Board. Nelson Bays Primary Health AGENDA. Open. Distribution. Date: 1 June Time: 2.00pm. Place: Meeting Room Queen Street Richmond

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1 Distribution Board Members: John Hunter (Chair) Pat Curry Philip Chapman Sarah Green Stuart Hebberd Helen Kingston Lisa Lawrence Sue Stubbs Management: Angela Francis, CE Emily-Rose, EA/Board Secretary Karen Winton, Acting GM Health Services Linzi Birmingham, GM Golden Bay Community Health Trudi Price, HR/Support Services Manager Wolfgang Kloepfer, Finance Manager Public: Hard copies (3) Open Agenda Distribution List (e) Website Contact Details Board Secretary: Emily-Rose Richards Tel: Nelson Bays Primary Health Date: 1 June 2017 Time: 2.00pm AGENDA Board Open Place: Meeting Room 2 Nelson Bays Primary Health 281 Queen Street Richmond Next Meeting Date: Thursday 6 July 2017

2 Nelson Bays Primary Health Board Meeting 2.00pm Thursday 1 June 2017 Open Agenda pm: Te Reo Training held for Board Members pm: Public Forum Page 1.0 Welcome/Karakia John Hunter 2.0 Apologies: Stuart Hebberd 3.0 Register of Interests 3.1 Amendment to the Register of Interests 3 For review 3.2 Declaration of Conflicts in Relation to Today s Business 4.0 Confirmation of Agenda For review 5.0 Minutes of 4 May Confirmation of Minutes 4 For approval 5.2 Matters Arising (and not for discussion in 5.3) 5.3 Discussion of Action Points 7 For review 6.0 Environmental Scan Discussion 7.0 Reports 7.1 Chief Executive s Report Open Section 8 For information 7.2 GM Health Services Operational Report 23 For information 7.3 Health and Safety Report 26 For information 8.0 Policies for Approval 28 For approval Confidentiality Policy Privacy Policy Deputy Chairperson Selection Policy Independent Chairperson Selection Policy Subcommittee Selection Policy Fixed Asset Management Policy For approval For approval For approval For approval For approval For approval 9.0 Position Descriptions for Approval 56 For approval Position Descriptions: Independent Board Chairman Position Description: Trustee For approval For approval 10.0 Board Work Programme 61 For information 11.0 General Business Discussion Next Meeting: Thursday 6 July 2017

3 Register of Interests Board as at 4 May 2017 Name Existing Health Interest Relates To Existing Other (Role) Chair John Hunter PHO Alliance Executive PHO Alliance Member PHO Ara Institute of Canterbury (Director since April 2011) Powerhouse Ventures Ltd Director Possible Future Conflicts None notified Helen Kingston Abbeyfield Golden Bay Inc Medical Adviser and Committee Member Lisa Lawrence Member of the Order of St John Motueka Family Service Centre Motueka Family Service Centre Motueka Health Alliance PHARMAC Community Advisory Committee Incorporated Society providing accommodation for elderly Have a provider contract with NBPH Location of a lactation clinic for Motueka area Primary Health Services in Motueka Member None declared Non- Governmental Provider Motueka Family Service Centre None notified (Kaiwhakahaere) Pat Curry Director Accuro Private Health Insurance None declared None notified Philip Chapman Employed by Nelson Public Health Manager Men s Centre (Male Room) National Chairman of Male Survivors Of Sexual Abuse A.N.Z Sarah Green Tasman Medical Centre Nursing leadership Clinical Governance Committee NZNO College of Primary Nurses NZNO College of Respiratory Nurses Men s health; positive fathering research; improve access to family health services for fathers, men & boys; The Male Room receives money from the NBPH Primary Mental Health Initiative. Employee Nursing Member Member Member Whakatu Boxing Trust Potential Community Initiative Funding None declared None notified Stuart Hebberd None declared None declared None declared None notified Sue Stubbs Tima Health General practice owner with PHO contract None declared None notified Nelson Bays General Practice Limited Shareholder ACC Nelson Branch Medical Advisor CE Angela Francis Institute of Directors, NZ Australasian College of Health Service Management Medical & Injury Centre Health Systems Solutions ToSHA Member Fellow Director Director Rotating Chair None declared None notified 3

4 Nelson Bays Primary Health Board Meeting Minutes of meeting held at 2.00pm on Thursday 4 May 2017 at Nelson Bays Primary Health, 281 Queen Street, Richmond Open PRESENT: John Hunter (Chair), Pat Curry (Deputy Chair), Helen Kingston, Lisa Lawrence, Philip Chapman, Sarah Green, Stuart Hebberd, Sue Stubbs. IN ATTENDANCE: Angela Francis, Chief Executive; Emily-Rose Richards, Board Secretary; Karen Winton, Acting GM Health Services; Linzi Birmingham, GM Golden Bay Community Health (GBCH); Trudi Price, HR/Support Services Manager; Wolfgang Kloepfer, Finance Manager. Public: (2) Lew Solomon and Dr Doug Smith Public Forum Mr Solomon informed the Board on his interest in Mental Health and discussed the research papers by Jonathon Schaefer and others on Suicide Facts Deaths and Intentional Self-Harm Hospitalisations MoH Nov The paper shows that while Nelson Marlborough is below the New Zealand average in suicide deaths, it is well above average in hospitalisation owing to intentional self-harm. It also shows that while New Zealand is about average in the OECD for rate of suicide, it is very much above the OECD rate in youth suicide. J Schaefer - J Schaefer - Is Enduring Mental He abnormal psycholo MOH - Suicide and Self Harm.pdf Dr Smith introduced himself to the Board, being a GP, with specialisation, seeking employment in the area. 1.0 Welcome/Karakia Sarah Green 2.0 Apologies: Alistair Sowman, Chairman of Marlborough Primary Health. 3.0 Register of Interests 3.1 Amendment to the Register of Interests Remove for Mr Chapman: Chair of Waimea Men s Shed Remove for Ms Curry: Board of Trustees on Abbeyfield Nelson Inc. TO BE CONFIRMED 4

