HOSPITAL ADVISORY COMMITTEE (HAC) MEETING. Wednesday 29 November 2017 A G E N D A

Transcription

1 HOSPITAL ADVISORY COMMITTEE (HAC) MEETING Wednesday 29 November pm A G E N D A VENUE Waitemata District Health Board Boardroom Level 1, 15 Shea Tce Takapuna 1

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3 1 HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 29 November 2017 Venue: Waitemata DHB Boardroom, Level 1, 15 Shea Terrace, Takapuna Time: 1.30pm Committee Members James Le Fevre Committee Chair Max Abbott WDHB Board Member Kylie Clegg WDHB Deputy Chair Sandra Coney Deputy Committee Chair Brian Neeson WDHB Board Member Morris Pita WDHB Board Member Allison Roe WDHB Board Member cc All Waitemata DHB Board Members WDHB Management Dale Bramley Chief Executive Officer Robert Paine Chief Financial Officer and Head of Corporate Services Andrew Brant 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 Board Secretary APOLOGIES: Max Abbott 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 1.30pm 2.1 Confirmation of Minutes of Hospital Advisory Committee Meeting (18/10/17) Actions Arising from previous meetings 3. PROVIDER REPORT 1.35pm 3.1 Provider Arm Performance Report September 2017 Executive Summary Human Resources Acute and Emergency Medicine Division Specialty Medicine and Health of Older People Services Child, Women and Family Services Specialist Mental Health and Addiction Services Surgical and Ambulatory Services/Elective Surgery Centre 3.2 Provider Arm Performance Report October pm 2.40pm 2.45pm 4. CORPORATE REPORTS 4.1 Clinical Leaders Report 4.2 Human Resources Report 4.3 Quality Report 5. INFORMATION PAPER 3.25pm 5.1 Summer Plan 2017/ pm 6. RESOLUTION TO EXCLUDE THE PUBLIC 2

4 1 Waitemata District Health Board Hospital Advisory Committee Member Attendance Schedule 2017 NAME MAR MAY JUN JULY SEP OCT NOV Max Abbott Kylie Clegg Sandra Coney x James Le Fevre (Committee Chair) Brian Neeson Morris Pita x x Allison Roe Attended the meeting x Absent * Attended part of the meeting only # Absent on Board business ^ Leave of absence 3

5 1.1 Board/Committee Member Max Abbott Kylie Clegg Sandra Coney James Le Fevre Brian Neeson Morris Pita Allison Roe Register of Interests Hospital Advisory Committee Involvements with other organisations 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 Trustee - Well Foundation Director Auckland Transport Director Sport New Zealand Board Member - Hockey New Zealand Trustee and Chair - the Hockey Foundation Trustee and Beneficiary - Mickyla Trust Trustee and Beneficiary - M&K Investments Trust (includes a share of less than 1% in Orion Health Group and a shareholding in Nextminute Holdings Ltd) Trustee and Beneficiary - M&K Investments Trust (owns 99% share in MC Capital Ltd and MC Securities Ltd and a minority shareholding in HSCP1 Ltd) Member Waitakere Ranges Local Board, Auckland Council Patron Women s Health Action Trust Member Portage Licensing Trust Member West Auckland Trusts Services Deputy Chair Auckland District Health Board Emergency Physician Auckland Adults Emergency Department Pre-hospital Physician Auckland HEMS ARHT/Auckland DHB Trustee Three Harbours Foundation Member Medical Protection Society Member ACEM Hospital Overcrowding Subcommittee Shareholder Pacific Edge Ltd DHB Representative (Auckland and Waitemata DHBs) Air Ambulance Codesign Procurement Governance Board. James wife is an employee of the Waitemata DHB, Department of Anaesthesia and Perioperative Medicine and a Medico-Legal Advisor for the Medical Protection Society 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 Owner/operator Shea Pita and Associates Limited Shareholder Turuki Pharmacy Limited Member - Eden Park Trust Board Morris wife is member of the Northland District Health Board Shareholder and Director of Healthcare Applications Limited Chairperson Matakana Coast Trail Trust Member - Rodney Local Board, Auckland Council Last Updated 19/03/14 17/08/17 15/12/16 05/05/17 15/12/16 06/12/16 02/11/16 4

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7 Minutes of the Hospital Advisory Committee Meeting held on 18 October 2017 Recommendation: That the draft minutes of the Hospital Advisory Committee meeting held on 18 October 2017 be approved. 5

8 2.1 Minutes of the meeting of the Waitemata District Health Board Hospital Advisory Committee Wednesday 18 October 2017 held at Waitemata District Health Board Boardroom, Level 1, 15 Shea Terrace, Takapuna, commencing at 1.35pm PART I Items considered in public meeting COMMITTEE MEMBERS PRESENT James Le Fevre (Committee Chair) Max Abbott Kylie Clegg Sandra Coney Brian Neeson Morris Pita (until 3.44pm, item 4.3) Allison Roe ALSO PRESENT Warren Flaunty (Waitemata DHB, Board Member) (until 3.23pm, item 4.1) Dale Bramley (Chief Executive Officer) Andrew Brant (Chief Medical Officer) Cath Cronin (Director of Hospital Services) Fiona McCarthy (Director of Human Resources) David Price (Director of Patient Experience) Peta Molloy (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 WELCOME APOLOGIES Sue Claridge (Auckland Women s Health Council) The Committee Chair welcomed those present. Apologies were received from Tamzin Brott (Director of Allied Health) and Jocelyn Peach (Director of Nursing and Midwifery). DISCLOSURE OF INTERESTS There were no additions or other amendments to the Interests Register. Later in the meeting, Morris Pita stepped out of the meeting for the discussion of the Acute and Medicine Division update in item 3.1 due to his disclosed interested of Healthcare Applications Limited. 6

9 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 06 September 2017 (agenda pages 5 to 13) Resolution (Moved Brian Neeson/Seconded Kylie Clegg) That the Minutes of the Hospital Advisory Committee meeting held on 06 September 2017 be approved. Carried Actions Arising (agenda page 14 ) Noted. 3. PROVIDER ARM PERFORMANCE REPORT 3.1 Provider Arm Performance Report August 2017 (agenda pages 15 to 72) Cath Cronin (Director Hospital Services) summarised the executive overview of the report. Robert Paine (Chief Financial Officer) summarised the financial section of the executive overview. Matters covered in discussion and response to questions included: That with regard to unfavourable financial reporting for infrastructure and nonclinical supplies, it was noted that the area of facilities maintenance was being looked into. Some comparison costs had been obtained from Counties Manukau DHB and were being sought from Auckland DHB. In response to concern expressed about the reported DNA rate for Maori and Pacific patients, Cath Cronin noted that steps are being taken to reduce DNA rates and that some improvements being seen. Noting that with regards to the average time for complaint responses, there has been some complex issues raised with multidisciplinary teams involved. However, the majority of complaints are responded to in a timely matter. Cath Cronin advised that when required there is frequent contact with people who have raised an issue with regular updates and interaction occurring throughout the investigation prior to a response being sent. Noting with regard to food services that the unbudgeted increase in price was the result of contractual terms allowing for an increase if the food services agreement did not achieve required volumes. Human Resources (agenda page 32) Fiona McCarthy (Director, Human Resources) summarised this section of the report. She noted that after the winter season there has been a continuing reduction in sick 7

10 2.1 leave. Also noted was that a final validation of internal/external turnover was being completed, with the intention of reporting this to the Committee at its next meeting. Matters covered in discussion and response to questions included: That sick leave reported is primarily cyclical. In response to a query, Fiona McCarthy noted that with regard to sick leave and a possible influenza outbreak, there had been learnings following a pandemic in Australia a few years ago. Max Abbott noted that the focus of the World Mental Health day was mental health in the workplace. He noted the very positive work being undertaken in this area. With regard to the DHB, Michael Rodgers advised that a PHD student was currently looking at how the DHB measures the wellbeing of its theatre staff. The Committee requested a presentation in the first quarter of 2018 around the work of Helen Wood, who has a key role in the development of a mental health workplace policy that will be rolled out across all United Nation agencies. Acute and Emergency Medicine Division (agenda page 35) Morris Pita stepped out of the meeting for the discussion of this section of the report due to his disclosed interest in Healthcare Applications Limited. Alex Boersma, (General Manager, Acute and Emergency Medicine), Shirley Ross (Head of Division Nursing) and Gerard de Jong (Division head Acute and Emergency Medicine) were present for this section of the report. Alex Boersma summarised the report. The Committee Chair acknowledged the report presented. Matters covered in discussion and response to questions included: That the uptake of the White Cross voucher system was not as effective at Waitakere Hospital. Work has been undertaken to refer patients to White Cross if appropriate. Patients are categorised with high risk patients are seen in the emergency department. That the DHB Emergency Department Clinical Director and colleagues had liaised with Shorecare and defined lists of presentation types that are appropriate for emerging care model were identified. Shirley Ross noted the existing roles in the area of nurse practitioner/nurse specialist models of care. Morris Pita returned to the meeting. Specialty Medicine and Health of Older Persons (agenda page 44) John Scott (Head of Division, Speciality Medicine and Health of Older People Services), Brian Millen (Acting General Manager, Medicine and Health of Older People Services) and Shirley Ross (Head of Department Nursing) presented this section of the report. The Committee welcomed Brian Millen. John Scott and Brian Millen summarised the report. Matters covered in discussion and response to questions included: 8

11 2.1 Sandra Coney requested a copy of the published findings of the Waitemata DHB Fracture Liaison Service in the New Zealand Medical Journal. That with regard to healthy bones, John Scott advised that there is an emphasis on lifestyle and health promotion. With regard to further information on the Health Promotion Agency and its role, it was suggested that this be covered at the Community and Public health Advisory Committee. Child Women and Family (agenda page 51) Dr Meia Schmidt-Uili (Division Head), Stephanie Doe (General Manager Child, Women and Family Services), Emma Farmer (Head of Division Midwifery) and Susan Peters (Head of Division Allied Health) were present for this item. Stephanie Doe summarised the report, of particular note was the highlighted Health Promoting Schools service. The programme has been successfully led by the same person for approximately 18 years; it is a targeted programme and it is intended that it remain small in scale. Further information will be provided to the Committee about the programme at its next meeting. With regard to the Gateway Assessment Programme, Direct Purchasing and Enhancing Health s Response report and the numbers of children encountered, Stephanie advised that the Waitemata DHB had been a demonstration site for this programme. It is around access to children who potentially have fetal alcohol spectrum disorder. The Committee will be provided with a further update eon this at its next meeting. Specialist Mental Health and Addiction (agenda page 58) Susanna Galea (Director, Speciality Mental Health and Addiction Services) and Grace Preston (Finance Manager Mental Health) were present for this section of the report. Apologies from Pam Lightbrown (General Manager, Mental Health) were noted. Susanna Galea introduced the report, noting in particular Mental Health Awareness week which commenced the week beginning 9th October. In addition Susanna summarised the update provided on the Substance Addiction Compulsory Assessment and Treatment implementation (page 59 of the agenda); the DHB continues to work closely with the Ministry of Health around the model of care. Susanna brought to the Committee s attention the need to temporarily close five mental health beds due to staff shortages. There has been some difficult in recruiting staff and in assessing the situation it was determined that five beds be temporarily closed to ensure there is no clinical risk. It was noted that four staff have been appointed and will be commencing in their roles soon. It was also noted that in dialogue with the Communications Team, work is underway to clarify the diversity of mental health and that there are peaceful environments for mental health services, it is not as is often portrayed about aggression and violence. Surgical and Ambulatory Services/Elective Surgical Centre (agenda page 64) Dr Michael Rodgers (Chief of Surgery) and Debbie Eastwood (General Manager Surgical and Ambulatory Services) were summarised this section of the report. 9

12 2.1 Matters covered in discussion and response to questions included: That with regard to retaining allied and technical staff and whether there is an issue around the cost of living in Auckland, it was noted that staff from overseas are recruited and then may not stay as long as anticipated, sometimes moving out of Auckland. The DHB have incentives in place (training and the like) to increase retention. Noting that the area of improving theatre utilisation is being looked at for Waitakere; North Shore Hospital theatres are well utilised. The aim is for utilisation to be at around 85%. The Committee Chair noted that it would be beneficial for the region to have a common numerator/denominator in this area. The Committee Chair acknowledged the Emergency Department targets reported. Resolution (Moved Kylie Clegg/Seconded Max Abbott) That the report be received. Carried 4. CORPORATE REPORTS 4.1 Clinical Leaders Report (agenda pages 73 to 78) Andrew Brant (Chief Medical Officer) was present for this item. Apologies were noted from Tamzin Brott (Director of Allied Health) and Jocelyn Peach (Director of Nursing and Midwifery). Medical Staff Andrew Brant summarised this section of the report. Allied Health, Scientific and Technical Professions The Committee Chair acknowledged and congratulated Katrina Wallis Recipient of the Occupational Therapy New Zealand Whakaora Ngangahau Aotearoa Achievement Award for Resolution (Moved Max Abbott/Seconded Kylie Clegg) That the report be received. Carried 4.2 Human Resources (agenda pages 79 to 86) Fiona McCarthy (Director Human Resources) introduced this report. In response to a question from the Committee Chair about the update provided related to on-boarding for operations managers, Fiona noted that new on-board (orientation) checklists and tools for are being piloted for operations managers. That the report was received. 10

13 Quality Report (agenda pages 87 to 252) Penny Andrew (Clinical Lead Quality), Jacky Bush (Quality and Risk Manager) and David Price (Director of Patient Experience) were present for this item. Stephanie Doe (Acting General Manager Child, Women and Family Services) and Emma Farmer (Head of Division Midwifery) were present for the maternity update. Jacky Bush introduced the report. Matters covered in discussion and response to questions included: That with regard to the Waitemata DHB Maternity Quality and Safety Programme and reference to a review of the artificial rupture of membranes practice (page 248 of the agenda), it was noted the review was undertaken to promote natural births. There are times when breaking a membrane is justifiable in some instances, however, the review has determined that it is become a common practice. A campaign membranes matter was initiated and directed at staff to inform on when it was necessary to break a membrane. In addition further research is being undertaken to better understand decisions made around the artificial rupture of membranes. It is anticipated that this will be completed and presented to the Committee mid The importance of ensuring pregnant women are advised of and understand their decision making in this area was also noted. That with regard to diabetes and pregnancy it was noted that more Asian women are being diagnosed. That with regard to patient experience, it was noted key areas of ongoing focus include consistent communication, managing patients expectations, needs and wants. Noting that with regard to patient experience, patients advise that they want to be more informed and be in partnership with healthcare professionals; this is a challenging medical model, particularly when linked to information provided on the internet. A healthcare professional can support a patient s own research by providing validated sites for research. Penny Andrew advised that the Institute is undertaking work that includes digital health. The Committee Chair thanked those in attendance for the report presented. The report was noted. 5. RESOLUTION TO EXCLUDE THE PUBLIC (agenda page 253) Resolution (Moved Max Abbott/Seconded Kylie Clegg) 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: 11

14 2.1 General subject of Reason for passing this resolution in items to be considered relation to each item 1. Confirmation of That the public conduct of the whole or the Public Excluded relevant part of the proceedings of the Minutes Hospital meeting would be likely to result in the Advisory Committee disclosure of information for which good Meeting of reason for withholding would exist, under 06/09/17 section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act [NZPH&D Act 2000 Schedule 3, S.32 (a)] 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 [NZPH&D Act 2000 Schedule 3, S.32 (a)] 3. Human Resources 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 [NZPH&D Act 2000 Schedule 3, S.32 (a)] Ground(s) under Clause 32 for passing this resolution 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. 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)] 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)] Carried The open session of the meeting concluded at 4.13pm. Max Abbott retired from the meeting. SIGNED AS A CORRECT RECORD OF THE WAITEMATA DISTRICT HEALTH BOARD HOSPITAL ADVISORY COMMITTEE MEETING OF 18 OCTOBER 2017 COMMITTEE CHAIR 12

15 2.1 Actions Arising and Carried Forward from Meetings of the Hospital Advisory Committee as at 23 November 2017 Meeting Agenda Ref Topic 06/09/ Surgical and Ambulatory Services Provide indicator around ultrasound scans to demonstrate how the DHB performs with regard to timeliness. 06/09/ Provider arm Performance Report Presentation on the Whanau Centered Care Standards Programme, demonstrating a then and now situation. 06/09/ Quality Report Provide an update on a study by John Cullen about victim C treatment for carpal tunnel 18/10/ Provider Arm Performance Report A presentation from Helen Wood about the mental health workplace policy to be rolled out across all United Nation agencies. 18/10/ Provider Arm Performance Report Sandra Coney requested a copy of the published findings of the Waitemata DHB Fracture Liaison Service in the New Zealand Medical Journal. 18/10/ Provider Arm Performance Report Provide programme information for the Health Promoting Schools service Person Responsible Debbie Eastwood Expected Comment Report Back 29/11/17 Actioned. See agenda item 3.1. Deferred to 14/02/17 14/02/17 First quarter Actioned. Website link sent to Sandra Coney. 29/11/17 Actioned. See agenda item

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17 3.1 Provider Arm Performance Report September 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 September

18 3.1 Table of Contents Glossary How to interpret the scorecards Provider Arm Performance Report September 2017 Executive Summary/Overview Scorecard All services Health Targets Elective Performance Indicators Strategic Initiatives Financial Performance Human Resources Divisional Reports Acute and Emergency Medicine Division Specialty Medicine and Health of Older People Division Child, Women and Family Services Specialist Mental Health & Addiction Services Surgical and Ambulatory Services Elective Surgery Centre 15

19 Glossary 3.1 ACC - Accident Compensation Commission ADU - Assessment and Diagnostic Unit ARDS - Auckland Regional Dental Service AT&R - Assessment Treatment and Rehab CT - Computerised Tomography CWF - Child, Women and Family service ED - Emergency Department ECHO - Echocardiogram ESC - Elective Surgery Centre ESPI - Elective Services Performance Indicators FASD - Fetal Alcohol Spectrum Disorder FTE - Full Time Equivalent ICU - Intensive Care Unit MHOPS - Medicine and Health of Older People Services MRI - Magnetic Resonance Imaging MoH - Ministry of Health ORL - Otorhinolaryngology (ear, nose, and throat) RMO - Registered Medical Officer S&A - Surgical and Ambulatory Services SMHA - Specialist Mental Health and Addiction Services SMO - Senior Medical Officer WIES - Weighted Inlier Equivalent Separations YTD - Year To Date 16

20 How to interpret the scorecards 3.1 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 description Traffic light Trend indicator Actual Target Trend Better help for smokers to quit - hospitalised 98% 95% 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 % achieved 0.1 5% away from target Substantially Achieved % away from target AND Not achieved, but progress %*achieved improvement from last month made % away from target, AND no <94.9% achieved 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 Current > Previous month (or reporting period) performance Improvement 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: Key notes 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. 17

21 Provider Arm Performance Report September Executive Summary/Overview Summary The Provider has completed the first quarter with strong performance in all health targets. While the Provider continues with a financial deficit we have achieved savings of $7.6m YTD. Highlight of the month Patient and Whanau Centred Care Standards Platinum Awards ICU and Lakeview have both met accreditation against Standard 10 of the Patient and Whanau Centred Care Standards (a copy of the accreditation resource book is available for viewing in the Diligent Boardbooks resource centre). A short video will be presented at the meeting by each service that highlights their achievement. Waitemata DHB Pharmacist Pharmacist Avril Lee, together with the Clinical Education Training Unit team, presented at the SingHealth Duke- NUS Education Conference last month, in front of over 1,000 delegates. Out of several hundred abstract submissions, all Waitemata's submissions were selected as finalists for the poster/presentation prize. Avril Lee was awarded the best oral presentation trophy for her work in the pharmacy buddy system she has implemented to help us with the international medical graduates settling in at our DHB. A second oral presentation delivered by Avril Lee and Vani Chandran, linked with pharmacy training in our transition programme for Trainee Interns, was first runner up in this category. Key Issue of the Month Did Not Attend In March 2017 Medical Services went live with patient focused booking. The principle being that a patient will confirm their availability and will arrive for the appointment. Gynaecology commenced a patient focused improvement project based on the successful principles medicine developed. Over the next year we expect to see a pattern of improved access to services for patients due to patients informing their availability and confirming appointments. 18

22 Financial Performance Summary The Provider Arm result for the month ended September 2017 was unfavourable by $469k. The unfavourable variance was driven by unbudgeted and increased cost commitments. The Provider Arm is progressing a comprehensive multi-year portfolio of initiatives to drive sustainable reductions in its cost base. The portfolio is executive lead, pan-directorate with regular status reporting. The portfolio includes strategic focus on both clinical transformation and value-based programmes of work along with a DHB wide improvement portfolio of over 100 service lead projects focused on enhanced productivity and quality, workforce deployment, procurement and supply chain and revenue optimisation. 3.1 Despite the result, the Provider has seen a reduced average length of stay as a result of initiatives implemented, leading to a reduction in operating costs that is mitigating the impact of unbudgeted expenditure and cost head winds. 19

23 Scorecard All services Waitemata DHB Monthly Performance Scorecard ALL Services September / Health Targets Service Delivery Actual Target Trend Elective Volumes Actual Target Trend Shorter Waits in ED 98% 95% Provider Arm - Overall 100% 100% Faster cancer treatment (62 days) 94% 90% Waiting Times ESPI 2 - % patients waiting > 4 months for FSA Compliant Best Care ESPI 5 - % patients not treated w/n 4 months Non-Compliant ESPI 1 - OP Referrals processed w/n 10 days Compliant Patient Experience Actual Target Trend Complaint Average Response Time 12 days <14 days Patient Flow Net Promoter Score FFT Average Length of Stay - Electives 1.49 days 1.65 days Average Length of Stay - Acutes 2.47 days 2.50 days Improving Outcomes Outpatient DNA rate (FSA + FUs) - Total 7% <10% Better help for smokers to quit - hospitalised 98% 95% Outpatient DNA rate (FSA + FUs) - Māori 17% <10% Outpatient DNA rate (FSA + FUs) - Pacific 20% <10% Quality & Safety Trend Older patients assessed for falling risk 94% 90% Rate of falls with major harm 0 <2 Good hand hygiene practice 87% 80% Financial Result (YTD) Value for Money Actual Target Trend S. aureus infection rate 0 <0.2 Revenue 227,764 k 221,547 k Occasions insertion bundle used 100% 95% Expense 231,026 k 220,795 k Pressure injuries grade 3&4 0 0 Net Surplus/Deficit -3,262 k 752 k Capital Expenditure (% Annual budget) 81% HR/Staff Experience Trend Sick leave rate 3.3% <3.6% Contracts (YTD) Turnover rate - external 12% 8-12% Elective WIES Volumes 4,855 4,901 Acute WIES Volumes 17,012 15,642 How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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 question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB Scorecard Variance Report Best Care The Provider complaint time is 16 days against a target of 14 days. There have been a number of complex complaints across service to address. The Division Heads, General Managers and teams are committed to have this target back on track. If there is a delay the complainant is kept informed and updated. Service Delivery Did Not Attend Update outlined in key issue of the month. Value for money While the Provider is in deficit the improvement work we are invested in, is improving our results and forecast. One improvement is noted in the period July - October There has been a 14% increase in acute General Medical (M0001) discharges and 10% increase in WIES compared with the same period last year. Almost all of the increased discharges are as a result of respiratory conditions arising from the flu in the first three months of this financial year. Only two additional beds (1.7% more than last year) have been required to manage this increased volume as a result of a range of initiatives underway in the service to reduce length of stay. The reduced length of stay is having a direct impact on the cost of these events as seen by the reduced WIES associated with the additional volumes. 20

24 Health Targets Faster Cancer Treatment 3.1 Shorter Stays in Emergency Departments 21

25 Inpatient Events admitted through ED 3.1 Emergency Department/ ADU Presentations 22

26 Improved Access to Elective Surgery 3.1 Note: Changes were made to the electives health target for 2015/16 Percentage Change ED and Elective Volumes September 2017 Month Volumes % Change (last year) YTD Volumes % Change (last year) ED/ADU Volumes 10,539 4% 33,131 7% Elective Volumes 1,173 7% 3, % 23

27 Elective Performance Indicators Zero patients waiting over four months Summary (September 2017) Speciality Non Compliance % ESPI2 0.69% ESPI5 0.33% 3.1 ESPI ESPI Compliant Non Compliant ESPI 2 Anaesthesiology % Cardiology % Dermatology % Diabetes % Endocrinology % Gastro-Enterology % General Medicine % General Surgery 1, % Gynaecology 1, % Haematology % Infectious Diseases % Neurovascular % Orthopaedic 1, % Otorhinolaryngology 1, % Paediatric MED % Renal Medicine % Respiratory Medicine % Rheumatology % Urology % Total 10, % ESPI 5 Cardiology % General Surgery % Gynaecology % Orthopaedic % Otorhinolaryngology % Urology % Total 3, % 24

