workforce design - Improving patients’ experience - Improving staff experience

Future Planning o Compress sense trial ends on 3

rd August 2019. There are impressive results so far. Philips

collecting data for final report and MRI team collecting patient feedback. o Trial of Robotic Process Automation – project approved in Leapfrog Phase 3 o i3 fellow to work in partnership with Radiology on testing AI methods o Choosing Wisely looking at pathways that are appropriate to implement in the hospital

setting

Project Risks: Nil Project Issues: Nil

Status Update:

Radiology dashboard in Qlik is pending service sign off. Next phase is to refine data for Ministry of Health targets and inter-DHB requests and scans.

Improvement efforts focused on the following priority areas from longer list of opportunities identified for improvement: o Winter Acute Flow

Radiology appointments on Ward Whiteboard – Planned roll out is July 2019

Radiology Ready – Working with the eNotes team to draft an electronic sticker to trial. Outcome data collected on patients not radiology ready

Engaged a nurse educator around difficult IV access. Cannulation policy under review. Exploring IQ butterfly trial with Medical Education Fellow.

Developing a communication plan for early August roll out of Radiology Ready.

o CT Bay Blockages Data collection and analysis underway. The focus is on peak times,

communication flows and recovery space for biopsy patients. Analysis of Smartpage data is underway to understand flow in and out of the CT bay.

o Demand Analysing demand information from outpatient clinics Investigating Access to Diagnostic Funding, a model that is available in

ADHB/CMH but not Waitematā DHB which allows a GP to refer patients to a community radiology provider directly for ultrasound and X-Ray.

Next Steps:

Publish Radiology Dashboard

Winter Acute Flow – roll out Radiology Ready which includes the Radiology appointments on the ward whiteboard, eNotes sticker and education back to wards

CT bays – Complete the analysis of Smartpage data to understand flow into and out of the CT bay

Timeline


Initiating Complete 14 April 2019

Planning Underway 31 May 2019

Execution Underway 30 June 2020

Close TBC


Capex $ N/A N/A $0 N/A

Opex $ N/A N/A $0

149


ED Residential Care Improvement Advisor Programme Project

Sponsors: Penny Andrew

Project Manager: Kelly Fraher

Phase: Initiating

Opportunity:

It is important for the organisation to explore innovative models of care that provide care closer to or within the patient’s home

Working closely with the patients’ main caregivers who know the patient well and providing additional advice, would help to provide the best care for those patients

The use of telehealth ED consultations could help to reduce unnecessary ED presentations for those who could receive care closer to home

A more integrated team approach between ED and aged residential care could contribute to overall better outcomes and better experiences for our patients and clinical teams

Objective / Aim:

To reduce presentations to the Emergency Department from Lady Allum residential care facility by 25% by November 2019

To reduce the time from arrival to disposition decision (for patients who present to the Emergency Department from Lady Allum residential facility) by November 2019 [amount of reduction of time to be determined]

Project Risks:

Nil

Project Issues:

Nil

Status Update:

Residential care facility identified

Team formed

Problem statement and aim statement complete

Data collection started and ongoing

Current state process map drafted

Driver diagram drafted and in progress

Next Steps:

Continue data collection and analysis

Gather additional clinical data and look at cases to inform scope

Add residential care flag/filter to ED Qlik dashboard

Cause and effect

Complete driver diagram and refine change ideas

Timeline


Initiating In progress June 2019

Planning On track July 2019

Execution On track October 2019

Close On track December 2019



Opex $ N/A N/A $0

150


6. Safe Care

6.1 Infection Prevention and Control (IP&C)

IP&C Surveillance Overview and Audit Results for 2018/2019

Month Total ESBL (Def) Total HABSI

Total C.diff

(HO-HCA)

Total Waitematā

DHB Hand

Moments

% National HH Moments

Passed (Ave

%I&PC Facilities

Standards Met Overall

(Ave)

% Commodes Clean

January 2018 8 4 2 4,935 88% 100% 97%

February 18 5 3 5,441 89% 98% 95%

March 12 8 4 5,272 89% 98% 98%

April 13 4 3 5,423 90% 98% 99%

May 15 9 5 5,664 90% 100% 98%

June 19 7 4 5,174 91% 97% 100%

July 13 5 6 5,521 89% 99% 100%

August 19 6 1 5,526 88% 99% 98%

September 12 2 5 4,694 89% 98% 95%

October 15 6 5 4939 89% 99% 97%

November 7 6 4 4718 88% 97% 97%

December 30 6 11 4753 91% 99% 100%

2018 Total 181 68 53 62,060 89% 98% 98%

January 2019 15 2 3 5079 89% 97% 100%

February 2019 18 4 3 4824 89% 98% 83%

March 2019 16 10 4 4939 90% 98% 98%

April 2019 14 6 4 4783 89% 97% 86%

May 2019 12 6 5 4722 90% 97% 91%

June 2019 4 4 TBA 4516 90% 97% 95%

RAG Rating Legend % National HH Moments Passed % I&PC Facilities Standards Met % of Clean Commodes

≥ 80% ≥ 99% ≥ 99%

≥ 70% ≥ 90% ≥ 90%

< 70% < 90% < 90%

151


6.2 Surveillance 6.2.1 Extended Spectrum Beta Lactamase (ESBL)

HA-ESBL is now defined as Isolation of ESBL producing Enterobacteriaceae (e.g. E.Coli or Klebsiella sp.) from a clinical or screening specimen >72 hours post admission (not 48 hours as per the old definition), in a patient with previously negative or unknown ESBL status. This new definition now aligns with ICNET and CDC Surveillance Definition

ESBL Overview 2019 YTD

An overall reduction in HA-ESBL was seen both at NSH and WTH in the first half of 2019 (table below).

A total of 82 HA-ESBL patients (66 at NSH) with either new colonisation or infection were identified compared to 157 for a similar period in 2018.

0

5

10

15

20

Hospital Acquired (HA) Definite ESBL - Rate per 10,000 Bed Days

HA - Def NSH HA - Def WTH

HA –ESBL NSH WTH

Counts Rates Counts Rates

Jan 2019 14 8.9 3 4.8

Feb 2019 13 9.5 5 8.8

Mar 2019 14 8.7 2 3.0

Apr 2019 12 8.3 3 4.9

May 2019 9 5.6 3 4.2

June 2019 4 2.4 0 0.0

152


There has been a significant reduction in ESBL cross-transmission despite the disestablishment of Ward 11 as a Multi-drug resistant organisms (MDRO) ward and relaxation in cohorting rules for ESBL E coli. This reduction also follows a change in our HA-ESBL definitions from August 2018; the old definitions were likely to over attribute ESBL acquisition to healthcare.

A continued focus on prevention strategies will assist in further reduction of ESBL transmission

ESBL E coli (EC) is more likely to be community acquired (88%) in comparison to ESBL Klebsiella Pneumoniae (KP), which was 66%

Despite a high prevalence of ESBL in Waitematā DHB patients, the number of clinical isolates with ESBL in hospitalised patients remained relatively low with only seven hospital acquired (HA) ESBL E coli (EC); six HA ESBL Klebsiella Pneumoniae (KP), and one HA ESBL (other); in comparison to community acquired (CA), 58 CA ESBL EC, 10 CAESBL KP and seven CA ESBL (other)

ESBL EC still contributes to 50% (41/82) of total HA ESBL

90% of these patients have urinary tract infections

29% HA ESBL isolates were from blood cultures

HA-ESBL were distributed throughout the NSH wards predominantly with the number of cases attributable to wards ranging from:

nine on Ward 7

seven on Ward 4

seven on Ward 8

six on Ward 5

four each for Wards 2, 3, 9, 10 and Titirangi Ward (WTH)

the four surgical wards contributed to 33% (n=27) of HA-ESBL cases

Place of Acquisition

ESBL KP ESBL EC Other

HA 26 41 15

CA 51 319 27

Total 77 360 42

153


6.2.2 Carbapenem resistant Enterobacterales and Pseudomonas (CRE/O)

Nationally, since 2015, concern has been raised about emergence and spread of carbapenemase producing Enterobacterales (CPE’s), a subset of CRE/O bacteria. These are the

‘next generation’ of antimicrobial resistant bacteria with minimal or no effective antibiotics that can be used for treatment of infections caused by them. In addition, CPE’s

have important IPC implications. Different types of Carbapenemase genes (NDM, OXA-48, and KPC’s) confer resistance detected by molecular testing.

Waitematā DHB has undertaken CRE screening as part of active MDRO screening for high risk patients since 2017. Any patient suspicious of CRE/CRO on initial testing is placed in contact isolation pending further confirmation.

CRE/O Overview 2019 YTD

In 2019 to date, seven of 17 isolates flagged by the Waitematā DHB lab were confirmed as CPE by molecular testing performed by the reference lab.

Five patients were deemed high risk and hospitalised or travelled overseas

None of the CPE was attributed to NSH or WTH

No clusters or outbreaks have been identified at Waitematā DHB to date 6.2.3 Methicillin Resistant Staphylococcus Aureus (MRSA)

MRSA Overview 2019 YTD

Waitematā DHB continues to have low MRSA infection rates based on information primarily collected from laboratory antibiotic susceptibility data

99% of MRSA are community acquired

MRSA isolates in 2018-2019

2018 NSH/WTH (TOTAL)


MRSA isolates 157/105(262) 96/75 (171)

Community MRSA and other HCF (new cases) 117/82 (199) 62/48 (110)

Community MRSA (known on admission) IC-NET not collecting data from July onwards

10/13 (23) 31/27(58)

New healthcare onset (hospital acquired) 24/14 (38) 3/0 (3)

Health care onset (known on admission) 6/1 0

154


6.2.4 Vancomycin Resistant Enterococci (VRE)

Active VRE surveillance, similar to ESBL since 2007 and CPE since 2017, is performed at WDHB since May’15 after an outbreak at NSH in 2014. Identification of new VRE colonisation or infection continues to be very low due to enhanced IPC measures including use of Deprox for environmental decontamination in selected situations.

VRE Overview 2019 YTD

Only two HA VRE were identified in 2019 YTD, one in Ward 5 (March) and one in ward 8 (May); contact tracing of patients sharing rooms did not find in evidence of cross transmission at NSH

One community acquired VRE isolated from high risk patients. No VRE infections were seen over a prolonged period and the burden of VRE has also reduced slightly.

6.2.5 Clostridium Difficile (now called Clostridioides difficile)

Waitematā DHB Surveillance Definitions for CDI

Healthcare facility Onset (HO-HCA) - CDI symptom onset is more than 48 hours after admission (third calendar day). Community Onset healthcare facility associated (CO-HCA) -Discharged from a healthcare facility within previous four weeks. Community Onset Community Associated (CO) -No admission in the last 12 months. Indeterminte -Discharged from a healthcare facility within the previous 4-12 weeks. Recurrent -Episode of CDI that occurs eight weeks or less after the onset of a previous episode provided the symptoms from the prior episode have resolved. Clostridium difficile (C.difficile) infection (CDI) Summary

Clostridium difficile infection (CDI) typically results from the use of antibiotics that affect the normal gut flora, promoting the growth of gut flora. Prevention, therefore, is dependent on appropriate antibiotic use. C.difficile has the potential to spread in healthcare facilities due to its persistence in the environment and contamination of healthcare workers’ hands. There is no national data on the rate of CDI in NZ hospitals, but it is thought to be lower than European countries and the USA, with hyper virulent strains being very rare in NZ. The MoH is considering a hospital-based CDI surveillance strategy with an initial focus on standardisation of testing and definitions. Waitematā DHB commenced quarterly surveillance of CDI in mid-2013 using standard definitions from the US (Society of Healthcare Epidemiology and Centre for Disease Control). The surveillance strategy has been updated to include real-time notification, feedback, and prevention strategies to reduce hospital-acquired CDI. Waitematā DHB has an active feedback process for all cases of HO‐HCFA (definitions below) where root cause analysis is undertaken by the ID physician/ Microb iologist and Antimicrobial Stewardship (AMS) pharmacist at the time of diagnosis of CDI. A letter outlining the causes and corrective actions are sent to the responsible clinician if the case is considered avoidable. The CDI, working group in conjunction with AMS group /IPC team, will continue to focus on early recognition, improving diagnostic testing requests, isolation practice and antimicrobial stewardship as the key areas.