5 3.2 Declaration of Conflicts in Relation to Today s Business There were none. 4.0 Confirmation of Agenda The agenda was confirmed. 5.0 Confirmation of Minutes of 2 March 2017 The minutes of 2 March 2017 were confirmed as a true and accurate record. Stubbs/Curry 5.1 Matters Arising There were none. 5.2 Action Points Some matters for consideration this month had been dealt with, formed part of today s agenda or were discussed as follows: A53 Discussions with Pharmacy Guild. A meeting was held between the Chief Executive and Jo Mickleson on 8 March 2017 who will contact the Pharmacy Guild Chief Executive to discuss local initiatives. Completed. A59 Hon Annette King report. Completed. A61 Update on interpreters service. Ms Winton attended a meeting at Nelson Marlborough Health (NMH) with the GM Maori Health to discuss the interpreters service. A follow up meeting is being held with Red Cross to see how there can be one organisation looking after the service. An update will be provided to the Board when information is to hand. Ongoing. A62 Board Strategic Planning Day agenda. Completed. A63 Doodle poll for Board Strategic Planning Day. Completed. 6.0 Environmental Scan Mr Chapman noted he has been competing surveys from ACC, Ministry of Health and Parliament on family violence. Noting it is a government initiative to look at family violence. Ms Winton noted the government has also provided more funding to Family Start. Mr Hunter asked if there is a role for NBPH to help our population with family violence and the possibility of accessing the latest funding initiative announced by the Government? Ms Green noted we could be starting the conversation on NBPH forms asking along the lines of is the patient safe at home? The Board will discuss further at the Board Strategic Planning Day on 8 May Ms Francis informed the Board on the following: Ministry for Vulnerable Children established NMH have appointed a Consumer Council 7.0 Reports 7.1 Chief Executive s Report Open Section Report taken as read. TO BE CONFIRMED 5

6 Ms Francis noted NBPH is tracking very well to budget and predicting a good surplus for yearend. The Board held a discussion about the population who are unenrolled in a PHO in the top of the south to see how NBH can enrol the 3% of the population who are not enrolled. The requirements for enrolling in a General Practice were discussed and it was decided for a discussion on simplifying the requirements for registration, by linking to registration information already held by WINZ, to be taken to the Primary Health Alliance. Ms Winton was asked to write a one-pager on simplifying the requirements (including identification proof) for new patients enrolling in a General Practice, and send to Mr Hunter (cc Ms Lawrence), to then discuss with the Primary Health Alliance. A General Manager Health Services Operational Report Open Report taken as read. Ms Winton advised that the ACC Falls Prevention Community Strength and Balance Programme contract has been received and signed. The Brief Intervention Service waiting list is down to 2 weeks and the waiting time for the Primary Mental Health Initiative is 1-2 weeks. NMH funded NBPH $170k for 6 months to increase the primary mental health service, while they undertake a full service review. Management have had involvement in the re-design process and are awaiting the outcome for the mental health service in the future. 7.3 Health and Safety Update Report Report taken as read. Mr Hunter asked if Management are using the near miss data at GBCH to prevent future recurrences? Ms Price informed the Board that the data is reviewed at the Health and Safety Committee meetings. 8.0 Board Work Programme The Board Work Programme was received. The Board asked for the Board meeting and Strategic Planning Day to be held on consecutive days, from 2018 onwards. 9.0 General Business There was none. The meeting closed at 2.57pm. Next Meeting: Thursday 1 June 2017 TO BE CONFIRMED 6

7 OPEN Action List v 23 May 2017 Meeting date Action number Action Bring up Who Status Mar 17 A61 A follow up meeting is being held with Red Cross regarding the interpreter service to see how there can be one organisation looking after the service. An update will be provided to the Board when information is to hand. June 17 GM HS Ongoing May 17 A64 Ms Winton was asked to write a one-pager on reducing the requirements (including identification proof) for new patients enrolling in a General Practice, and send to Mr Hunter (cc Ms Lawrence), to then discuss with the Primary Health Alliance. June 17 GM HS Refer to agenda item (closed agenda) 7

8 To Nelson Bays Primary Health Board From Angela Francis, Chief Executive Meeting date 1 June 2017 Subject Chief Executive s Report Open Section For approval For action For information 1. PURPOSE To provide the Board with an update of the organisation s progress against strategy, risk and budget. Where appropriate, fuller details are provided in the Closed Agenda. 2. OVERVIEW Business as usual continues: Risk identification and mitigation. Refer Closed Agenda Risk Register Staffing levels Nelson Bays Primary Health (NBPH) staffing levels remain constant. Refer Closed Agenda for attrition rates Financial forecast NBPH continues to track well against budget forecasting a surplus year-end. Refer to the Financial Report in the Closed Agenda for further details o Budget for 2017/18 was endorsed by the Board on 4 May 2017 Progress against strategy continues as articulated through annual operational plan deliverables with new strategic priorities identified and confirmed at the Board Strategic Planning Day on 8 May A revised approach has been developed with additional reporting framework embedded. Refer to agenda item 3.3 (Strategic Initiatives) in the closed agenda. 3. MEDIA AND GOOD NEWS STORIES 3.1 Nelson Bays Primary Health Media Coverage New Regional Director of Primary Health Nursing An article in the Nelson Mail on 5 May 2017, provided coverage on the new Regional of Director of Primary Health Nursing for NBPH and Marlborough Primary Health. Nurses will be better supported following the creation of a new role that will strengthen services across Nelson and Marlborough. Refer to Appendix 1 for the Regional Primary Health Nursing article in The Nelson Mail on 5 May A link to a Stuff article follows: 4. CORPORATE SERVICES UPDATE Information Systems The formal requisition forms were completed and submitted last month to Chorus, to enable installation of separate broadband for Collingwood Clinic. This has struck delays in implementation. Chorus advised that trenching and ducting of a separate cable would be required by their separate rural work team, unless completed by an alternative rural contractor both options requiring additional investment and time delays. Timelines and costing details of these options are being sought, with the Chorus Account 8

9 Liaison Manager being informed of our discontent with the late advice, time delays and additional costings experienced. The alternative solution is also being scoped, utilising Spark 4G wireless connections now available in the region; recent changes in plan options increase potential affordability of this option. Current scoping will be complete and a decision made in May 2017 to progress and resolve this outstanding issue. Other projects continue to progress as scheduled. This includes the IT infrastructure tasks, remote desktop upgrades, NBPH Website Review and preparation for a new server installation at GBCH scheduled for June Human Resources The Stakeholder surveys were presented during the Governance and Remuneration Committee meeting on 10 April 2017 as scheduled. The Multi-Union Collective Agreement (MUCA) was received for countersignature by NBPH on 12 May Implementation plans to enact this agreement are now being scheduled against timelines to enable completion prior to end of June 2017, in line with the current financial year. 5. HEALTH SERVICES UPDATE Health Services are tracking well against contractual and financial targets. Refer to agenda item 7.2 in the open agenda and agenda item 4.4 in the closed agenda. 6. GOLDEN BAY COMMUNITY HEALTH UPDATE GBCH continues to perform in all areas. Refer to agenda item 4.1 in the closed agenda for further detail. 7. LOCAL PLATFORM 7.1 Nelson Marlborough Health (NMH) NMH are awaiting their funding envelope to be confirmed by the Ministry of Health, due end of May NMH is currently planning a series of reviews in specific service areas, some of which interface with primary care. These include: Mental Health District Nursing Palliative Care Top of the South Health Alliance (ToSHA) ToSHA including NBPH are undertaking a roadshow to update community and other stakeholders on the progress made towards the Primary and Community Strategy. Refer to agenda item in the closed agenda for the community meetings dates/venues. 8. NATIONAL FORUMS Primary Health Alliance For updates on the PHO Alliance and PSAAP, refer to agenda item 4.5 in the Closed Agenda. 9