28 90% of outpatient referrals acknowledged and processed within 10 days ESPI 1 (September 2017) Specialty Compliance % Anaesthesiology 98.25% Cardiology 99.78% Dermatology 99.38% Diabetes 96.36% Endocrinology % Gastro-Enterology 99.63% General Medicine % General Surgery 96.94% Gynaecology 99.77% Haematology 98.10% Infectious Diseases 96.30% Neurovascular % Orthopaedic 97.53% Otorhinolaryngology 99.23% Paediatric MED 99.81% Renal Medicine % Respiratory Medicine % Rheumatology 98.08% Urology 99.03% Total 98.81% ESPI 1 ESPI 2 ESPI 5 Legend Green if 100%, Yellow if between 90% and 99.9%, and Red if 90% or less. 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. 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 3.1 Discharges by Specialty and Average Length of Stay Discharges by Specialty 25

29 Average Length of Stay Acute 3.1 Average Length of Stay Elective 26

30 Bed days by Division * excludes events ended in ED Month comparison Year comparison Division Sep 2016 Sep 2017 Change Sep Sep Change Aug 2016 Aug 2017 Acute and Emergency Medicine 9,761 8,719-1, , , Specialty Medicine and HOPS 3,411 2, ,694 39, Child, Woman and Family 4,149 4, ,690 48,551 1,861 Surgical and Ambulatory Services 5,719 5, ,464 72,042 2,578 23,040 21,892-1, , ,385 3,950 Total Growth -5% 1% 3.1 Cumulative Bed Days saved through Hospital Initiatives Predicted versus Actual Bed Days 27

31 Strategic Initiatives Variance Report Deliverable/Action On Track Faster Cancer Treatment We will implement sustainable service improvement activities to improve access, timeliness and quality of cancer services: Confirm a process to ensure all tumour streams appropriately apply the High Suspicion of Cancer flags December 2017 Work with Māori Health to (EOA): - appoint a Māori Cancer Nurse Coordinator September develop and implement a work plan to ensure equitable health outcomes for Māori patients September Document a clear pathway for all external and internal HSC P1 (high priority) gastroenterology patients, in conjunction with the Gastroenterology Service September Design a process to ensure all cancer follow-up patients are identified and receive follow-up at the correct time December Contribute to the development of plans for local delivery of medical oncology Developed by December All cancer-related MDMs will use electronic forms to document meeting outcomes In place by June 2018 Improve waiting times for diagnostic CT and MRI by reviewing options to increase capacity and implement changes to service model of care and delivery to improve planned patient access December 2017 National Bowel Screening Meet the bowel screening quality standards for the Waitemata DHB programme - Ongoing Continue to meet the waiting time standard for bowel screening colonoscopies - Ongoing Waitemata DHB bowel screening programme structure and staffing in place to join the national programme January Areas off track for month and remedial plans Recruitment for the Maori Cancer Nurse has been approved and recruitment commenced 28

32 Financial Performance 3.1 STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 Provider ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency 73,297 71,426 1, , ,358 4, ,462 Other Income 2,535 2, ,490 7,188 1,301 31,357 Total Revenue 75,832 73,841 1, , ,547 6, ,819 EXPENDITURE Personnel Medical 13,870 14, ,363 43,177 (186) 181,088 Nursing 18,980 19, ,857 59, ,130 Allied Health 9,224 10, ,953 29,609 1, ,860 Support 1,484 1, ,559 4, ,774 Management / Administration 5,429 5,413 (16) 16,890 16,714 (176) 67,010 Outsourced Personnel 1,325 1,104 (220) 4,047 3,396 (650) 12,820 50,311 51,704 1, , ,776 1, ,683 Other Expenditure Outsourced Services 4,088 3,864 (224) 12,909 11,953 (957) 46,938 Clinical Supplies 10,302 9,776 (526) 31,187 29,800 (1,387) 116,083 Infrastructure & Non-Clinical Supplies 10,355 7,252 (3,103) 31,263 22,266 (8,997) 87,452 24,744 20,892 (3,853) 75,359 64,019 (11,340) 250,473 Total Expenditure 75,055 72,596 (2,459) 231, ,795 (10,231) 887,156 Cost Net of Other Revenue 777 1,245 (469) (3,262) 752 (4,014) 663 Comment on major financial variances The Provider result was $4.014m unfavourable to budget for the YTD to September The key variances are described below: Revenue Revenue was $6.218m favourable to budget YTD. This includes $5.000m received from Funder for additional acute activity which was 9% ahead of contract volume YTD September. Expenditure Overall expenditure was unfavourable to budget by $10.231m YTD. The key variances are summarised below: Personnel ($1.109m favourable YTD) The unfavourable variance was driven by: Medical staff costs unfavourable by $186k YTD. The unfavourable variance was driven by registrar cost increases in Acute and Emergency Medicine. Nursing staff costs favourable by $212k YTD. The favourable variance was driven by vacancies and monitoring overtime hours. The favourable variance was partially offset by unfavourable outsourced bureau costs to cover vacancies, watch cover and sick leave. Allied Health staff costs favourable by $1.656m YTD. The favourable variance was driven by vacancies across all service areas. Support staff costs were favourable by $252k YTD. Management and Administration staff costs were unfavourable by $176k YTD. 29

33 Outsourced Personnel were unfavourable by $650k YTD. This unfavourable variance was driven by Specialist Mental Health and Addiction Services locum spend of $400k covering vacancies and leave. 3.1 Outsourced Services Costs ($957k unfavourable YTD) The unfavourable variance was driven by unbudgeted cost commitments for outsourced gastroscopy procedures particularly for Surgical and Ambulatory Services (S&A) unfavourable by $699k YTD and Sub Specialty Medicine and HOPS unfavourable by $130k YTD. Clinical Supplies Costs ($1.387m unfavourable YTD) The unfavourable variance was driven by increased costs for clinical supplies, inpatient pharmaceuticals and unbudgeted repairs. The unfavourable variances YTD by service area were S&A $291k, Acute and Emergency $52k, Sub Specialty Medicine and Health of Older People Services (MHOPS) $440k, Child Women and Family Services (CWF) $164k, Specialist Mental Health and Addiction Services (SMHA) $62k and Hospital Operations $668k. Infrastructure and Non-Clinical Supplies ($8.997m unfavourable YTD) The unfavourable variance was driven by unbudgeted repairs and maintenance in Facilities and Development and planned saving targets recorded in infrastructure not realised. S&A had an unfavourable variance of $1.222m YTD due to unmet savings obligation. Hospital Operations had an unfavourable variance of $197k driven by unfavourable outsourced security and patient meal costs. Getting back on track Initiative The Provider Arm is progressing a comprehensive multi-year portfolio of initiatives to drive sustainable reductions in its cost base. The portfolio is executive lead, pan-directorate with regular status reporting. The portfolio includes strategic focus on both clinical transformation and value-based programmes of work along with a DHB wide improvement portfolio of over 100 service lead projects focused on enhanced productivity and quality, workforce deployment, procurement and supply chain and revenue optimisation. One such initiative is TransforMED which has reduced average length of stay leading to a reduction in operating costs. 30

34 STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 Provider ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget CONTRIBUTION Surgical and Ambulatory (15,658) (15,126) (532) (40,856) (38,676) (2,180) (152,494) Acute and Emergency (12,410) (12,364) (46) (33,862) (33,592) (270) (138,944) Sub Specialty Med and HOPS (8,180) (8,151) (29) (21,378) (20,658) (720) (80,159) Child Women and Family (8,362) (8,685) 322 (21,587) (22,209) 622 (85,198) Specialist Mental Health and Addiction (11,623) (12,136) 514 (30,311) (30,987) 676 (126,561) Elective Surgery Centre (2,208) (2,426) 218 (6,736) (7,318) 582 (28,294) Provider Support 59,218 60,133 (915) 151, ,193 (2,723) 612,313 Net Surplus/Deficit 777 1,245 (469) (3,262) 752 (4,014) Comment on major variances by Provider Service The Provider result was $4.014m unfavourable to budget for the YTD to September The key variances are described below. Surgical and Ambulatory Services Surgical and Ambulatory Services was unfavourable by $2.180m YTD. The unfavourable result is driven primarily by unbudgeted outsourced radiology services as a result of capacity constraints associated with unfilled vacancies, and the impact of savings targets. The service management team is closely monitoring surgical health targets on a weekly basis with the Director Hospital Services. There are several identified projects under way as part of the organisational savings programme. Tight cost controls are in place in all key areas of expenditure with regular reviews between the management team and Deputy Chief Financial Officer. Acute and Emergency Medicine Acute and Emergency Medicine was unfavourable by $270k YTD. The volume of Acute Non Inter District Flow WIES was 1,035 or 11.1% above contract for the YTD. The unfavourable result was driven predominantly by the cost of Registrars where pricing variations, additional allocations and allowances have contributed to an overspend of $605k. Key factors that have mitigated the Registrar impact were vacancies within SMOs contributing $222k and efficiencies within the infrastructure and non clinical supply costs of $112k. Sub Specialty Medicine and HOPS Sub Specialty Medicine and HOPS was unfavourable by $720k unfavourable YTD. The result was driven predominantly by unbudgeted outsourced gastroscopy and colonoscopy procedures costing $896k and an additional spend of $212k on high level community care for complex needs patients within the Mental Health of Older Adults service. Vacancies within Allied Health have had a favourable impact, alleviating the result by $482k. Child Women and Family Services Child Women and Family Services was favourable by $622k YTD. Service vacancies across Allied Health community based specialties and Management/Administration remain the key driver of the favourable result. The service continues to actively recruit to clinical positions but is still being challenged by regional or national workforce shortages across Midwives and Paediatric Physiotherapists. Midwifery services have strategies in place to meet service delivery through skill mix changes and part time staff increasing their working hours. Embedded efficiency initiatives are being achieved primarily through these vacancies. Service output activity has remained positive overall with Gynaecology acute activity 101%, Gynaecology electives at 86%, Maternity Inpatient acute 117% and Paediatric Inpatient acute 130%. The latter related to the high winter demand. Specialist Mental Health and Addiction Services Specialist Mental Health and Addiction Services was favourable by $676k YTD. This was primarily driven by favourable variances in personnel. The personnel variance of $727k YTD was driven by a large number of 31

35 vacancies in nursing partially offset by casual staff and overtime cover. There are also vacancies in medical which is offset by locum cover. Other direct costs are unfavourable by $131k YTD. This is mainly due to overspend in pharmaceuticals, as well as the flexifund being in high demand as we are in the process of sourcing contracted beds for service users with no alternative funding streams. 3.1 Elective Service Centre The service was favourable by $582k YTD. The favourable result is being driven by lower than budgeted clinical supplies associated with less complex cases. The ESC production plan YTD is on target, however, we need to review the case mix as it relates to package of care. Provider Support Services Provider Support was unfavourable by $2.723m YTD. The Corporate and Support Services includes centrally budgeted efficiencies which are the major contributor to the unfavourable variance. Provider Support has a number of efficiency initiatives that are focused on areas of improvement including cost effectiveness, cost containment, productivity, process improvements and service reconfigurations. In addition Corporate Services is undertaking a number of efficiency projects relating to procurement and supply chain and treasury management. Hospital Operations was unfavourable by $543k YTD. This was primarily due to unfavourable activity related nonpay costs. This included the cost of pharmaceuticals and patient meals which were unfavourable due to a 2.5% unbudgeted increase in price for indexation per the terms of the contract plus a further 5.5% uplift in price due to lower than anticipated number of DHBs participating in the national Food Services Agreement. 32

36 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 0-24 days: Count of Staff with less than 25 equivalent 8 hour days accumulated leave entitlement. 4. Annual Leave balance days: Count of Staff with between 25 and 50 equivalent 8 hour days accumulated leave entitlement. 5. Annual Leave balance days: Count of Staff with between 50 and 75 equivalent 8 hour days accumulated leave entitlement. 6. Annual Leave balance 75+ days: Count of Staff with over 75 equivalent 8 hour days accumulated leave entitlement. 7. Voluntary Turnover and internal turnover 12month rolling average: 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. 3.1 Sick Leave The sick leave rate has continued a downwards trend for this period and is very close to target and the same trend is reflected in the twelve month rolling average results into October. This is positive, indicating an ongoing and sustained pattern of sick leave reduction. All divisions are tracking favourably and CWF and SMHA, who have both reported high sick leave levels historically, are continuing to track down. CWF has reduced its sick leave rate from 13.5 days per person in July to 11.5 days for September reporting and lower into October. ARDS continues to be the highest contributor to sick leave in the Division with several longer term absences under monitoring and management processes. SMHA have also reflected a further decrease to 9.1 days per person and continue to implement a robust programme of monitoring sick leave levels and responding with processes within the current guidelines and divisional initiatives. 33

37 Overtime In contrast to the continued reduction in sick leave levels, overtime has increased in this reporting period. The rate is driven by Hospital Operations and SMHA with other divisions tracking favourably. 3.1 Hospital Operations are running another assessment centre for Cleaner and Orderly recruitment in November and are also looking at other options to reduce overtime, in particular related to their current rostering practices. These initiatives start to make an impact on overtime in October. SMHA overtime levels continue to be driven by Forensics and Adult Inpatient units. In this reporting period there were five high acuity patients across three units and one patient on 2:1 constant observation. Overtime levels have been compounded by nursing vacancies across five inpatients units, however with vacancies being filled we see overtime reduce in October. It also needs to be noted that 40% of overtime spend in Forensics is contractual due to unrelieved meal breaks. Close monitoring continues, along with focused recruitment and retention activity. 34

38 Annual Leave While there has not been a significant change in balances mainly due to a busy winter season, we are maintaining slightly lower balances over 25 days than last year. All divisions continue to plan annual leave and work directly with staff to reduce leave balances over two years. 3.1 Annual Leave Management (headcount) Divisions Leave Bal 0-25 days Leave Bal days Leave Bal days Leave Bal 75 days + Surgical and Ambulatory Elective Surgery Centre Child Women & Family Hospital Operations Facilities and Development Corporate Acute and Emergency Medical Divison Director Hospital Services Elective and Outpatient Services Mental Hlth & Addiction Sub Specialty Med and HOPS WDHB Governance and Funding Total 5,335 1,

39 Staff Turnover This month s results reflect a reduction in turnover overall with most areas continuing to track in or around target. We are also able to show internal turnover for the first time which is tracking at 10.4%. 3.1 Acute and Emergency continues to report the highest turnover with an average of 16.4% with the Nursing group continuing to reflect high turnover. The most common reason for resignation continues to be overseas travel with some retirements. While the rates continue to be high in the division there are no apparent specific concerns and resignations appear to reflect similar reasons to other divisions. In relation to internal turnover, the most movement is in the corporate groups however this reflects the following activity; recent reviews and internal movements in the quality and i3 teams; the transfer of professional leads into the Directorate for Allied health, Scientific and Technical professions; and graduate roles being formed and then moved from the Director of Nursing RC into service RCs. 36

40 Divisional Reports Acute and Emergency Medicine Division 3.1 Service Overview This Division is responsible for the provision of General, Acute and Emergency Medicine services. The division includes the departments of General Medicine, Assessment and Diagnostic Unit (ADU), Assessment, Diagnostic and Cardiology Unit (ADCU), Emergency Medicine, Emergency Department (ED), 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), Head of Division Nursing is Shirley Ross. The Clinical Directors are Dr Hamish Hart for General Medicine, Dr Willem Landman for Emergency Care, Dr Tony Scott for Cardiology, Dr Laura Chapman for ADU and ADCU and Dr Chris Sames for Hyperbaric Medicine. Highlight of the Month Significant improvement in waiting times for Dobutamine Stress ECHO (DSE) An ECHO is a test used to assess the heart s function and structures. A stress ECHO is a test done to assess how well the heart works under stress. There are two types of stress tests used in cardiology the stress can be triggered by either exercise on a treadmill or by medication called dobutamine. Patients who have symptoms of chest pain and who are able to exercise routinely undergo exercise stress testing, with an exercise tolerance test (ETT) which can be performed on a treadmill. However, for patient unable to exercise, a DSE may be performed which artificially increases the heart rate to assess heart function. Heart function is assessed before and during the procedure. The drug Dobutamine is injected into the patient intravenously to increase the patient s maximum heart rate by 75-80%. This stresses the heart to help identify areas of ischaemia which can indicate significant coronary disease. Stress ECHO is a powerful prognostic tool in chronic coronary disease, after myocardial infarction, and in evaluation of patients before major non-cardiac surgery, as well as providing valuable information before going on for consideration of valve surgery. The waiting times for an Outpatient Dobutamine Stress ECHO have improved considerably over the last three months and as a consequence the median wait time has reduced from over 164 days in April 2017 to 16.5 days in the week ending the 28 th October. The number of patients waiting for this test has reduced to 26 from over 100 waiting in April Similarly, the median waiting time for the Outpatient Stress ECHO is 17 days. 37

41 It is anticipated that this trend will continue. With an average of four patients added to the list each week we are on track to maintain the current waiting times. 3.1 Key Issues Update on TransforMED The TransforMED programme is on-going with both divisions working well together. The highlight this month has been the home ward trial in Ward 2. This began on the 18 September Ward 2 is a General Medicine/ Stroke Ward and Consultants based on the ward round daily on the patients admitted to the ward, supported by a Stroke team, including Stroke Charge Nurse Specialist. We have been monitoring the activity on Ward 2 on a daily basis and while it is still early days, the following benefits have been realised. 8% special cause drop in acute General Medicine bed occupancy (hospital wide) No material change in the number of General Medicine discharges off Ward 2 No increase in acute readmissions for General Medicine patients Positive team feedback nursing, Allied Health and RMO sense of belonging, improved communication between the teams We are working to implement Home Based Care on Ward 10 in October/November and to ensure that the new model of care supports effective flow in the ADU. 38

42 Scorecard Acute and Emergency Medicine Division Waitemata DHB Monthly Performance Scorecard Acute and Emergency Medicine September / Health Targets Actual Target Trend Waiting Times Actual Target Trend a. Shorter Waits in ED 98% 95% ADU - % seen from triage w/in 120 mins 62% 85% Best Care Service Delivery Elective coronary angiography w/in 90 days 100% 95% Angiography for ACS w/in 72 hours 79% 70% c. Chest pain clinic wait time under 6 weeks 46% 80% Patient Experience Actual Target Trend c. O/P Transthoracic Echo wait time under 12 weeks 49% 95% Complaint Average Response Time 20 days <14 days Net Promoter Score FFT Patient Flow Elective Discharge Volumes (Cardiology) 113% 100% Improving Outcomes Outpatient DNA rate 7% <10% b. PCI w/in 120 minutes (STEMI patients) 82% 80% Average Length of Stay - Acutes 2.35 days <2.38 days Better help for smokers to quit - hospitalised 100% 95% Patients with EDS on discharge 88% 85% Quality & Safety Value for Money Older patients assessed for falling risk 96% 90% Rate of falls with major harm 0 <2 Financial Result (YTD) Actual Target Trend Good hand hygiene practice 85% 80% Revenue 1,012 k 915 k Pressure injuries grade 3&4 0 0 Expense 34,874 k 34,507 k Net Surplus/Deficit -33,862 k -33,592 k HR/Staff Experience Capital Expenditure (% Annual budget) 190% Sick leave rate 3.1% <3.6% Turnover rate - external 16% 8-12% Contracts (YTD) Elective WIES Volumes Acute WIES Volumes 9,518 8,456 How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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 b. MoH based Average length of stay definition. c. One month in arrears - August data A question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB Scorecard Variance Report Best Care Complaint average response time- 20 days against a target of 14 days The average days to resolve/close complaints across the Acute and Emergency Medicine Division were 20 days during September Acute and Emergency Medicine Division Complaints resolved/closed 20 complaints during September 2017 which included 12 complaints that were received prior to September 2017 which resulted in resolution/closure times for these complaints being > 14 days (range days), which in conjunction with a complex and involved complaint that took >30 days to resolve, resulted in the overall Divisional resolution/closure time for complaints being greater than the 14 days target. The General Manager of Acute and Emergency Medicine is meeting weekly with the Division s Quality Lead to monitor the resolution rate to ensure compliance with the 14 days target. Additionally, the Division s Quality Lead is following up with individual Operation Managers to ensure resolution of complaints in a timely and efficient, effective manner, both for the complainant and for the Division. Turnover Rate 16.4% against a target of 12% The rolling 12 month turnover average rate for the Acute and Emergency Medicine Division was 16.4% at September This is against a target of 12%. This is an increase since August 2017 when the rolling average rate was 15.7%. The voluntary turnover rate (quarterly roll average) shows an increase this month compared to this time last year when the figure was 14.2% in September The two services with staff showing the highest turnover rate in September are Acute and Emergency and the Medical Wards. Mitigations continue to be an encouragement with regular use of annual leave, support for development and encouragement of exit interviews to gain further insight into staff reasons for leaving. 39

43 Service Delivery ADU % seen from triage within 120 minutes 62% against a target of 85% We aim to see 85% of the patients triaged or referred to the ADU within 120 minutes of arrival in the ADU. The ADU is currently utilised by a number of specialities, general surgery, orthopaedics and general medicine. 3.1 Surgery 85% In September 66% of surgical patients were seen within two hours of triage. Orthopaedics - 85% In September 74% of orthopaedic patients were seen within two hours of triage. General Medicine 85% In September 61% of patients in North Shore ADU and 80% of General Medicine patients in the Waitakere ADU were seen within two hours. We have reviewed the medicine work flows and patients arriving between 08:00 and 13:00 are seen within the triage time. We are developing a system to ensure that the ward based teams come to admit patients in the ADU from 13:00 onwards and we are continuing the Ambulatory Acute Care (ASAP) clinic on a daily basis. Patients are currently streamed into same day, next day, and long stay and we are looking to put dedicated resources in each stream to increase the number of same day and next day discharges and to reduce the number of long stay patients. Chest Pain Clinic wait time under six weeks - 46% against a target of 80% The data indicates 46% against target for August as this is always a month behind; however, we have achieved 65% compliance in September which is our best achievement to date. Our Cardiology capacity planning predictions indicate that we shall maintain this 65-67% in October improving to 70-80% in November/December. Whilst improvement against this specific target has continued to be slow as we work our way through the backlog of patients on the waiting list we remain on target for year end. The numbers of patients waiting has reduced from over 600 in April, to well under 242 in September. The services aim is to reduce the backlog of Chest pain patients and to ensure there is a sustainable level of capacity going forward to enable us to see 80% of patients within six weeks of referral. We currently have 38 patients requiring a date before the end of November and we are working to ensure we have capacity to see all of these patients. We should be close to compliance in November and aim to achieve 80% by December. We have the highest referral to Chest Pain Clinics in the Northern Region and we are also working to understand and manage on-going requests, particularly from ED. Approximately 40 patients are added to the Outpatient Chest Pain Clinic waiting list on a weekly basis. We have sufficient on-going capacity in the form of Nurse Lead ETT clinics and Doctor Lead ETT clinics (total 46 clinic slots per week). The challenge is in additional short term capacity to reduce the waiting list. During the next six months we have a fellow covering SMO sabbaticals who is doing an additional weekly Chest Pain Clinic as part of his job size. The median waiting time for Chest pain patients is 25 days. 40

44 O/P Transthoracic ECHO wait time under 12 weeks - 49% against a target of 95% This is a significant improvement over the previous month and we shall continue to work on the ECHO target. 3.1 However this target will continue to be challenging due to the volume of referrals received. The productivity within Cardiology 2D ECHO has improved over time, which in turn has led to an increase in the number of ECHO reports requiring review. We are working to develop a strategy to manage this increase. With an increase in sonographer time and an SMO appointed to commence in January this will further increase our capacity. We have implemented a robust validation process and we are looking to implement patient focused booking for routine (P3) ECHO. Strategic Initiatives Variance Report Deliverable/Action Shorter Stays in Emergency Departments On Track Analyse ED mental health attendances to understand the profile of presentations June 2018 Work with Mental Health to develop clinical and shared care pathways for regular and high users of ED with plans developed for known service users of Specialist Mental Health services March 2018 Implement shared care Mental Health pathways June 2018 Formalise the use of primary options for acute care in the ED develop and implement a range of pathways March 2018 Implement the OptimisED project in Waitakere ED to effectively utilising new ED areas to maximise patient flow June 2018 Continue to work with urgent care/primary care partners to improve access to primary care for primary care issues June 2018 Promote access afterhours to reduce low acuity presentations December 2017 Develop a pilot in Waitakere ED to more efficiently assess the low acuity patients June 2018 Delivery of Regional Service Plan Cardiac Services ACS Audit compliance with the current pathway and the Timi assessment criteria/process December 2017 Audit the appropriate referral pathway for exercise tolerance test (ETT) December 2017 Audit the rate of negative vs. positive ETTs to inform this work December 2017 Cardiac Services Heart Failure Audit all patients with a first diagnosis of heart failure to track their readmission rates December 2017 Engage in the regional process via the regional cardiac network to agree protocols, guidance, processes and systems to ensure optimal management of patients with heart failure June 2018 Areas off track for month and remedial plans All areas on track 41