155


C-Diff Overview 2019 YTD

A total of 57 cases of CDI (excluding recurrence) identified 2019 YTD compared to 49 cases during a similar period, and 107 cases in the entire year in 2018)

This includes 33 new cases in Q1 and 24 cases in Q2

The proportion of healthcare facility onset (HO-HCA) infections were 38% in Q1 and 45% in Q2

Approximately 20% (7 of 37 cases) of HO-HCA CDI that were reviewed by antimicrobial stewardship team as part of an on-going active feedback process were

considered avoidable as shown in flow chart below; this proportion is similar to 2018

156


6.2.6 Seasonal Influenza Surveillance

Waitematā DHB has a yearly seasonal Influenza surveillance program which usually commences in March every year. In addition, hospital acquired (HA-Inf) is a unique designation used in our surveillance since 2017. It identifies inpatients admitted initially for other medical reasons but developed Influenza during their hospital stay, likely through acquisition from either other patients, staff, visitors or environment. Therefore, confirmation of Influenza after 72 hrs of admission is defined as HA-Inf. Data includes only confirmed patient cases where influenza like illness (ILI) symptoms developed 48 hours after admission. Source of acquisition variable (healthcare worker, patient, visitors)

Influenza Overview 2019 YTD The 2019 season so far has been characterised by earlier onset (high number of confirmed CA-Influenza cases at Waitematā DHB in Jan/Feb mostly acquired from

Northern Hemisphere travel), and higher than seasonal baseline of ILI presentations with 959 confirmed Influenza cases at NSH/WTH.

Waitakere Hospital proportionately has a higher number of confirmed Influenza cases

Majority of confirmed influenza is the H3N2 strain followed by Influenza B; both strains are included in the 2019 quadrivalent vaccine

In 2019 a concerning trend in HA-Inf cases is noted with 80 cases (46 NSH, 25 WTH and 9 Mental Health WTH) diagnosed to 12 July:

this includes two outbreaks of seasonal Inf A- Muriwai ward in June involving 10 patients and Ward 14 with eight cases between 4 -9 July

Staff illness has been reported during both these outbreaks and in clusters in other patient care areas but it is difficult to establish an epidemiological link

In 2017, during a high influenza season, HA-Inf cases were unacceptably high (100) but this reduced significantly to 34 in 2018

North Shore Hospital (NSH) Influenza 2019

Feb Mar Apr May Jun19 Jul (up to 12th

) Total YTD

Community Acquired 27 30 35 75 178 78 423

Hospital Acquired 1 0 1 3 20 21 46

Waitakere Hospital (WTH) Influenza 2019

Feb Mar Apr May Jun19 Jul (up to 12th

) Total YTD

Community Acquired 9 30 22 121 201 73 456

Hospital Acquired 1 0 3 1 27 2 34

The impact of influenza illness in the elderly patient population remains under-appreciated; to date we have identified five patients who have died in hospital with HA-Infuenza A diagnosed within 10 days prior to death. While influenza may not be the only contributor to their demise, it likely contributed significantly to the deterioration of their health

157


Waitematā DHB staff flu vaccine uptake for 2019 has increased to 65.5% compared to 59% in 2018 uptake of 59% as shown below:

020406080

100120140160180200

Act

ual

Vo

lum

e

Influenza Data at NSH Apr 2017 - Jun 2019

Influenza at NSH Community Acquired Influenza at NSH Healthcare Acquired

0 7 8 6 1 0 0 0 0 0 0 0 0 0 1 5 0 0 0 0 0 1 0 3 1 27

020406080

100120140160180200220

Act

ual

Vo

lum

e

Influenza Data at WTH Apr 2017 - Jun 2019

Influenza at WTH Community Acquired Influenza at WTH Heatlhcare Acquired

63.9% 74.1%

63.1% 65.7% 59.1%

0.0%

20.0%

40.0%

60.0%

80.0%

Allied Health Medical Mgt/Admin Nursing Support

Percentage of Vacination Received by Occupation

158


6.2.3 Communicable Diseases, Clusters and Outbreaks – Update May/June

Disease Total cases

Ward No of pt. contacts

No of staff contacts

Comments

HA- Influenza 22 Muriwai Ward,

Ward 14 and Rata Unit

Mason

8 29 Muriwai B wing had prolonged Influenza A outbreak in June across several rooms involving 10 patients and wing closure for eight days.

Ward 14 had outbreak eight patients in July with HA influenza spread across two rooms

Both Rooms 1 and 2 was closed to admission

Confirmed cases and their contacts were treated with Tamiflu in both outbreaks

Unable to identify source of cross transmission. There was two staff with influenza like illness (ILI) symptoms at the time

Rata Unit - four patients with confirmed Influenza A

Restrictions placed on patient movement and visitors

Measles 60 ED WTH/ Rangitira

586 395 West Auckland has had the highest number of measles cases in the Auckland

region

60 of the suspected 183 cases tested positive for measles

Three staff also had confirmed measles which accounted for the majority of the

staff and patient contact tracing required

To date three measles cross-transmissions have been attributed to the ED WTH

waiting room

Norovirus

3

Ward 10

3

7

Ward 10 had eight patients and seven staff reported symptoms of diarrhoea and/or vomiting

Index case was admitted with diarrhoea but not isolated in enteric precautions on admission

Two rooms (L and M) were closed from the 15-18 April 2019

With heightened infection control measures and increased environmental cleaning the norovirus did not spread to rest of the ward

N meningitidis (Meningococcus)

5 ED WTH (2) ED NSH (3)

0 18 Front line staff involved with resuscitation and intubation without appropriate

standard precautions when performing aerosol generating procedures

Confusion around administering post-exposure prophylaxis (PEP) to staff

Issues with differentiating staff exposure between high and low risk

Occupational Health and Safety Team are working on clarifying the process so

that there is clear case definition, visibility of the policy and management of the

PEP

Staff education provided on adherence to standard precautions i.e. use of

appropriate personal protective equipment

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Pertussis (Whooping Cough)

18 ED NSH ED WTH

6 22 Majority of cases were from paediatrics at Waitakere ED who had not been placed in droplet precautions on admission

Mycobacterium TB 8 ED NSH Ward 10 Huia Ward Ward 6 Muriwai Ward

4 52 Staff member with Laryngeal TB which resulted in contact tracing of staff and patients

Patients were not isolated in airborne precautions as TB was not the diagnosis on admission

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7. Patient and Whānau Centered Care 7.1 Patient Experience Feedback – May update

7.2.1 National Inpatient Survey

Table 1: National Survey Quarter One (January – March 2019)

Table 1 above represents the first quarter of 2019 for the adult inpatient patient experience survey. The date range for this survey was patients discharged between 4 February and 17 February 2019. Following a similar trend from the previous quarter, all surveys were sent electronically due to the increased collection of patient emails. The response rate for quarter four was 32%, which is an increase from last quarter (27%). National response rate for this quarter was 24%. For this quarter (like previous quarters) there was little variation between district health boards. Waitematā DHB scores for communication and partnership were our highest scores since the national survey was introduced. There was a notable increase in the communication and partnership domain this quarter as seen in the run chart below (Graph 1). All other domains are above our median score. The lowest scoring areas remain the same as previous quarters and are in line with the lowest scoring questions nationally. These are: Did a staff member tell you about medication side effects to watch when you went home? Did the hospital staff include your family/whānau or someone close to you in discussion about your care? And Do you feel you received enough information from the hospital on how to manage your condition after your discharge? Waitematā DHB exceeded the National Average in the availability of cultural support scoring 9.3/10. Waitematā DHB fell against the national average in involving family/whānau in discussion about care and providing enough information on discharge. All other questions were within .4 points of the national average

HQSC final weighted results

Communication Partnership Co-ordination Needs

8.3 National Average




8.4 WDHB

8.5 WDHB

8.2 WDHB

8.5 WDHB

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Graph 1: Waitematā DHB run chart

7.2.2 Friends and Family Test In May 2019 our Net Promoter Score (NPS) increased one point to 76 and we received feedback from 1,206 people, an increase of 24% from the previous month. The NPS continues to perform well and scores above the DHB target of 65.

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Friends and Family Test Overall Results

Figure 1: Waitematā DHB overall NPS

Graph 2: Waitematā DHB overall FFT results

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Table 2: Waitematā DHB FFT results (each question)

The net promoter scores in May have met target for all Friends and Family Test questions. This month, all measures improved slightly on the previous month, with the exception of ‘did we see you promptly’ which dropped slightly from 75 last month to 74 this month. Net Promoter Score over time

Graph 3: Waitematā DHB Net Promoter Score over time

5052545658606264666870727476788082

WDHB Target

Net Promoter Score

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Total Responses and NPS to Friends and Family Test by ethnicity

May 2019 Māori Overall Asian

Overall Pacific

Other

Responses 80 85 67 226

NPS 79 75 84 79

Table 3: NPS by ethnicity This month, all ethnicities have met the Waitematā DHB NPS target and score 65 and above. All scores have increased since last month, with the biggest gain for Pacific which increased 20 points from 64 to 84.