10 9. CORRESPONDENCE St John Funding Announcement Correspondence from St John was received regarding the funding boost they have received from the Government. St John will receive more than $100m in the budget for 2017/18 to provide double crewing of all emergency ambulance responses over the next four years. Refer to Appendix 2 for the correspondence from St John regarding the funding boost they have received from the Government. Cyber Security Attack Correspondence from Health Systems Solutions (HSS) and Patients First was received regarding the actions they have undertaken from the Worldwide Cyber Security Attack. NBPH submitted an update to NMH regarding the status of NBPH. Refer to Appendix 3 for the NBPH status update to NMH and correspondence from HSS and Patients First regarding the actions undertaken from the Worldwide Cyber Security Attack. 10. RECOMMENDATION It is recommended that: The Board receives the report. Appendices: 1. New Regional Director of Primary Health Nursing article in The Nelson Mail 2. Correspondence from St John regarding the funding boost they have received from the Government 3. NBPH status update to NMH and correspondence from HSS and Patients First regarding the actions undertaken from the Worldwide Cyber Security Attack 10

11 APPENDIX 1 New regional director of nursing provides strategic vision across top of the south NELSON MAIL, SAMANTHA GEE 5 MAY 2017 Christine Andrews Regional Director of Nursing for Primary Health. MARTIN DE RUYTER Nurses will be better supported following the creation of a new role that will strengthen services across Nelson and Marlborough. Christine Andrews has been appointed the new regional director of primary health nursing. She said the new role would provide strong leadership for nurses across the top of the south. Nurses were the "glue in the health system" and the role would enable her to be a voice for nurses and the opportunity to have a strategic view across the industry. The role had been developed between Nelson Bays Primary Health and Kimi Hauora Wairau Marlborough's primary health organisation. "We are one big family of nurses really, we ought to be on the same page doing the same things." Andrews said there had been a shift in thinking that was reflected in the Nelson Marlborough Primary and Community Care Strategy. "That is looking at supporting people closer to home and that is what nurses do, getting people well, preventing disease, giving good advice and health promotion, those are key nursing roles." The health system was becoming increasingly complex and Andrews said her role involved helping nurses to navigate it. She worked with around 120 nurses in Marlborough and there were 110 practice nurses in Nelson and at least a hundred more working in the community. 11

12 "They have quite a variety of roles but they have the same needs often for workforce, for training, for education opportunities and professional development." Andrews is based in Marlborough where she worked for Kimi Hauora Wairau in a nursing leadership role. Before that, she spent 12 years as a senior policy analyst with the Ministry of Health. She had worked in a variety of nursing roles in primary care, including in paediatrics, community health and in general practice as well as at Plunket. Nelson Bays Primary Health chief executive Angela Francis said the innovative new role would provide leadership across the top of the south. "Given that nurses are a critical part of the workforce for the future, this appointment is timely and will enhance primary health nursing competencies, capability and leadership." Kimi Hauora Wairau chief executive officer Beth Tester said she was delighted the PHOs could work together, which would strengthen nursing leadership across the region. 12

13 APPENDI 2 15 May 2017 Angela Francis Chief Executive Officer Nelson Bays PHO Dear Angela You may have already heard yesterday s announcement from the Government that more than $100 million will be included in this year s budget to provide double crewing of all emergency ambulance responses over the next four years. The package also introduces a new sustainable funding model to increase St John s baseline funding and to meet growing demand for ambulance services while addressing historic shortfalls. Ending single crewing is one of the most significant developments for our ambulance service ever, as it provides rural New Zealand with the same crewing levels as urban a move that will save more lives and make it safer for our crews. We, of course, remain a charity and fundraising will continue to be part of our funding model we ll still need to raise more than 25% of our costs through donations, part charges and our commercial services. As we progressively move to end single crewing, we ll be working closely with local communities and we ll keep you informed as we proceed. In the meantime, I ve attached a copy of our media statement and accompanying fact sheet. If you have any questions, please do let me know I d be happy to discuss this significant development with you. Kind regards David Thomas General Manager South Island Region Encl. Available attachments: Media release Map 13

14 MEDIA RELEASE EMBARGOED 14/5/17 St John welcomes Government funding boost St John welcomes today s news that more than $100 million will be included in this year s budget to provide double crewing of all emergency ambulance responses over the next four years. The package also introduces a new sustainable funding model to increase St John s baseline funding and to meet growing demand for ambulance services while addressing historic shortfalls. Ending single crewing is one of the most significant developments in our ambulance service history, says Chief Executive Peter Bradley. We will be able to recruit 430 frontline jobs over four years and provide rural New Zealand with the same crewing levels as urban areas a move that will save more lives and make it safer for our crews. It will also give us the chance to promote from within and for a large number of our volunteer ambulance officers to become paid staff. Mr Bradley says the funding shows the Government s commitment to ambulance services and recognises St John s unique role in the New Zealand health system. It means we ll be in a better position to meet the growing demand for emergency primary care and community health services. While 375 of these roles will address single crewing, the remaining roles will be to deal with current and future increases in demand. He says phasing out single-crewed emergency ambulances has been a priority for several years, the new funding model means St John can now plan for it with certainty. It will take time to gear up and implement, and the first step is reviewing each station across the country. One size does not fit all and we ll be talking with local communities and our people on the ground to find the best approach in each area. One thing that won t change is St John s charity status and we will still need the support of New Zealanders through donations and part charges for ambulance services. We ll still need to fund more than 25 per cent of our costs through donations and will continue to rely on the generosity of New Zealanders to maintain services and continue improving. -ENDS- Page 1 14

15 ST JOHN AMBULANCE - FACTS: St John provides emergency ambulance services to nearly 90% of New Zealanders and covers 97% of the country s geographical area St John treated and/or transported 437,978 patients in the last financial year (end June 2016) St John is made up of a mix of full-time paid employees and volunteer staff St John has contracts with Ministry of Health and ACC who have been funding just under 70% of the operating costs for the ambulance service. The remaining 30% has been funded through emergency ambulance part charges, fundraising and revenue from commercial activities such as first aid training and medical alarms. St John s fundraising and commercial activities also support the organisation s charitable community programmes. How St John is funded for Ambulance Services Page 2 15