45 Financial Results - Acute and Emergency Medicine STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 Acute and Emergency Medical Divison ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency ,075 Other Income Total Revenue , , EXPENDITURE Personnel Medical 4,801 4,730 (71) 11,703 11,179 (524) 43,472 Nursing 5,163 5,110 (54) 15,359 15, ,013 Allied Health (5) ,551 Support Management / Administration ,812 1,796 (16) 6,881 Outsourced Personnel ,059 10,992 (68) 29,775 29,325 (450) 121,848 Other Expenditure Outsourced Services Clinical Supplies 1,285 1,219 (66) 3,835 3,783 (52) 14,638 Infrastructure & Non-Clinical Supplies ,142 1, ,582 1,711 1,671 (40) 5,099 5, ,798 Total Expenditure 12,770 12,662 (108) 34,874 34,507 (368) 141,646 Cost Net of Other Revenue (12,410) (12,364) (46) (33,862) (33,592) (270) (138,015) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The overall result for Acute and Emergency Medicine was $46k unfavourable for September and $270k unfavourable for the YTD. In September there was a 241 (+9%) increase of Acute Non IDF WIES above Funder contracted volumes for the division. Elective Non IDF WIES volumes were marginally above contract for September. Revenue ($62k favourable for September, $97k favourable YTD) The favourable result for September and the YTD position was due to increased university training revenue. Expenditure ($108k unfavourable for September, $368k unfavourable YTD) The unfavourable result for September was due to RMO cost increases of $223k. Registrar costs are the most significant factor at $203k and are being driven by over allocations, pricing variations and allowance costs. SMO costs were $152k favourable for the month with continuing medical education costs, vacancies and sick leave being the most significant contributing factors. Personnel ($450k unfavourable YTD) Medical ($524k unfavourable YTD) The YTD unfavourable position was driven predominantly by Registrar cost increases of $605k, through over allocations, pricing variations and additional allowance costs. SMO costs were $75k favourable driven by vacancies and reduced expenditure on continuing medical education, mitigated by additional allowances and unbudgeted costs for sabbatical cover. 42

46 Nursing ($15k favourable YTD) The YTD favourable position was attributable to vacancies within the Patient Attendance program and the Cardiology service offset by unfavourable variances at Waitakere Hospital in both their ED and Medical Wards. North Shore Hospital has benefited from improved flow initiatives and bed flexing, the benefits of which have been transferred to the Director of Hospital Services via a budget transfer. 3.1 Allied Health ($11k favourable YTD) Vacancies within Cardiology have generated the favourable position. Support and Management/Administration ($12k unfavourable YTD) The unfavourable position was driven by pricing variations and an unbudgeted role both within Patient Care and Access. Outsourced Personnel ($58k favourable YTD) Locum costs for SMOs were favourable YTD. Other Expenditure ($83k favourable YTD) Outsourced Services ($23k favourable YTD) Laboratory send away tests make up the majority of the outsourced services favourable position. Clinical Supplies ($52k unfavourable YTD) Acute pressures contributed to a $128k unfavourable variance in ED, ADU and the Medical Wards. This was offset by favourable variance of $76k in Cardiology and the Air Ambulance service. Infrastructure and Non-Clinical Supplies ($112k favourable YTD) Incremental savings across the services have contributed to the favourable position. Getting back on track initiatives The TransforMED and ADUcare initiatives are showing positive results. The home ward pilot on Ward 3 is continuing to be a success and has been expanded into Ward 2. These initiatives are combining to improve patient flow and shorten the average length of stay at North Shore Hospital and are a factor that has facilitated progress in the bed flexing program. We will continue to build on the operational successes achieved from these programs with a view to being in an optimal position to respond to the budgeted savings targets now commencing in October. 43

47 Specialty Medicine and Health of Older People Division 3.1 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 (Acting General Manager), with Shirley Ross Head of Department Nursing. The Clinical Directors are Dr Cheryl Johnson for Geriatric Medicine, Dr Rob Butler for Psychiatry for the Older Adult, 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. The Clinical Director for Palliative Care is currently vacant. Highlight of the Month Advances in nursing practice and the development and appointment of the first Nurse Practitioner for Mental Health Service for Older Adults community The community mental health service for older adults (MHSOA) has a primary focus on ensuring that the health needs of their population are met. The development of effective and contemporary service models is an essential component of care and the use of nurse practitioners within MHSOA was borne out of an inability to recruit a second registrar in the team. A community based registrar role is not a priority for Mental Health Service training and the position had remained vacant for more than five years. Over the last five years the number of senior nursing roles in Waitemata DHB has increased as service needs have changed and nurses have embraced the academic and clinical opportunities to develop their expertise and offer an advanced level of care to Waitemata DHB clients. There are currently 9 nurse practitioners employed across a number of services: Urology, Colposcopy, Emergency Care, Cardiology, Gerontology and most recently Mental Health. Nurse practitioners have a broader scope of practice, related to population and specialty and are not restricted to a specific area of practice. As advanced clinicians, they are trusted to practise within their areas of competence and experience. They have advanced education, clinical training and the demonstrated competence and legal authority to practise beyond the level of the registered nurse scope as a clinical nurse specialist. Nurse practitioners work autonomously and in collaborative teams with other health professionals, to promote health, prevent disease, improve access and population health outcomes for a specific patient group or community. Nurse practitioners manage episodes of care as the lead healthcare provider in partnership with health consumers and their families/whānau. They combine advanced nursing knowledge and skills with diagnostic reasoning and therapeutic knowledge to provide patient-centred healthcare services including the diagnosis and management of people with common and complex health conditions. They provide a wide range of assessment and treatment interventions, ordering, interpreting diagnostic and laboratory tests and prescribing medicines 44

48 within their area of competence and admitting and discharging from hospital and other healthcare services/settings. As clinical leaders they work across healthcare settings and influence health service delivery and the wider profession. Nurse Practitioners also demonstrate leadership as consultants, educators, managers and researchers and actively participate in professional activities and local and national policy development. 3.1 The MHOSA nurse practitioner will practice independently, and in collaboration with, Psychogeriatricians, General Practitioners and other health care professionals; service users and whanau to promote health, and to diagnose, assess and manage the mental health needs of the Waitemata DHB older adult population. The needs of this population are complex, incorporating elements of behavioural problems, psychosocial issues and often medical concerns. The nurse practitioner will need to work autonomously, conduct assessments, order laboratory tests, make diagnoses, and prescribe and manage medication. The ability to do this will allow them to provide a onestop shop which will mean that people will not need to see a number of different mental health professionals. Southern DHB introduced nurse practitioner roles into older people s mental health in Otago in 2006 and found the benefits to include: new assessments can go directly to the nurse practitioner clinic, resulting in reduced waiting time for people needing psychiatric assessments the consultant psychiatrist has more time to keep clinical notes up-to-date reduced need for out-of-hours contact with the consultant psychiatrist improved health/mental health as a result of early intervention and by improving capacity for complex nursing interventions in community decreased preventable geriatric mental health exacerbations reduced length of stay for unavoidable admissions ability to prescribe enabled them to provide more timely medication adjustments, resulting in faster stabilisation for people. Having now completed his orientation the Waitemata DHB MHOSA nurse practitioner will build on the learnings of Otago and other similar roles and begin on what will be an exciting and fulfilling journey for both staff and patients. Key Issue Delays in lung function testing The respiratory physiology laboratory provides measurement of pulmonary function in support of hospital based medical services and primary care. Numerous tests of lung and aerobic function required in the assessment and management of many respiratory illnesses are performed including: Full lung function tests Bronchodilator testing Bronchial provocation challenges (hypertonic saline, methacholine and exercise) Cardiopulmonary Exercise Test Maximal Inspiratory/Expiratory Muscle Pressures Fraction of Exhaled Nitric Oxide measurement Six minute walk test Arterial Blood Gas sampling In addition, the service provides assessments and follow-up for adult patients who require long term oxygen therapy and organises the supply of equipment for paediatric patients and those who require oxygen on a palliative basis. 45

49 As of 30 October 2017, there were 460 patients waiting for a lung function test. Of these, 92 were within compliance and 368 were non-compliant. The service currently receives between 110 and 150 referrals per month and has the capacity to see 100 in the same period. 3.1 Referrals Received/Lung Function Test Completed After an extended recruitment campaign, the service has appointed two trainee respiratory physiologists. With the appointment of the two graduate physiologists capacity will increase to around 130 per month by the end of December 2017 and to 150 per month by mid-2018 when they can work more independently. To further mitigate risk, the waitlist has been reviewed to ensure patients with the greatest clinical needs are prioritised for testing. 46

50 Scorecard Specialty Medicine and Health of Older People Services Waitemata DHB Monthly Performance Scorecard Specialty Medicine and Health of Older People September / a. a. b. Best Care Service Delivery Patient Experience Actual Target Trend Waiting Times Actual Target Trend Complaint Average Response Time 12 days <14 days Urgent diagnostic colonoscopy w/in 14 days 98% 90% Net Promoter Score FFT Diagnostic colonoscopy w/in 42 days 86% 70% Surveillance colonoscopy w/in 84 days 94% 70% Improving Outcomes Patients admitted to stroke unit 76% 80% Patient Flow Acute Stroke to rehab w/in 7 days 71% 80% Outpatient DNA rate 10% <10% InterRAI assessments - LTHSS clients 98% 95% Average Length of Stay - AT&R 15 days <19 days Better help for smokers to quit - hospitalised 100% 95% Patients with EDS on discharge 88% 85% Quality & Safety Older patients assessed for falling risk 96% 90% Rate of falls with major harm 0 <2 Value for Money Good hand hygiene practice 93% 80% Pressure injuries grade 3&4 0 0 Financial Result (YTD) Actual Target Trend Revenue 1,628 k 2,184 k HR/Staff Experience Expense 23,005 k 22,842 k Sick leave rate 3.5% <3.6% Net Surplus/Deficit -21,378 k -20,658 k Turnover rate - external 11% 8-12% Capital Expenditure (% Annual budget) 175% Contracts (YTD) Elective WIES Volumes Acute WIES Volumes How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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. August dependent on coding b. Quarterly June data - Sep n/a A question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB Scorecard Variance Report Best Care Acute stroke to rehab within 7 days - 71% against a target of 80% September s result again represents an improvement over previous months. This may to some degree reflect gains made by having a clinical person from our rehabilitation service attending the multidisciplinary team meetings on the ward to support transfer to the Early Discharge and Rehabilitation Service (EDARS) or to AT&R rehabilitation. Also the introduction of home warding for Ward 2 means daily review by the team and this facilitates earlier decision making about discharge. As noted in earlier Hospital Advisory Committee reports we have commissioned a piece of work to review the feasibility/options to develop one of our existing wards into an integrated stroke unit. The feasibility study confirmed that Ward 6 which is currently an acute medical ward in the North Shore tower block would not be suitable; however Ward 15 which is currently an AT&R ward at North Shore could be extensively remodelled into an integrated stroke unit. A business case process is being embarked on using Treasury guidelines. 47

51 Strategic Initiatives Variance Report Deliverable/Action Better Help for Smokers to Quit Health Target Produce reporting by ethnicity for Smoking Status, Brief Advice and Cessation Support for priority healthcare settings (Hospital population) January 2018 Improve data entry and IT tools to improve reporting of Brief Advice and Cessation Support in priority healthcare settings (e-vitals, hospital only) June 2018 Bowel Screening Access across all endoscopy services Recruit two nurses with full 5-day week coverage to ensure timely access for high priority (P1) patients September 2017 Develop an annual production plan for all endoscopy procedures to enable weekly performance tracking In place by July 2017 Recruit to the two endoscopy fellow roles December 2017 Clinical Nurse Specialist endoscopist role in place December 2017 Regional collaboration, through a contractual arrangement, to improve access and timeliness to colonoscopy procedures. Work with Auckland DHB through an outsourcing arrangement to do weekly lists for Waitemata DHB patients July 2017 Delivery of Regional Service Plan Stroke Ensure all Allied Health and Nursing staff in In-Patient Rehabilitation and Community Rehabilitation services complete a stroke competency training programme within the first year of employment - Ongoing Support a range of health professionals working in stroke care to attend the Stroke Society of Australasia s annual conference - August 2017 Hepatitis C Support the roll-out of the integrated Hepatitis C service across the region including GP practice support, raising awareness, extending services and monitoring progress Over 2017/18 On Track 3.1 Areas off track for month and remedial plans 6. Clinical Nurse Specialist Endoscopist role in place December 2017: This is still in progress. This will require a budget bid which has yet to be approved. The Nurse that planned to employ for this role is also currently on maternity leave and is expected to be back around March She will however need to enrol and start her papers with The University of Auckland from February

52 Financial Results Specialty Medicine and Health of Older People STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 Sub Specialty Med and HOPS ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency (249) 1,361 1,875 (514) 7,455 Other Income (45) (42) 1,358 Total Revenue (294) 1,628 2,184 (556) 8, EXPENDITURE Personnel Medical 2,262 2, ,351 5,323 (29) 19,909 Nursing 2,035 2,001 (35) 6,010 5,890 (120) 26,881 Allied Health 2,229 2, ,272 5, ,566 Support Management / Administration ,459 1, ,199 Outsourced Personnel ,158 7, ,246 18, ,179 Other Expenditure Outsourced Services (130) 2,848 Clinical Supplies 1, (154) 3,130 2,690 (440) 10,646 Infrastructure & Non-Clinical Supplies ,756 1,464 1,328 (136) 4,760 4,210 (549) 16,250 Total Expenditure 8,622 8, ,005 22,842 (164) 88,430 Cost Net of Other Revenue (8,180) (8,151) (29) (21,378) (20,658) (720) (79,616) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The overall result for Specialty Medicine and Health of Older People was $29k unfavourable for September and $720k unfavourable for the YTD. Revenue ($294k unfavourable for September, $556k unfavourable YTD) The unfavourable result for September was driven by a $181k charge for the outsourced gastroscopy services undertaken by MacMurray and deducted by the Funder from the gastroscopy revenue line. ACC revenue for AT&R was $70k unfavourable for the month. The YTD effect of the gastroscopy outsourcing is $472k unfavourable. ACC revenue is $56k unfavourable YTD. Expenditure ($265k favourable for September, $164k unfavourable YTD) The favourable result for September was driven by $301k of vacancies and churn within the Allied Health service and a current favourable position of $101k with NASC (Needs Assessment Service Centre) respite expenditure offset by $110k of unbudgeted outsourced gastroscopy services and $49k of high level community care for complex needs patients within the Mental Health of Older Adults service. The YTD unfavourable position was due to $498k of savings targets, $430k of unbudgeted gastroscopy procedures outsourced to Auckland DHB, $212k of additional community care costs within the Mental Health of Older Adults, countered by $482k of churn and vacancies within the Allied Health service and a $255k favourable position within NASC respite. 49

53 Personnel ($386k favourable YTD) Medical ($29k unfavourable YTD) The unfavourable YTD position was due to an unmet savings allocation. 3.1 Nursing ($120k unfavourable YTD) The unfavourable YTD position was due to a savings allocation of $141k. Allied Health Support ($482k favourable YTD) The favourable YTD position was due to vacancies and churn of $534k within the Allied Health service, $100k in the Diabetes and Renal service and $125k within the NASC service offset by $318k of savings targets. The impact of headcount restrictions, the vacancy factor and limited availability of appropriate candidates within Allied Health service is having a significant benefit on the financial performance of the division and is likely to continue into the second quarter. Support and Management/Administration ($45k favourable YTD) The favourable YTD position was due to vacancies and churn of $169k offset by a $124k savings target. Outsourced Personnel ($7k favourable YTD) The favourable YTD position was due to a reduced need for SMO locum shifts. Other Expenditure ($549k unfavourable YTD) Outsourced Services ($130k unfavourable YTD) The unfavourable YTD position was due to $430k of unbudgeted gastroscopy procedures outsourced to Auckland DHB offset by a $255k favourable position within NASC respite. Clinical Supplies ($440k unfavourable YTD) The unfavourable YTD position was due to an overspend of $212k on high level community care for complex needs patients within the Mental Health of Older Adults service and $96k of savings targets. Infrastructure and Non-Clinical Supplies ($21k favourable YTD) The favourable YTD position was due to a series of opportunistic savings. Getting back on track initiatives The main challenge facing the division is the unbudgeted cost commitment for outsourced gastroscopies and colonoscopies. In light of the planned contraction of the Bowel Screening Program, we are in the process of presenting the benefits of utilising this internal resource rather than incurring the premium for outsourcing. 50

54 Child, Women and Family Services 3.1 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, Dr Diana Ackerman for Gynaecology and Dr Helen Allen (Acting) for Obstetrics. Highlight of the Month Better, Best, Brilliant Family Centred Tube Feed to Weaning Management Current work being undertaken on a Tube Feeding Management Pathway by the Child Health and Women s Health teams, in conjunction with the i3 team, resulted in the concept of a Waitemata DHB led Symposium entitled Family-Centred Tube Feeding to Weaning Management. Elizabeth Maritz (Clinical Leader for Dietetics) led a team of professionals to plan the day with support from the i3 team. Specifically, the symposium was designed to provide an opportunity for: Professionals involved in the care of the infant/child along the tube feeding journey to network The sharing of regional interventions and national initiatives Families to share their stories and experiences. The Symposium was held on 26 October 2017 at Whenua Pupuke and was well supported 90 delegates from 20 sites in 16 DHBs participated via video-conferencing and a further 90 delegates attended in person. Twenty one speakers contributed to the delivery of the programme. Among the presenters was a Behavioural Psychologist, who shared the home-based work she has completed to wean two children off enteral feeding and the impact that this short-term psychology intervention has made. The highlight of the day was the sharing of videos, made by mothers who told their stories. These contained important messages to delegates, such as we felt so isolated, listen to us and we needed to meet other families in the same situation. Acknowledging the importance of collaborative care with families involved in the decision making process at all times, and recognising the complexity of children who require enteral feeding were themes for the day. A co-design project continues with support from i3, on the development of a family-centred electronic pathway from point of tube insertion to weaning, with roles defined and best practice identified. 51

55 Key Issues Services for children with Fetal Alcohol Spectrum Disorder Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe the range of effects that can occur when a fetus is exposed to alcohol during pregnancy. In the broadest sense, this includes miscarriage, stillbirth, premature birth, physical abnormalities and an increased risk of negative health outcomes for the child. However, FASD more commonly refers to a constellation of physical and neurodevelopmental impairments experienced by people who were exposed to alcohol during pregnancy. 3.1 In 2016 the Ministry of Health released Taking Action on Fetal Alcohol Spectrum Disorder: : An action plan, which aims to create a more effective, equitable and collaborative approach to FASD. The evidence outlined in the development of the plan indicates that: At least one in two pregnancies are exposed to alcohol; one in ten are exposed at high-risk levels Two in five pregnancies are unplanned, increasing the chance they will be exposed to alcohol Pregnant women do not consistently receive timely maternity care or support for their alcohol and/or other drug issues Health professionals do not consistently provide information on the risks of drinking during pregnancy or routinely screen for alcohol issues Most clinicians lack the capability to diagnose FASD Families of people with FASD struggle to access appropriate support and report a lack of understanding from services, professionals and even other family members FASD affects about 50 percent of children and young people in Child, Youth and Family care. Detail on the incidence of FASD is difficult to establish, however one estimate from the NZ Child and Youth Epidemiology Service suggests that 1% of children have experienced the effects of fetal exposure to alcohol to one degree or another. A smaller proportion of children are severely and obviously affected. There are ten key action areas identified in the plan. At a local level, the implementation of these will require a co-ordinated and collaborative response across community, maternity, child health, mental health and primary care services. To date, the service has provided specialist training to upskill some paediatricians and child mental health clinicians and is routinely recording alcohol intake in pregnancy. General Paediatric developmental and Gateway assessments are provided to help identify children with FASD. Work has also commenced on exploring the feasibility of introducing a neuro-developmental pathway across Child Health and Child Mental Health Services. However, there are significant challenges in providing care to this group of children. These include providing: A consistent and appropriate clinical response for women who require assistance with their alcohol and/or other drug use during pregnancy Routine neuropsychology assessments for children at 7-8 years to establish a definitive diagnosis. In addition, the experience of some families with young people with FASD (who are often children with misunderstood behaviours, difficulty learning from consequence and a degree of impulsivity) is less than ideal. They can struggle to get access to disability support services and appropriate behavioural interventions unless a diagnostically confirmed Intellectual Disability can be demonstrated. Health Promoting Schools Health Promoting Schools (HPS) is a school community focused service funded by the MoH. The service has been designed to help schools assess and address the health and wellbeing requirements of their students to advance student learning and achievement. HPS guides schools to collaborate with students, parents, whānau, and the wider community to develop their own ideas and activities to improve the wellbeing of children and adults. 52

56 The MoH currently reviews and renews the HPS contract on an annual basis. This has provided challenges for planning of future projects with schools and retaining staff. Waitemata DHB is contracted to employ four HPS coordinators, who work with 94% of the target schools (decile 1-4 year 1-8 schools who have high Maori and Pacifica student rolls). In Waitemata this equates to 78 schools. In addition, three new schools who meet the priority criteria have requested to join the programme in Over 2017 a national external evaluation was completed that identified that HPS makes a significant contribution to achieving improvements in schools in particular increases in attendance and reading achievement, and reductions in stand downs and suspensions. Clarification has been sought from the MoH as to whether there is outcome data from the national evaluation at a DHB level, but the service has been advised that this is not available. Scorecard Child, Women and Family Services Waitemata DHB Monthly Performance Scorecard Child Women and Family Services and Elective Surgical Centre September /18 Health Targets Service Delivery Actual Target Trend Elective Volumes Actual Target Trend Shorter Waits in ED 98% 95% Provider Arm - Overall 100% 100% CWF Services 90% 100% Best Care Waiting Times Gateway referrals waiting over 6 weeks 22 5 Patient Experience Actual Target Trend Complaint Average Response Time 18 days <14 days Patient Flow Net Promoter Score FFT Outpatient DNA rate 9% <10% a. Average Length of Stay - Maternity 2.4 days <2.5 days Improving Outcomes b. Average Length of Stay - Paediatrics 1.70 days <1.55 days Exclusive breastfeeding on discharge a. 80% 75% Average Length of Stay - SCBU days <10.4 days Women smokefree at delivery 95% 95% Theatre utilisation Gynaecology 82% 85% Better help for smokers to quit - hospitalised 96% 95% Patients with EDS on discharge 92% 85% c. Oral health - % infants enrolled by 1 year 67% 95% c. Oral health - exam arrears 0-12 yr 18% <10% Quality and Safety Good hand hygiene practice 88% 80% Financial Result (YTD) Value for Money Actual Target Trend Revenue 1,328 k 1,338 k HR/Staff Experience Trend Expense 22,916 k 23,548 k Sick leave rate 3.7% <3.6% Net Surplus/Deficit -21,587 k -22,209 k Turnover rate - external 13% 8-12% Capital Expenditure (% Annual budget) 49% Contracts (YTD) Gynaecology Elective WIES (excl ESC) Gynaecology Acute WIES Maternity WIES 2,389 1,810 Paediatrics WIES Neonatal WIES How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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. Internal definition and targets for 'Average length of stay'. b. MOH based 'Average length of stay' c. Oral health data - Total WDHB, ADHB and CMDHB, DHB of service not domicile A question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB Scorecard Variance Report Best Care Complaint Average Response Time 18 days against a target of <14 days The complaint average response time is above target this month. This is primarily due to two complex complaints, which required extended investigations and a complaint where the staff member involved was on leave. Active communication occurred with all complainants to ensure that they were aware of the reasons for the delays. 53

57 Oral health - % infants enrolled by 1 year 67% against a target of 95% The service continues to achieve the target for Waitemata DHB. Progress has been limited in Auckland DHB, as the birth list data that has been requested weekly has not yet been received. This is being actively followed up. There has also been no progress in achieving the target in the Counties Manukau area, as while they have agreed to proceed with the multi-enrolment process, they are yet to provide the specific information required that will enable implementation (in particular, in relation to how privacy issues are managed). 3.1 Oral health - exam arrears 0-12 yrs 18% against a target of <10% The service continues to focus on: Ensuring productivity expectations (seeing an average of eleven children per day per chair) are maintained Improving access by extending Saturday clinics and ensuring extended hours clinics utilisation is maximised Ensuring that children are being seen within the correct timeframes (according to clinical need) Over the last month, two new Saturday clinics have commenced (in Otara and Pt England) and the review of the preschool prioritisation tool (which determines the frequency of appointments) has been completed. Work is also progressing well with three teams (one from each DHB) to develop robust systems and monitoring processes to ensure that recall dates set are aligned with clinical need. The implementation of these new processes will commence on 1 November 2017 and, if successful, the systems developed will be extended across all teams in Arrears continue to be particularly high in the South Auckland teams where the recruitment and retention of staff has been challenging. However, recruitment of new graduate dental therapists for 2018 has commenced and the initial indication is that there are several applicants who have a preference to work in South Auckland. 54