May 2019 Māori Overall Asian

Overall Pacific

Other

Did we see you promptly? 86 76 79 81

Did we listen and explain? 84 81 82 82

Did we show care and respect? 87 82 89 86

Did we meet you expectations? 83 76 74 77

Were we welcoming and friendly? 91 80 86 85

Table 4: NPS for all questions by ethnicity

Our highest performing scores are for ‘welcoming and friendly’, ‘showing care and respect’ and ‘listen and explain’. ‘Did we see you promptly’ is consistently one of our poorest performing indicators, however this month all ethnicities showed an increase on last month, particularly Pacific, increasing from 66 last month to 79 this month. Friends and Family Test Comments

“Everyone I saw was cheerful and kind and extremely helpful.” Gastroenterology, NSH

“So helpful and informative. Such a wealth of knowledge and support.” Community Child Health North, Allied Health

“Respectful staff, good service and they look after patients very well. Love their passion and commitment to their patients.” Titirangi Ward, WTH

“I have been in private hospitals and this tops all. So happy with all my care from staff and doctors.” Elective Surgery Centre, NSH

“I would like to thank you all for your care and compassion during my stay. Not only did you show empathy and care, you were genuinely concerned for my recovery and welfare. You encouraged me and gave me the confidence to get mobile which was vital to my recovery” Ward 7, NSH

“The physiotherapist was welcoming, helpful, gave good guidance and encouragement.” Outpatients Physiotherapy, WTH

“Amazing staff during a stressful time.” SCBU, NSH

“Staff are attentive, knowledgeable and friendly.” Dialysis, Apollo Drive

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Friends and Family Test by ward

May-2019

Division Ward Responses NPS

AH Allied Health Bariatric Dietitian Outpatients 1 -100

AH Allied Health Community Adults North 5 80

AH Allied Health Community Adults Rodney 1 100

AH Allied Health Community Adults West 4 100

AH Allied Health Community Child Health North 5 100

AH Allied Health Early Discharge and Rehabilitation Service (EDARS) 11 90

AH Allied Health Outpatients Physiotherapy NSH 17 100

AH Allied Health Outpatients Physiotherapy WTH 14 71

ESC Elective Surgery Centre 22 95

A&EM North Shore Hospital Assessment Diagnostic Unit (ADU) 37 51

SMHOP North Shore Hospital Dialysis Unit 1 100

A&EM North Shore Hospital Emergency Department (ED) 37 58

SMHOP North Shore Hospital Gastroenterology 13 92

SMHOP North Shore Hospital Haematology Day Stay 21 71

S&AS North Shore Hospital Hine Ora Ward 21 100

S&AS North Shore Hospital Intensive Care Unit/High Dependency Unity (ICU/HDU) 14 86

A&EM North Shore Hospital Lakeview Cardiology 78 86

CWF North Shore Hospital Maternity Unit 89 72

S&AS North Shore Hospital Outpatients 19 53

CWF North Shore Hospital Outpatients Women’s Health 3 100

S&AS North Shore Hospital Radiology 1 100

CWF North Shore Hospital Special Care Baby Unit (SCBU) 11 91

A&EM North Shore Hospital Ward 2 36 61


S&AS North Shore Hospital Ward 4 50 74





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SMHOP North Shore Hospital Ward 12 KMU 2 -100

SMHOP North Shore Hospital Ward 14 31 77

SMHOP North Shore Hospital Ward 15 25 84

CWF Wilson Centre 9 44

A&EM Waitakere Hospital Assessment Diagnostic Unit (ADU) 95 80

A&EM Waitakere Hospital Anawhata Ward 18 65

SMHOP Waitakere Hospital Dialysis Unit 1 100

A&EM Waitakere Hospital Huia Ward 20 50

CWF Waitakere Hospital Maternity Unit 16 75

SMHOP Waitakere Hospital Muriwai Ward 25 64

S&AS Waitakere Hospital Outpatients Reception 1 1 100

CWF Waitakere Hospital Rangatira Ward 25 88

CWF Waitakere Hospital Special Care Baby Unit (SCBU) 10 80

S&AS Waitakere Hospital Surgical Unit 14 100

A&EM Waitakere Hospital Titirangi Ward 37 62

A&EM Waitakere Hospital Wainamu Ward 20 85

Table 5: FFT results by ward Key for above table: Service/Ward Responses: Green – achieved response target, Red – did not achieve response target NPS: Green – met NPS target (65+), Amber – nearly met target (50-64), Red – did not meet target (<50)

This month, 63% of services and wards met their response targets, a slight improvement from 59% last month. Of these wards/services, 70% scored at or above the Waitematā DHB target. The top three ranking wards are Hine Ora, Elective Surgery Centre and Special Care Baby Unit, NSH (see table 6 below). The main reasons for these positive scores include great staff (friendly, kind, caring, efficient, helpful and supportive), outstanding care and great facilities/environment. This month, the lowest NPS are for Huia Ward, Waitakere Hospital and Assessment and Diagnostic Unit (ADU), North Shore Hospital (NPS 50 and 51 respectively). The reason for a low NPS score in Huia Ward is because 40% of respondents provided a neutral rating ‘likely to recommend’. In ADU, the main reasons for the negative feedback include long wait times, slow service, busy staff, short staffed, poor communication and a lack of basic skills i.e. wound cleaning and dressing.

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A summary of the FFT results can be seen below.

Ward/Service – Exceptional NPS Target

Responses Achieved

NPS Score

Hine Ora Ward, North Shore Hospital Elective Surgery Centre, North Shore Hospital Special Care Baby Unit, North Shore Hospital

10 20 10

21 22 11

100 95 91

Ward/Service – Low NPS Target

Responses Achieved

NPS Score

Huia Ward, Waitakere Hospital Assessment and Diagnostic Unit, North Shore Hospital

10 20

20 37

50 51

Table 6: FFT Results Summary

Kōrero Mai/Talk to Me Programme Kōrero Mai is a patient and whānau led escalation service that was launched in mid-November 2018. Patients are empowered to use a three step process to escalate their concerns. The third step instructs patients/whānau to call an 0800 number which is triaged by a Senior Nurse 24 hours/7 days a week who can request a medical review for a reported deterioration or intervene to support patient concerns. At the end of April we have had 18 phone calls, please see details of two May phone calls below. Out of the 18 calls, four were not Kōrero Mai calls and were forwarded to the phone line via switchboard.

DATE Department Caller Event detail Follow up actions (as stated in RiskPro)

May 2019

ESC Patient Wife

Not clear what is going on with treatment plan, limited answers. Saw five different doctors in four days with no clear plan or outcome of what is causing pain

DNM advised patient wife to escalate to Chare Nurse Manager in AM to address issue. Patient wife agreed and followed up pro-actively by CNM in morning. Outcome: Patient and wife thankful appreciate the escalation process and how quick all their concerns were addressed the next day.

May 2019

Ward 2 Patient Father

Father rang due to concerns related to lack of medical updates and lack of communication from staff regarding son refusing treatment. Father unaware that this was occurring after stating he was available to assist. Not yet had psych RV (waiting one week) as father feel he is cognitively impaired post stroke.

Family meeting organised, escalation to CNM. Outcome: Patient Experience Director appointed key contact due to relationship challenges that were resolved following increased family contact.

Table 7: May Kōrero Mai Call Summary

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7.3 Patient Experience Activity Highlights

Volunteer Recruitment Statistics Volunteer numbers have decreased by three from previous month. The numbers may start to increase the following month as we will expand our ways of recruitment.

Green Coats Volunteers

(Front of House) (A)

Other allocated Volunteers

(B)

Volunteers on boarded awaiting

allocation (C)

Total volunteers available (D)

(A) + (B) + (C) =(D)

53 94 5 152

Table 8: Volunteers Recruitment

Volunteer Activity Highlights Recruitment We are receiving and processing applications regularly with an average of two applications per fortnight received. A recruitment video we created with the Communications team for social media did not attract as many volunteers as we were expecting. We will advertise with Volunteering Auckland in July and advertise in local newspapers. Volunteer Celebration – National Volunteer Week Waitematā DHB celebrates our volunteers during National Volunteer week each year. Morning teas were held each day with fruit picked from the Director of Patient Experience’s fruit trees and cake. This year our larger celebration will be held on 29 July and 1 August 2019 at North Shore and Waitakere Hospital respectively. Ward Volunteer receives compliment Ward volunteers who support patients, their whānau and visitors in our wards have received more compliments.

Over the past few months retaining ward volunteers has been challenging. Various reasons for this include the ability to commit to a shift a week and limits to the scope of the roles. Those who are integrated into ward teams are highly successful. The overall aim of the programme is to have volunteers on all inpatient wards, however filling current vacancies is delaying the expansion.

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Patient Experience Team Highlights Consumer Council Short Listing completed Sixty two applicants for the Consumer Council were short listed for interview in May. Through the recruitment process and nominations from Ngāti Whātua and Waipareira, Healthilnk North and Waitakere Healthlinks the following twelve members have been appointed:

Boyd Broughton (Te Rūnanga o Ngāti Whātua)

Lorraine Symons (Te Whānau o Waipareira)

Angela King (Healthlink North)

David Lui (Waitakere Healthlink)

Kaeti Rigarlsford

DJ Adams

Ravi Reddy

Vivien Verheijen

Doaa Bayoumy

Insik Kim

Neli Alo

Jeremiah Ramos

The first meeting took place on 3 July 2019 and the council will have six-weekly meeting for the rest of the year.

Asian Health Services Team Highlights Asian culture workshops for Allied Health New Graduates Asian Health Services (AHS) has been providing regular cultural workshops for new nursing graduates and expereinced nurses newly employed by Waitematā DHB. The Allied Health team apporached Asian Health Services to present cultural workshop for their new graduates. Two workshops were provided and excellent feedback was received. #WannaTalk – Asian Youth Life skills workshop New Zealand has the highest youth (15-18 yrs) suicide rate according to global data. Their mental health and wellbeing are priorities of the Mental Health and Addction (MH & A) services. Asian Mental Health Service (AMHS) hosted a sucessful youth suicide prevention workshop called #WannaTalk in May. Youths aged 14 to 18, parents and caregiver were encouraged to attend this workshop to learn useful information that could help teenagers build positive coping strategies when they are stressed or at risk of self-harm. Asian Health Services (AHS) staff – Full time Equivalent (FTE)

No. of current staff 22 FTE

No. of management 1

No. of iCare Call Centre & Asian Patient Support Service (APSS) 4.7

No. of APSS Bureau (contractors) 9

No. of Asian Mental Health Service (AMHS) 5.5

No. of AMHS Bureaus (contractors) 20

No. of WATIS interpreting service 9.5

No. of interpreters (contractors) 164

Vacancy 1.3 (0.5 APSS & 0.75 WATIS)

Total 228 (22FTE + 206 contractors)

Asian Patient Support Service & iCare call Centre (May 2019)

No. of total enquiries 1,400

No. of iCare call centre enquiry - NZ Health info, GP, Breast Screen etc. 953

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No. of new inpatient referrals - complex issue & cultural support 99

No. of support episodes by cultural support coordinators 447

No. of clinical meetings & face to face liaison 271

No. of phone support 91

No. of clinical coordination 85

No. of health or cultural workshop or promotion or survey 1

No of cultural talks for health professionals 3 (1 for Nursing & 2 for Allied Health)

No. of document – cultural review /input 2

Asian Mental Health Service (May 2019)

No. of active mental health clients (target KPI: 75) 92

No. of new referral - mental health client 12

No of client support hours 243

No. of support meeting hours 141

No. of liaison psychiatry referral 2

No. of active forensic MH clients 1

No. of acute MH inpatient ward or crisis team referral 8

No. of Asian Clinical Psychological Service referral 6

No. of exit 7

No. of Asian Wellbeing Group Sessions /meetings 4

WATIS Interpreting Service (May 2019)

No. of interpreters (cover 90+ languages & dialects) 177

No of interpreting episodes 4,803

No. of face to face interpreting 2,749

No. of appointment confirmation 1,528

No. of telephone assignment 389

No. of telephone interpreting 136

No. of document translated or proof reading 1

% DNA of WATIS users 1.35%

Booking unfulfilled 2.14%

Pastoral Care Update The Chaplains were involved with the planning and facilitation of many events for the opening of the Waitakere Chapel. A dedication service led by the Catholic and Anglican Bishops was held on 4 June. Other community events were put on throughout the week, including a dawn service, a Pasifika celebration, Asian Health services, community open day and a multi-faith celebration. These were all well attended by our community. Due to many complaints from several DHBs about recent decisions and changes made by the Interchurch Council for Hospital Chaplaincy (HCH) – the Ministry of Health (in which ICHC is funded) will be facilitating a tripartite approach to resolve some issues and determine how spiritual care is supported within DHBs.