16 What s Changing Current State April 2017 Future State % full crewing 100% full crewing 35,849 single crewed responses (May 2016-April 2017) 4,321 ambulance personnel (2,512 rural) 1,168 paid ambulance staff 3,153 ambulance volunteers Zero single crewed responses 4,702* ambulance personnel (2,888 rural) 1,588 paid ambulance staff (up 420 plus 10 Clinical Control Centre staff, 430 up in total ) 3,114 ambulance volunteers *NB 39 volunteer positions have been absorbed into full-time paid roles For further information: Victoria Hawkins St John Acting Head of Communications T ext 7877 M E Victoria.Hawkins@stjohn.org.nz Noreen Hegarty St John Media & Public Relations Advisor T ext 8095 M E noreen.hegarty@stjohn.org.nz Questions and Answers Is this new funding enough to run an emergency ambulance service? Yes. The additional funding recognises the growing demand for our services and the challenges on staffing levels and resources. This investment addresses that and a number of issues, in particular a plan to introduce double crewing of emergency transporting ambulances across the whole country. What are the advantages of double crewing? Double crewing will benefit patients, especially in rural areas where it means they will receive clinical care while they re being driven to hospital something that couldn t be done with single crewing. It will make the job safer for our ambulance officers and help reduce fatigue, manual handling injuries and stress. New Zealand is the only first world ambulance service with single crewed ambulance responses we currently do this 100 times a day across the country. Are rural communities the biggest winners here? The additional government investment means that within four years, we ll have the same level of service across all our areas. At the moment, most rural areas have some form of single crewed emergency transporting ambulances. We ve wanted to address this for some time Page 3 16

17 and the new funding means rural communities will soon have the same crewing levels available as in urban areas a move that will improve safety and save lives. Why is it taking four years to end single crewing? It s important we get this right. The first step is reviewing our delivery model station by station and we ll get input from our own people and local communities to make sure we get the best configuration of services in each area. It will also take time to recruit and train the extra 430 people and the staggered funding recognises that it will be a four year job. Will St John still need to fundraise for donations? St John is and will always remain a charity. We ve always worked closely with our communities and rely on the generosity of the public, both for donations and volunteers. The increased funding allows us to phase out single crewing and meet expected growth in demand, but St John will still need to fund about 25 per cent of its costs through donations, income from part charges and commercial activities like medical alarms to maintain current services. That figure s currently about $54 million but will grow steadily as the service expands and in five years, we ll be looking to raise close to $70 million a year above the funding from government to maintain services and programmes. Will the number of ambulance stations change? There will be changes as we introduce 430 trained ambulance staff and replace single crewed ambulance responses with double crewed transporting responses. What that will look like is what we will be discussing with staff and local communities. We expect the number of stations to stay about the same and that s part of the detail we ll be working on next. Why the reduction in volunteer numbers? We expect the number of volunteers to remain about the same though, on paper, some positions could be absorbed into the paid work force. It takes many volunteers to cover the equivalent of one full time ambulance officer. As we train and employ more permanent ambulance officers, we ll need fewer volunteers to cover those roles. We hope many of our current volunteers will apply for those permanent paid roles and we ll also need more than 1,400 volunteers to crew an increase in First Response Units. Where will the extra ambulance officers be deployed? The location and the timing of the deployment is what we need to turn our attention to now. Initial panning suggests the district distribution shared on the next page in map diagram form. We ll consult with staff and our communities to find the best fit and mix. Page 4 17

18 Distribution of 430 additional ambulance staff over four years Northland Auckland 46 Central East (Bay of Plenty and Lakes) 65 (Auckland, Counties Manukau and Waitemata) 45 Clinical Control Centre staff (Auckland) 10 Central West (Waikato and Taranaki) 78 Central South (Mid Central, Hawkes Bay and Whanganui) 69 Tasman (Nelson Marlborough and West Coast) 41 Canterbury (Canterbury and South Canterbury) 44 Total Southland/Otago Frontline staff These numbers are indicative only. St John will consult internally and externally to find the best approach and fit for each community. St John does not operate emergency services in the Wellington/ Wairarapa area.

19 APPENDIX 3 From: David Stichbury Sent: Monday, 15 May :51 a.m. To: Kirsty Martin <Kirsty.Martin@nmdhb.govt.nz> Cc: Angela Francis <Angela.Francis@nbph.org.nz>; Management Operations Group <Mogs@nbph.org.nz>; John Herd <John.Herd@nbph.org.nz> Subject: Cyber Security Attack Update NBPH Hi Kirsty An update regarding the status of NBPH. 1. Infection Status: No infections 2. Patching: We are working closely with CCL to ensure we are fully compliant with up-to-date patches. Additional patching to ALL desktop PCs and laptops will take place today. Servers will also undergo further patching this evening to ensure they are fully compliant. 3. Key Mitigation Activities: An has been sent to all users over the weekend with key message regarding unexpected s and the need for vigilance. This will be followed up today. We will be pushing the If you didn t expect it, reject it campaign. NBPH has 15 minute backups of the MedTech database in Golden Bay, hourly replication backups of all file systems and key servers (Exchange, File Server, etc.) across Richmond and Golden Bay sites. NBPH has an active firewall (hardware) and up-to-date antivirus (software) 4. Service Impact: There will be patching for all desktops today which may impact on productivity for 15 to 30 minutes Patching of servers this evening will impact on some users. They will be notified regarding this. Regards David David Stichbury IT and Communications Manager Tel: Mob: David.Stichbury@nbph.org.nz 281 Queen Street, Richmond. PO Box 1776, Nelson 7040 Ph

20 From: Kyle Forde Sent: Sunday, 14 May :37 p.m. To: Bill Eschenbach Angela Francis Susan Iversen Ian Macara Laila Cooper Beth Tester Cc: Nathan Bell Subject: Cyber Security Attack Update HSS Importance: High Hi Team Following the Cyber Attack over the weekend the following actions were taken: 1. HSS hosted Servers checked for up to date patches and internet security updates All Passed 2. Karo hosted Servers checked for up to date patches and internet security updates All Passed 3. CHCHPHO hosted Servers checked for up to date patches and internet security updates All Passed 4. WellSouth on-premise Servers checked for up to date patches and internet security updates All Passed Where servers, laptops and desktops are managed onsite by your local third party provider we recommend you contact your provider asap to check these devices. The Ministry of Health have requested all PHO s report to them daily 10am and 4pm to report status of the below items. Organisation: Date/time: 1. Infection Status: No Infections/Infections 2. Patching status (client and server OS): Complete/In progress 3. Key mitigation activities: Provide brief summary 4. Service impact: Provide brief summary of any service impact due to the response and mitigation activities If you have any questions please feel free to call me directly. Kind Regards. Kyle Forde, Chief Information Officer, WellSouth wellsouth.org.nz Level 1, 333 Princes St, PO Box 218, Dunedin