58 Turnover rate 13% against a target of 8 12% The turnover rate is above target this month. Further investigation by service area and professional group has commenced to identify if there are trends or issues that require addressing. 3.1 Service Delivery Elective Volumes 90% against a target of 100% Gynaecology has not achieved the target this month. This is the result of ongoing high levels of extended unplanned leave within the team. It is anticipated that there will be an improvement over the coming months, as a new SMO has recently joined the service, a fellow and new SMO will commence in December 2017 and a short term locum has been identified from 1 December Gateway referrals waiting over 6 weeks 22 against a target of 5 There has been an increase in the number of children waiting beyond contracted timeframes this month. This appears to be related to a change in referral practice, where now social workers are sending education profiles at the point of referral. Previously there were often significant delays in receiving education profiles, which meant the start date of the waiting time was also delayed because the assessment cannot progress until the education profile is received. This has created a backlog. All children waiting have an assessment booked during October and November. Average Length of Stay Paediatrics 1.70 days against a target of <1.55 days The increased length of stay primarily appears to be driven by a child with complex needs who has a prolonged admission of 77 days. There have also been three other children who required stays of longer duration (between eight and eleven days). Value for Money Neonatal WIES 516 against a target of 546 There has been low occupancy in both the North Shore and Waitakere Special Care Baby Units over the past month. This has impacted on discharges for September. 55

59 Strategic Initiatives Variance Report Deliverable/Action Supporting Vulnerable Children Increase screening rates for family violence - Ongoing Implement an enhanced assessment and referral pathway inclusive of mental health and neurodevelopmental assessments as part of the Gateway programme and improve processes to follow up referrals (pending MSD/MoH approvals) June 2018 Continue to work with Oranga Tamariki and education staff to monitor delivery and timeliness of services for children who have had a Gateway assessment, as outlined in the Interagency Services Agreement. In partnership with Oranga Tamariki, implement quality improvement actions in areas where access or timeliness is below expectations - Ongoing Healthy Mums and Babies Develop a programme to support new graduate midwives to enter the self-employed Lead Maternity Carers workforce June 2018 Continue to improve breastfeeding support for mothers and babies in the community - Ongoing Keeping Kids Healthy Increase oral health promotion and implement a system to deliver fluoride varnish for preschoolers June 2018 Roll out a supported process for high needs children who do not attend dental therapy appointments June 2018 On Track 3.1 Areas off track for month and remedial plans All areas on track 56

60 Financial Results - Child, Women and Family Services STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 Child Women & Family ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency (19) 1,136 1,205 (70) 4,821 Other Income Total Revenue (13) 1,328 1,338 (10) 5, EXPENDITURE Personnel Medical 1,980 2, ,737 4, ,243 Nursing 2,209 2, ,633 6,622 (11) 28,942 Allied Health 3,054 3, ,743 7, ,398 Support Management/Administration ,185 1, ,834 Outsourced Personnel (26) 1,281 7,895 8, ,713 20, ,976 Other Expenditure Outsourced Services (13) (8) 461 Clinical Supplies (71) 1,530 1,365 (164) 4,988 Infrastructure & Non-Clinical Supplies (9) 1,500 1,477 (23) 4, (93) 3,203 3,008 (196) 10,269 Total Expenditure 8,802 9, ,916 23, ,245 Cost Net of Other Revenue (8,362) (8,685) 322 (21,587) (22,209) 622 (84,829) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The overall result for CWF is $322k favourable for September and $622k favourable for the YTD. Revenue ($13k unfavourable for September, $10k unfavourable YTD) The unfavourable result for September and YTD is primarily related to a reduction in Colposcopy activity. Expenditure ($335k favourable for September, $632k favourable YTD) The favourable result for September and YTD continues to be driven by significant Allied Health vacancies across ARDS and Child Health community based services. The services are actively recruiting where possible with regional and/or national workforce shortages and the timing of new graduate availability having an influence on the ability to fill vacancies. Personnel ($827k favourable YTD) Medical ($152k favourable YTD) The favourable medical result is a combination of several short term vacancies, a one off reimbursement for a prior year staff over payment and reduced spending in allowances and course and conference activity. Nursing ($11k unfavourable YTD) The unfavourable nursing position is being driven predominately by staff retention and recruitment challenges across Maternity services resulting in the need for alternative staffing skill mix changes, part time staff increasing their hours and use of overtime to cover roster gaps. Maternity WIES is tracking at 117% of target YTD. High 57

61 winter demand for inpatient Paediatric services is also contributing to cost pressures with acute Paediatric WIES at 130% of target to date. 3.1 Allied Health ($578k favourable YTD) The favourable Allied Health result is attributed to vacancies across CWF community services. Ongoing recruitment challenges and availability of new graduates are major factors. The service group is looking to maximise recruitment of new graduate Dental Therapists when they become available in February Support and Management/Administration ($135k favourable YTD) The favourable result is being driven solely by service wide Management/Administration vacancies. Outsourced Personnel ($26k unfavourable YTD) This result is being driven largely by outsourced nursing due to increased winter demand for Paediatric inpatient activity and vacancy cover across residential respite services. Other Expenditure ($196k unfavourable YTD) Outsourced Services ($8k unfavourable YTD) The unfavourable YTD position results from a shortfall in achieving the embedded savings of $50k YTD. Clinical Supplies ($164k unfavourable YTD) The unfavourable Clinical Supplies result relates largely to unmet savings lines embedded across all services $124k as well as the introduction of new unbudgeted dental products associated with recent infection control changes and increased repairs and maintenance costs. Infrastructure and Non-Clinical Supplies ($23k unfavourable YTD) The adverse Infrastructure cost position continues to be aligned with embedded savings. Reduced transportation and utilities spending has partially offset the $162k of embedded savings. This reduced spend accounts for 85% of the budgeted savings YTD. Getting back on track initiatives Plans for changes in the model of care for both Colposcopy and Urodynamic studies continue. Both activities are being impacted by resourcing across Obstetrics and Gynaecology at present and will likely be delayed until the New Year. Work continues on an internal review of the financial viability of all CWF service level agreements and purchase unit activity. The intended action will be to seek cost reductions, renegotiate funding or discontinue contracted activity. Annual leave management continues to be a focus for the group with the average annual leave balance per FTE dropping from 22 days in October 2016 to 18 days in September The Kanban stock management system along with new scanning facilities continues to be rolled out across CWF. The introduction of a dedicated clinical supplies coordinator for CWF Waitakere Hospital wards is yet to be finalised. A recent ARDS service change that has resulted in financial benefit being realised is a move from sending out eligibility letters to parents. An alternative process for determining eligibility through the school system has been introduced. The saving on the 33,000+ letters per annum is expected to be approximately $30k. A new ARDS cleaning supplier contract is expected to be signed off within the next fortnight with anticipated annual financial benefits of $119k. 58

62 Specialist Mental Health and Addiction Services 3.1 Service Overview This service is responsible for the provision of specialist community and inpatient mental health services to Waitemata residents. This includes child, youth and family mental health services, community alcohol, drug and other addiction services across the Auckland metro region, Maori and Pacifica 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 the Dr Susanna Galea-Singer (Director, Speciality Mental Health and Addiction Services), Dr Jeremy Skipworth (Clinical Director Forensic Services) and Pam Lightbown (General Manager). Highlight of the Month Opening of Courtyards Adult Inpatient Units All courtyards in Adult Inpatient Units are now completed. In September the courtyards were blessed and following staff training, courtyards were fully opened and able to be used with un-restricted access by all service users. Feedback from service users and staff has been extremely positive. 59

63 Seclusion use Adult Inpatient Unit Zero seclusions in adult Mental Health units for the month of September. This is the first time we have had a calendar month of no seclusions at He Puna Waiora. This has been a result of a focus on seclusion reduction, review panels, continued implementation of the six core strategies, focus on the national KPI, nursing leadership in place with Adult Nurse Lead appointed and full leadership team in He Puna Waiora. 3.1 Key Issues Closure of Beds at He Puna Waiora Due to slow recruitment of Registered Nurses on the North Shore, resignations and retirement of Registered Nurses, five beds were temporarily closed at He Puna Waiora on 11 th October With the temporary closure of five beds at He Puna Waiora, we have been working closely with our community teams and non-government Organisation (NGO) service providers. Additional community NGO beds (5) have been purchased as needed. To date not all beds have been needed to be purchased. Staff recruitment is ongoing. Five new nurses have recently commenced work some being new graduate nurses therefore are supernumerary. As soon as these staff are incorporated into the roster we are expecting to open the beds. Child Youth and Family Mental Health Services Facilities continue to be an issue on the North Shore with clinical service delivery and staff morale being affected. The staff moved into Nile road on 28 November A project has been initiated in order to transform the facility into a more appropriate space for staff and service users in the medium term. However, work is being undertaken around a longer term building, future proofing for identified growth with fit for purpose staff and clinical space. Child Youth and Family referral numbers across the service continue to increase (approximately 23% increase from same the time last year). We continue to look at how this is managed in regards to workload and on-going capacity to meet KPIs without impacting on the model of care including timely follow up treatment. 60

64 Scorecard Specialist Mental Health and Addiction Services Waitemata DHB Monthly Performance Scorecard Specialist Mental Health and Addiction Services September / Health Targets Service Delivery Actual Target Trend Waiting Times (latest available) Actual Target Trend Shorter Waits in ED 85% 80% a. Youth (0-19) <3 weeks 71% 80% a. Adult (20-64) <3 weeks 86% 80% a. CADS (0-19) <3 weeks 89% 80% Best Care a. CADS (20-64) <3 weeks 93% 80% a. Patient Experience Actual Target Trend Forensic (20-64) <3 weeks 93% 90% Complaint Average Response Time 20 days <14 days Prison inpatient waiting list 0% 0% Improving Outcomes Patient Flow Better help for smokers to quit 97% 95% Average Length of Stay - Adult Acute 19 days days Seclusion use Forensics - Episodes 51 <14 Average Length of Stay - CADS Detox 7 days 6-8 days Seclusion use Adult - Episodes 0 <5 Bed Occupancy - Adult Acute 100% 85% Adult Inpatient Units AWOL (clients) 0 1 Bed Occupancy - CADS Detox 114% 90% Forensic Units AWOL (clients) 0 1 Bed Occupancy - Forensics Acute&Rehab 89% 90% Bed Occupancy - ID 75% 90% a. MH Access Rates 0-19 years (Total) 3.65% 3.10% a. MH Access Rates 0-19 years (Maori) 4.85% 4.40% Community Care a. MH Access Rates years (Total) 3.60% 3.40% Treatment days per service user - adult 3.3 days 3-5 days a. MH Access Rates years (Maori) 8.16% 7.60% Treatment days per service user - child 1.8 days 2-4 days Treatment days per service user - youth 2.0 days 2-4 days HR/Staff Experience Treatment days per service user - CADS 2.4 days 2-4 days Sick leave rate 3.5% <3.6% Treatment days per service user - forensics 2.0 days 2-4 days Turnover rate - external 10% 8-12% Preadmission community care - adult 78% 75% Value for Money Post discharge community care - adult 83% 90% Community service user related time - adult 41% 35% Financial Result (YTD) Actual Target Trend Contact time with client participation - adult 78% 80-90% Revenue 1,672 k 1,592 k Whanau contacts per service user - adults 61% 70% Expense 31,983 k 32,579 k Whanau contacts per service user - child 100% 80% Net Surplus/Deficit -30,311 k -30,987 k Whanau contacts per service user - youth 100% 80% Capital Expenditure (% Annual budget) 41% How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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 3 months in arrears (June data). A question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB Scorecard Variance Report Best Care Complaint Average Response Time - 22 days against a target of <14 days Forensics has been receiving a higher than usual number of complaints from one service-user. To ensure we respond to each of the service-users concerns a more robust process was implemented that has increased the response time. A review of this process is ongoing and response timeframes are monitored weekly. Seclusion use Forensics 51 against a target of <14 Forensic Services have experienced an increase in acuity this month. This is particularly related to three individuals contributing to episodes of seclusion who could not be managed in a high care environment outside of seclusion. There is also one service user who has planned seclusion overnight equating to 7.5 hours daily which contributes to the variance. Service Delivery Youth 0 19 <3 week Wait Time 71% against a target of 80% The service continues to make incremental improvement. Referral numbers to Child, Adolescent Mental Health Service continue to increase causing an increased demand for first appointments. The service is looking at ways to manage this without compromising capacity to provide follow-up treatment. Access Rates for 0-19 including Māori remain higher than National benchmark. Face to Face contacts continue to meet benchmark and Family Whanau contact remain at 100% across Child and Youth services. 61

65 Bed Occupancy ID 75% against a target of 90% The maximum capacity of the unit is nine care and rehab beds and two assessment beds. In the reporting period we had 10 care and rehab patients, and were therefore at 91% capacity. We have since gone to 100% capacity. 3.1 Treatment Days per service user Child 1.8 days against a target of 2.4 days Lower number of treatment days offered is a result of higher numbers of staff off sick. Adult - Post Discharge Community Care - 83% against a target of 90% We continue to work on this KPI consequently increasing by 10% since August There has been continued focus to ensure that community teams are actively engaged with seeing service users following discharge from an inpatient unit. Active interface between community and inpatient teams has provided earlier community engagement. Furthermore, a project looking at discharge planning with emphasis on identifying a date for the first community assessment post discharge on the discharge summary. This regional pilot is being lead by Dr Rob Waller from Waitemata DHB. Adult - Contact Time with Client Participation 78% against a target of 80-90% Further discussion with services is required to identify if this is either a trend or a one off result. Also, this will be highlighted on the agenda for adult clinical governance and on the next Adult KPI steering group to identify actions to increase time with client participation. Adult - Whanau Contacts per Service User 61% against a target of 70% There has been variability in the number of whanau contacts per service user. There are a number of challenges in reporting this through various contact types in HCC (health electronic recording system). Services have also indicated that a growing number of referrals and assessments have contributed to growing workloads impacting on services being able to contact and provide support through to whanau. Strategic Initiatives Variance Report Deliverable/Action Prime Minister s Youth Mental Health Project Develop integrated care plan pathways for young people accessing DHB and NGO mental health and youth Alcohol and Other Drugs (AOD) Services September 2017 Implement pathways December 2017 Audit pathways and implement recommendations June 2018 Mental Health Reduce Māori under community treatment orders (CTO) rate Undertake analysis of underlying data to understand pathways, gaps and opportunities for improvement December 2017 Develop recommendations for evidenced-based interventions to address the disease and health burden June 2018 Physical health outcomes Establish metabolic screening and primary care services protocols for people with serious myocardial infarction >12 months, including reporting June 2018 Establish baseline volumes of physical health screening Suicide prevention and postvention Fully implement Suicide Prevention in ED guidelines June 2018 Pilot and evaluate Kaupapa Māori Suicide prevention trainings (EOA) June 2018 On track Areas off track for month and remedial plans All areas on track 62

66 Financial Results Specialist Mental Health and Addictions Services STATEMENT OF FINANCIAL PERFORMANCE Specialist Mental Health & Addiction Services ($000 s) Reporting Date Sep-17 MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency (77) ,538 Other Income (122) 3,120 Total Revenue (38) 1,672 1, , EXPENDITURE Personnel Medical 2,832 3, ,738 7, ,107 Nursing 4,162 4, ,484 12, ,396 Allied Health 3,236 3, ,885 8, ,600 Support Management / Administration ,524 1, ,041 Outsourced Personnel (128) (404) 1,036 11,209 11, ,516 30, ,970 Other Expenditure Outsourced Services 43 4 (38) (88) 54 Clinical Supplies (30) (62) 1,572 Infrastructure & Non-Clinical Supplies (4) 1,907 1, , (73) 2,467 2,337 (131) 9,456 Total Expenditure 12,073 12, ,983 32, ,426 Cost Net of Other Revenue (11,623) (12,136) 514 (30,311) (30,987) 676 (125,768) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The overall result for SMHA was $514k favourable for September and $676k favourable for the YTD. The September result was mainly due to vacancies, as well as high leave taken. Revenue ($38k unfavourable for September, $80k favourable YTD) The unfavourable result for September was mainly due to a transfer in revenue received in August for Youth addiction money to corporate. YTD we have had a wash up of ID billing at $56k, court reporting surplus of $160k and contribution received from IYSS contract at $55k. These were offset by unfavourable variance due to the service level agreements requiring Mental Health overspend before funding for new and extended Child and Youth services in Rodney will be received ($333k) YTD. Expenditure ($552k favourable for September, $596k favourable YTD) September result was mainly due to the high value of vacancies as a result of the three pay period month, as well as higher than expected leave taken for this time of year. The YTD result of $747k favourable for expenditure is also a reflection of vacancies. Personnel ($625k favourable YTD Medical ($353k favourable YTD) This is mainly due to vacancies valued at $510k (average of 12 FTE), which is offset by locum cover in outsourced personnel below. Allowances are also over budget at ($78k) due to insufficient budget for job sizing. 63

67 Nursing ($344k favourable YTD) This is due to vacancies valued at $1,093k (average of 103 FTE), offset by casuals and overtime $582k. Allowances are also over budget by $73k. 3.1 Allied Health Support ($303k favourable YTD) Allied health is favourable YTD due to vacancies (Average of 32 FTE) as well as higher leave taken than anticipated in September. There was also a budget transfer in September for three months worth of the Youth addiction team salaries. Support and Management/Administration ($131k favourable YTD) This is mainly due to vacancies valued at $176k YTD. Outsourced Personnel ($404k unfavourable YTD) This is due to locum spend to cover medical vacancies. Other Expenditure ($131k unfavourable YTD) Outsourced Services ($88k unfavourable YTD) This is an offset to additional staffing for the Intellectual Disability nurses which are an unbudgeted cost commitment. Clinical Supplies ($62k unfavourable YTD) This is mainly due to pharmaceutical overspend and is in line with historical spend levels. Infrastructure and Non-Clinical Supplies ($20k favourable YTD) Infrastructure and Non-Clinical supplies is currently on budget. 64

68 Surgical and Ambulatory Services/Elective Surgery Centre 3.1 Service Overview The Surgical and Ambulatory Services provides 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) and Debbie Eastwood (General Manager). The Head of Division Nursing is Kate Gilmour. The Elective Surgery Centre provides elective surgical services to our community, managed by Dr Bill Farrington (Clinical Director) and Lyn Wardlaw (Operations Manager). Highlight of the Month Radiology Service Replacement CT Scanner at Waitakere The core purpose of Waitemata DHB s Radiology Service is to provide patients and their referring health practitioner s timely access to high quality diagnostic and therapeutic imaging procedures. This is required for the provision of safe and efficient hospital and community patient care. Waitakere Radiology Department has, as part of their medical imaging facility, one Siemens Somatom slice 16 CT machine which is due for replacement. A collaborative taskforce involved representatives from the Service to work alongside project managers and the procurement teams to facilitate the build and CT purchase and liaise with architects, quantity surveyors, builders etc. It was quickly identified the need for two CT scanners at Waitakere Hospital with upgraded and extended facilities to provide accommodation for the new machines along with appropriate support spaces. One CT scanner is a replacement for the current machine which has reached the end of its life while the additional machine is required to meet increasing demand and provide a constant acute CT service when outages and routine maintenance occur. The project was managed in two stages to minimise disruption to patients and service operations. Acquisition of one Toshiba Aquilion PRIME has arrived on site and is currently undergoing installation. Waitakere-based Medical Imaging Technologists have had training over the past few months at North Shore Radiology, ready for their first patient scan that was scheduled for Monday 16 October. An advantage of having the same machine at both sites allows consistency in imaging and ability to utilise Medical Imaging Technologists efficiently through staff shortages or high demand periods. The second CT scanner, Toshiba Aquilion ONE Vision, is due for delivery September The journey has been long and complex. However, the excitement and anticipation of working with new equipment in a new work space will help us meet our promise of Best Care for Everyone. Above shows an executed delivery of the CT scanner requiring a traffic management plan due to the sheer size of the equipment 65

69 Key Issues Ultrasound Update Wait Times The elective demand from both outpatients and General Practitioners for ultrasound scans has increased by an average of 21% over the past three years as can be seen in Graph 1 below. 3.1 Ultrasound Elective Demand Graph 1 Over the same time period our elective activity/completed scans increased by an average of 18% as can be seen in Graph 2. Completed Elective Ultrasounds Graph 2 Table 1 - Average Wait Time for Urgent Elective Ultrasounds Year Days (YTD June) 14 The wait time for the urgent elective ultrasounds has remained stable over the last three years at days. Table 2 - Average Wait Time for Non - Urgent Elective Ultrasounds Year Days (YTD September) 35 (September 47) The wait time for non urgent elective ultrasounds as noted in Table 2 was stable at days over 2015 and 2016 and reduced down to 35 days in We have seen an increase in the average wait time in September at 47 days, however this remains in line with our performance over the last two years. 66

70 Opportunities to Reduce Inpatient Length of Stay (LOS) General Surgery One of the aims for General Surgery is to develop pathways and to ensure we have the right resources to support a decreased LOS for elective and acute: abscess, hernia, gallbladder and appendix patients. Our progress to date to improve the timeliness of our service and as a consequence reduce delays/los for patients has been: Completed the documentation for a cholecystectomy pathway with a goal of reducing the LOS for patients with uncomplicated cholecystitis from 128 hours to 48 hours. 2. A pilot has been organized for acute arranged laparoscopic cholecystectomies. A theatre list has become available on Fridays in Week four. Scorecard - Surgical and Ambulatory and Elective Surgical Centre Waitemata DHB Monthly Performance Scorecard Surgical and Ambulatory Service / Elective Surgical Centre September /18 Health Targets Service Delivery Actual Target Trend Elective Volumes Actual Target Trend Shorter Waits in ED 99% 95% Provider Arm - Overall 100% 100% Surgical and Ambulatory Services 92% 100% Elective Surgical Centre - ESC (YTD) 98% 100% Elective Surgical Centre - ESC (month) 99% 100% Best Care Waiting Times Patient Experience Actual Target Trend % of CT scans done within 6 weeks 94% 95% Complaint Average Response Time 8 days <14 days % of MRI scans done within 6 weeks 96% 90% Complaint Average Response Time - ESC 7 days <14 days % of US scans done within 6 weeks 72% 75% Net Promoter Score FFT - SAS Patient Flow Improving Outcomes Outpatient DNA rate (SAS & ESC) 8% <10% b. a. #NOF patients to theatre w/in 48 hours 88% 85% Average Length of Stay - Acutes 3.0 days <3.57 days Better help for smokers to quit - hospitalised a. 97% 95% Average Length of Stay - Electives 1.5 days <2.16 days a. Average Length of Stay - Electives - ESC 1.1 days <1.05 days Quality & Safety Theatre utilisation - NSH 88% 85% Older patients assessed for falling risk 100% 90% Theatre utilisation - WTH 63% 85% Occasions insertion bundle used 100% 95% Theatre utilisation - ESC 79% 85% Good hand hygiene practice 85% 80% Patients with EDS on discharge 89% 85% ICU - rate of CLAB per 1000 line days 0.86 <1 Value for Money HR/Staff Experience Sick leave rate 3.2% <3.6% Financial Result (YTD) Actual Target Trend Sick leave rate - ESC 3.5% <3.6% Revenue 2,115 k 1,985 k Turnover rate - external 12% 8-12% Expense 49,708 k 47,979 k Turnover rate ESC - external 16% 8-12% Net Surplus/Deficit -47,592 k -45,994 k Capital Expenditure (% Annual budget) 98% Contracts (YTD) Elective WIES Volumes - SAS 2,196 2,165 Elective WIES Volumes - ESC 1,706 1,704 Acute WIES Volumes - SAS 3,565 3,763 How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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. 2015/16 MoH Average length of stay definition, new 2017/18 targets. b. Aug data - coding dependent A question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB 67