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7.4 Patient Experience Activity Overview

Project Name Project Summary Patient Experience Lead

Update Domain Status

Organisation wide / Multiple Divisions

Kōrero Mai – Whānau/Patient led escalation

Kōrero Mai (Talk to Me) aims to co-design a patient/family/whānau-led escalation system for patients whose condition is deteriorating (getting worse).

David Price Jeanette Bell Ravina Patel Lara Cavit

- Patient Experience Director is Project Sponsor. - All working/steering groups formed - Ongoing communication plan and audit of Kōrero

Mai promotional reach and evaluation of calls that are made to the Kōrero Mai phone lines.

- Nine calls and one text message received to date. - KMU roll out completed in February. - Roll out to maternity and SCBU completed - Staff and Patient Surveys on all wards to assess

awareness of the programme. Over half of the wards have been surveyed. An evaluation and baseline report is available.

- Translated collateral development completed. - Kōrero Mai is now business as usually and will be

regularly evaluated and regular campaigns to promote the service.

Patient & Community Participation

Consumer Council As part of the annual planning DHB priorities guidelines for 2016/17 an expected focus for improving quality at WDHB is to ‘commit to either establish or maintain a consumer council (or similar) to advise the DHB’. Waitematā DHB is a unique position with key stakeholders (Waitakere Healthlink and Healthlink North), contracted to support consumer engagement activity.

David Price

- Key principles agreed following two meetings with Healthlink Boards, awaiting sign off before progressing to Board presentation.

- ToR and Board paper draft completed and endorsed by ELT.

- Presentation to the Board in July – endorsement received with revisions to Board recommendations to be presented in September.

- Further presentation to Board in September - Presentation to Board at December for approval –

endorsement received to establish Consumer Council.

- Recruitment for Consumer Council completed. - First meeting scheduled for 3 July.

Governance

Mystery Shopping Programme

To further understand the experiences of patients and consumers accessing our services via phone a mystery shopping

Ravina Patel - PE team has developed a programme for 2019 to ensure that the mystery shopper phone calls are undertaken monthly. SMT has endorsed the

Measurement & Evaluation

On track Generally on track – minor issues/delays

Off track/not started

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programme will be piloted. programme. - Each month 10-12 services are contacted. - 10 calls completed in May. Calls are underway for

June. - Quarterly report complete and presented to CEO. - PE team will progress training of Contact Centre

and Patient Service Centre staff with best practice guidelines that are co-designed with staff.

Patient & Community Participation

Patient Stories Capturing patient stories on video for internal and external audiences. The purpose is for staff to learn from experiences and assist with providing the best level of support and care to our patients.

Ravina Patel

- Patient story - PACU. Educational video taking patients through PACU and what to expect from surgery. Filming complete.

- Patient Story – Asian Health. Filming scheduled for 25 June. Three Asian patients will provide stories of their experience.

- Patient Story – Stroke. Two potential patients have been identified and are available for filming from July.

- Patient Story – Disability. Improving the patient experience for deaf people.

- Patient story – Autism. Challenges people with autism face and augmented communication. Seeking a patient to support the video. Disability Advisor to provide patient details.

- Patient Story – Maternity. Educational video to support new parents with caring for their new born baby.

- Patient Story – Māori Health planned to take place mid-2019.

Patient Feedback - Survey Design

Advisory role supporting services to develop patient surveys which capture feedback to understand if we are providing our patients with a quality service.

David Price Ravina Patel

- Awhi tamariki families and whānau - Community Mental Health - Joint replacement - Pacemaker Clinic - Parenteral nutrition - Enteral Feeding - Idiopathic Pulmonary Fibrosis - Assistance with accessing Survey Monkey data


Health Literacy Collaboration with Auckland DHB to enhance health literacy awareness across the organisation in supporting patients to make

David Price Leanne Kirton

- Health Literacy Policy endorsed by Executive Leadership Team in April for endorsement.

- Health Literacy intranet site updated and to went

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informed choices about their healthcare and improve communication both written and verbal.

live in March. - Launch of awareness campaign across

organisation to promote policy, new resource intranet page and e-learning modules adapted from a Hawkes Bay DHB resource to progress in July/August.

- Health Symposium to be organised for 31st

of October 2019 – Key note speakers confirmed.

Patient and Whānau Centered Care Standards (PWCCS) Review

The Patient Experience team is leading a review of the Patient and Whānau Centred Care Standards to engage the multi-disciplinary team in the process and ensure the results of the survey provide effective insight into ward performance in the fundamentals of patient and whānau centred care.

David Price Meg Smith

- Interviews with all CNMs, Clinical Nurse Directors and Heads of Division have been completed.

- Four focus groups have been completed with focus on solution generation.

- Meetings with cultural teams have taken place. - Allied Health planning meeting occurred in

February – pilot requested on AT&R wards. - Further investigation into medical engagement in

process. - Recommendations for change finalised and

presented to the PWCCS Steering group. - Socilisation of recommendations to be completed

with development of recommendations and improvements to continue throughout 2019.

Joint Māori Health and Patient Experience Action Plan

Patient Experience reporting lacks cultural understanding and the ability to tell the story of our Māori patients and their whānau. The Māori Health and Patient Experience team have come together to align our focus and understand the Māori patient experience.

David Price Riki Nia Nia

- Joint team meeting on Waitakere Marae conducted in late November 2018.

- Draft paper collated and circulated to both teams for endorsement – paper endorsed.

- Presented to and endorsed by Maori Equity Committee – action plan now to be created to meet objectives of the Maori Health & Patient Experience Team collaboration.

#hellomyname is Campaign

Following on from the successful campaign last year, the Patient Experience Team is leading the #hellomynameis campaign on the 23

rd of July. There are plans to extend the

campaign into ARDs and to also collaborate with Counties.

Lara Cavit - Meeting set up with End Of Life champions who will be responsible for distributing resources on wards

- Communications plan to be developed with the Comms team

- Date set for July 23 to launch campaign - ARDs on board for promotion of campaign and

resources translated in six languages.

Volunteers

Ward and outpatients Volunteer Programme

Waitematā DHB aims to have volunteers working on all wards throughout the

Genevieve Kabuya

- Hine Ora, Waitakere ADU, Short Stay Ward, Anawhata, Titirangi wards have been set up and

Patient and community

174


organisation to support specific tasks and enhance the patient experience. Providing social connections and meeting basic patient needs in a busy ward environment is important to our patients.

Lara Cavit

functioning independently with pool of volunteers. - Consultation between Patient Experience team

and ward 14 staff still in the process to set up agreed measures to fully utilise volunteer pool and establish the profile of Ward 14 volunteer

- The St John volunteers who settled well in ward 15 are unable to continue with their volunteer work. We will be working with St John to find new candidates

- Follow up and recruitment continue for Rangatira, Outpatient service, Muriwai ward and maternity at Waitakere.

- Consistent on-boarding processes and support systems have been developed.

- Positive feedback about this service start to come through Friend and Family Tests (FFT)

- To commence recruitment for Ward 5 and Ward 10 volunteers in July 2019.

participation

Better Impact An online volunteer management system that provides access to volunteer information within one database.

Team - Spread sheet containing volunteer information has been sent to Better Impact to input into the Better Impact System

- Five training sessions were completed in August. - Better Impact linked with Waitematā DHB website

to streamline the volunteer application process. - Better Impact automation of rosters has

commenced. - Ongoing data maintenance progressing with July

2019 go-live date for volunteers to actively use Better Impact.

Patient and community participation

On-boarding and training for volunteers

Developing systems and processes to ensure that the on boarding and training programme for staff aligns with current processes for Waitematā DHB staff/contractors. This will be linked to a central database managed through Occupational Health and Safety. This new process will ensure that volunteers have completed their mandatory training before receiving or renewing their Waitematā ID cards. The aim is to have all

Lara Cavit Genevieve Kabuya

- Review of current processes has been completed and a recruitment and on boarding process has been developed.

- Learning and Development have included volunteers in Welcome to Waitematā for orientation with staff.

- An online training module has been developed with Occupational Health and Safety Services which will include mandatory training for volunteers.

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current volunteer on boarded into this new training system by the end of 2019.

- This online training is currently being rolled out with current volunteers.

- We are meeting with St John’s and liaising with their National coordinator to get all of the St John’s volunteers integrated into this new system

Child Woman and Family

Auckland Regional Dental Service (ARDS) Patient Experience paediatric measurement

Currently the experience of paediatrics who access ARDS is not measured. There is some research in to various methods of paediatric patient experience and ARDS would like to explore these to determine which overarching method can be adopted by their services. From paediatric feedback, service improvement priorities can be identified.

Lara Cavit

- Patient Experience training with all ARDs staff took place in January 2019 across four days.

- Indepth training of all ARDs staff progressing over April/May and June – four hour sessions focussed on communication and health literacy.

- Currently waiting for the youth version of the FFT to be finalised which be rolled out across the ARDS.


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Monthly Report for Hand Hygiene May 2019

Waitemata DHB Hand Hygiene Monthly Report April 2019

Highlights: The overall Waitemata DHB hand hygiene compliance for the month of May 2019 is 89%.

Special mention to the following clinical units that achieved compliance of above 90%

o CVU NSH 100%

o Maternity NSH 100%

o Ward 5 100%

o Ward 4 99%

o Ward 6 97%

o Haematology Day Stay 96%

o Ward 11 96%

o Ward 14 95%

o Ward 7 95%

Special mention to the following clinical units that achieved compliance of above 95%

o Kahikatea Unit Mason Clinic 100%

o Pohutukawa Unit Mason: 100%

o Te Aka Unit Mason Clinic 100%

o Rangitira Unit 98%

o CADS 96%

o Haemodialysis WTK HR 96%

o Theatre WTK 95%

Congratulations to the professional group with the highest compliance rate: o Phlebotomy Invasive Technician = 94%

Areas of concern: Clinical units performing below the 80% benchmark are

o Muriwai ward 79% o Theatre NSH 78% o Emergency Department NSH 77% o CCU NSH 66%

Accessing department reports: Monthly reporting is available via two reports:

o A short 6 page DHB level report (this report). o Individual department reports are be available from the shared drive:

NSH site on G drive: G:\Nurses\AUDITS PROGRAM\1 Audit Schedule & Specific Results 2019\Hand Hygiene\2019 WTK site on M drive: M:\Nurses\AUDITS PROGRAM\1 Audit Schedule & Specific Results 2019\Hand Hygiene\2019

o It is recommended that the department reports are printed and publically displayed in each department’s quality board.

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Hand Hygiene Program Update New Waitemata DHB Hand Hygiene Policy authorized Please see controlled documents > policies & procedures > infection control to view the Waitemata DHB Hand Hygiene Policy authorized in November 2018. This new policy has an expanded section on the Below the Elbows (BBE) policy and Waitemata DHB’s expectations of HCWs. Number of moments required by clinical units

Inpatient medical, surgical, radiology, endoscopy, maternity, paediatric units = 100 moments per month

Outpatient units (including outpatient Haemodialysis and Haematology units), Wilson Centre, Hine Ora, CVU, interventional radiology NSH (AIR) = 50 moments per month

Inpatient mental health / detox units, hyperbaric unit = 25 moments per month Hand hygiene auditor training for 2019

Friday 21st June 2019 08:00 – 16:00 hours

Kawakawa Room, level 1, Whenua Pupuke, NSH

Friday 20th September 2019 08:00 – 16:00 hours


Recommendations for improving compliance: If your compliance is below 80%:

Work with your hand hygiene auditors to identify any compliance issues

Notify the Waitemata DHB hand hygiene coordinator (Graham Upton – Mobile: 021828047) of any issues that may need further assistance. These issues will be discussed at the monthly Waitemata DHB hand hygiene committee meeting.