21 From: Helmut Modlik Sent: Saturday, 13 May :42 p.m. To: Adrian Rasmussen Adrian Tucker Aman Sanhu Andra Cornea Angela Francis Barbara Stevens Beth Tester Bill Eschenbach Bridget Allan Chiquita Hansen Chris Walmsley Craig Treanor Daniel Grassam Darren Walmsley David Stichbury Diane Taylor Donovan Clarke Gideon du Toit Grant Ardern Grant White Helen Reriti Hugh Kininmonth Ian Macara Janice Kuka Jensen Webber John Macaskill-Smith John Ross Jonathan Murray Judith MacDonald Keith Gregory Ken Biswell Ken Hippolite Kirsten Stone Kyle Forde Laila Cooper Lisa Wickham Loretta Hansen Lyn Allen Maple Zhang Mark Vella Martin Hefford Matiu Rei Michael Shapleski Michelle Murray Nancy Taneja Nicola Ehau (Interim from 19/9 Phil Murphy Rodney Burger Roger Taylor Rose Kahaki Ruth Kibble Sam Callander Sharon Cavanagh Simon Royal Stephen Powell Steve Boomert Symon McHerron Trish Anderson Valerie Wilburn-Fowler Vince Barry Wayne Williams Cc: Peter Jordan Mahalia Mills Subject: CYBERSECURITY ALERT! Importance: High Hello everyone, Worldwide health IT systems have been subject overnight to a cybersecurity attack as outlined in the following release: Today, widely reported in the media is a wide-scale cybersecurity attack that was first reported affecting the healthcare system in the UK. News outlets are reporting that the infection has spread to as many as 74 countries. Press accounts detail a ransomware attack that has been leveraged using a leaked National Security Agency (NSA) hacking tool. The New York Times reported, "The malware was circulated by ; targets were sent an encrypted, compressed file that, once loaded, allowed the ransomware to infiltrate its targets." The Guardian reports that countries are being hit with a "huge, fast-moving and 21

22 global ransomware attack that locks computers and demands the digital equivalent of $300, according to Kaspersky Lab, a Russian-based cybersecurity company." The Ministry of Health and District Health Boards are working hard today to ensure appropriate measures are being taken to mitigate the risk of this attack on the New Zealand health sector. PHOs are asked to liaise as soon as possible with their member practices to (a) warn about the heightened risk of opening unsolicited s and attachments, and (b) implement remedial measures e.g. patches to remove the malware risk involved. Further information and/or updates will be provided by the Ministry and DHBs, and will be distributed as required. Lastly, please advise urgently if you become aware of any Practice that is affected by this cyber attack. Regards Helmut Modlik Chief Executive Officer m e helmut.modlik@patientsfirst.org.nz w a 50 Customhouse Quay, Level 4, PO BOX Wellington 22

23 To Nelson Bays Primary Health Board From Karen Winton, Acting GM Health Services Endorsed by Angela Francis, Chief Executive Meeting date 1 June 2017 Subject General Manager Health Services Operational Report Open Section For approval For action For information 1. SERVICE OVERVIEW The Health Services Division cost centres is tracking to budget with a surplus forecast for year-end. System Level Measures (SLM) workshops continue to be held, in conjunction with Nelson Marlborough Health (NMH), to ensure NBPH is working together to achieve contributory measures with clear action plans across the sector. NBPH has led the development of, and recently welcomed, the newly appointed Regional Director of Primary Health Nursing, who will be working across Nelson Marlborough primary care and will provide professional leadership for the nursing workforce. The Health Services Team welcomes the newly appointed Primary Health Facilitator in June. 2. HEALTH PROMOTION Falls Prevention ACC community-based Strength and Balance partnership agreement is currently in the implementation stage with this part being due for completion by the 30 June The Fracture Liaison Service (FLS) requires funding from DHB to be provided to implement the osteoporosis/ falls/malnutrition screening tool. This has been raised at recent Falls Alliance meeting and formal written agreement is yet to be received. No further service improvements can be provided without this tool in place. Green Prescription The Hip and Knee programme has delivered a further two clinics within the last month to address osteoarthritis self-management across our rural communities. There is a huge demand for this selfmanagement course at this time but these programmes will reduce to funded target of one per month in the future. The Quick Start programme has run two sessions and Kick Start have run three within the month. The referral target is reduced due to no referral links on current web-based forms. This is currently being investigated. Community Nutrition The Toddler Better Health programme is currently in progress in Richmond. Clinics continue to be provided with 42 clients seen in the last month. 23

24 There is limited dietician services regionally to manage malnutrition issues. This is becoming more of a challenge with the aging population growth. This issue has been raised at the local Nelson Marlborough Falls Alliance Steering group. Cardiac Rehabilitation NBPH are still awaiting results from the budget bid submitted to continue to provide this unique primary care service, these are not expected until May. One session has been delivered this month with 12 people attending. Interpreter Services NMH have now agreed to work alongside Red Cross and Pacific Trust to sub-contract interpreter services to manage this service line. This will include Red Cross having responsibilities for training, all bookings and potentially financial responsibilities. A meeting to further discuss terms and which services are linked will be held shortly. 3. PRIMARY HEALTH After Hours Telephone Nurse Triage A meeting was held in May to discuss this contract further and the outcome is there is expected to be no change to the current agreement with a further meeting to be held in approximately six months to look at potential future options between services. Respiratory Service The Pulmonary Rehabilitation Service programme has completed its first full programme with excellent results and feedback from all participants involved. This programme will continue to be run by the Asthma Society via funding from NBPH and with the support of NBPH s Respiratory Nurse. NBPH s Respiratory Nurse is currently supporting NMH to review the significant waitlist for Respiratory clients with an agreement on resourcing reached. Smoking Cessation NBPH s latest results are 89%, which is similar to last months results. NBPH are continuing to work with General Practices to ensure this issue is raised as a priority across their services and is currently recruiting for a new staff member who will focus on both Smoking Cessation and Respiratory Health. National Enrolment Service (NES) This is now operative following the temporary shutdown by the MOH due to potential privacy concerns. All General Practices have been sent the required information to update their systems back online. 4. SPECIALIST SERVICES Infectious Diseases NBPH s Infectious Diseases Specialist is currently working with Dr Dave Dixon to combine hospital and community (Health Pathways) guidelines for improved consistency of approach. They are also investigating the potential use of a South Island wide smart phone app to support professionals in the future. Telephone advice and face-to-face appointments are provided in an efficient timeframe. More virtual clinics are happening with positive feedback from clients. 24

25 Community Rheumatology Service This service has an overdue waitlist so NBPH is increasing clinics provided to redress this issue. NMH have agreed to provide ongoing increased funding, with an expectation on increased targets and reporting arrangements requested. 5. MAORI HEALTH Kaiatawhai Service Referrals remain steady with goods outcomes. Currently working on formal evaluations of this service. Kaitakawaenga Luke Katu is providing Staff with weekly Māori language lessons. Four Treaty of Waitangi workshops and two Cultural awareness sessions have been held. 6. MENTAL HEALTH Primary Mental Health Initiative (PMHI) and Brief Intervention Service (BIS) A Mental Health review has been held this month across all Non-Government Organisations by an independent panel, with an emphasis on identifying perceived gaps and opportunities for aligning service provision where this may improve outcomes for clients. A timeframe for the report from this has not been provided. The current demand for services across PHMI and BIS remains high. 7. RECOMMENDATION It is recommended that: The Board receives the report. 25