71 Scorecard Variance Report Best Care Turnover Rate ESC external 16% against a target of 8-12% The 12-month rolling average turnover for ESC is 15% and this result is influenced by the increase in turnover in the last 2-3 months. In September we have one leaver from ESC. However, as noted in earlier reports we will continue to monitor our turnover along with length of service and reasons for leaving. 3.1 Service Delivery Surgical and Ambulatory Services 92% against a target of 100% (as at 15/10/2017) The elective volumes as at the 24/10/2017 for the YTD September for S&A has improved from 92% to 98% compared to the target. This is due to the increase in the completed coding of discharges for September and the subsequent impact on our results as noted in the table below. Gynaecology is struggling to meet their budget due to unforeseen staffing issues and Urology has a vacant medical officer role which has contributed to their shortfall against budget. Urology have appointed to this vacancy effective December and this appointment will assist them to get back on track. Gynaecology also has a plan in place. ESC S&A WDHB Health Target Activity* Discharges Discharges Discharges 01/07/2017 to 30/09/2017 Actual Budget % Actual Budget % Actual Budget % Ear, Nose, and Throat (ORL) General Surgery Gynaecology Orthopaedics Urology Skin Lesion Removal Total *Health Target Activity: This volume excludes IDF(In), ACC and Acute Volumes. It relates to the Provider MoH Surgical Discharge Health Target. Theatre Utilisation Waitakere 63% against a target 85% ESC 79% against a target 85% Session Utilisation Definition the difference between first patient ready and last patient out of theatre for a session as a proportion of the scheduled session time (excluding early starts and late finishes). The theatre session utilisation for both Waitakere and ESC remains below target. We have seen some overall improvement at ESC and note that while some sessions are underutilised in time the productivity is high. We will be reviewing options to shorten the all day session time for some surgeons who are highly productive but don t require the allocated time. We have reviewed the Waitakere Hospital lists and have taken the opportunity to reallocate some session from theatre sessions to outpatients sessions to meet patient demand and in some specialties where there is no surgeon available to cover the lists. There will be no impact to patient waiting times or access to surgery. Value for Money Acute WIES Volumes SAS 3,565 against a target of 3,763 Orthopaedics and General Surgery account for the majority of the acute WIES contract for S&A at a combined total of 14,839 WIES per annum. Urology and ORL have a minimal combined volume at 53 WIES per annum. YTD September General Surgery is running at 100% of contract and Orthopaedics is at 90% or 186 WIES below contract. The volumes for the first three months of this financial year for Orthopaedics appear to be fairly stable with a mean of 549 WIES per month. 68

72 Strategic Initiatives Variance Report Deliverable/Action Improved Access to Elective Surgery Recruit additional specialist workforce in ORL and Orthopaedics to maintain elective surgical volumes Appointed by June 2018 Reduce unnecessary follow-up appointments through different ongoing strategies, including: Develop standardised patient care pathways for outpatient clinic follow-up appointments June 2018 Implement self-referral of symptoms initiative for follow-up appointments in ORL December 2017 Engage with primary care to develop community assessment and undertake minor ORL procedures: Develop service model of care with GPs for ORL assessment of patients and minor ORL procedures to be delivered from primary/community care settings June 2018 Train GPs to assess patients and perform minor ORL procedures June 2018 Complete roll out of E-triage process in all surgical specialties June 2018 Continue to implement and appropriately use national Clinical Prioritisation Access Criteria tools to improve referral quality and appropriateness, and ensure fair and equitable access - Ongoing On Track 3.1 Areas off track for month and remedial plans All areas on track 69

73 Financial Results - Surgical and Ambulatory and Elective Surgery Centre Combined STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 S&A and ESC ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency ,816 1, ,984 Other Income ,486 Total Revenue ,115 1, , EXPENDITURE Personnel Medical 6,935 7, ,623 16,417 (206) 63,910 Nursing 3,399 3, ,092 10, ,766 Allied Health 1,610 1, ,802 3, ,791 Support ,590 Management / Administration ,876 2, ,515 Outsourced Personnel (50) 2,027 2, ,679 13,695 14, ,021 35, ,251 Other Expenditure Outsourced Services (199) 1, (662) 3,196 Clinical Supplies 3,903 3, ,754 11, ,564 Infrastructure & Non-Clinical Supplies (515) 1, (1,204) 80 4,885 4,184 (701) 14,687 12,844 (1,843) 48,840 Total Expenditure 18,580 18,213 (367) 49,708 47,979 (1,729) 190,090 Cost Net of Other Revenue (17,866) (17,552) (314) (47,592) (45,994) (1,598) (179,620) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The overall result for S&A and ESC was $314k unfavourable for September and $1,598k unfavourable YTD. The unfavourable variance for September was primarily driven by Radiology outsourced costs $199k and unmet savings targets $515k. Unfavourable variances have however been offset by an increase in ACC revenue in Orthopaedics and churn savings through vacancies in personnel costs. Revenue ($53k favourable for September and $131k favourable YTD The favourable result for September was attributed to Orthopaedics ACC revenue of $47k, General Surgery recharge revenue to Auckland DHB for clinical Supplies $17k (unbudgeted revenue offset by unbudgeted cost). The favourable variance was offset by a reduction in Auckland DHB recharges for Botox revenue for Waitakere Surgical Unit. Expenditure ($367k unfavourable for September and $1,729k unfavourable YTD) Personnel ($114k favourable YTD) Medical ($206k unfavourable YTD) The YTD unfavourable variance for medical personnel was attributed to Anaesthesia - MOSS unbudgeted cost commitment from 2016/17 uplift ($25k), General Surgery House Officers skill- mix variance ($47k), Surgical Pathology SMO unbudgeted cost commitment from 2016/17 uplift ($13k) and unmet savings targets of ($224k), offset by churn savings in Radiology SMO $37k and a reduction in SMO time required for Bowel Screening $52k. 70

74 Nursing ($13k favourable YTD) YTD favourable variance for nursing personnel was attributed to churn savings through vacancies in Theatres $44k, Surgical Services $42k, and Surgical Wards $54k. Bowel screening $14k favourable due to unfilled vacancies caused by reduction in Bowel Screening volumes. This was offset by the removal of the ICU 2016/17 budget uplift of 1.4 FTE senior nurses for Outreach $26k, Radiology over-recruitment of registered nurses 1.4 FTE $33k to be offset by Sonographer vacancies until December 2017, and savings targets of $68k. ESC YTD variance was driven by Theatres casual costs $8k, ESC Outpatients 2016/17 uplift unbudgeted cost commitment $10k, which was offset by vacancies in wards. 3.1 Allied Health ($99k favourable YTD) YTD favourable variance for Allied Health was attributed to churn savings through vacancies in Radiology $114k, Anaesthetic Technicians $38k, Surgical Pathology $17k, Bowel Screening $20k, offset by savings target of ($87k) and Surgical Services overspend ($4k). Support and Management/Administration ($199k favourable YTD YTD favourable variances for Management/Administration was attributed to churn savings through vacancies in Radiology $44k, Surgical Services $19k, Surgical Wards $10k and Bowel Screening $31k. Outsourced Personnel ($9k favourable YTD) YTD favourable variance was driven by outsourced Medical underspend for Bowel Screening $25k, Surgical Services $43k, offset by external agency costs for Surgical wards ($15k) and Theatres ($24k), Surgical Services ($13k) and Bowel Screening administrative services cost (6k). Other Expenditure ($701k unfavourable for September and $1,843k unfavourable YTD) Outsourced Services ($662k unfavourable YTD) YTD unfavourable variances were attributed to outsourced Radiology procedures, Ultrasound ($297k), MRI ($206k), CT scans ($201k), offset by other Radiology services cost of $10k and ESC outsourced hook wire procedures $37k. Clinical Supplies ($24k favourable YTD) YTD favourable variance was driven by ESC lower package of care volumes impacting favourably on clinical supplies cost by $315k, hip prostheses cost in S&A theatres due to lower joints volume $108k, offset by overspend in Surgical Pathology for testing kits ($47k), repairs and maintenance cost for theatres ($49k), Gastro scope repairs ($64k), S&A theatre cost increase due to significant increase in non-joint volumes, 81 above planned contributing to cost increase for implants and prostheses cost ($165k), shunts and stents ($18k), spinal plates and screws ($17k), grafts ($24k) and pharmaceuticals ($17k). Infrastructure and Non-Clinical Supplies ($1,204k unfavourable YTD) The unfavourable variance was driven by unmet savings targets of $1,309k, offset by laundry cost savings of $31k. ESC also delivered savings on laundry cost of $54k, $9k on compliance cost and $6k on other operating expenses. Getting back on track initiatives Costs are being tightly managed, with on-going focus on tactical activities to reduce annual leave and sick leave, as well as managing overtime. Christmas closure plans are being finalised to ensure opportunities are maximised for staff to take leave by extending the ESC closure by an additional week, as well as early closure of lists at Waitakere Hospital. Opportunities to bring in external work to Waitakere Hospital theatres, is also being investigated. A portfolio of cost reduction, and longer-term strategic efficiency optimisation opportunities have also been identified, and are being monitored as part of an overall Waitemata DHB Financial Sustainability programme. These are currently being reviewed to identify the nature and timing of the business benefits, as well as the resources required to deliver the programs of work associated with their delivery. Some of these opportunities include the following: 71

75 Procurement and supply chain reviews. Improved surgical clinical pathways for the management of appendicitis, cholecysistis and abscesses to reduce length of stay. Improved utilisation of the internal registered nursing bureau, reducing reliance on external agencies. Improved practices regarding negative pressure wound care. Model of care improvements by implementing electronic elective theatre bookings driving improved list management and theatre utilisation. Electronic rostering system for Anaesthesia SMOs, driving improved utilisation of SMOs time and leave management. Improved management of out-patient flow, driving improved demand management and patient experience. Improved processes for monitoring Inter District Flow patient inflow and reduction of patient bed days

76 Surgical and Ambulatory Services S&A STATEMENT OF FINANCIAL PERFORMANCE S&A ($000 s) Reporting Date Sep-17 MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency (0) 1,797 1, ,984 Other Income ,486 Total Revenue ,097 1, , EXPENDITURE Personnel Medical 6,935 7, ,623 16,411 (213) 63,886 Nursing 2,906 2, ,646 8, ,517 Allied Health 1,610 1, ,802 3, ,787 Support ,506 Management / Administration ,822 1, ,162 Outsourced Personnel (163) (227) (64) (602) (700) (98) (2,524) 12,291 12, ,872 30,846 (25) 124,333 Other Expenditure Outsourced Services (218) 1, (699) 2,964 Clinical Supplies 3,104 3,033 (71) 9,364 9,073 (291) 35,488 Infrastructure & Non-Clinical Supplies 504 (86) (590) 1,277 0 (1,277) (988) 4,073 3,195 (879) 12,081 9,815 (2,267) 37,464 Total Expenditure 16,364 15,787 (576) 42,953 40,661 (2,292) 161,797 Cost Net of Other Revenue (15,658) (15,126) (532) (40,856) (38,676) (2,180) (151,327) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The overall result for S&A was $532k unfavourable for September and $2,180k unfavourable for the YTD. The unfavourable variance for September was primarily driven by Radiology outsourced costs $257k and unmet savings targets of $598k, offset by churn savings through vacancies in medical personnel of $188k, Allied Health $59k and management/administration vacancies $67k. Revenue ($44k favourable for September, $112k favourable YTD) The favourable result for September was driven by higher than budgeted ACC revenue $47k, General Surgery recharge revenue from Auckland DHB for clinical supplies $17k (unbudgeted revenue offset by unbudgeted cost), offset by a reduction in recharge revenue for Waitakere theatres for Botox $24k. The favourable YTD variance was driven by Auckland DHB revenue for Radiology services $43k, ICU research nurse cost reimbursement $21k, Orthopaedics ACC revenue $37k, offset by a reduction in revenue for General surgery under review $15k, Anaesthesia revenue for The Royal Australasian College of Medical Administrators and research $27k unbudgeted revenue to offset unbudgeted personnel cost. 73

77 Expenditure ($576k unfavourable for September, $2,292k unfavourable YTD) Personnel ($25k unfavourable YTD) Medical ($213k unfavourable YTD) The YTD unfavourable variance for medical personnel was driven by Anaesthesia MOSS unbudgeted cost commitment from 2016/17 uplift $25k, General Surgery House officer skill mix variance of $47k, Surgical Pathology SMO unbudgeted cost commitment from 2016/17 uplift $13k and unmet savings targets of $224k, offset by churn savings in Radiology SMO $37k and Bowel Screening $52k. 3.1 Nursing ($27k favourable YTD) The YTD favourable variance for nursing personnel was driven by churn savings through vacancies in Theatres $44k, Surgical Services $42k, Surgical Wards $54k and Bowel Screening $14k due to unfilled vacancies driven by reduction in Bowel Screening volumes, offset by unbudgeted cost commitments for ICU Outreach 2016/17 uplift for 1.4 FTE senior nurses $26k, Radiology - recruitment of 1.4 FTE registered nurses $33k cost, to be offset by Sonographer vacancies until December 2017, as well as savings targets of $68k. Allied Health Support ($98k favourable YTD) YTD favourable variance for Allied Health personnel was driven by churn savings through vacancies in Radiology $114k, Anaesthetic Technicians $38k, Surgical Pathology $17k, Bowel Screening $20k, offset by savings targets of $87k and Surgical Services overspend. Support and Management/Administration ($160k favourable YTD) YTD favourable variance for Management/Administration personnel was driven by churn savings through vacancies in Radiology $44k, Surgical Services $19k, Surgical Wards $10k and Bowel Screening $31k. Outsourced Personnel ($98k unfavourable YTD) YTD unfavourable variance was driven by outsourced Medical cost underspend for Bowel Screening $25k and Surgical Services $43k, offset by lower than planned package of care volumes $113k, external agency costs for wards $15k and theatres $24k, Surgical Services $13k and Bowel Screening administrative services cost. Other Expenditure ($879k unfavourable for September, $2,267k unfavourable YTD) Outsourced Services ($699k unfavourable YTD) The YTD unfavourable variance was driven by outsourced Radiology procedures, Ultrasound scans $297k, MRI $206k, CT scans $201k, offset by other favourable Radiology services costs of $10k. Clinical Supplies ($291 unfavourable YTD) YTD unfavourable variance was driven by overspend in Surgical Pathology for testing kits $47k; repairs and maintenance cost for theatres $49k; Gastro scope repairs $64k; Theatres cost increase is due to significant increase in non-joint volumes than planned impacting on implants and prostheses cost for S&A theatres $165k, shunts and stents $18k, spinal plates and screws $17k, grafts $24k and pharmaceuticals $17k, offset by hip prostheses cost in S&A theatres due to lower than planned joint volumes $108k. Infrastructure and Non-Clinical Supplies ($1,277k unfavourable YTD) Unfavourable variances for September were attributed to unmet savings targets of $552k, Accreditation costs for Radiology $26k and compliance cost for CSSD $18k, offset by laundry cost savings of $4k. YTD unfavourable variances were attributed to unmet savings obligations of $1,309k, offset by laundry cost savings of $31k. 74

78 Elective Surgery Centre (ESC) STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Sep-17 ESC ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency (0) Other Income Total Revenue (0) 3.1 EXPENDITURE Personnel Medical Nursing (5) 1,445 1,431 (14) 6,248 Allied Health Support Management / Administration Outsourced Personnel ,629 2, ,203 1,405 1, ,149 4, ,918 Other Expenditure Outsourced Services Clinical Supplies ,390 2, ,076 Infrastructure & Non-Clinical Supplies , ,606 3, ,376 Total Expenditure 2,216 2, ,755 7, ,293 Cost Net of Other Revenue (2,208) (2,426) 218 (6,736) (7,318) 582 (28,293) * Government and Crow n Agency : Includes MoH direct revenue, ACC and CTA revenue. Excludes PBFF revenue. Comment on major financial variances The YTD favourable variance for ESC were attributed to $10k unbudgeted ACC revenue, churn savings through vacancies for management/administration $39k, medical personnel outsourced cost savings of $112k and clinical supplies cost savings of $315 due to lower than planned package of care volumes, reduction in outsourced hookwire procedures $36k and reduction in laundry costs of $70k. Revenue ($8k favourable for September and $10k favourable YTD) The favourable result for September and YTD were attributed to unbudgeted ACC revenue, offsetting unbudgeted cost. Expenditure ($210k favourable for September and $563k favourable YTD) Personnel ($139k favourable YTD) Medical ($7k favourable YTD) The favourable variances were attributed to churn savings through vacancies $7k YTD. Nursing ($14k unfavourable YTD) The unfavourable variance is attributed to over recruitment of ESC Outpatients nursing personnel $14k YTD. 75

79 Support and Management/Administration ($40 favourable YTD) The favourable variance is attributed to the incorrect cost centre allocation of S&A administration costs, which needs to be corrected. 3.1 Outsourced Personnel ($107k favourable YTD) The favourable variance of $14 is attributed to lower than planned package of care volumes for the month, and $112k YTD. Other Expenditure ($178k favourable for September, $424k favourable YTD) Outsourced Services ($36k favourable YTD) The favourable variance is attributed to reduced volumes in outsourced hookwire procedures. Clinical Supplies ($315k favourable YTD) The YTD favourable variance was driven by lower than planned package of care volumes resulting in lower than planned spend in treatment disposables $66k, implants and prostheses $210k, instruments and equipment $23k, diagnostic supplies $6k and patient appliances $5k. Infrastructure and Non-Clinical Supplies ($73k favourable YTD) The YTD favourable variance was driven by lower than planned spend on laundry cost of $54k, $9k on compliance cost and $6k on other operating expenses. 76

80

81 3.2 Provider Arm Performance Summary Report October 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 October Table of Contents Glossary How to interpret the scorecards Provider Arm Performance Report October 2017 Executive Summary / Overview Scorecard All services Health Targets Elective Performance Indicators Financial Performance 77

82 Glossary 3.2 ESPI - Elective Services Performance Indicators WIES - Weighted Inlier Equivalent Separations YTD - Year To Date 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 description Traffic light Trend indicator Actual Target Trend Better help for smokers to quit - hospitalised 98% 95% 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 % achieved 0.1 5% away from target Substantially Achieved % away from target AND Not achieved, but progress %*achieved improvement from last month made % away from target, AND no <94.9% achieved 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 Current > Previous month (or reporting period) performance Improvement 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: Key notes 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. 78

83 Scorecard All services 3.2 Health Targets Waitemata DHB Monthly Performance Scorecard ALL Services October /18 Service Delivery Actual Target Trend Elective Volumes Actual Target Trend Shorter Waits in ED 97% 95% Provider Arm - Overall 99% 100% Faster cancer treatment (62 days) 94% 90% Waiting Times ESPI 2 - % patients waiting > 4 months for FSA Compliant Best Care ESPI 5 - % patients not treated w/n 4 months Compliant ESPI 1 - OP Referrals processed w/n 10 days Compliant Patient Experience Actual Target Trend Complaint Average Response Time 17 days <14 days Patient Flow Net Promoter Score FFT Average Length of Stay - Electives 1.74 days 1.59 days Average Length of Stay - Acutes 2.52 days 2.25 days Improving Outcomes Outpatient DNA rate (FSA + FUs) - Total 8% <10% Better help for smokers to quit - hospitalised 99% 95% Outpatient DNA rate (FSA + FUs) - Māori 19% <10% Outpatient DNA rate (FSA + FUs) - Pacific 21% <10% Quality & Safety Trend Older patients assessed for falling risk 97% 90% Rate of falls with major harm 0 <2 Good hand hygiene practice 88% 80% Financial Result (YTD) Value for Money Actual Target Trend S. aureus infection rate 0 <0.2 Revenue 304,911 k 295,408 k Occasions insertion bundle used 100% 95% Expense 310,052 k 294,733 k Pressure injuries grade 3&4 0 0 Net Surplus/Deficit -5,140 k 675 k Capital Expenditure (% Annual budget) 81% HR/Staff Experience Trend Sick leave rate 3.3% <3.6% Contracts (YTD) Turnover rate - external 12% 8-12% Elective WIES Volumes 6,428 6,419 Acute WIES Volumes 22,505 20,912 How to to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track Performance declined compared to previous month Performance was maintained Key notes 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-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 question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB 79

84 Health Targets Faster Cancer Treatment 3.2 Shorter Stays in Emergency Departments 80

85 Emergency Department/ ADU Presentations 3.2 Improved Access to Elective Surgery Note: Changes were made to the electives health target for 2015/2016 Percentage Change ED and Elective Volumes % Change % Change October 2017 Month Volumes YTD Volumes (last year) (last year) ED/ADU Volumes 10,833 3% 43,964 6% Elective Volumes % % 81

86 Elective Performance Indicators Zero patients waiting over four months Summary (October 2017) Speciality Non Compliance % ESPI2 0.26% ESPI5 0.17% 3.2 ESPI ESPI Compliant Non Compliant ESPI 2 Anaesthesiology % Cardiology % Dermatology % Diabetes % Endocrinology % Gastro-Enterology % General Medicine % General Surgery 1, % Gynaecology % Haematology % Infectious Diseases % Neurovascular % Orthopaedic 1, % Otorhinolaryngology 1, % Paediatric MED % Renal Medicine % Respiratory Medicine % Rheumatology % Urology % Total 10, % ESPI 5 Cardiology % General Surgery % Gynaecology % Orthopaedic % Otorhinolaryngology % Urology % Total 2, % 82

87 90% of outpatient referrals acknowledged and processed within 10 days ESPI 1 (October 17) Specialty Compliance % Anaesthesiology 98.18% Cardiology 99.64% Dermatology % Diabetes % Endocrinology 99.54% Gastro-Enterology 99.34% General Medicine % General Surgery 98.12% Gynaecology % Haematology % Infectious Diseases 98.36% Neurovascular % Orthopaedic 99.44% Otorhinolaryngology 98.33% Paediatric MED % Renal Medicine 99.10% Respiratory Medicine % Rheumatology 99.32% Urology 99.66% Total 99.30% ESPI 1 ESPI 2 ESPI 5 Legend Green if 100%, Yellow if between 90% and 99.9%, and Red if 90% or less. 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. 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

88 Financial Performance STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Oct-17 Provider ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE * Government and Crown Agency 74,612 71,441 3, , ,799 8, ,524 Other Income 2,535 2, ,025 9,609 1,416 31,357 Total Revenue 77,147 73,861 3, , ,408 9, , EXPENDITURE Personnel Medical 15,453 15,120 (334) 58,816 58,296 (520) 181,197 Nursing 19,820 19,476 (344) 78,677 78,545 (132) 239,188 Allied Health 9,584 10, ,536 39,695 2, ,926 Support 1,677 1, ,236 6, ,785 Management / Administration 6,065 5,645 (420) 22,955 22,359 (596) 67,227 Outsourced Personnel 1,338 1,030 (309) 5,385 4,426 (959) 12,735 53,937 53,053 (884) 209, , ,058 Other Expenditure Outsourced Services 4,319 3,881 (438) 17,229 15,834 (1,395) 46,854 Clinical Supplies 10,554 9,524 (1,030) 41,741 39,324 (2,417) 115,907 Infrastructure & Non-Clinical Supplies 10,215 7,481 (2,734) 41,479 29,747 (11,731) 88,704 25,088 20,886 (4,203) 100,448 84,904 (15,543) 251,466 Total Expenditure 79,026 73,938 (5,087) 310, ,733 (15,318) 888,524 Cost Net of Other Revenue (1,879) (77) (1,802) (5,140) 675 (5,815) (643) STATEMENT OF FINANCIAL PERFORMANCE Reporting Date Oct-17 Provider ($000 s) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget CONTRIBUTION Surgical and Ambulatory (13,009) (12,368) (641) (53,865) (51,044) (2,822) (152,834) Acute and Emergency (11,040) (10,715) (325) (44,902) (44,307) (595) (138,944) Sub Specialty Med and HOPS (6,618) (6,085) (533) (27,995) (26,743) (1,252) (80,159) Child Women and Family (6,060) (6,324) 265 (27,647) (28,534) 887 (85,198) Specialist Mental Health and Addiction (9,598) (9,785) 187 (39,909) (40,772) 863 (126,561) Elective Surgery Centre (2,302) (2,207) (95) (9,038) (9,525) 487 (28,294) Provider Support 46,748 47,406 (659) 198, ,599 (3,382) 611,348 Net Surplus/Deficit (1,879) (77) (1,802) (5,140) 675 (5,815) (643) Comment on major financial variances The Provider result was $5.815m unfavourable to budget for the YTD to October The key variances are described below. Surgical and Ambulatory Services Surgical and Ambulatory Services was unfavourable by $2.822m YTD. Continued reliance on unbudgeted outsourced radiology services as a result of unfilled vacancies and capacity pressures, as well as unmet savings remains the key drivers for the unfavourable variance. Unfavourable repairs and maintenance costs, together with an increase in laparoscopic cases, spines, implants and prosthesis (non-joints) have also contributed to the 84