A plan for improvement will be created between the hand hygiene committee, line managers and auditors. Your area does not have any auditor:

Please nominate a staff member and book them into the next hand hygiene training day. Please contact Merissa Rajoo – Mobile: 021764956 for the booking / or via email.

You did not meet the required moments for your department:

Please provide your auditors with dedicated time to collect the required moments.

Graph 1: Waitemata DHB hand hygiene compliance in the last 12 months

Table 1: Overall Waitemata DHB hand hygiene compliance by facility

70%

75%

80%

85%

90%

95%

100%

May

20

18

Jun

20

18

Jul 2

01

8

Au

g 2

01

8

Sep

20

18

Oct

20

18

No

v 2

01

8

De

c 2

01

8

Jan

20

19

Feb

20

19

Mar

20

19

Ap

r 2

01

9

May

20

19

Han

d H

ygie

ne

Co

mp

lian

ce %

Waitemata DHB Hand Hygiene Compliance last 12 months

Series28 Series29 Series1

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Name Correct Moments Total Moments Compliance Rate

Mental Health 129 132 97%

Waitakere Hospital 1246 1403 88%

Elective Surgery Centre 248 285 87%

Wilson Centre 45 50 90%

North Shore Hospital 2736 3034 90%

Waitemata DHB 4230 4722 89%

Table 2: Overall Waitemata DHB hand hygiene compliance by professional group


Phlebotomy Invasive Technician 230 240 97%

Nurse/Midwife 2348 2574 91%

Student Allied Health 31 38 91%

Health Care Assistant 458 506 91%

Student Doctor 40 46 87%

Student Nurse/Midwife 229 249 92%

Medical Practitioner 478 569 84%

Allied Health Care Worker 234 278 84%

Orderly & Cleaners & Others 138 167 82%

Meal staff 23 28 82%

Administrative and Clerical Staff 21 27 78%

Table 4: Overall Waitemata DHB hand hygiene compliance by moment


1 - Before Touching A Patient 1210 1398 86%

2 - Before Procedure 557 616 90%

3 - After a Procedure or Body Fluid Exposure Risk 638 671 95%

4 - After Touching a Patient 1218 1356 95%

5 - After Touching A Patient's Surroundings 577 681 84%

Table 5: North Shore Hospital hand hygiene compliance by department


Haematology Day Stay NSH HR 96 101 98%

Maternity NSH 106 106 100%

Ward 4 112 113 99%

Hine Ora Ward 98 104 96%

ADU NSH 82 101 81%

Ward 11 136 142 96%

Ward 7 95 100 95%

Ward 14 100 105 95%

Ward 12 KMU 93 100 93%

Endoscopy NSH 79 84 94%

Haemodialysis NSH HR 94 101 93%

Ward 6 116 120 96%

179



Outpatients Department NSH 13 16 81%

Short Stay NSH 91 102 89%

Ward 5 100 100 100%

PACU 1 & 2 NSH 70 77 90%

Haemodialysis Apollo HR 55 61 88%

ICU HR 46 51 90%

Ward 15 89 100 87%

SCBU NSH 121 137 88%

CVU NSH 50 113 82%

Ward 2 87 102 85%

Radiology NSH 69 78 88%

Ward 10 94 100 94%

Ward 3 99 108 86%

Ward 8 145 167 86%

Ward 9 107 119 89%

Emergency Department NSH HR 118 153 77%

CCU NSH 75 113 66%

Theatre NSH 38 49 77%

Table 6: Waitakere hospital hand hygiene compliance by department


Emergency Department WTK HR 6 7 85%

Radiology WTK 41 50 82%

Rangitira Unit 123 126 97%

Titirangi 108 116 93%

Haemodialysis WTK HR 48 50 96%

Theatre WTK 95 100 95%

Endoscopy WTK 86 100 86%

Anawhata 30 36 83%

Huia 91 100 91%

SCBU WTK 110 128 85%

Maternity WTK 84 100 84%

Muriwai Ward 103 130 79%

ADU WTK 83 101 82%

CADS 24 25 96%

PACU WTK 87 101 86%

Wainamu Ward nil nil 0%

Table 7: Elective Surgery Centre hand hygiene compliance by department


180



ESC PACU 72 73 97%

Cullen Ward 108 111 92%

Theatre ESC 74 101 73%

Table 8: Mental Health hand hygiene compliance by department


Kahikatea Unit Mason Clinic 32 32 100%

Kauri Unit Mason Clinic nil nil 0%

Pohutukawa Unit Mason Clinic 25 25 100%

Rata Unit Mason Clinic nil nil 0%

Tane Whakapiripiri Unit Mason Clinic 23 25 100%

Te Aka Unit Mason Clinic 25 25 100%

Totara Unit Mason Clinic nil nil 0%

Waiatarau Acute Mental Health Unit nil nil 0%

He Puna Waiora 23 25 92%

181

Monthly Report for Hand Hygiene June 2019


Highlights: The overall Waitemata DHB hand hygiene compliance for the month of June 2019 is 90%.

Special mention to the following clinical units that achieved compliance of above 90%. North shore Hospital:

o Maternity NSH 100%

o Ward 4 98%

o Ward 12 97%

o Ward 6 97%

o Ward 11 94%

o Haematology Day Stay 96%

o Ward 10 93%

o Ward 8 94%

o Ward 7 94%

o Hinero 92%

o Ward 5 92%

o SSW 90%

o Haematology Apolo 90% Waitakere Hospital:

o Kahikatea Unit Mason Clinic 100%

o Kauri Unit Mason Clinic 100%

o Te Aka Unit Mason Clinic 100%

o Totara Unit Mason Clinic 100%

o Maternity WTK 97%

o Anawhata 97%

o Titirangi 97%

o Haemodialysis WTK HR 92%

o SCBU WTK 91%

o Theatre WTK 91%

o Huia 90%

o Outpatients 90%

Congratulations to the professional group with the highest compliance rate: o Phlebotomy Invasive Technician = 94%

Areas of concern: Clinical units performing below the 80% benchmark are

o Theatre NSH 78% o Theatre NSH ESC 77% o Emergency Department NSH 67% o Endoscopy No data o Emergency Department WTK No data

182



Accessing department reports: Monthly reporting is available via two reports:

o A short 6 page DHB level report (this report). o Individual department reports are be available from the shared drive:

NSH site on G drive: G:\Nurses\AUDITS PROGRAM\1 Audit Schedule & Specific Results 2019\Hand Hygiene\2019 WTK site on M drive: M:\Nurses\AUDITS PROGRAM\1 Audit Schedule & Specific Results 2019\Hand Hygiene\2019

o It is recommended that the department reports are printed and publically displayed in each department’s quality board.

Hand Hygiene Program Update New Waitemata DHB Hand Hygiene Policy authorized. Please see controlled documents > policies & procedures > infection control to view the Waitemata DHB Hand Hygiene Policy authorized in November 2018. This new policy has an expanded section on the Below the Elbows (BBE) policy and Waitemata DHB’s expectations of HCWs. Number of moments required by clinical units

Inpatient medical, surgical, radiology, endoscopy, maternity, paediatric units = 100 moments per month

Outpatient units (including outpatient Haemodialysis and Haematology units), Wilson Centre, Hine Ora, CVU, interventional radiology NSH (AIR) = 50 moments per month

Inpatient mental health / detox units, hyperbaric unit = 25 moments per month Hand hygiene auditor training for 2019

Friday 7th November 2019 08:00 – 16:00 hours


Recommendations for improving compliance: If your compliance is below 80%:

Work with your hand hygiene auditors to identify any compliance issues

Notify the Waitemata DHB hand hygiene coordinator (Merissa Rajoo– Mobile: 021764956 of any issues that may need further assistance. These issues will be discussed at the monthly Waitemata DHB hand hygiene committee meeting.

A plan for improvement will be created between the hand hygiene committee, line managers and auditors. Your area does not have any auditor:

Please nominate a staff member and book them into the next hand hygiene training day. Please contact Merissa Rajoo – Mobile: 021764956 for the booking / or via email.

You did not meet the required moments for your department:

Please provide your auditors with dedicated time to collect the required moments.

Graph 1: Waitemata DHB hand hygiene compliance in the last 12 months

183



Table 1: Overall Waitemata DHB hand hygiene compliance by facility


Mental Health 119 122 97%

Waitakere Hospital 1,273 1,427 89%

Elective Surgery Centre 239 272 88%

Wilson Centre 42 50 84%

North Shore Hospital 2,517 2,817 91%

Waitemata DHB 4,083 4,516 90%

Table 2: Overall Waitemata DHB hand hygiene compliance by professional group


Phlebotomy Invasive Technician 231 246 94%

Nurse/Midwife 2278 2472 94%

Student Allied Health 15 16 94%

Health Care Assistant 528 574 92%

Student Doctor 40 46 87%

Student Nurse/Midwife 77 88 88%

Medical Practitioner 562 645 87%

Allied Health Care Worker 221 243 91%

Administrative and Clerical Staff 12 14 85%

Cleaner and Meal staff 23 30 76%

Orderly & Others 99 145 68%

Table 4: Overall Waitemata DHB hand hygiene compliance by moment

Name Correct Moments

Total Moments Compliance Rate

70%

75%

80%

85%

90%

95%

100%

May

20

18

Jun

20

18

Jul 2

01

8

Au

g 2

01

8

Sep

20

18

Oct

20

18

No

v 2

01

8

De

c 2

01

8

Jan

20

19

Feb

20

19

Mar

20

19

Ap

r 2

01

9

May

20

19

Han

d H

ygie

ne

Co

mp

lian

ce %

Waitemata DHB Hand Hygiene Compliance last 12 months

Series28 Series29 Series1

184



1 - Before Touching A Patient

1,166

1,344 86%

2 - Before Procedure 490 525 93%

3 - After a Procedure or Body Fluid Exposure Risk 596 621 96%

4 - After Touching a Patient 1,177 1,247 94%

5 - After Touching A Patient's Surroundings 654 779 84%

Table 5: North Shore Hospital hand hygiene compliance by department. Name Correct Moments Total Moments Compliance Rate

Ward 6 191 197 97.0%

Ward 11 159 170 94.0%

SCBU NSH 154 168 91.0%

Ward 12 KMU 129 132 98.0%

Ward 5 117 127 92.0%

Ward 14 112 128 88.0%

Maternity NSH 105 105 100.0%

CCU NSH 102 116 88.0%

Ward 8 100 107 94.0%

Ward 4 99 101 98.0%

ADU NSH 97 104 93.0%

Ward 7 94 100 94.0%

Short Stay NSH 93 103 90.0%

Ward 10 93 100 93.0%

Ward 15 88 100 88.0%

Ward 2 88 104 85.0%

Haemodialysis NSH HR 87 100 87.0%

Hine Ora Ward 80 87 92.0%

Radiology NSH 80 93 86.0%

PACU 1 & 2 NSH 78 94 83.0%

Outpatients Department NSH 68 74 92.0%

Haemodialysis Apollo HR 54 60 90.0%

CVU NSH 49 52 94.0%

Haematology Day Stay NSH HR 48 50 96.0%

Wilson Centre 42 50 84.0%

ICU HR 38 40 95.0%

He Puna 25 30 83.0%

Ward 9 36 41 88.0%

Ward 3 65 84 77.0%

Theatre NSH no data no data no Data

Endoscopy NSH no data no data no Data Emergency Department No data No data no data