26 To Nelson Bays Primary Health Board From Naomi Johnson, Lead Health and Safety Representative Endorsed by Angela Francis, Chief Executive Meeting date 1 June 2017 Subject Health and Safety Report For approval For action For information 1. OVERVIEW AND UPDATE The following provides a high level update on Health and Safety for Nelson Bays Primary Health (NBPH). This report presents records from both Richmond and Golden Bay sites. This month there are no issues of concern to report. 2. INCIDENT AND HAZARD REPORTING All incidents reported in April occurred at Golden Bay Community Health (GBCH). Three of these incidents were classified as Health and Safety incidents, relating to staff injury or were risks for increased staff stress due to staffing or resourcing issues. The following graph compares the incidents previously reported in February and March, as well as the newer incidents from April this year. No incidents were serious harm. Table 1. Near Miss and Incident Records April 2017: Incident Reporting: 1 February to 30 April GBCH - Staff GBCH - Patients Richmond GBCH - Staff GBCH - Patients Richmond GBCH - Staff GBCH - Patients February March April Near-Miss: no harm Actual: no harm Actual: injury Serious Harm Richmond 3. OTHER HEALTH AND SAFETY ACTIVITIES Stress in the Workplace It is difficult to identify stress in the workplace, as stress can be mediated by both workplace and personal factors. To guide the organisation in this the workplace monthly usage of the Employee Assistance 26

27 Programme (EAP) services is considered. EAP is a confidential service and the matters raised are not necessarily stress related. There has been no use of the EAP service in the past month. Golden Bay Activities Monthly meeting attended as scheduled Four GBCH staff attended Coordinated Incident Management Training (CIMS 4) 43 staff members completed their online and practical Fire Safety Training Awaiting feedback from South Island Emergency Planning Coordinator on GBCH Emergency Plan 281 Queen Street Activities Four Richmond NBPH staff attended Coordinated Incident Management Training (CIMS 4) Regular input into staff newsletter No new hazards, nor incidents to manage at this time. 4. RECOMMENDATION It is recommended that: The Board receives this report. 27

28 To Nelson Bays Primary Health Board From Emily-Rose Richards, Executive Assistant/Board Secretary Endorsed by Angela Francis, Chief Executive Meeting Date 1 June 2017 Subject Policies for Approval For approval For action For information 1. PURPOSE To provide the Board with updated policies, which require the Board s approval. 2. SUMMARY OF POLICIES At the Governance and Remuneration Committee meeting on 7 February 2017, the following policy amendments were agreed on: Confidentiality Policy The following amendments were made to the Confidentiality Policy: Include a paragraph on the obligations/consequences of not complying with the confidentiality policy, in terms of remedies under the employment agreement, common law and contracts Mr Hunter to forward a confidentiality agreement to Ms Francis to use as Appendix 1 At the following Governance and Remuneration Committee meeting on 10 April 2017, the Confidentiality Policy was recommended to the Board for approval. Refer to Appendix 1 for the Confidentiality Policy. Privacy Policy The following amendments were made to the Privacy Policy: Amend section 5.3, rules 1 12: Rules to be simplified and referenced to Appendix 1 Policy to be simplified Change Rule to read Principle throughout the Policy Amend page 2, section 2, last paragraph to read: All NBPH employees are required to complete training in relation to the Privacy Act to understand their responsibilities, with refresher training to be completed every three years as a maximum. This training is to be recorded by the line manager in the employee files. At the following Governance and Remuneration Committee meeting on 10 April 2017, the Privacy Policy was recommended to the Board for approval. Refer to Appendix 2 for the Privacy Policy. At the Governance and Remuneration Committee meeting on 10 April 2017, the following policy amendments were agreed on: Deputy Chairperson Selection Policy The Deputy Chairperson Selection Policy was recommended to the Board for approval, subject to the following amendments being made: Amend page 1, section 4, last bullet point to include at the end: provided however, that the Chair retains the right to reject the candidate for good reason. 28

29 Refer to Appendix 3 for the Deputy Chairperson Selection Policy. Independent Chairperson Selection Policy The Independent Chairperson Selection Policy was recommended to the Board for approval, subject to the following amendments being made: Amendments to page 2, section 5, paragraphs 5 8 to read: Advertise in relevant print media, NBPH and DHB websites, NZ Institute of Directors and other avenues as appropriate. The Selection Panel will review the interview questions, shortlist and interview candidates, and references of recommended candidates to be contacted. A search utilising media search will be undertaken. The Board will meet with the recommended candidates prior to discussing appointment to determine the fit with the Board, the NBPH in general, our enrolled population, providers, community and iwi. There will also be a limited opportunity to pose any questions, however, this is considered a meet and greet rather than a second interview. The Board will make the final selection. The appointee to be confirmed at the AGM (or by Special Resolution in the event of the Chairperson not seeing out their full term). Refer to Appendix 4 for the Independent Chairperson Selection Policy. Subcommittee Selection Policy The Subcommittee Selection Policy was recommended to the Board for approval, subject to the following amendments being made: Amend page 1, section 3, bullet point 4 to read: There is the ability to have alternates/proxy at the meetings. Refer to Appendix 5 for the Subcommittee Selection Policy. At the Audit and Financial Risk Committee meeting on 12 April 2017, the following policy amendments were agreed on: Fixed Asset Management Policy The Fixed Asset Management Policy was recommended to the Board for approval, with no amendments made. Refer to Appendix 6 for the Fixed Asset Management Policy. 3. RECOMMENDATION It is recommended that the Board approves the: Confidentiality Policy, Privacy Policy, Deputy Chairperson Selection Policy, Independent Chairperson Selection Policy, Subcommittee Selection Policy, and Fixed Asset Management Policy. Appendices: 1. Confidentiality Policy 2. Privacy Policy 3. Deputy Chairperson Selection Policy 4. Independent Chairperson Selection Policy 5. Subcommittee Selection Policy 6. Fixed Asset Management Policy 29