89 unfavourable variance. This has been partially offset by favourable variances driven by vacancies in medical, allied health, management and admin personnel, unbudgeted ACC revenue and other revenue. 3.2 Acute and Emergency Medicine Acute and Emergency Medicine was unfavourable by $595k YTD. The volume of Acute Non Inter District Flow WIES is 749 above contract YTD. In addition the volume of Acute Inter District Flow WIES is 567 above contract YTD. The unfavourable result was driven predominantly by the cost of Registrars where pricing variations, additional allocations and allowances have contributed to an overspend of $761k. Savings targets embedded within the budget total $280k YTD. Key factors that have mitigated the Registrar impact were vacancies within Senior Medical Officers contributing $285k and efficiencies within the infrastructure and non-clinical supply costs of $117k. Sub Specialty Medicine and HOPS Sub Specialty Medicine and HOPS was unfavourable by $1,252k YTD. The result is driven predominantly by unbudgeted outsourced gastroscopy and colonoscopy procedures costing $1,022k and an additional spend of $343k on high level community care for complex needs patients within the Mental Health of Older Adults service. Vacancies within Allied Health have had a favourable impact of $593k, absorbing a majority of the embedded savings targets. Specialist Mental Health and Addiction Services Specialist Mental Health and Addiction Services was favourable by $863k YTD. This was primarily driven by favourable variances in personnel. The personnel variance of $919k YTD was driven by a large number of vacancies in nursing partially offset by casual staff and overtime cover. There are also vacancies in medical which is offset by locum cover. Other direct costs are unfavourable by $60k YTD. This is mainly due to overspend in pharmaceuticals and in line with historical levels of spending. Child Women and Family Services Child, Women and Family service was favourable by $887k YTD. Ongoing service vacancies across Allied Health specialties, Community Nursing and Management/Administration remain the primary drivers of the favourable YTD result. The service continues to actively recruit to clinical positions but is still being hindered by regional or national workforce shortages across Midwives and Paediatric Physiotherapists. The Regional Dental Service is focused on maximising its recruitment of Dental Therapy staff when new graduates become available early in February/March 2018 and Midwifery services continue to manage their service delivery through skill mix changes (employment of Registered Nurses) and part time staff increasing their working hours. Embedded efficiency savings are being met predominately through vacancies. Service output activity has remained positive overall with Gynaecology acute activity 106%, Gynaecology electives at 84%, Maternity Inpatient acute 119% and Paediatric Inpatient acute 127%. Elective Surgery Centre The service was favourable by $487k YTD. The favourable result is being driven by slightly favourable personnel costs, lower than budgeted outsourced services and clinical supplies costs associated with lower complexity cases. A higher mix of non-joint volumes compared to joints is also contributing to the favourable variance. Provider Support Services Provider Support was unfavourable by $3.382m YTD. The Corporate and Support Services includes centrally budgeted efficiencies which are the major contributor to the unfavourable variance. Provider Support has a number of efficiency initiatives that are focused on areas of improvement including cost effectiveness, cost containment, productivity, process improvements and service reconfigurations. In addition Corporate Services is undertaking a number of efficiency projects relating to procurement and supply chain and treasury management. Hospital Operations was unfavourable by $1,111k YTD. This was primarily due to unfavourable activity related non-pay costs. This included the cost of pharmaceuticals and patient meals which were unfavourable due to a 2.5% unbudgeted increase in price for indexation per the terms of the contract plus a further 5.5% uplift in price due to lower than anticipated number of DHBs participating in the national Food Services Agreement. 85

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91 Clinical Leaders Report Recommendation: That the report be received. Prepared by: Dr Andrew Brant (Chief Medical 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 SMOs Dr Diana Ackerman has joined us as the new Clinical Director of Gynaecology. She is an obstetriciangynaecologist with extensive clinical experience from the west coast of the United States. She has a Bachelor of Arts in Women s Studies from Yale University and completed her medical degree at the University of California, Irvine. She completed her residency at the University of Washington in Prior to coming to Waitemata DHB, she worked in specialty private practice and was a member of the leadership team. She also served as the chairperson of the obstetrics and gynaecology department at St Charles Medical Centre in Bend, Oregon. In this role, she helped develop quality indicators for both obstetrics and gynaecology. She had previously served on the board for Saving Grace (a community based non profit organization) which provided services for victims of intimate partner violence and/or sexual assault. Diana is committed to the health of women across their life spans. She has special interests in high risk obstetrics and laparoscopic surgery. Mr Ian Stewart has been awarded the 2017 Royal Australasian College of Surgeons supervisor and clinical assessor of the year for New Zealand. It recognises an exceptional contribution toward supporting surgical trainees. It is part of his efforts why the Waitemata DHB general surgical department is one of the top choices for senior trainees in New Zealand Clinical Education and Training Unit All the first year house surgeons (PGY1) have completed their requirements for their first year of training via the eport. This is of great credit to Ian Wallace (Clinical Director of training and education of clinical supervisors). The educational programme and training experience has been very well received by the first year house surgeons. The new cohort of PGY1 start at the end of November, and the majority of the medicine trainee interns with us at Waitemata DHB have elected to stay at Waitemata DHB for the PGY1 year, we believe partly as a result of a bridging programme we have put in pace. A new orientation programme in November is now introducing a buddy system during the week so the new doctors get familiar with the team prior to starting their attachment. This initiative is in response to feedback from previous orientations. The work of the Clinical Education and Training Unit (CETU) has been presented at a number of conferences this year, as both posters and oral presentations. Of note the presentations at the Medical Education Conference in Singapore were recognised with first and first runner up prizes in the best presentation competition, as well as all posters rating as finalists in the poster competition. The team 86

92 4.1 has worked closely to develop high quality, learner focused programmes that develop our early career medical workforce as they deliver best care for everyone at Waitemata DHB. SingHealth Duke NUS Medical Education Conference, Singapore 29 and 30 September Poster Enhancing medical education through online portal. Poster Creating learning opportunities for post graduate year two House Officers within Waitemata DHB; a programme co design poster. Poster Trainee Intern Ward Call Teaching A Transition Initiative. All posters were finalists in the poster competition. Presentation Avril Lee Pharmacy coaching for international medical graduate doctors; a new paradigm in orientation. Won the first prize for best presentation. Presentation Avril Lee and Dr Vani Chandran Medication Safety Option: Inter Professional Program to Improve Junior Medical Staff Transition. Won first runner up for best presentation. Australia and New Zealand Prevocational Medical Education Forum, Brisbane November Presentation Dr Leah Pointon Creating learning opportunities for post graduate year two House Officers within Waitemata DHB; a programme co design. Presentation Dr Vani Chandran Trainee Intern Ward Call Teaching: A transition initiative. Poster Naomi Heap and Dr Vani Chandran Waitemata DHB Medical Education Pipeline. Presentation Naomi Heap Enhancing medical education through online portal. International Association for Medical Education, Helsinki August Poster Dr Ian Wallace Creating learning opportunities for post graduate year 2 House Officers within Waitemata DHB; a programme co design poster. Australia New Zealand Association for Health Professional Educators, Adelaide July Poster Avril Lee Pharmacy coaching for international medical graduate doctors; a new paradigm in orientation. New Zealand Hospital Pharmacist Association Conference, Whenua Pupuke September Poster Avril Lee Pharmacy coaching for international medical graduate doctors; a new paradigm in orientation. Presentation Medication Safety Option: Inter Professional program to improve junior medical staff transition. Presentation Pharmacy coaching for international medical graduate doctors; a new paradigm in orientation. 87

93 4.1 Research We have awarded the 2017 Waitemata DHB contestable research grants for Daniel Chang received the project grant of $20,000 for looking into risk factors and mechanisms for the development of persistent pain after breast cancer surgery. Joanna Hikaka was awarded the small project grant of $10,000 for medicine optimisation for Kaumatua understanding the needs of kaumatua in relation to medicines optimisation services and well being. Richard Martin was awarded the summer studentship of $5,000 for analysis of the GP scheme to manage skin cancer referrals. Nursing and Midwifery Nurses, Midwives and Health Care Assistants account for 43% of the total DHB workforce. Professional Development and Recognition Programme [PDRP] for Nurses and Quality Leadership Programme [QLP] for Midwives The PDRP and QLP is a key professional framework that ensures that we select the best people, support their development, recognise their practice contribution and assure the quality of their practice. Part of this framework allows for recognition at expert level and presentation of a significant portfolio which is assessed by a Panel. The Panel meets twice annually [April, October] and in October 27 nurses applied. Excellent evidence was presented and we are proud of the 143 front line nurses and midwives that are now recognised at Level 4. Workforce Development Waitemata DHB has a strong commitment to support new graduate nurses and midwives through a structured first year of practice programme. These new employees work in general health, primary care, mental health and midwifery. There has been a continous increase in numbers of new graduates employed [see table below] with three cohorts employed [February 109, May 16 and September 52]. In the 2017 calender year we will have supported 181 beginning practitioners. 88

94 4.1 The mental health programme graduated 25 nurses on 10 November from their 10 month programme. It was a happy event with great energy and celebration. Mental Health graduation November nurses with the Nurse Educator Clinical Effectiveness and Patient Outcomes Waitemata DHB implemented the Patient and Whanau Centred Care Standards programme in 2014 in order to provide assurance of clinical effectiveness, focus on improved quality and patient outcomes. The 43 inpatient wards/units have continued to participate in six monthly audits of the nine essential standards, with the Charge Nurse/Midwife Managers and their teams working hard to achieve the expectations and celebrate the results with their teams. The November December audit is currently underway again. There has been consistent improvement in results over time from 80.5% to 88.2% in general heath wards/units. Mental Health has achieved 84.4%. 89

95 4.1 There has been an increase in the number of wards/units achieving gold status recognising the focus on improvement and team engagement. PWCCS Platinum status. Two areas have achieved four gold status results in the nine standards and were eligible in October to apply for accreditation at Platinum status in the Inter disciplinary Leadership standard [standard 10]. Both areas Intensive Care/High Dependency and Lakeview Cardiology were successful in meeting the accreditation standards and are being celebrated for their achievement this month. Emergency Systems Planning Work continues to update service contingency plans. These are also updated after each incident to ensure learning and readiness. Focus in the past few months has been on the security issues, pager transition, IT i.pm outage, potential for a cyberattack and unit fire sprinkler activation and recovery. There is also work underway to review the DHB influenza plan in anticipation of next winter. Waitemata DHB is hosting a northern region health table top on 14 November to update the health pandemic plan and response capability. The Ministry has issued an updated pandemic framework and the northern region needs to align the regional response plan. There is continued work regionally with Residential Aged Care and Primary Health Care to ensure increased awareness and preparedness with emergency systems and also working with Auckland Council Emergency Management on priority inter agency readiness and response issues. 90

96 4.1 Allied Health, Scientific and Technical Professions Everyone Matters, With Compassion, Connected and Better, Best, Brilliant Friends and Family Test Allied Health October 2017 Some of the comments received in October 2017 include: Because having things explained I am more aware how to help myself remain healthy. There was a lot to learn about the health issues I am facing and I found the class very helpful. Very friendly and caring. Friendly Listen Results are good. Proficient, Professional, Knowledgeable and friendly. Friendly and caring staff. Really enjoyed the experience and feel so much better with the physiotherapy sessions. Will miss the team. Amazing service... Jess Draper is the most understanding and caring OT, she has really supported us as a family and has taken great care of our boy. Appointment of the Older Adult and Vulnerable Adult (OAVA) Abuse Prevention Coordinator I am pleased to announce the appointment of Petra Fowler to the role of Older Adult and Vulnerable Adult (OAVA) Abuse Prevention Coordinator Waitemata DHB. Petra started in the 0.60 FTE role on the 23 October Petra comes to this new and exciting role with over twenty year s social work experience across multiple sectors including working with refugees, paediatrics, Barnardos, Heart and Lung Transplant Team at Auckland City Hospital, Community Health Waitemata DHB and most recently our new Early Discharge and Rehabilitation Service (EDARS). The purpose of the OAVA Abuse Prevention Coordinator role is to facilitate best practice at Waitemata DHB with a focus on the prevention, identification and management of vulnerable adult abuse issues. Aspects of the role include triaging referrals, facilitating response groups, and supporting employees to achieve a high standard of practice in relation to vulnerable adults under the Crimes Act Amendment (2011). Better, Best, Brilliant Showcasing Waitemata DHB Allied Health We have had a busy six weeks with Waitemata DHB allied health quality improvement projects being presented at a number of national and international forums resulting in a number of ongoing conversations with other DHBs and Australian health providers who are very interested in the work we 91

97 4.1 have done. Alongside the above events we have hosted two very successful events from our new clinical skills centre, Whenua Pupuke, with both local and national participation. Some of these events are highlighted below: Health Round Table Meeting Allied Health Chapter October 2017 (Adelaide, Australia) The Allied Health Round Table Chapter Meeting is consistently the most strongly attending chapter meeting within the Health Round Table. This year the number of attendees grew again, reaching 107 registered attendees from 39 health providers across New Zealand and Australia. Amanda Bishop (Allied Health Quality Improvement Lead) presented an over view of our current project Occupational therapy home visits: A virtual approach, reviewing how we undertake occupational therapy home visits from an inpatient setting. Occupational Therapists complete home visits for a select number of patients prior to discharge home for a range of clinical reasons. Home visits are time intensive and removes the occupational therapist from the ward reducing their availability to see other patients. There has been an emerging trend in using technology as a means to increase efficiency and effectiveness of the occupational therapists in a variety of settings. We are trialling a range of options (no home visit, environmental questionnaire and videos / photographs, Therapy Assistant home visit (without patient), no home visit by Occupational Therapist/video call family, Therapy Assistant home visit with patient, Occupational Therapist home visit) utilising technology (e forms, photos, videos and skype/face time) with families to reduce the number of home visits while continuing to provide best care for the patient and family pre discharge. Amanda Bishop (Allied Health Quality Improvement Lead) Health Informatics New Zealand Annual Conference 1 3 November 2017 (Rotorua) The Health Informatics New Zealand (HiNZ) Annual Conference is the largest digital health event in New Zealand with 800+ registered delegates this year. Attendees at the conference range across multiple fields including clinicians, Chief Information Officers, Directors of Allied Health and Nursing, vendors, service users, private health providers, not for profit organisations, quality improvement leads and many more. We presented two posters alongside our I 3 colleagues who also presented a number of verbal presentations. The first, an expanded view of the Occupational therapy home visits: A virtual approach project and the second focusing on our raising the visibility of the availability of Allied Health in the impatient adult setting on a daily basis via an Allied Health Capacity at a Glance screen. The Allied Health workforce is department based and is therefore not managed or allocated to a specific ward. Clinicians communicate workload via meetings and cell phones as required with a view to 92

98 4.1 reallocating resources according to patient clinical need and priorities. There is no transparency of Allied Health staffing capacity on each ward to nursing and medical teams on any given day. Changes in capacity may result from sick leave, annual leave or vacancies within the team. Allied Health Team Leaders correspond with Charge Nurse Managers if there are specific staffing shortages. The benefits of having availability of staffing in one place that is accessible from multiple places includes the ability to have a consistent and transparent approach to managing workload, a defined variance response management plan to provide the best Allied Health service within staffing capacity across the inpatient wards, and to enable a connection between the Allied Health team and the inpatient wards to streamline and integrate the service provided. 93

99 4.1 Regional Occupational Therapy Symposium 4 October 2017 (Waitemata DHB) The Regional Occupational Therapy Symposium was hosted by Waitemata DHB and held at Whenua Pupuke in October 2017 with 80 people attending in person from Waitemata, Counties Manukau and Auckland DHBs along with several students. More excitingly, the symposium was able to be made accessible outside the region via video conference to 15 remote sites from Kaitaia to Timaru! We would like to acknowledge and thank Charlie Aitken for supporting us in optimising the reach of the symposium outside of the DHB. Six Waitemata DHB clinicians presented: Michelle Lummis Occupational Therapy Clinical Coach Role Ellen Smith and Tane Dikstaal Smith Early Discharge and Rehabilitation Service (EDARS) Occupational Therapy role after one year Sonya Wilson Clinical Reasoning in Fast Paced Settings Amanda Bishop The digital age of occupational therapy home visits Michael Parker Short Project Summary, e Whiteboard and occupational therapy referrals Family Centred Tube Feed to Weaning Management Symposium 26 October 2017 (Waitemata DHB) Current work being undertaken on a Tube Feeding Management Pathway by the Child Health and Women s Health teams, in conjunction with the I 3 team, culminated in a Waitemata DHB led Symposium entitled Family Centred Tube Feeding to Weaning Management. Elizabeth Maritz (Clinical leader for Paediatric Dietetics), planned the day along with a multi disciplinary team and support from I 3. The symposium provided an opportunity for: Health care professionals involved in the care of infants/children along the tube feeding journey to network Sharing of regional interventions and national initiatives Families to share their stories and experiences 94

100 4.1 The Symposium was well supported with over 200 delegates from 16 DHBs, with over 20 sites video conferencing in. Approximately 110 attended in person with the remainder participating via videoconferencing. Twenty one speakers contributed to the delivery of the programme. The highlight of the day was the sharing of videos, made by mother s to share their stories. These contained important messages to delegates, such as we felt so isolated, listen to us and we needed to meet other families in the same situation. Themes for the day were acknowledging the importance of collaborative care with families involved in the decision making process at all times, and recognising the complexity of children who require enteral feeding. A co design project continues with support from I 3, to develop a family centred electronic pathway from point of tube insertion to weaning, identifying best practice and defining key roles at each stage. National Dietetic Renal Education Workshop 27 October 2017 (Waitemata DHB) Renal dietitians must have knowledge of renal anatomy and physiology, haematology and the impact of environment and food intake on patient outcomes. This national workshop planned and facilitated by Sharleen Nancekivell, senior renal dietitian Waitemata DHB, provided an opportunity for dietitians across New Zealand who did not specialise in renal nutrition to attend a day of up skilling and education. A group of renal dietitians across the Auckland region assisted in presenting material for the workshop. This was an excellent clinical opportunity that attracted around 50 dietitians across New Zealand to attend. Most attendees came from community, private or outpatient positions. In these services many dietitians are faced with complex nutrition cases and renal may be a component of this complexity. For many dietitians the incidence of renal complications alongside a diagnosis of Type 2 diabetes is becoming a more frequent occurrence. Having the knowledge of what to treat and what to prioritise is important clinically, as well as improving a patient s quality of life. Sessions were interactive requiring the audience to participate in case histories and apply new knowledge. We are currently reviewing feedback via post workshop surveys to test the new learning and gage the efficacy of the workshop with a view to repeating it at this time in National Wound Care Workshop 28 October 2017 (Waitakere Hospital) Co facilitated by Dietitians New Zealand and the New Zealand Wound Care Society, the theme of this workshop was Preventing Pressure Injury Blurring the Edges, the concept being that the care and treatment of pressure injuries is undertaken within a model of interdisciplinary care. The workshop focused on the many aspects of wound care including dressing options, equipment and nutrition care with approximately 100 people from multiple professions and across many services (e.g. residential aged care, NGO s and private practice facilities) across New Zealand attended. Key note speakers included Professor Marion Jones, Auckland University of Technology who opened the workshop with a presentation demonstrating how interdisciplinary care improves outcomes in pressure injury management and Michelle Barakat Johnson (District Lead Pressure Injury Prevention and Management, PHD Candidate, Lecturer in Nursing, University of Sydney) focused on pressure injury prevention, the role of nursing in the identification of risks and on going care in pressure injury. Other contributors were Anne McMahon (Moving and Handling consultant Waitemata DHB), Laura Chaston (Senior Occupational Therapist Waitemata DHB), Kaye Dennison and Desiree Lowe (Dietitians). 95

101 4.1 Allied Health Quality Improvement Lead Overview of current work plan The Allied Health Quality Improvement Lead role was implemented in August 2016 with a view to having a dedicated quality improvement focus in the Allied Health space across the DHB. Prior to this role there were often great ideas from clinicians in the quality improvement space but limited to no resource to assist the execution. Often important projects would start and not gain traction as the Allied Health clinicians leading them were required clinically. The establishment of this role is to ensure that Allied Health is firmly embedded in the quality improvement space, to promote and build capability and capacity in quality improvement across the Allied Health teams, to enable research and evaluation of the impact of quality improvement projects, to encourage innovation, and to support the Director of Allied Health Scientific and Technical Professions, Operational Leaders and/or senior clinicians to ensure the implementation of innovation and quality programmes and initiatives for which they are responsible. Since the inception of the Allied Health Quality Improvement Lead role a number of projects have been completed and the work plan is full with a range of pending projects to be initiated as current projects are closed off. Items on the work plan have been unearthed via surveys across the Allied Health teams and selected utilising the I 3 prioritisation tool and agreed by the Allied Health Clinical Governance Group. Current Work Concept Initiate Planning Execution Closure Allied Health Capacity at a Glance Board Occupational Therapy Home Visits Virtual Friends and Family Test Reporting and Feedback Allied Health Reporting Allied Health CeDSS (Clinical e Decision Support) Community Occupational Therapy Booking and Scheduling Community Physiotherapy Capacity and Demand Review Paediatric Capacity and Demand Review Social Work Supporting Transition to the Community New Graduate Program Allied Health Scientific and Technical Rental Equipment Project Centralised Equipment Process Allied Health Dashboard Scorecard Needs Assessment and Service Coordination Administration Business Case Community Booking and Scheduling Allied Health Patient Reported Outcome Measures (PROMs) 96

102 4.1 Proposed Work Concept Initiate Planning Execution Closure Child Health In Reach Model understanding the impact on the community team Quantifying non clinical time for Allied Health (skill mix) Community Snapshot understanding complexity, intensity, workloads and waiting lists across community Staffing Models in Assessment, Treatment and Rehabilitation (AT&R) North Shore and Waitakere Hospital Sites Therapy Assistant role in non complex inpatient occupational therapy 'assessments' on the wards Scorecard addition of Auckland Regional Dental Service (ARDS) to the score card Development of whanau/family care standards for the Auckland Regional Dental Service Paperless working Community Allied Health Completed Work Concept Initiate Planning Execution Closure Service Accreditation (Emergency Department/Orthopaedics) Nurse Led Referrals to Allied Health (inpatient wards) Housing for vulnerable populations and the Protection of Personal and Property Rights Act (PPP&R) Pathway Community Occupational Therapy Snapshot and Review Allied Health Scientific and Technical Action Plan Regional Allied Health Benchmarking Comp Completed Concept Initiate Phases Planning Execution Closure Developing an understanding of the required work The start of the project includes identifying the key people involved and a general understanding of what and what the work is being undertaken Processes to establish the total scope, defined objectives and develop the course of action required to attain those objectives "doing phase", change happens and outcomes are achieved All phases are completed, reference to future work and lessons learnt shared 97

103 4.2 Human Resources Report Recommendation: 4.2 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 Waitemata DHB and reports on progress with workforce plan actions. 1. Strategic Alignment Community, whanau and patient centred model of care Service integration and/or consolidation Intelligence and insight Evidence informed decision making and practice Outward focus and flexible, service orientation Operational and financial sustainability The report outlines recruitment, workforce or organisational development programmes and actions that can impact internal and external models for care. The report outlines work undertaken collaboratively across the organisation. The recruitment and ethnicity dashboards give information and insight into the impact of our recruiting processes. 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. Improvements sought in relation to policy, process or programmes will be co-designed with service users. Robust recruitment, workforce and organisational development frameworks, strategies and actions support sustainable business practises. 2. Recruitment 2.1 Recruitment Dashboard September and October 2017 September 2017 October 2017 Total number of hires 169 Hires, 195 offers accepted 160 Hires, 161 offers accepted (Headcount) Average time to hire (days) (days) Current number of vacancies by speciality we are recruiting to (FTE) Medical Nursing Allied Health Support Mgt/Admin (vacancy rate of 5.2% of total FTE) (as at 2 Oct 2017) Medical Nursing Allied Health Support Mgt/Admin (vacancy rate of 4.9% of total FTE) (as at 3 Nov 2017) 98

104 In October we have seen positive movements with a reduction in time to hire and reduced vacancy rates from September. At this time of year recruitment starts to slow down for nursing as new graduate intakes and summer arrangements are in place. The hires have stayed consistent at 160, of this 83 were in nursing. 4.2 Current hard to fill roles are: Midwives, Cleaners and Orderlies, Anaesthetic Technicians and Mental Health Registered Nurses. For these roles we have active recruitment methods and attractions strategies underway, including expressions of interest adverts, assessment centres, videos on staff experience, attending JobFest careers expos, international recruitment campaigns, billboard advertising, external sourcing agencies and using social media. We have also engaged with Work and Income to attract people wishing to start their career in health. 2.2 Time to Hire The average time to hire (YTD) for October has decreased to days since September (Table 1) and is still trending downwards overall. The average time to hire this time last year was just over 59 days so we are still progressing well year on year. Thirty-three roles took longer than 90 days, including Case Manager for Maori Mental Health that took 300 days to hire, a physiotherapist taking 261 days to hire and a Respiratory Physiologist taking 225 Days to hire. Most Senior Medical Officer (SMO) roles tend to take longer to recruit so Table 3 shows the average time to hire for SMOs which was 119 days in October. If we exclude SMOs, the average time to hire is days (Table 2). NB Time to Hire - Calculated from the time a Recruitment Requisition is approved to the time an offer is verbally accepted by a candidate Average Time to Hire (OverAll) Total Linear (Total) Table 1: Overall Average time to hire November 2015 to October