185



Table 6: Waitakere hospital hand hygiene compliance by department


Rangitira Unit 113 127 89%

Titirangi 112 116 97%

Muriwai Ward 95 109 87%

Maternity WTK 104 107 97%

Wainamu 92 105 88%

SCBU WTK 94 103 91%

ADU WTK 82 102 80%

Endoscopy WTK 81 101 80%

Huia 90 100 90%

PACU WTK 77 100 77%

Theatre WTK 91 100 91%

Haemodialysis WTK HR 46 50 92%

Outpatients Department WTK 45 50 90%

Anawhata 28 29 97%

CADS 22 25 88%

Emergency Department WTK HR 4 6 67%

Radiology no data no data no data

Table 7: Elective Surgery Centre hand hygiene compliance by department


ESC PACU 52 55 94%

Cullen Ward 110 117 96%

Theatre ESC 77 100 77%

Table 8: Mental Health hand hygiene compliance by department


Kahikatea Unit Mason Clinic 32 32 100%

Kauri Unit Mason Clinic 23 23 100%

Te Aka Unit Mason Clinic 25 25 100%

Totara Unit Mason Clinic 17 17 100%

Pohutukawa Unit Mason Clinic no data no data no dats

Rata Unit Mason Clinic no data no data no dats

Tane Whakapiripiri Unit Mason Clinic no data no data 10 no data

Waiatarau Acute Mental Health Unit no data no data no data

186

Waitemata DHB Infection Prevention and Control

May 2019

1. Hospital acquired bacteremia (HABSI)

HABSI is defined as a positive blood culture more than 48 hours after admission, or after procedure or previous admission in last

48 hours. Of the 6 HABSI’s in May (Table below), 2 were considered unavoidable from a urinary catheter source since both had

unsuccessful TROC after urinary retention.

Tables 2 and 3 below shows the number, rate and source of HABSI’s in 2019

HABSI source Jan- May 2019

HABSI SOURCE

Jan-May 2019

n= 28

Vascular device

Total 6 (2 CLAB & 4 IVL)

CAUTI 2

Post proc/ surgical 1

Other (mostly non-IDC related UTI) 14

Unknown 5

Source Total Ward Organism Comments

CAUTI 2

Muriwai Serratia marcescens

Pt. with CVA. Indication for IDC was appropriate. Unsuccessful TROC

Ward 10 PAER

IDC inserted for urinary retention on admission. Unsuccessful TROC requiring reinsertion followed by CAUTI.

Other (all non-CAUTI

urosepsis)

3

Ward 11 E coli

Muriwai E coli

Ward 14 ESBL E Coli

Unknown

1 ICU /HDU Enterococcus

faecium

Ward transfer to ICU for severe cryptogenic organising pneumonia. Died from respiratory failure unrelated to HABSI

2019 Jan Feb March April May

Total No. HABSI 3 3 10 6 6

Rates/1000 Bed Days 0.14 0.14 0.44 0.27 0.25

187

2. Extended spectrum Beta lactamase producing bacteria (ESBL)

HA-ESBL is defined as Isolation of ESBL producing Enterobacteriaceae (e.g. E.coli or Klebsiella sp.) from a clinical or screening specimen > 72 hrs post admission in a pt. with previously negative or unknown ESBL status.

Reduction in HA ESBL rate for NSH in May as shown in Table below. About 2/3rd HA-ESBL are E.coli

No evidence of outbreak or clusters as HA ESBL is spread across 7 wards

While some aspects of the bundle like hand hygiene (monthly) and contact precautions (periodically) are audited and successful, consistent and sustained implementation of a DHB wide prevention strategy can be improved further

.

3. Seasonal Influenza (till 10th June 2019)

WDHB has a yearly seasonal Influenza surveillance program which has been effective since March for 2019 (most confirmed cases seen in Feb had overseas travel to Northern Hemisphere).

Trends for 2019 so far include an earlier onset of Flu season and higher than expected number of ILI presentations and confirmed Influenza. In May, approximately 20 patients per day were tested of which about 25% were positive for Influenza.

Waitakere hospital proportionately has a higher number of confirmed Influenza.

Majority of confirmed influenza is H3N2 followed by Inf B. Both strains are included in the 2019 quadrivalent vaccine.

Cases of HA influenza have been diagnosed despite dedicated influenza wards and heightened influenza education and awareness

WDHB staff flu vaccine uptake remains suboptimal at 60% (bar graph)

WAITAKERE HOSPITAL

Feb March April May June (till 10

th)

TOTAL

CA 9 30 22 120 64 246

HA 1 0 3 1 2 7

NORTH SHORE HOSPITAL

Feb March April May June TOTAL

CA 27 30 35 75 34 201

HA 1 0 1 3 4 9

Aug –Dec 2018

2019

Jan

Feb

March

April

May

HA-ESBL rate/10,000 bed days (number)

8.8 (70)

NSH

8.9 (14)

9.5 (13)

8.7 (14)

8.3 (12)

5.6 (9)

4.4 (15)

WTH

4.8 (3)

8.8 (5)

3.0 (2)

4.9 (3)

4.2 (3)

188

4. Communicable Diseases, Clusters and Outbreaks- MEASLES EPIDEMIC –Mar to June 13th

Disease Total Confirmed cases

Ward /Hospital

No of pt. contacts

No of staff contacts

Comments

Measles

47

WTH ED = 44 NSH ED = 3

579

365

West Auckland has had the highest number of measles

cases in the Auckland region.

47 of 135 suspected cases tested positive for measles.

3 staff also had confirmed measles which accounted for

majority of staff and patient contact tracing.

Majority of contact tracing for patients occurred prior to

be triaged; these were from ED waiting room contacts

To date 3 person to person measles cross-transmissions

have been attributed to ED waiting room.

37% cases were < 14 mths age (no MMR)

67% cases >14 mths had no measles immunity or

equivocal Immunoglobulin G (IgG) antibody

62% cases required hospitalisation due to secondary

infections.

N meningitidis

5

ED WTH -2 EDNSH - 3

0

18

Front line staff involved with resuscitation and intubation without appropriate standard precaution when performing aerosol generating procedures.

Confusion around administering post exposure prophylaxis (PEP) .Issues with differentiating staff exposure between high and low risk. OCH&S working on process that clear identifies case defination. visibility of policy, management of PEP

Staff education provided on adherence to standard precautions i.e. use of appropriate PPE

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Waitemata DHB Infection Prevention and Control

Mid-Year Report Jan- July 2019

Prepared by Doctor Hasan Bhally, Poobie Pillay, Merissa Rajoo (Hand Hygiene report) and Kristen Bondesio and Mariam Basheer (C.diff report)

This report includes IPC surveillance data for last 6 months. Highlights are as follows

• Overall decrease in ESBL cross transmission rates and sustained low prevalence of CPE/VRE colonisation and hospital acquired MRSA infection

• Reduction in CAUTI related HABSI • Increase in vascular device related HABSI • High rates of HA influenza in staff with unknown burden of illness in staff • Measles outbreak in West Auckland

Please refer to attached Appendix for definitions of terms/categories used in this report

1a. Hospital Acquired Bloodstream Infections

A total of 32 HABSI’s were identified from January to June 2019- rate 0.24/1000 bed days which is comparable to the HABSI rate at WDHB over the last few years. The monthly distribution of HABSI in 2019 (Table 1), source of HABSI (Table 2) and summary of cases in June (Table 3) can be found below.

• E.coli was the most common pathogen (15/32- 47%), which included 3 ESBL E.coli HABSI’s. S.aureus (n=5) and Pseudomonas (n=4) were the next commonest. Only one case of ESBL K.pneumoniae HABSI was identified.

• As shown in Table 2, vascular access devices, predominantly IV luers continue to cause most of the HABSI’s with identifiable causes. Any device related HABSI is considered a potentially preventable event.

• While the two CLAB’s did not have any apparent correctable causes, complete assessment of preventability for IV luer related HABSI’s has been difficult due to poor documentation in addition to excessive duration of IV luers and use of antecubital fossa for insertion (non-preferred site).

HABSI source

2017

2018

Jan –June 2019

Vascular device

9

5 CLAB 4 IVL

18

7 CLAB 11 IVL

7

(2 CLAB & 5 IVL) CAUTI 15 8 2

Post proc/ surgical 14 8 1 Other (mostly non-IDC

related UTI) 16 25 17

2019 Jan Feb March April May June Total No. HABSI 3 3 10 6 6 4

Rates/1000 Bed Days 0.14 0.14 0.44 0.27 0.25 0.17

Table1: Monthly HABSI rate (per 1000 bed days) at WDHB 2019

Table 2: Comparison of sources of HABSI 2017- mid 2019

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Unknown 13 11 5 TOTAL 67 70 32

1b. Healthcare associated bacteremia (HCA-BSI)

A total of 14 HCA-BSI’s occurred during this period. All except one were in haemodialysis patients with tunnelled lines or fistulas as the expected predominant group. Two patients had more than one episode of HCA-BSI during this period. S.aureus was the most common pathogen (n=4). Table: Attributable causes of HCA- BSI Jan –June 2019

1c. Healthcare associated S.aureus bacteremia (SAB HCA-BSI)

Surveillance for S.aureus HCA-BSI is a requirement from Health Quality and Safety Commission as a quality indicator and outcome measure for hand hygiene. This includes both HABSI and HCA-BSI (1a and 1b) caused by S.aureus. • A total of nine SAB HCA - BSI were identified (rate 0.068 per 1000 bed days) of which eight were vascular device

related.

Source Total Ward Organism Comments

IVL

1 6 S. Aureus Identified 5 days post luer insertion and considered

avoidable. Limited documentation about indication for insertion and care.

Other/ Unknown

3

Muriwai S.aureus Source unknown 8 E coli Non-CAUTI UTI

Anawhata ESBL E.coli Non- CAUTI UTI

Source Total Ward Comments

CLAB

13

Renal Services

All chronic haemodialysis patients with either tunnelled lines or AV fistulas

Other

1

Urology

48 hours post renal procedure i.e. cystoscopy

Table 3: HABSI cases in June 2019

WDHB

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Our rates are comparable to 2018 and remain low compared to the national average as shown below

2. Extended spectrum Beta lactamase producing bacteria (ESBL) - E.coli (ESBL EC), K.pneumoniae (ESBL KP) and others

• An overall reduction in HA-ESBL was seen both at NSH and WTH in the first half of 2019 (Table 1). • A total of 82 HA-ESBL patients (66 at NSH) with either new colonisation or infection were identified compared to 157

for a similar period in 2018. • There has been a significant reduction in ESBL cross-transmission despite the disestablishment of Ward 11 as a multi-

drug resistant organisms (MDRO) ward and relaxation in cohorting rules for ESBL E coli. This reduction is also despite the change in our HA-ESBL definitions from August 2018; the old definitions were likely to over attribute ESBL acquisition to healthcare.

• While some aspects of the TAKE CHARGE ESBL bundle like hand hygiene (monthly) and contact precautions (periodically) are audited and successful, consistent and sustained implementation of a DHB wide prevention strategy can be further improved.