30 APPENDIX 1 TITLE: Confidentiality Policy 1. Statement / Purpose The purpose of this policy is to ensure Nelson Bays Primary Health (NBPH) Board Trustees, committee members, employees, volunteers, and the workers of organisations contracted to NBPH understand that information gained in the course of their involvement and activities with NBPH Is confidential and May not be disclosed outside of NBPH business without authorisation from the NBPH Board Chair or Chief Executive. 2. Scope This policy applies to all NBPH Board Trustees, committee members, employees, volunteers, contracted organisations and their workers. 3. Details 3.1 All matters that are the subject of public excluded (closed) sessions of the Board are confidential until disclosed in an open session of the Board. 3.2 All matters that are before a Committee or task force of the Board are confidential unless they have been determined not to be confidential by the NBPH Committee Chair or Chief Executive. 3.3 All information that may be sighted or acquired during the course of work is confidential. This includes, but is not restricted to, information about: NBPH s funding, business practices and clients Contractual relationships and information Performance data Confidential and contact lists e.g. personal details of GPs, board members and employees NBPH providers and its contracted providers business information including performance data/information Medical practitioners and other health practitioners, including the number of consultations they undertake Information about the patients of medical practitioners Individual and collated clinical and/or service-based data Aggregated and/or non-identifiable data about the organisation, membership, members and/or patients 3.4 The parties to confidential information gained during the course of their work and activities with NBPH must treat the information in absolute confidence and will not at any time attempt to use such information for: Their personal gain or advantage Nelson Bays Primary Health Organisation Authorised by: Issue Date: February 2012 NBPH Board Version Date: May 2017 Policy: Confidentiality Policy Review Date: May 2020 Version: 3 Page 1 of 4 30

31 The personal gain or advantage of any person, partnership or corporation with whom the employee may become associated The disadvantage of NBPH as an organisation The disadvantage of any individual within NBPH. Confidential information of any nature is not to be passed on to any external party without the prior permission of the NBPH Board Chair or Chief Executive. Breaches of this policy may be viewed as serious misconduct under the NBPH Code of Conduct and the consequences of not complying with this policy will be implemented according to this Code of Conduct. 4. Related Documents a) Confidentiality Agreement Form (Appendix 1) b) NBPH Media Relations Policy c) NBPH Individual Employment Agreements d) NBPH Code of Conduct e) NBPH Contract for Services 5. References Privacy Act 1993 and Privacy Principles Health Information Privacy Code Approved by: NBPH Board Nelson Bays Primary Health Organisation Authorised by: Issue Date: February 2012 NBPH Board Version Date: May 2017 Policy: Confidentiality Policy Review Date: May 2020 Version: 3 Page 2 of 4 31

32 APPENDIX 1 CONFIDENTIALITY AGREEMENT For completion by NBPH Trustees, Committee Members, Employees, Volunteers, Contractors and their Workers Parties: And Nelson Bays Primary Health (NBPH) (Full Name): From (Name of Organisation): Agreement to Comply with NBPH Policy on Confidentiality In agreeing to comply with NBPH Policy on Confidentiality, you are agreeing to adhere to the Privacy Act 1993, Privacy Principles within the Act and the Health Information Privacy Code The parties acknowledge that during the course of work on behalf of Nelson Bays Primary Health (NBPH), you may sight and/or will acquire confidential information. It is agreed that such confidential information includes that which may relate to, but is not restricted to: NBPH s funding, business practices and clients Contractual relationships and information Performance data Confidential and contact lists e.g. personal details of GPs, board members and employees NBPH providers and its contracted providers business information including performance data/information Medical practitioners and other health practitioners, including the number of consultations they undertake Information about the patients of medical practitioners Individual and collated clinical and/or service-based data Aggregated and/or non-identifiable data about the organisation, membership, members and/or patients The parties agree that you will at all times treat all information obtained during your duties in absolute confidence and will not at any time attempt to use such information for: Your personal gain or advantage The personal gain or advantage of any person, partnership or corporation with whom the employee may become associated The disadvantage of Nelson Bays Primary Health as an organisation The disadvantage of any individual within Nelson Bays Primary Health. Confidential information of any nature is not to be passed on to any external party without the prior permission of the Nelson Bays Primary Health Board Chair or Chief Executive. Signed: Date: Relationship (please circle): Trustee / Committee Member / Employee / Volunteer / Contractor On behalf of Nelson Bays Primary Health: Nelson Bays Primary Health Organisation Authorised by: Issue Date: February 2012 NBPH Board Version Date: May 2017 Policy: Confidentiality Policy Review Date: May 2020 Version: 3 Page 3 of 4 32

33 Signed: Name: Date: Nelson Bays Primary Health Organisation Authorised by: Issue Date: February 2012 NBPH Board Version Date: May 2017 Policy: Confidentiality Policy Review Date: May 2020 Version: 3 Page 4 of 4 33

34 APPENDIX 2 TITLE: Privacy Policy 1. Statement / Purpose To ensure that Nelson Bays Primary Health (NBPH) meets its duties and responsibilities with respect to the Privacy Act 1993 and the Health Information Privacy Code Background The Privacy Act establishes that information concerning an individual should be collected, stored, used and destroyed in a manner which ensures that the individual concerned (and in certain circumstances their relatives) are not either actually, or potentially harmed. Failure to comply with the 12 Information Privacy Principles in the Privacy Act can result in severe legal penalties for the individual and/or organisation breaching the principles. The Health Information Privacy Code applies to all health agencies and individuals who use health information. The code does not apply to statistical or anonymous information which does not enable the identification of an individual. The Health Information Privacy Code does not supersede standards of ethical and professional conduct of health professions, but sets minimum standards with which all individuals and organisations have to comply. All health agencies must have a recognised and authorised Privacy Officer. 3. Scope The policy applies to all NBPH employees and volunteers, workers contracted to NBPH, and Board and Committee members as they carry out NBPH business. 4. Definitions Not Applicable. 5. Details 1. NBPH Privacy Officer The Privacy Officer is the Chief Executive, or a duly authorised representative. The responsibilities of a Privacy Officer include: Ensuring NBPH compliance with the provisions of the Privacy Act and Privacy Principles (Appendix 1) covering the collection, use, management and storage of personal information Dealing with access and correction requests made to NBPH Working with the Privacy Commissioner on any investigation into NBPH Nelson Bays Primary Health Organisation Authorised by: Issue Date: August 2013 NBPH Board Version Date: May 2017 Policy: Privacy Policy Review Date: May 2020 Version: 3 Page 1 of 5 34