105 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec Average Time to Hire (other) Other Linear (Other) 4.2 Table 2: Average time to hire for all other roles (excluding SMOs) November 2017 to October Average Time to Hire (SMO) SMO Linear (SMO) Table 3: Average time to hire for SMOs November 2017 to October Top sources of Applications Rank/Source 1. Waitemata DHB careers and career section October 2016 October 2017 Comments 39% 36% Strongest source of candidates 2. A Friend 11% 20% Increase in friend referrals is positive 3. Waitemata DHB Intranet 11% 8% Slight decrease in internal applicants applying % 9% % 3% Table 4: Top 5 Sources of Hire for October 2017* Increase in the number of non-clinical roles we are advertising on Seek could be the reason Decrease in applicants using KHJ from last year *The above source dashboard is taken from Taleo E Recruitment system. Applicants enter where they heard about the position when they apply for a job. 2.4 Ethnicity of new employees Below are two tables detailing the ethnicities of current employees by profession (Table 5) and the ethnicities of staff recruited in the last three months, also by profession (Table 6). Analysis for the last three months shows strong recruitment in Asian, Maori and Pacific ethnicities. 100

106 Asian Pacific Maori MELAA European Other Total FTE Row Labels FTE % FTE % FTE % FTE % FTE % FTE % MEDICAL PERSONNEL % % % % % % % NURSING PERSONNEL % % % % 1, % % 2, % ALLIED HEALTH PERSONNEL % % % % % % 1, % SUPPORT PERSONNEL % % % % % % % MGT/ADMIN PERSONNEL % % % % % % % Grand Total 1, % % % % 3, % % 6, % Table 5: Ethnicity of all staff for three months as at 30 October Total % 4.2 MELAA is a group amalgamation of Middle Eastern, Latin American and African ethnicities. NB. The ethnicity criteria used is level 1 which means that NZ ethnicity is classed as Other. Asian Pacific Maori MELAA European Other Total FTE Total % Row Labels FTE % FTE % FTE % FTE % FTE % FTE % MEDICAL PERSONNEL % % % % % % % NURSING PERSONNEL % % % % % % % ALLIED HEALTH PERSONNEL % % % % % 0.0% % SUPPORT PERSONNEL % - 0.0% % % % - 0.0% % MGT/ADMIN PERSONNEL % % % % % % % Grand Total % % % % % % % Table 6: Ethnicity of staff recruited within the last three months MELAA is a group amalgamation of Middle Eastern, Latin American and African ethnicities. NB. The ethnicity criteria used is level 1 which means that NZ ethnicity is classed as Other. 101

107 3. Organisation Development Pacific Health Science Academies It has been a successful year for the Pacific Health Science Academy programme with students receiving many awards and scholarships to continue their Health Science journey. Prize giving at Waitakere College. Health Science Academy year 13 student Alapeti Tepapaaoatua receiving and Otago scholarship to study medicine in Otago. Younger cousin on his right, year 11 Health Science Academy student, Tiatia Iloni receives a Waitemata DHB scholarship as well as takes the top student award in mathematics. 102

108 4.2 Health Science Academy year 13 students Asal Aziziyan receives First Foundation scholarship $16,000 to study at medical school; Isabel Jones receives Waitakere College Foundation Scholarship $5,000 to study; Year 11 students Ashley Ahchong and Malena McCullogh-Iuta receive Waitemata DHB scholarship $ Promotion of health sciences as a building block towards a reward career in Health still continues to be important, as seen in September, when Malcolm Andrews Health Science Academy Programmes Coordinator (pictured below) spoke to interested students in applying to enter academy programmes at the 2017 NZMA Vocational Careers Expo at the Vodafone Events Centre, Manukau City, Auckland. The Health Science Academies will have completed their third year of operations at the end of this year. The Ministry of Health have renewed the contracts for another two years with minimal change to deliverables. This was the first year that we had our academy students graduate to tertiary studies next year. We look forward to many more students transitioning into tertiary studies in the coming years. 103

109 3.2 Auckland and Waitemata DHB Maori Workforce Plan Scholarship programme The Health Scholarship Programme is one of Waitemata DHB s key targeted investments in developing Maori and Pacific as priority groups in the healthcare workforce pipeline. Feedback highlights the value scholarship students get from strong connections with their DHB. 4.2 A range of critical activity continues to facilitate sustainable leadership and delivery of the programme: Hui were held in October 2017 at both North Shore and Waitakere hospital sites, enabling students and their support networks to connect with the Waitemata DHB Workforce Development team. Reciprocal relationships with Unitec have been strengthened, improving access to resources for our students and highlighting student achievement and the success of the Scholarship programme within the tertiary sector. Visits with Auckland University of Technology and University of Auckland are agreed and scheduled. At this time of year our new scholarship students are busy with examinations and those who are graduating are busy securing employment. To this end, interview skills coaching workshops are in place, enabling students transition into employment with Waitemata DHB Rangatahi Student Cadetships This summer, Waitemata DHB will again offer Rangatahi Student Cadetships for ten weeks over the 2017/18 summer break. Five part-time roles are offered to the top Rangatahi Cadets who have clearly demonstrated interest in a career as healthcare professional. The cadetship offers workplace exposure, supported by structured mentoring and coordinated networking opportunities. Recruitment is currently underway for the 2017/18 programme. There has been considerable interest and the caliber of applicants very high. The recruitment process has also effectively identified a number of candidates for the Waitemata DHB Health Scholarship Programme. Planning and preparation for the 2017/18 Cadetships has created a fruitful opportunity for Waitemata DHB and Auckland DHB to collaborate even more closely in aligning our processes. The outcome being increased consistency and an enhanced experience for cadets and their clinical placement teams JobFest 2017 Members of the Workforce Development and Kia Ora Hauora teams represented the Waitemata DHB at Jobfest 2017 in October. This event hosted annually by Auckland City Council is targeted primarily at young people, and is promoted by the Ministry of Social Development across the wider community. The Workforce Development Team capitalized on Jobfest as a forum to promote the DHB as an employer of choice, and to connect directly with job seekers, engaging the young people about their interest in, and suitability for the real job options we have here at Waitemata DHB. A number of candidates for both scholarships and Kia Ora Hauora support were identified. As a result of attending Jobfest, 21 Maori and/or Pacific young people have been engaged and enrolled in our workforce development pipelines Puhoro Counties Manukau DHB in conjunction with the Tindall Foundation have extended an invitation to both Waitemata and Auckland DHBs to participate in the Puhoro STEM Academy in

110 Puhoro is a community and industry collaboration that recognises whanau as a key driver of success for Rangatahi. The programme provides academic and programme support to increase engagement in core science subjects at upper secondary level. Puhoro has been recognised as transformative for young people at this critical stage of their lives and has achieved significant success in its pilot in the Manawatu region. Waitemata DHB has been offered funding and resource to offer the programme to 20 students in the first year. Waitemata DHB will continue to collaborate with the Auckland DHBs in the delivery of this programme throughout the region over the next six years Management Foundations Since 2011 the DHB has offered a well-regarded programme for management development. The Management Foundations programme runs once per year with 20 staff attending each programme. The programme offers 11 modules covering: Patient experience Developing people Organisational leadership and management Coaching Health and Safety Managing performance Recruitment and selection Quality Financial management Project management For the Quality module participants undertake a quality improvement project enabling them to showcase the skills learnt during the programme and demonstrate both the Waitemata DHB values as well as the commitment to innovation in practise. Improvement projects this year include: Pharmacy - Opiate Use and how we counsel patients. Dental - Project around the setting up of Saturday Clinics in Auckland Central/Glen Innes to enhance access for children and whanau Emergency Department, Nursing - Management of morphine administration and related issues Mason Clinic Unit - New processes for management of Staff Sick Leave usage Infection Prevention Control - Introducing influenza vaccination programme for patients of the Assessment, Treatment and Rehabilitation (AT&R) service. The 2018 programme is almost fully subscribed. The Waitemata DHB also offers a programme for aspiring mangers which is a programme over one year comprising six modules including Maori cultural perspectives, communicating more effectively, culture and cultural competency, performance fundamentals, conducting behavioural interviews and bullying and harassment prevention. 105

111 3.4 Business Skills As well as providing clinical and leadership training, the DHB also offers a variety of short courses on business skills. September presented the opportunity for the Organisation development team to refine programme for delivery during 2018, and the way in which we engage with our audience. Some of the short courses offered include: Leading our values Improving and managing leave Everyday coaching conversation Train the Trainer and Introduction to Adult Learning Presenting with Impact Speed reading Money week As part of the Healthy Workplaces Steering group Aim 3: Health and Wellbeing, financial wellbeing was identified as an area of interest for staff. Leveraging off Money Week a nationwide campaign from 5-11 September focusing on financial literacy, we partnered with the Waitemata DHB s new banking partner BNZ to provide information and education on financial wellbeing. We held health checks at Waitakere, Mason Centre and North Shore hospitals where over 71 staff received 1:1 feedback with a BNZ business advisor on personal areas of interest. We also hosted the BNZ economist Tony Alexander on a lively journey through the financial challenges of today. We received good feedback on the sessions over Money week and next year we, adding to the health checks will arrange education sessions on key topics such as mortgages, retirement and budgeting. 3.6 The Clinical Education Training Unit This has been a busy and rewarding time for the Clinical Education Training Unit team, their exemplary work and dedication has been recognised and rewarded on a number of fronts. These include, presenting at international and national conferences, awards and recognitions, and great feedback from learner cohorts th year formal bedside teaching Second and third year medical students receive teaching on examination technique in the Clinical Skills Resource Centre. Third year students undertake a Professional, Clinical and Communication Skills course (PCCS). This course has several components: seven weekly bedside tutorials, whole class lectures and small group activities. Students are able to practice their patient history taking skills and examination technique and also cover topics such as: generating a problem list, communication skills, death and dying, ethics and clinical reasoning. The purpose of the Clinical Methods Refresher is to ensure that: 1. Within the first two weeks of starting a medical rotation at Waitemata DHB students will be able to perform a clinical history and examination at the same level or higher that they had achieved on the original Clinical Methods course. 2. Students will maintain these clinical skills throughout their medical rotations at Waitemata DHB. 3. By the end of their general medical rotations students will be able to detect clinical pathology and be able to suggest differentials for pathology. 106

112 Table 1: feedback on 4 th year clinical methods refresher Presenter was Topic engaging Relevent Average scores from the session where 1 is strongly disagree and 6 is strongly agree was Structure supported learning Sessions meet purpose 4.2 6/6 6/6 6/6 6/6 The Trainee Interns (TIs) ward call simulation As part of on-going teaching, Trainee Interns participate in Ward Call simulations designed to: To assess a deteriorating patient using ABCDE framework To formulate differential diagnosis based on clinical information. To plan appropriate investigations. To construct appropriate plan and call for help To transfer concise information using ISBAR communication format. After several theoretical sessions, the group were put through their paces on a simulation day. The simulation sessions were run in the Moving and Handling training room and were facilitated by Leigh Edwards (Team Leader Clinical Resuscitation) and Dr Vani Chandran (Medical Education Fellow). The next session was held on the 19 October Attended by: - Six Trainee Interns (Primary and Secondary Participant) - One Nursing Student - Two 4 th Year Medical Students as observers Scenarios: 1. Chest pain scenario patient deteriorates to cardiac arrest 2. Anaphylaxis scenario Average confidence level in dealing with ward call scenario (out of 10) Prior to session 5.5 After the session

113 Useful Scenario 83.33% 4.2 Material covered was relevant 83.33% Simulation Session Feedback Increased understanding of subject 83.33% Resources used were appropriate and useful 83.33% Sesssion was clearly structured 66.67% Photo: Leigh Edwards (Team Leader for Clinical Resuscitation Services) coaches Trainee Interns through the cardiac arrest scenario. 4. Knowledge and Research 4.1 Library access The Waitemata DHB has two facilities and an online portal (EZProxy) where staff can access books, journals and articles for clinical, professional and research purposes. EZProxy enables staff to access the e-resources from outside of the Waitemata DHB. A new collection of databases have been made available to DHB staff called Health Research Premium Collection, from Proquest. As a result of this collection being purchased the Library is able to offer access to GPs and others in the Primary Care sector within Waitemata DHB. We will be making it available to GPs and Primary Care workers via the external website and are currently working on getting the Library site live. Library Statistics: September -October 2017 Items lent to our own people 625 Items lent to other libraries 50 Items borrowed from other libraries 12 Computer searches by Library staff 664 Number of searches/downloads from our on line journal collections 18, Research projects underway The research and knowledge management team continue to support a large number of audit and clinical research projects. Eighty five new projects were registered in the quarter August/September/ October 2017: By Project Type 43 Audit/Evaluation - includes Programme Implementation, Resource Develop and Innovation. 24 Observational Research. 18 Interventional Research - 2 industry sponsored. Research Publications: 2,120 publications have been notified and recorded in the database for all years. 2016: 256 publications. 2017: 163 publications. 108

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115 4.3 Quality Report (September/October 2017 Data) Recommendation: 4.3 That the report be received. Prepared by: Dr Penny Andrew (Clinical Lead, Quality) and Stacey Hurrell (Corporate Compliance Manager) Contents 1. Health Quality and Safety Markers 2. HQSC QSM Dashboard 3. DHB Quality Indicator Trends Sept/Oct Key Quality Indicators 5. Improvement Active Projects Report 6. Safe Care 7. Patient and Whānau Care Centered Care 109

116 Acronyms Acronym Definition Acronym Definition ADU Assessment and Diagnostic Unit MALT Maori Alliance Leadership Team AH Allied Health M&M Mortality and Morbidity AMS Antimicrobial Stewardship MORSim Multidisciplinary Operating Room Simulation BSI Blood Stream Infections MRO Micro Resistant Organism BAU Business As Usual MRSA Methicillin Resistant Staphlococcus aureus CAUTI Catheter Associated Urinary Tract MSU Mid Stream urine Infection CD Clinical Directors N/A Not Applicable CDI Clostridium difficile (C.difficile) NOF Neck of femur (C.diff) infection CI Confidence Interval NSH North Shore Hospital CLAB Central Line Associated Bacteraemia ORCA Orthopaedic Review Clinic and Assessment CVL Central Venous Line PDP Patient Deterioration Programme epa Electronic Prescribing and PDSA Plan Do Study Act Administration emr E Medicine Reconciliation PERSy Patient Experience Reporting System ED Emergency Department PICC Peripherally Inserted Central Catheter ELT Executive Leadership Team PIR Post Implementation Review ESC Elective Surgery Centre PROM Patient Reported Outcome Measure FY Financial Year QI Quality Improvement GP General Practitioner QSM Quality and Safety Markers HA Hospital Acquired RMO Registered Medical Officer HABSI Hospital Acquired Blood Stream RN Registered Nurse Infection HDU High Dependency Unit SAB S.aureus bacteraemia HH Hand Hygiene SAC Severity Assessment Code HOPE Health Outcomes Prediction S&A Surgical and Ambulatory Engineering HQSC Health Quality and Safety Commission SAQ Safety Attitude Questionnaire HRT Health Round Table SMO Senior Medical Officer ICU Intensive Care Unit SMT Senior Management Team IP&C Infection, Prevention and Control SSI Surgical Site Infection ISBAR Identify, Situation, Background, TBA To Be Advised Assessment, Recommendation IT Information Technology UAT User Acceptance Testing IVL Intravenous luer UTI Urinary Tract Infection LOS Length of Stay WIP Work In Progress WTK Waitakere Hospital

117 1. Health Quality and Safety Markers 4.3 The Health Quality and Safety Commission (HQSC) commenced quarterly publication of the national Quality and Safety Markers (process markers) in December 2013 (reporting Quarter 3, June September 2013 data). 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 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 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 The future timetable for Health Quality and Safety Marker reporting in 2017 is: Period covered Period covered SSI Period covered Hand Hygiene Publication date 2017 April June 2017 January March 2017 April June September 2017 July September 2017 April June 2017 July October December

118 2. Health Quality and Safety Commission QSM Dashboard Health Care Associated Infections Falls Quality Safety Markers (QSM) Hand Hygiene (HH) CLAB Surgical Site Infections % older patients assessed for falls risk % older patients assessed as significant risk of falling with an individualised care plan Target Q Q Q Q Q Q Q Q Q Last Quarter Change 90% 99% 99% 97% 98% 99% 99% 98% 95% 95% 90% 97% 95% 97% 98% 95% 96% 96% 96% 97% % of compliant HH moments 80% 80% 81% 81% 83% 85% 86% 86% 86% 87% % occasions insertion bundle used in ICU % occasions maintenance bundle used in ICU (not currently an HQSC Target) Surgical Site Infections rate per 100 procedures [target has not been set by HQSC. National Q rate 1.1 infections per 100 ops) 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% primary hip and knee replacements appropriate skin antisepsis 90% 100% 100% 99% 99% 100% 100% 99% 100% 99% 90% 97% 93% 98% 92% 97% 97% 95% 98% 91% HQSC has not defined a target % 98% 96% 92% 92% 98% 95% 94% 95% 96% 95% 94% 94% 95% 97% 96% 100% 100% 99% 100% 100% 1.2* 0.3* *Preliminary Results Waiting for HQSC data (QSM results delayed by one quarter) No longer being reported by HQSC

119 Peri Operative Care Medication Safety Quality Safety Markers Surgical Safety emr Uptake, %age of audits where all components were reviewed Engagement, %age of audits with engagement scores of 5 or higher Observations, number of observational audits carried out for each part of the surgical checklist (Minimum of 50 observations per quarter) % patients with emr completed within 24 hours on admission and discharge Target Q Q Q Q Q Q Q % 90% 99% 92% 95% Commenced from July % 86% 89% 50 Sign In Time Out Sign Out Q Data not available Data not available Q Waiting for HQSC data (QSM results delayed by one quarter) Last Quarter Change 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 113

120 Rate per 1,000 Occupied Bed Days Jan DHB Quality Indicator Trends September/October 2017 Mar 14 Jun 14 Sep 14 Dec 14 Mar 15 Jun 15 Sep 15 Dec 15 Mar 16 Jun 16 Sep 16 Dec 16 Mar 17 Jun 17 Fall Definition A fall is defined as inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change of position to rest in furniture, wall or other objects. (World Health Organisation, 2007: WHO global report on falls prevention in older age) Outcome data is based on the rate of falls with major harm (SAC 1 and 2) or with harm (SAC 1 3) per 1,000 bed days 0.25 Falls per 1,000 Occupied Bed Days Jan 2014 Oct 2017 Falls with Major Harm per 1,000 Occupied Bed Days Jan 2014 Oct 2017 Oct 17 UCL=5.740 _ X=4.393 LCL=3.046 UCL= Hospital Diagnosis Standardised Mortality Ratio (HDxSMR) (12 months (July 2016 June 2017) Waitemata s (NSH + WTH) HDxSMR = 92 Episodes = 102,101 Deaths = 792 Expected deaths = Combined HRT HDxSMR = 87 NZ HDxSMR = 105 Network HDxSMR = N/A Using the legacy HRT HSMR Methodology Waitemata s HSMR would have been 86 compared to a combined HRT HSMR of 75 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) Funnel plot of HRT HDxSMRs compared to the combined NZ HDxSMR Jul 2016 Jun 2017: HRT Waitemata = 92 (all HRT = 87; NZ HRT = 105) Y Axis = HDxSMR (0 200) + X Axis = Expected Deaths (0 1200). Rate per 100 Patients Jan 14 1 Mar 14 Jun 14 Patients with Pressure Injuries per 100 Patients Jan 2014 Oct 2017 Sep 14 Dec 14 Mar 15 Jun 15 Sep 15 Dec 15 Mar 16 Jun 16 Sep 16 Dec 16 Mar 17 Jun 17 Pressure Injury Definition A pressure injury is a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. (National Pressure Ulcer Advisory Panel, 2007). Outcome data is based on the rate of pressure injuries Grade 3 and 4 + ungradeables or total, per 100 patients 2.5 Oct 17 Stage 3, 4 & Unstageable Pressure Injuries per 100 Patients Jan 2014 Oct UCL=5.760 _ X=1.627 LCL= Rate per 1,000 Occupied Bed Days Jan 14 Mar 14 Jun 14 Sep 14 Dec 14 Mar 15 Jun 15 Sep 15 Dec 15 Mar 16 Jun 16 Sep 16 Dec 16 Mar 17 Jun 17 Oct 17 _ X= LCL=0.00 Funnel based on two standard deviations from NZ rate, adjusted for over dispersion Rate per 100 Patients Jan Mar 14 Jun 14 Sep 14 Dec 14 Mar 15 Jun 15 Sep 15 Dec 15 Mar 16 Jun 16 Sep 16 Dec 16 Mar 17 Jun 17 1 Oct 17 UCL=1.643 _ X=0.354 LCL=

121 Rate per 1,000 Occupied Bed Days Sep 14 Dec 14 Jan 14 Mar 14 Jun 14 Hospital Acquired Blood Stream Infections (HABSI) Jan 2014 Oct 2017 (IP & C Occupied Bed Days) Mar 15 Jun 15 Sep Mar 16 Jun 16 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. Typicallyy 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 targett for HABSI. Comment Overall HABSI rate for 2016 was 0..35/1,000 bed days (n=89). Dec 15 HABSI rate 2017 (January October) YTD 0.29/1,000 bed days (n=58); HABSI rate for the same time period in 2016 was 0.35/1,000 bed days. HABSI rate for: September 2017 = 0.31 October 2017 = 0.21 Quarter three 2017 = 0.18 Source Sept (n=7) CAUTI 2 Other 3 Procedure Unknown 2 Oct (n=4 ) Sep 16 Dec 16 Mar 17 Jun 1 n 17 Oct 17 UCL= _ X= LCL=0.00 Rate per 1,000 Line Days Jan 14 Mar 14 Jun 14 Sep 14 Dec 14 Ma Central Line Associated Infections (CLAB) Jan 2014 Oct Mar Jun 15 Sep Dec 15 Mar 16 Jun 16 S Dec 16 Mar 17 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 proceduree for insertion and maintaining lines (insertion and maintenance bundles of care). North Shore Hospital s ICUs compliance withh standard procedure and rates of CLAB are Health Quality and Safety Markers. Comment Rate of CLAB/1,000 line days: September 2017 = 0.86/October 2017 = 0. 85; the target for this is <1 per 1,000 line days. d ICU/HDU 306 CLAB Free days as at 31 October 2017 (* restarted as of 01/01/2017). May 17 Aug 17 Oct 17 The National target is >90% compliance for insertion and maintenance bundles use. Month Sept 2017 Oct 2017 Insertion Bundle 100% 100% Maintenance Bundle 98% 98% Ward maintenance compliance rates and CLAB free days for other areas are reported in the Quality Report 1 Sep UCL= _ X= LCL= Staph Aureus Blood Stream Infections The rate of S.aureus bacteraemiaa (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. There were no S.aureus infections for September 2017 and two identified in October One infection was related to a procedure and the other to a CLAB. Waitemata DHB s SAB rate (quarterly rate of per 1,000 bed days) is consistently well below the national average ( per 1,000 bed days) with an approximate average of one SAB per month. The SAB Rate for Quarter three (July September 2017) =

122 4. Key Quality Indicators 4.1 Hospital Acquired Blood Stream Infections (HABSI) Target Measure 0 Total # of infections 0.00 # of infections per 1,000 occupied bed days Previous Report Period 7 (September) 0.31 (September) Current Report Period 4 (October) 0.17 (October) Commentary 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 benchmarking acceptable rate or target for HABSI. Mean rates of HABSI/1,000 occupied bed days over the last three years are: Rate N= A total of 52 HABSI identified between January September 2017 in comparison to 71 HABSI for the similar time period in % (17/53) HABSI are related to devices i.e. 10 urinary catheters and seven vascular devices. Overall 13 cases of HABSI for Quarter three (July September) 2017 compared to 25 cases in Quarter one (January March) % (5/13) HABSIs in Quarter three 2017 were related to CAUTI; analysis of these cases identified that the indication of indwelling urinary catheters were appropriate. A planned audit by the Infection Prevention and Control team at the end of 2017 will be undertaken reviewing the use of Quit CAUTI prevention bundle of care, the aseptic non touch technique (ANTT) along with monitoring of indwelling catheter insertion and maintenance practice. This will assist in reinforcing the requirements to reduce incident of CAUTI. The majority of vascular device related HABSI were identified within the first two quarters of 2017 (three IVL, three PICC, one CVL). CVL and PICC line related HABSI did not identify any breaches in their insertion and maintenance bundles of care. 4.3 The 12 post procedure/surgical HABSI were attributed to various procedures with no specific trend identified. Wards with the highest attribution and device related HABSI for 2017 YTD: Ward 8 (Surgical) = Total of eight HABSI including two CLAB and two CAUTI Ward 15 (AT & R) =Total of seven HABSI including two CAUTI Muriwai Ward (AT & R) = Total of five HABSI including one CAUTI 116