TABLE 1: HA-ESBL rates/number at WDHB

• Despite a high prevalence of ESBL in Waitematā DHB patients, the number of clinical isolates with ESBL in hospitalised patients remained relatively low with only seven hospital acquired (HA) ESBL E coli (EC); six HA ESBL Klebsiella Pneumoniae (KP), and one HA ESBL (other)

• In comparison to community acquired (CA), 58 CA ESBL EC, 10 CAESBL KP and seven CA ESBL (other) • 90% of these patients have urinary tract infections • 29% HA ESBL isolates were from blood cultures • HA-ESBL were distributed throughout the NSH wards predominantly with the number of cases attributable to wards

ranging from: − nine on Ward 7 − seven on Ward 4 − seven on Ward 8 − six on Ward 5 − four each for Wards 2, 3, 9, 10 and Titirangi Ward (WTH) − the four surgical wards contributed to 33% (n=27) of HA-ESBL cases

2018

Jan

2019

Feb

March

April

May

June 2019

HA-ESBL rate/10,000 bed days (number)

9.7

(256)

NSH 8.9 (14)

9.5 (13)

8.7 (14)

8.3 (12)

5.6 (9)

2.4 (4)

WTH 4.8 (3)

8.8 (5)

3.0 (2)

4.9 (3)

4.2 (3)

0

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

Jan-18

Feb-18

Mar-1

8Ap

r-18

May-1

8Jun

-18 Jul-18

Aug-1

8Sep

-18Oc

t-18

Nov-1

8De

c-18

Jan-19

Feb-19

Mar-1

9Ap

r-19

May-1

9Jun

-19

SAB ra

te per

1000

inpati

ent da

ys

Waitemata SAB rate versus National SAB rate

Waitemata SAB rate

National SAB rate

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• Differences between types of ESBL and place of acquisition are shown in Table 2 with ESBL EC more likely to be community acquired compared to ESBL KP (88% vs 66%). However, it is worth noting that ESBL EC still contributes to 50% (41/82) of total HA ESBL.

TABLE 2: Comparison of ESBL KP, EC, other sp. in terms of place of acquisition

3. Carbapenem resistant Enterobacterales and Pseudomonas (CRE/O)

Nationally, since 2015, concern has been raised about emergence and spread of carbapenemase producing Enterobacterales (CPE’s), a subset of CRE/O bacteria. These are the ‘next generation’ of antimicrobial resistant bacteria with minimal or no effective antibiotics that can be used for treatment of infections caused by them. In addition, CPE’s have important IPC implications. Different types of Carbapenemase genes (NDM, OXA-48, and KPC’s) confer resistance detected by molecular testing. Waitemata DHB has undertaken CRE screening as part of active MDRO screening for high risk patients since 2017. Any patient suspicious of CRE/CRO on initial testing is placed in contact isolation pending further confirmation. In 2019 to date, seven of 17 isolates flagged by Waitematā DHB lab were confirmed as CPE by molecular testing performed by the reference lab. Five patients were deemed high risk and hospitalised or travelled overseas. None of the CPE was attributed to NSH or WTH. No clusters or outbreaks have been identified at WDHB to date.

4. Methicillin Resistant Staphylococcus Aureus (MRSA) MRSA Overview 2019 YTD

• Waitematā DHB continues to have low MRSA infection rates based on information primarily collected from laboratory antibiotic susceptibility data

• 99% of MRSA are community acquired Table below shows the number of MRSA isolates in 2018-2019

5. Vancomycin resistant Enterococci (VRE) Active VRE surveillance, similar to ESBL since 2007 and CPE since 2017, is performed at WDHB since May’15 after an outbreak at NSH in 2014. Identification of new VRE colonisation or infection continues to be very low due to enhanced IPC measures including use of Deprox for environmental decontamination in selected situations.

VRE Overview 2019 YTD

• Only two HA VRE were identified in 2019 YTD, one in Ward 5 (March) and one in ward 8 (May); contact tracing of patients sharing rooms did not find in evidence of cross transmission at NSH

• One community acquired VRE isolated from high risk patients

ESBL KP ESBL EC Other

HA 26 41 15

CA 51 319 27

TOTAL 77 360 42



MRSA isolates 157/105 (262) 96/75 (171) Community MRSA and other HCF (new cases) 117/82 (199) 62/48 (110) Community MRSA (known on admission) IC-NET not collecting data from July onwards

10/13(23) 31/27(58)

New healthcare onset (hospital acquired) 24/14 (38) 3/0 (3) Health care onset (known on admission) 6/1 0

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• No VRE infections were seen over a prolonged period and the burden of VRE has also reduced slightly 6. Clostridium Difficile (now called Clostridioides difficile)

A total of 57 cases of CDI (excluding recurrence) were noted in first half of 2019 (compared to 49 cases during a similar period, and 107 cases in the entire year in 2018) – (Graph) • This includes 33 new cases in Q1 and 24 cases in Q2 • The proportion of HO-HCA infections was 38% in Q1 and 45% in Q2

Approximately 20% (seven of 37 cases) of HO-HCA CDI that were reviewed by antimicrobial stewardship team as part of an ongoing active feedback process were considered avoidable as shown in flow chart below. This proportion is similar to 2018.

7. Seasonal Influenza

Waitematā DHB has a yearly seasonal Influenza surveillance program which usually commences in March every year. In addition, hospital acquired (HA-Inf) is a unique designation used in our surveillance since 2017. It identifies inpatients admitted initially for other medical reasons but developed Influenza during their hospital stay, likely through acquisition from either other patients, staff, visitors or environment. Therefore, confirmation of Influenza after 72 hrs of admission is defined as HA-Inf. • The 2019 season so far has been characterised by earlier onset (high number of confirmed CA-influenza cases at

Waitematā DHB in Jan/Feb mostly acquired from Northern Hemisphere travel), and higher than seasonal baseline of ILI presentations with 959 confirmed Influenza cases at NSH/WTH

• Waitakere Hospital proportionately has a higher number of confirmed Influenza cases • Majority of confirmed influenza is H3N2 followed by Influenza B; both strains are included in the 2019 quadrivalent

vaccine

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• In 2019 a concerning trend in HA-Inf cases is noted with 80 cases (46 NSH, 25 WTH and 9 Mental Health WTH) diagnosed till 12th July. This includes two outbreaks of seasonal Influenza A- Muriwai ward in June involving 10 patients, and Ward 14 with eight cases between 4 - 9 July (see section10).

• Staff illness has been reported during both these outbreaks and in clusters in other patient care areas but it is difficult to establish an epidemiological link.

• In 2017, during a high influenza season, HA-Inf cases were unacceptably high (100) but this reduced significantly to 34 in 2018.

• The impact of influenza illness in the elderly patient population remains under-appreciated. To date we have identified

five patients who have died in hospital with HA-Inf A diagnosed within 10 days prior to death. While influenza may not be the only contributor to their demise, it likely contributed in a significant manner towards deterioration of their health.

• Waitematā DHB staff flu vaccine uptake for 2019 has increased to 65.5% compared to 59% uptake in 2018 as shown below

8. Surgical Site Infections (SSI) for knee and hip arthroplasties

In scope procedures for SSI surveillance are primary and revision hip/knee arthroplasty performed at either NSH or elective surgical centre (ESC) in accordance with National Surgical Infection Improvement (SSII) program. The surveillance criteria 90 days post-operatively for deep and 30 days for superficial infection.

• SSI rate for Jan-June 2019 was high in the Q1 2019 with four SSI’s (rate 1.6/100 Procedures) • One SSI has been identified to date in Q2 • Of the 5 SSI’s in two deep (one NSH and one ESC) and three superficial SSI’s (two ESC) were noted • A deep hip SSI from S.aureus occurred in March 2019 which was the first S.aureus SSI since introduction of • Staph decolonisation bundle in Nov 2017 • Cultures were negative in all other SSI’s Table: SSI number and rates 2016 till July 2019 at WDHB

Year 2016 2017 2018 2019

Quarter Q1 Q2 Q3 Q4 Q1 Q2

WDHB total procedures

1217 1191 217 304 240 229 261 250

SSI’s (n) 12 13 2 2 1 0 4 1

Rate 1% 1.1% 0.5% (5/990) 1.6% 0.4%

NSH Feb March April May June July till 12th TOTAL CA- INF 27 30 35 75 178 78 423 HA- INF 1 0 1 3 20 21 46

WTH Feb March April May June July till 12th TOTAL CA- INF 9 30 22 121 201 73 456 HA- INF 1 0 3 1 27 2 34

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• Our overall SSI rate (with exception of Q1 2019) remains comparable (2016-17) or lower (2018) to the national rate with ongoing regular compliance with QSM’s (Graph and table)

0.9

2.2

1.5

0.7

1.0

0.70.8

0.3 0.3

1.9

1.5

2.2

1.2

0.3

0.7

0.9

0.7

0.4

0.0

1.5

0.4

0.0

0.5

1.0

1.5

2.0

2.5Ap

r…

Jul-…

Oct

…

Jan…

Apr…

July

…

Oct

…

Jan…

Apr…

Jul-…

Oct

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SSI p

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Waitemata DHB versus National Orthopaedic SSI rateWDHB rate

9. Hand Hygiene

• Overall, Waitematā DHB hand hygiene compliance rate was consistently at 87% or higher for each month in 2019 • Hand hygiene compliance has reached an all-time high of 90% for Waitemata DHB in June 2019 • Key achievements in the hand hygiene program were a successful World Hand Hygiene Day celebration at

Waitakere and North Shore Hospitals on 7 May 2019 • Waitematā DHB has the largest commitment to the national hand hygiene program, with our moments of auditing

double second placed ADHB

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85

86

87

88

89

90

91

92

Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19

Perc

enta

ge %

Month

Compliance Rate NSH vs WTK

North Shore

Waitakere

0

20

40

60

80

100

120

Jan Feb Mar Apr May June

Perc

enta

ge %

Hand Hygiene Compliance North Shore

Nurse/Midwife

Medical Practitioner

Invasive Technician

Health Care Assistant

Student Nurse/Midwife

Student Doctor

0

20

40

60

80

100

120

Jan Feb Mar Apr May June

Perc

enta

ge %

Hand Hygience Compliance Waitakere

Nurse/MidwifeMedical PractitionerInvasive TechnicianHealth Care AssistantStudent Nurse/MidwifeStudent Doctor

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10. Communicable Diseases, Clusters and Outbreaks

Other communicable diseases- clusters and contact tracing

Disease Confirmed cases

Ward Staff contacts

Patient contacts

Comments

HA- Influenza

22

Muriwai , Ward 14, Rata Unit –Mason

8

29

• Muriwai B wing had prolonged Influenza A outbreak in June across several rooms involving 10 patients and wing closure for eight days.

• Ward 14 had outbreak eight patients in July with HA influenza spread across two rooms

• Both Rooms 1 and 2 was closed to admission • Confirmed cases and their contacts were

treated with Tamiflu in both outbreaks • Unable to identify source of cross transmission.