35 Ensuring all employees are educated about the privacy implications of information handling practices Through an annual audit, identifying any areas of the organisation that may be in breach of the Privacy Act or Health Information Privacy Code and if breaches are identified, ensuring remedial action is taken Ensuring adequate resource allocation for health information security Ensuring employees comply with security related policy Ensuring all NBPH information collection, use and storage complies with the Health Information Privacy Code Authorising access to health information for relevant employees. 2. Compliance and Training All NBPH employees, workers contracted to NBPH, NBPH Board and Committee members are to comply with the Privacy Principles and Health Information Privacy Code requirements in all contacts with an employee s personal information, patients and/or patient information, in all circumstances. Failure to comply may be viewed as serious misconduct as outlined in the NBPH Code of Conduct. All NBPH employees are required to complete training in relation to the Privacy Act to understand their responsibilities, with refresher training to be completed every three years as a minimummaximum. This training is to be recorded by the line manager in the employee files. 3. Privacy Principles and Health Information NBPH systems and processes must comply with the Privacy legislative and regulatory requirements. The Health Information Privacy Code builds on Privacy Principles and applies them specifically to Health information. These Rules Principles from the Health Information Privacy Code are aligned with NBPH policy as detailed below. The principles are as follows and may be found in Appendix 1: Rule Principle 1 Purpose of Collection of Health Information Most health information is collected in a situation of confidence and trust and the manner of collection should reflect that confidence and trust by: Ensuring that health information is only collected from a person if it is for a lawful purpose connected with the function or activity of the health agency and is necessary for that purpose (e.g. care and treatment, administration, training and education, quality assurance). Rule Principle 2 Source of Health Information Information shall be collected directly from the person concerned or from a person who he/she authorises or who is their legal representative. Rule Principle 3 Collection of Health Information from Individual All reasonable steps must be taken to ensure the person knows: That the information is being collected Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Heading 1, Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Nelson Bays Primary Health Organisation Authorised by: Issue Date: August 2013 NBPH Board Version Date: May 2017 Policy: Privacy Policy Review Date: May 2020 Version: 3 Page 2 of 5 35

36 The purpose for which the information is being collected The intended recipients of the information The name and address of the agency collecting and holding the information The consequences to that individual and/or representative if all or any part of the requested is not provided (e.g. that failure to provide information for education and training purposes will not prejudice treatment) The right of access to correct the health information. Rule Principle 4 Manner of Collection of Health Information Patient information shall not be collected by unlawful or unfair means or intrude to an unreasonable extent upon personal affairs of the individual concerned (sensitively taken history would not constitute intrusion ; however, areas that the individual regards as intrusive should not be pursued). Rule Principle 5 Storage and Security of Health Information NBPH will ensure that patient information is protected against loss, access, use, modification or disclosure or misuse. All efforts are to be made to prevent unauthorised use or unauthorised disclosure of the information, such as: Patients notes/records must not be taken from the places specified for their secure storage without prior authorisation from the Privacy Officer or delegate Patients notes/records authorised to be taken off the premises must be kept secure during transportation (e.g. carried in a locked case) and remain inaccessible to others No patient information is to be sent via unsecured or posted via the internet No patient files should be copied to local storage ( C drive ) of employee computers All patient information should be stored on secure ( R drive ) or password protected sites on the NBPH server Employees access to individual health information is determined and authorised by the Privacy Officer or delegate All patient health information is transferred between NBPH and General Practice or authorised service provider via a secure method i.e. Health Link. Rule Principle 6 Access to Personal Health Information NBPH shall provide to the patient, on request, confirmation of whether or not NBPH holds information about them and also provide access to that information. Rule Principle 7 Correction of Health Information Individuals have the right to request correction of their health information. NBPH will consider any request to correct health information, and will make the changes. When a change is made, it will be noted by the person authorising the change. Where a request for correction is refused, the individual must be informed of the following: Reasons for refusal Supporting grounds for refusal Right to request the attachment to the information of a statement provided by the individual of the correction sought Right to complain to the Privacy Commissioner and to seek an investigation and review of the decision. Rule Principle 8 Accuracy of Health information to be Checked before Use NBPH is required to check the accuracy of health information before using it. The steps which it is reasonable to take will vary depending upon the proposed use. Rigorous checks will be appropriate if decisions based on health care entitlements are to be based on the information but if it is to be aggregated for statistical purposes, few or no checks may be Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Nelson Bays Primary Health Organisation Authorised by: Issue Date: August 2013 NBPH Board Version Date: May 2017 Policy: Privacy Policy Review Date: May 2020 Version: 3 Page 3 of 5 36

37 needed, particularly if the checking process would unnecessarily intrude on the individual s privacy. Rule Principle 9 Retention of Health Information Health information must be retained under the express requirements of certain enactments, such as: The Health (Retention of Health Information) Regulations 1996 Clause 58 of the Medicines Regulation Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Generally the Health (Retention of Health Information) Regulations 1996 require health records to be retained by health agencies for 10 years. NBPH may lawfully retain records longer than this for the purposes of administration, monitoring, training and education. Where health information is stored for long periods, it is to be held in secure storage e.g. in a secure and locked filing cabinet or warehouse or off-line. When disposing of information e.g. hard drives, flash drives etc, NBPH will dispose of information in a manner that preserves the privacy of the individual. For example: document destruction through e.g. Online Security Services (Iron Mountain); computer information to be destroyed through the appropriate secure means. Rule Principle 10 Limits on Use of Health Information NBPH will not use the health information for any other purpose unless NBPH believes that: The disclosure of information is for one of the purposes in connection with which the information was obtained The information is a publicly available publication Use of the information is necessary to prevent or lessen a serious or imminent threat The information is used or will be published in a form in which the individual concerned is not identifiable. Rule Principle 11 Limits on Disclosure of Health Information NBPH shall not disclose information to a person or body or agency except as listed in Rule 10 above. Rule Principle 12 Unique Identifiers NBPH shall not assign a unique identifier unless it is necessary to carry out any one of more of its functions efficiently e.g. patient surveys. If unique identifiers are assigned NBPH will take all reasonable steps to ensure that the identifiers are only assigned to individuals whose identity is clearly established. NBPH does store information by National Health Index (NHI) number. If information is identifiable, it will be stored in accordance with Rule 5. Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm Formatted: Indent: Left: 0 cm, Hanging: 0.5 cm, Bulleted + Level: 1 + Aligned at: 0.63 cm + Indent at: 1.27 cm NOTE: If information is stored in a totally anonymous manner and the individual is not identified, some components of this policy do not apply. If unsure, employees should check with their line manager or the Privacy Officer. 6. Related Documents a) Privacy Principles (Appendix 1) b) NBPH Confidentiality Policy c) NBPH Building Security Policy d) NBPH Code of Conduct Nelson Bays Primary Health Organisation Authorised by: Issue Date: August 2013 NBPH Board Version Date: May 2017 Policy: Privacy Policy Review Date: May 2020 Version: 3 Page 4 of 5 37

38 7. References Privacy Act 1993 Privacy Principles Health Information Privacy Code On the Record: A Practical Guide to Health Information Privacy, 2 nd edition, July The Health (Retention of Health Information) Regulations 1996 Medicines Regulation 1984, clause 58. Approved By: NBPH Board Nelson Bays Primary Health Organisation Authorised by: Issue Date: August 2013 NBPH Board Version Date: May 2017 Policy: Privacy Policy Review Date: May 2020 Version: 3 Page 5 of 5 38

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