There was two staff with influenza like illness (ILI) symptoms at the time

• Rata Unit - four patients with confirmed Influenza A

• Restrictions placed on patient movement and visitors

Measles Epidemic

60

ED WTH /Rangitira

586

395

• West Auckland has had the highest number of measles cases in the Auckland region

• 60 of the suspected 183 cases tested positive for measles

• Three staff also had confirmed measles which accounted for the majority of the staff and patient contact tracing required

• To date three measles cross-transmissions have been attributed to the ED WTH waiting room

Norovirus

3

Ward 10

3

7

• Ward 10 had eight patients and seven staff reported symptoms of diarrhoea and/or vomiting

• Index case was admitted with diarrhoea but not isolated in enteric precautions on admission

• Two rooms (L and M) were closed from the 15-18 April 2019

• With heightened infection control measures and increased environmental cleaning the norovirus did not spread to rest of the ward

Disease Total cases

Ward No of pt. contacts

No of staff

contacts

Comments

Pertussis 18 NSH & WTH Ed 6 22 • Majority of cases were from paediatrics at Waitakere ED who had not been placed in droplet precautions on admission

Mycobacterium TB

8 NSH ED , ward 10, Huia, Ward 6 , Muriwai

4 52 • Staff member with Laryngeal TB which resulted in contact tracing of staff and patients

• Patients were not isolated in airborne precautions as TB was not the diagnosis on admission

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Infection Control involvement in DHB, Community, National Projects

• Review furniture, furnishings and fittings for Waitemata DHB projects • Health Benefits PPE project in progress Pressure care devices • Health Benefits – Mattress and pressure relieving devices project –in progress • Updated policies and procedures • Gold Auditors training • Link Reps Study Day • Influenza and measles in-service for DHB staff • Providing IP&C support during outbreaks for Providers • Assisting Health Alliance in sourcing substitute products • Reviewing new products -Product Management Committee • Welcome to Waitemata Orientation Programme

13. Building, Renovations and other issues • CT Scanning refurbishment NSH and WTH • IP&C input for ECIB • IP&C input SCBU refurbishment WTH • IP&C input Diagnostic Breast Screening • IP&C input Habitat Café • IP&C input NSH –Kitchen Renovation • IP&C input Primary Birthing Unit

Appendix –Waitemata DHB IPC Surveillance Definitions

ESBL Definitions HA-ESBL ( Hospital acquired) ESBL defination was changed in August 2018. HA ESBL includes both Definite, probable and possible

HA-ESBL is defined as Isolation of ESBL producing Enterobacteriaceae (e.g. E.coli or Klebsiella sp.) from a clinical or screening specimen > 72 hrs post admission (not 48 hrs. as per old definition), in a pt. with previously negative or unknown ESBL status

Community Acquired (CA) Isolation of ESBL from clinical or screening specimen within 48 hours of admission in a low risk patient with no exposure to acute or long term care facilities in last 6 months

Other Healthcare Facility onset ESBL (OHCF-E)

Isolation of ESBL on admission screen or clinical isolate within 48 hours admission in patients not previously ESBL colonised, admitted to WDHB acute care from rest home, private hospital, or other non WDHB acute care facilities

MRSA definitions

N Meningitis

12

ED NSH & WTH,

wards 3,5, 6,

4

8

• Front line staff involved with resuscitation and intubation without appropriate standard precautions when performing aerosol generating procedures

• Confusion around administering post-exposure prophylaxis (PEP) to staff

• Issues with differentiating staff exposure between high and low risk

• Occupational Health and Safety Team are working on clarifying the process so that there is clear case definition, visibility of the policy and management of the PEP

• Staff education provided on adherence to standard precautions i.e. use of appropriate personal protective equipment

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Community onset MRSA (CA)

New MRSA identified from either clinical isolate or screening within 48 hrs. of admission in a patient with no contact with acute healthcare or contact >30 days prior to identification

A) Hospital Acquired (HA) New MRSA identified after 72 hours of hospital stay

B) Healthcare associated (HCA)

Previous WDHB admissions and NEW MRSA identified in a patient admitted for <72 hours but had prior contact in the last 30 days with NSH/WTH

C) Healthcare associated-Other (HCA-O)

New MRSA identification in a patient admitted for <48 hours and had prior contact in last 30 days with any other DHBs or healthcare facility

D) Hospital acquired in known (HA in known)

MRSA identified in known patients after 72 hours of admission

VRE definitions VRE Burden Total number of new and previously known VRE colonised/infected patients seen

at NSH/WTK hospital during a month

VRE Incidence Newly identified VRE colonised or infected pts during particular month.

A: Definite hospital acquired (HA)

If admission screen was negative and subsequent screening cultures >48 hrs. after admission confirm VRE

B: Probable hospital acquired (HA-Prob)

If admission screen not performed and subsequent screening cultures >72 hrs. after confirm VRE.

C: Other (CA) If VRE is isolated on admission screen or within 72 hrs. Of admission to NSH/WTK.

VRE infection (HA inf in known)

Any infection diagnosed either on admission to or during hospital stay. Includes infections in previously colonised

CPE /CPO NSH defination and Alerts NSH PCR positive CPE = carbapenemase-producing Enterobacteriaceae

CPO = carbapenemase-producing organism i.e. Acinetobacter, pseudomonas

NSH PCR negative, ESR PCR pending

Possible CPO, awaiting confirmation

ESR PCR comes back negative

Non-CP CRO = non-carbapenemase producing, carbapenem resistant organism (R to carbapenems due to mechanisms other than carbapenemase production).This is confirmed by Clinical Microbiologist

Hospital Acquired (HA) New CPE/CPO identified after 72 hours of hospital stay Community onset (CA) New CPE/CPO isolated on admission screen or within 72 hr.’s admission Bacteraemia Hospital Acquired BSI (HABSI)

Positive blood culture greater than 48hours after admission, procedure in last 48 hours, previous admission in last 48 hours.

Healthcare Associated BSI (HCA)

Occurred with 48 hours of admission from patients that had procedure in last 30 days from WDHB or not admitted, outpatient receiving treatment from WDHB, include dialysis and home dialysis patients.

Community Associated BSI (CA)

Positive blood culture less than 48 hours after admission.

HABSI category Other - caused by UTI, wounds, pneumonia etc

Unknown -Source of bacteraemia unknown Surgical /procedure - ERCP , Nephrostomy, TURP, TRUS, SSI CLAB - CVL, Tunnel line, Groshong, PICC etc. IVL - Peripheral venous catheter CAUTI - IDC , SPC

Clostridium Difficile Healthcare Facility Onset - HO-HCA

CDI symptom onset more than 48hours after admission (3rd calendar day).

Community Onset health care facility associated - CO-HCA

Discharged from a healthcare facility within previous 4 weeks.

Community Onset Community Associated - CO

No admission in the last 12 weeks.

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Indeterminate Discharged from a healthcare facility within the previous 4 to 12 weeks.

Recurrent Episode of CDI that occurs 8 weeks or less after the onset of a previous episode provided the symptoms from the prior episode resolved.

Influenza Community associated CA positive result less than 72 hours after admission, admitted with coryzal

symptoms and febrile > 38.0 degrees Hospital acquired HA positive result after 72 hours from admission, not admitted with coryzal

symptoms and not febrile >38.0 degrees

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4.3 Human Resources Report

Recommendation:

That the report be received. Prepared by: Fiona McCarthy (Director Human Resources)

Purpose of report This report outlines key people and organisational development activities across Waitematā DHB and reports on progress with workforce plan actions.

1. Strategic Alignment

Community, whanau and patient centred model of care

The report outlines recruitment, workforce or organisational development programmes and actions that can impact internal and external models for care.

Service integration and/or consolidation

The report outlines work undertaken collaboratively across the organisation.

Intelligence and insight The recruitment and ethnicity dashboards give information and insight into the impact of our recruiting processes.

Evidence informed decision making and practice

Where possible, all improvement or new programmes of work will use evidence based frameworks to develop and/or evidence to enhance existing work. All programmes are evaluated to understand the value and return on investment.

Outward focus and flexible, service orientation

Improvements sought in relation to policy, process or programmes will be co-designed with service users.

Operational and financial sustainability

Robust recruitment, workforce and organisational development frameworks, strategies and actions support sustainable business practises.

2. Recruitment

2.1 Recruitment Dashboard

May 2019 June 2019

Total number of hires (Headcount)

233 offers accepted (headcount)

189 offers accepted (headcount)

Average time to hire 63.1 days 70.7 days

Current number of vacancies by speciality we are recruiting to (FTE)

Medical 36.55 Nursing 139.77 Allied Health 142.9 Support 25.20 Mgmt./Admin 49.85 394.27

Medical 35.55 Nursing 140.69 Allied Health 142.55 Support 25.4 Mgmt./Admin 52.25 396.44

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2.2 Additional Nursing Roles (Nursing Accord) Members will be aware that one of the outcomes from the Nursing and Midwives Collective Agreement Negotiations was the provision of additional funding for new Nursing roles. We have now completed recruitment to 100% of the 46 roles identified for this funding. 2.3 Top sources of Applications

Rank / Source May 2019 June 2019

1. DHB website 32% 34%

2. A Friend, referral 23% 26%

3. DHB internal website 10% 4%

4. www.kiwihealthjobs.co.nz 7% 6%

5. www.seek.com 6% 4%

Table 1: Top Sources of Hire

3. Workforce Development

3.1 Strengthening Health Equity 3.1.1 Progress and targets to grow Māori Workforces The DHB has made excellent progress over the last 12 months in our commitment to grow our Māori workforce. The DHB has 512 staff who identify as Māori. Our June target was 509 staff. The DHB is continuing to progress several workstreams that support attraction, recruitment and retention of Māori workforces as well as building cultural awareness and how all staff can progress health equity gains.

June 2019

Actual

June 2019

target

Dec 2019

target

June 2023

target

Total in the Maori Workforce

512 509

523 615

Total priority workforces* 244 234 255 326

*Nursing, Midwifery, Occupational Therapy, Resident Doctors, Dental Therapists, Physiotherapists, Dieticians, Nursing Support Workers

4. Learning and Education Some new performance and education tools have been introduced in the last 6 weeks: 1. Introduction of a new on line performance review format called “talking together”. The aim of

the new format is to encourage focus on the value of discussion about behaviours we love to see, achievements, future goals and career development, while making the process engaging to use.

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http://www.kiwihealthjobs.co.nz/

http://www.seek.com/


2. A new teamwork toolkit has been introduced, with provides new tools to support healthy teamwork including how to give constructive feedback.

3. Agreement to run train the trainer sessions to enable services and the wider DHB to facilitate sessions on the five ways of wellbeing and positive working environments. The five ways of wellbeing are:

The material has been developed by the Mental Health Foundation, is evidence based and provides

the foundation for positive and supportive workplace wellbeing conversations.

After the education sessions, trainers will learn the following, to be applied in their local teams:

Understanding of mental health and wellbeing, that enables people to think about things that keep us well

Understand why it’s important to think about wellbeing at work for individuals, teams and organisations

Learn about what we need to be thinking about to create a positive work environment for positive mental wellbeing

Learn practical things we can do within workplaces to create the wellbeing culture

Learn about the Five Ways to Wellbeing and how these can be used to improve mental wellbeing personally as well as in work environments.

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6. Resolution to Exclude the Public

Recommendation:

That, in accordance with the provisions of Schedule 3, Sections 32 and 33, 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:




1. Confirmation of Public Excluded Minutes – Hospital Advisory Committee Meeting of 19/06/19



Confirmation of Minutes

As per resolution(s) to exclude the public from the open section of the minutes of the above meeting, in terms of the NZPH&D Act.

2. Quality 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.


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 S.9 (2) (a)]

3. Human Resources Report



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 S.9 (2) (a)]

Negotiations

The disclosure of information would not be in the public interest because of the greater need to enable the board to carry on, without prejudice or disadvantage, negotiations.

[Official Information Act 1982 S.9 (2) (j)]

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