123 Target Measure Previous Report Period Current Report Period Commentary 4.3 HABSI SOURCE Jan Sep Vascular device related (6 CLAB, (6 CLAB, (3 CLAB, (4 CLAB, 3 IVL) 4 IVL) 8 IVL) 11 IV) CAUTI Post procedure/ surgical Other (mostly UTI) Unknown TOTAL HABSI Analysis September 2017 September 2017 Source Total Ward Organism Comments CAUTI 2 Other 3 Unknown 2 Ward 15 Muriwai Ward ICU/HDU Muriwai Ward Titirangi Ward Ward 4 Muriwai Ward Pseudomonas aeruginosa Klebsiella pneumonia and Proteus mirabilis Citrobacter Koseri ESBL E Coli Haemophilus Influenza E Coli E faecium The indication for the palliative patient to have an indwelling catheter was clinically appropriate. The indication for this patient to have an indwelling catheter was clinically appropriate so that urine output could be closely monitored. This patient acquired hospital pneumonia. This patient developed biliary sepsis secondary to a blocked common bile duct stent; they also had a dislodgement of a percutaneous transhepatic stent. A patient developed a bacteraemia which was not identified unit the day they died from respiratory failure secondary to hospital acquired pneumonia. This patient was four days post a total nephrectomy (kidney removal); the source of the HABSI was unable to be identified. This patient has a gastrointestinal bleed; their HABSI was possibly related to a spontaneous bacterial translocation. 117

124 Target Measure Previous Report Period Current Report Period Commentary 4.3 October 2017 Source CAUTI 2 Total Ward Organism Comments Ward 6 Wainamu Ward E Coli E Coli Other 1 Ward 8 Staph aureus Unknown 1 Ward 5 Pseudomonas aeruginosa The indication for this very unwell patient to have an indwelling catheter was clinically appropriate. The indication for this patient to have an indwelling catheter following a trial removal of catheter was clinically appropriate. Patient with rectal cancer; procedure related due to perforation of the ureteric (kidney tube) wall. Prolonged surgery with complication. Neutropenic patient (low white cell count) with several co morbidities (medical conditions). 4.2 Hand Hygiene (HH) Compliance Target Measure >80% % rate of compliance with five Hand Hygiene Moments Previous Report Period 87% (September) Current Report Period 88% (October) Commentary Waitemata achieved an overall 88% HH compliance rate for Quarter (July September); the DHB has consistently exceeded the National Target of 80% since August The Hand Hygiene Report for October 2017 is attached Appendix 1. In October 2017, highest achieving clinical areas with 100% compliance: Maternity North Shore Hospital Haemodialysis Waitakere Hospital Mason Clinic Units Kahikatea, Kauri, Pohutukawa, Rata, Tane Whakapiripiri, Te Aka and Totara. Clinical areas performing below the 80% benchmark are: Wilson Centre (64%) Endoscopy North Shore Hospital (68%) Ward 4 (71%) Theatre WTH (72%) ED North Shore Hospital (73%) Ward 3 (79%) Interventional Radiology (79%) CCU North Shore Hospital (79%) 118

125 Target Measure Previous Report Period Current Report Period Commentary 4.3 Healthcare worker groups with the highest compliance are: Phlebotomy Invasive Technician (93%) Administrative and clerical staff (93%) Healthcare worker (HCW) groups performing below the 80% HH compliance are: Medical practitioners (76%) Medical Students (78%) Hand Hygiene Compliance by Percentage Waitemata DHB Hand Hygiene Compliance Aug 2016 Oct The Infection Prevention and Control Q Executive Report is attached see Appendix 2. 0 Total # of Hospital Acquired Staphylococcus aureus bacteraemia infections 0 (September) 1 (October) The rate of Staphlococcus aureus bacteraemia (SAB) infections attributed to healthcare is the national outcome measure for improved hand hygiene compliance. The SAB rate is based on HHNZ s definition to maintain consistency in DHB reporting. Therefore, it includes patients with long term vascular devices diagnosed with bacteraemia on admission or in the community leading to hospital admission. If a patient has device related SAB detected in community and is not hospitalised (unlikely), or if hospitalised in another DHB, then these infections are not captured in Waitemata DHB s data. 119

126 Target Measure 0 # of Hospital Acquired Staphylococcus aureus bacteraemia infections per 1,000 Occupied bed day Previous Report Period 0.00 (September) Current Report Period 0.04 (October) Commentary There has been no significant decrease in the healthcare associated Staphylococcus aureus bacteraemia (SAB) rate since the increase in HH compliance in Waitemata DHB s SAB rate (quarterly rate of per 1,000 bed days) is consistently well below the national average ( per 1,000 bed days) with approximately one SAB per month The below graph includes healthcare associated blood stream infections (HCA BSI) and hospital acquired blood stream infections (HABSI) Staph. aureus bacteraemia. 16 SAB (including 1 MRSA) were isolated between January and September 2017 (four HCA, 10 HA and two where source are unable to be identified) 50% (8/16) of the SAB were attributed to vascular devices (three IVL and five CLAB) Healthcare Associated S.aureus Bacteraemia ( ) Waitemata DHB rate per 1,000 bed days vs. National Rate Q Q Q Q Q Q Q Q National Rate Waitemata DHB Rate Health Care Associated BSI (HCA BSI) HCA BSI (unlike HABSI) is generally incubating at the time of admission and is therefore diagnosed within 48 hours of admission. However, they are attributable to recent healthcare contact with surgical or invasive procedures performed within 30 days of bacteraemia, or in patients with long term vascular access devices. 15 HCA BSI are from renal patients receiving inpatient and community haemodialysis Total of 22 HCA BSI occurred between January September

127 Target Measure Previous Report Period Current Report Period Commentary Source Total Ward Organism Comments CLAB 12 Haemodialysis Unit Assortment of organisms Majority of CLAB attributed to renal dialysis patients with permanent tunnel line 3 Medical/Surgical Staph. aureus Line used for patient s nutrition feed (1) Portacath inserted in Advanced Interventional Radiology and patients received chemotherapy at Auckland City Hospital (2) Post Surgical 2 Haemodialysis Unit E coli + Staph. aureus Renal outpatients permanent arterio/venous fistula Procedure 2 Ward 4 E coli + Staph. aureus Post prostate biopsy (1) Post endoscopic procedure (1) Other 1 Ward 10 Staph. aureus Readmitted following chest drain removal Unknown 1 Maternity Staph. pyogenes Unable to identify source of BSI, patients were 1 Haemodialysis Unit Staph. aureus admitted within 30 days of discharge after having had a procedure Surgical Site Infections Target Measure Previous Report Period TBA 1.5% (SSI rate Q4 Oct Dec 2016) Current Report Period 2.2% (SSI rate Q1 Jan Mar 2016) Commentary 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 The National Orthopaedic Surgery Report January to March 2017 is attached see Appendix 3. Hip and knee arthroplasties Surgical Site Infection Improvement Programme. o The national rate of Surgical Site Infections (SSIs) for Q1 (January March 2017) was 1.1% (95% CI ) ; Waitemata DHB s rate was 2.2% (CI ). The national rate over the last 12 months was 1.0% (Waitemata DHB 1.4%);and the cumulative national rate from March 2013 is 1.1%; (Waitemata DHB 1.2% (CI )) o o o Nationally for Q there were 30 SSIs, 57% were deep/organ space and 43% superficial infections; Waitemata DHB had a total of six SSIs in Q1, three deep and three superficial. The preliminary Quarter SSI rate shows a reduction to 0.3/100 operations with one deep hip SSI identified. Waitemata DHB s results for the Quality and Safety Markers show 121

128 Target Measuree Previous Report Period Current Report Period Commentary o 93% compliance with timing of antibiotic prophylaxis for all procedures (National Target 100%; 3 rd lowest DHB) o 95% compliance with correctt dosing of antibiotic prophylaxis (National Target >=95% %; 7 th lowest) o 94% compliance with correctt duration of antibiotic prophylaxis (National Target >=95%; 4 th lowest) 4.3 ACC treatment Injury claim information has been included in the national report for the first time. 122

129 Target Measure Previous Report Period Current Report Period Commentary The future dates for SSI reporting by the HQSC are: o 15 December 2017 (surveillance period April June 2017) o 31 March 2018 (surveillance period July September 2017) o 30 June 2018 (surveillance period October December 2017) o 30 September 2018 (surveillance period January March 2018) 4.3 Future IP&C planned initiatives include undertaking a MDT review of the management of orthopaedic hip and knee arthroplasties to identify additional perioperative risk factors for SSIs (e.g. wound care, drains) and opportunities for improvement; an improved real time review and feedback process after a SSI event; and expansion of surveillance procedures when the regional automated IP&C surveillance system (icnet) becomes fully functional. SSIs per 100 operations (January 2014 September 2017) Quarter Q1 Q1 Q1 Q1 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q Q2 Q3 Procedures #SSIs Waitemata s Rate National Rate TBC TBC Number of SSI per quarter by classification (January 2014 September 2017) Quarter Q1 Q1 Q1 Q1 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q Q2 Q3 Superficial hip Deep hip Superficial knee Deep knee Total SSIs

130 4.4 Central Line Associated Bacteraemias (CLAB) Target Measure Previous Report Period Current Report Period Commentary 4.3 <1 # of CLAB infections per 1,000 line days (ICU) 0.86 (September) 0.85 (October) The ICU is currently 306 days CLAB Free as at 31 October 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 September = 28/October = 16 CLAB rates at Waitemata DHB remain very low as indicated in tables below. Most wards have very long CLAB free periods due to both good compliance and infrequency of patients with central lines. >98% % bundle compliance at insertion (ICU) >98% % bundle compliance maintenance (ICU) 100% (September) 95% September) 100% (October) 100% (October) 307 CLAB free days across the DHB as of 31 October2017 are: CLAB Free Days (as of 31/10/2017) Service/Department CLAB Free Days Surgical and Ambulatory Hine Ora Ward 276 ICU/HDU 307 Ward Ward Ward Ward Acute and Emergency Medicine Ward Ward Ward Ward 6 62 Ward Ward Anawhata Ward 307 Huia Ward 276 Titirangi Ward 307 Wainamu Ward 307 Child Women and Family SCBU WTH

131 Target Measure Previous Report Period Current Report Period Commentary Renal Tunnel Line CLAB Rate June 2016 June 2017 (HCA and HABSI) 4.3 Month/ Year Line days Averag e/day July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan ,814 1,828 1,731 1,948 2,001 2,071 2,155 1,879 2,121 2,152 2,195 2,086 2,229 2, Feb 2017 Mar 2017 Apr 2017 May 2017 June 2017 July 2017 Aug 2017 Renal CLAB Rate as of 30/09/2017 = 0.64/1,000 line days CLAB Falls with Harm Target Measure Total # of falls <5.0 # of falls per 1,000 Occupied bed day Total # of multi fallers >90% % patients 75 years and over (55 years and over Maori and Pacific) assessed for the risk of falling >90% % patients 75 years and over (55 years and over Maori and Pacific) assessed for the risk of falling within eight hours of admission >90% % 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 Previous Report Period 140 (September) 4.6 (September) 16 (September) 94% (September) 81% (September) 95% (September) Total # of falls with major harm (SAC 1 and 2) 2 (September) Current Report Period 172 (October) 5.5 (October) 23 (October) 98% (October) 86% (October) 94% (October) 6 (October) Commentary What are we doing to reduce further falls and harm? Work continues primarily across the medical and surgical wards to reduce the number of falls, especially falls with harm. The strategy is implemented with input from an interdisciplinary team. The aim is fewer falls, fewer falls with serious harm and enhanced return of function. There is strong focus on the following key areas: Proactive assessment and prevention planning Consistent use of approved care plans Eliminating deconditioning through the Get Up, Get Dressed, Get Moving campaign Patient and family education about falls prevention. While total rate of falls remains much the same, falls with major harm has decreased to a rate of 0.16 per 1,000 bed days [One to five per month]. 125

132 Target Measure # of falls with major harm per 1,000 Occupied bed day Previous Report Period 0.06 (September) Current Report Period 0.19 (October) Commentary 4.3 <1 Total # of fractured neck of femurs (NOF) as a result of a fall while in hospital (included in the major falls with harm rate) 1 (September) 1 (October) 4.6 Peri Operative Harm Target Measure 100% Uptake, %age of audits where all components were reviewed 95% Engagement, %age of audits with engagement scores of five or higher 50 Observations, number of observational audits carried out for each part of the surgical checklist (Minimum of 50 observations per quarter) Previous Report Period 92% (January March 2017) 89% (January March 2017) Sign in 52 Time Out 56 Sign Out 49 (January March 2017) Current Report Period Data not available Data not available Sign in 52 Time Out 53 Sign Out 49 (April June 2017) Commentary Perioperative Quality and Safety Markers: All three parts (sign in, time out and sign out) of the surgical safety checklist are used in 100% of surgical procedures, with levels of team engagement with the checklist at five or above, as measured by the 7 point Likert scale, 95% of the time. Commitment to sustain achievement at or above the old QSM threshold of all three parts of the WHO surgical safety checklist (sign in, time out and sign out) being used in a minimum of 9% of operations. A Theatre Reference Group is overseeing the coordination of three national quality surgical safety quality improvement programmes: Surgical Safety Checklist observational audit; Introduction of Briefing and Debriefing; and Multidisciplinary Operating Room Simulation (MORSim). The three programmes are sponsored by the Health Quality and Safety Commission and one (MORSim) co sponsored by ACC. Waitemata DHB is a pilot site for the MORSim programme, which involves all of theatre team safety simulation training. 126

133 4.7 Pressure Injuries Target by 10% Measure # patients with pressure injuries per 100 patients % patients risk assessed within specified time frame (8 hours) % patients audited who received a score % patients with the correct care plans implemented 0 Stage 3, 4 or unstageable pressure injuries Previous Report Period 1 (September) 65% (September) 90% (September) 99% (September) 0 (September) Current Report Period 2 (October) 66% (October) 88% (October) 99% (October) 0 (October) Commentary The Pressure Injury Prevention Steering Group continues to oversee pressure injury prevention activities. This includes pressure injury risk assessment on admission [using e vitals] and regularly thereafter, assessment of nutrition and hydration, regular pressure care e.g. skin care, turning, patient and family education, appropriate additional equipment e.g. air mattresses. The e Learning module on pressure injury assessment and staging has been added to Mandatory training for all Nursing staff and is available to Allied Health and Medical staff. In December the Pressure Injury Prevention Steering Group is running a Train the Trainer Pressure Injury Champion study day to improve ward pressure injury assessment accuracy. The campaign to support patients who are identified as frail i.e. get people up, dressed and moving, to reduce deconditioning and loss of function, will continue to benefit pressure injury minimisation. Close monitoring of pressure injury data is being analysed to identify anatomical areas of greatest risk and therefore what strategies to apply to reduce pressure injuries. Identified pressure injuries. The data is monitored and reviewed by the charge nurse manager and nurse educator ensuring appropriate treatment is in place Specimen Errors Target Measure <1% Total # of specimen errors/month Previous Report Period 696 (September) Current Report Period 676 (October) Commentary The FY2015/16 specimen error defect rate is 1.7% which is consistent with the previous two financial years; the data collected at that time was combined non phlebotomy staff and phlebotomy staff (specially trained to draw blood) which gave a lower error defect rate. The average error defect rate for FY2016/17 is 2.7% which is attributed to the non phlebotomy staff data only. 21% (n=145) of the September 2017 specimen errors were related to labelling; October 2017 had 23% FY2016/17 Error rate July % August 2.6% September 2.3% October 2.8% 127

134 Target Measure Previous Report Period Current Report Period Commentary November 2.5% December 3.0% January % February 2.6% March 2.4% April 2.9% May 2.5% June 2.8% July 2.0% August 2.7% September 2.6% October 2.5% E Medicine Reconciliation (emr), eprescribing and Administration (epa) Target Measure 100% % patients with emr completed within 24 hours on admission and discharge Previous Report Period Current Report Period Commentary Electronic Medicines Reconciliation (emr) emr is now live in 894 beds. Highlights over the past year include upgrading to SMT which has allowed for emr to be completed in the Emergency Department and Assessment and Diagnostic Unit. The upgrade has also allowed us to complete electronic medicines reconciliation across recent encounters (such as transfers to AT&R and between hospitals) resulting in improved efficiency. Our emr coverage for inpatients remains between 70 80% across all live services. Plans for the next year include rolling out emr to paediatrics; continue to work with Orion to develop planned enhancements and development of a business case for deployment of upgrade(s)/enhancements once available; and we will be working with the Health Quality and Safety Commission to refine and develop appropriate national quality and safety markers for Medicines Reconciliation. Electronic Prescribing and Administration (epa) epa is in place in 965 beds across three sites. The remaining patient beds that do not have epa are: Maternity, Paediatrics, SCBU, ESC (partial) and the Inpatient Detox Unit. We are currently testing a new MedChart version but it has significant performance issues. Further releases are delayed until later this year. The ipad freezing issues are still causing significant frustration for nursing staff. The issue is being managed by 128

135 Target Measure Previous Report Period Current Report Period Commentary healthalliance and several avenues are being investigated. A key focus is on the SWA wireless network, and a lack of resources on the ipads themselves. MedChart performance is also still sub standard. We are focussing all efforts on getting it moved to the cloud, as a test environment hosted in Amazon web services has shown performance improvement of > 35% compared with our current on premise production environment Complaint Responsiveness Target <15 days Measure Average time to respond to complaints in the reporting month Previous Report Period 12 (Sept) Current Report Period 17 (Oct) Commentary Services continue to work hard to meet the target <15 day average complaint response time; however there have been some complex complaints across services that have taken longer than the target 15 days and this is reflected in the average response time for October Hospital Mortality Key Quality Indicators Mortality (death rate) Target Measure <100 Hospital Standardised Mortality Ratio (HDxSMR) Previous Report Period 98 [NSH + WTH FY ] Current Report Period 92 [NSH + WTH FY ] Commentary See also latest data under Section 3 DHB Quality Indicators Dashboard. There has been a 6.3% reduction in Waitemata s Mortality rate from FY 2015/16 (98) to FY 2016/17 (92) 129

136 Key Quality Indicators Target Measure Previous Report Period Current Report Period Commentary 4.3 Analysis of in hospital death data from 2013 to 2017 has shown that: In hospital deaths per 1,000 episodes declined from 8.2 per 1,000 episodes (2013/14) to 7.6 per 1,000 episodes (2016/17 year to May) 7% reduction. In hospital mortality following admission for fractured neck of femur (# NOF) decreased from 5.1% (2011/12) to 3.0% (2015/16) and 30 day mortality decreased from 9.2% (2011/12) to 5.4% (2015/16). Analysis of suicides has shown that Waitemata DHB s suicide rate has reduced by 10% from 9.23 in 2013/14, to 8.32 per 100,000 populations in 2015/

137 5. Improvement Team Active Projects Report Innovationn and Improvement Project Team: Active Projects Report 4.3 October 2017 Project Name Organisation wide / Multiple Divisionss Patient Deterioration Programme (PDP) Project Summary An organisation and national programme to improve the management of the clinically deteriorating patient. Programme has three main streams: Recognition and response systems; Kōrero mai: Patient, family and whānau escalation; and Shared goals of care. PDP: Standardised communication tool (ISBAR). PDP: Kōrero mai: Patient, family and whānau escalation. PDP: Recognition and Response Systems. Sponsor(s) Dr Andreww Brant Jos Peach Jos Peach Mike Rodgers David Price Penny Andrew Project manager Resource Jeanette Bell Jeanette Bell Olivia Anstis Sue French Budget N/A N/A N/A N/A Forecast Variance N/A N/A N/A N/A This Period Overall Status Last Period Phase Initiating Executing Initiating Planning Survive Sepsis Improvement Collaborative Leapfrog (refer to Leapfrog project update) To reduce inpatient sepsis mortality to <15% by Dr Penny Andrew September Dr David Grayson G Dr Matt Rogers R Shirley Ross Kate Gilmour Data Discovery Project (Qlik): Implement and Penny Andrew ensure use of QlikSense Business Intelligence tool acrosss Waitemata DHB. District Nurse Mobility. Dale Bramley Outpatients. Robyn Whittaker Kelly Bohot N/A Arti Chandra Kelly Fraher Renee Kong Renee Kong $1.2 Kelly Bohot N/A Kelly Bohot N/A N/A 0% N/A N/A Closing Executing Scoping Planning PROMs Programme Establish a system for developing, collecting and utilising patient reported outcome measures to inform patient experience and outcome improvements in clinical practice and healthh care delivery planning. Jay O Brien Olivia Anstis Sue French N/A N/A Planning 131

138 October Overall Status Project Name Project Summary Sponsor(s) Project manager Resource Patient Safety Survey Connecting Journeys Surgical IC Net Optimisation Tracheostomy Outreach Service ED Urine Testing Process Improvement Medical Acute assessment and admission documentation ADU Whiteboards Gastroenterology M&M development ED SWIFTCare Develop process for patient safety surveys as part of the Patient and Whānau Centred Care Standards and Ward Accreditation Programme, and for organisational use. To implement an improved orderly task management system (Smartpage) to improve workflow, efficiency, patient flow, reduce wasted resources and improve communication and visibility across services. To operationalise the ICNet solution in the Waitemata DHB environment for the IP&C team. To introduce a multidisciplinary tracheostomy outreach service to improve the experience and outcome for patients with a tracheostomy being cared for on general wards. To establish a lean end to end process for MSU testing that is aligned to best practice to achieve accurate and timely diagnosis and treatment of patients presenting with UTIs in ED. To improve the staff satisfaction in the order of acute assessment and admission documentation by identifying and implementing a solution by July Design, build and implement a solution ADU Boards, which will allow ADU nurses and doctors to provide a centralised view of key information. Introduce an M&M model that meets international best practice recommendations and fits this service s needs. Enhance ED capacity and patient flow while providing the most appropriate care. This project Maggie O Brien Carolyn Czepanski Budget Forecast Variance This Period Last Period Phase N/A N/A Initiating Leith Hart Kelly Fraher N/A N/A Planning Matthew Rogers Stuart Bloomfield Jonathan Casement Jocelyn Peach Matt Rodgers Andrew Brant Laura Chapman Cecilia Rademeyer Arti Chandra N/A N/A Executing Arti Chandra N/A N/A Planning Dina Emmanuel N/A N/A Executing Renee Kong N/A N/A ON HOLD Pending decision mid October Laura Chapman Kelly Bohot N/A N/A Closing Zoë Raos Sue French N/A N/A Closed Willem Landman Dina Emmanuel N/A N/A Executing

139 October Overall Status Project Name Project Summary Sponsor(s) Project manager Resource Budget Forecast Variance This Period Last Period Phase 4.3 has two streams (North Shore Hospital, Waitakere Hospital) under one project charter but different Gantt charts due to the different dynamics between North Shore Hospital and Waitakere Hospital. Child Woman and Family Family Centred Tube Feeding Co design project to improve management of paediatric feeding tubes at home. Susan Peters Olivia Anstis N/A N/A Executing Other Work In Progress Overview Involvement Sponsor(s) Project manager Resource Comment TransforMED Acute Patient Flow Programme: Four workstreams Medical Model, Inpatient Wards, ADU Care and Pathway for Acute Care of the Elderly. Partnership with The Francis Group. Alex Boersma Kelly Fraher Arti Chandra Kelly Bohot Renee Kong Ongoing Allied Health Care Pathway Development Improve model of care for five key patient cohorts. Support team through application of QI tools to improve Orthogeriatric Model of Care. Jude Sprott John Scott TBA On track: Completion December 2017 Medicines Governance Walk Around Describe what medicines governance is. Support Pharmacy in setting up a Medicines Governance Walk Around format at Waitemata DHB. Marilyn Crawley Arti Chandra On track: Completion in November 2017 Medical Devices Purchasing Process Improve process for approval to purchase restricted use medical devices within surgical service. Facilitate series of quality improvement workshops. Leith Hart TBA Delayed: Completion in August 2017 General Surgery Clinical Pathways (appendicitis, laparoscopic cholecystectomy, abscesses) Improve general surgery patient experience: reduce LOS, variation and cost of care. Angie Hakiwai will commit 0.5 FTE and be supported by Renee Kong on a consultation/mentoring role. Richard Harman Renee Kong Completion in August 2018 Management Foundations Teach QI skills to 22 participants and mentor each to deliver a QI project. Content development and delivery Ongoing mentorship. Sue Christie TBA On track: Completion December 2017 Clinical Portal Upgrade Clinical Portal Upgrade Working Group. Participate in working group and facilitate Stuart Kelly Bohot Ongoing 133

140 Other Work In Progress Overview Involvement Sponsor(s) Project manager Resource Working Group Innovation Partnership Patient and Whānau Centred Care Standards and Ward Accreditation Programme Safety in Practice Healing Green Space Develop, test and refine mobile app review process. Increase visibility of care and promote safe, consistent high quality care. Safety in Practice is designed to enhance quality improvement capability of general practice teams within the Auckland region, by focusing on patient safety. The DHB current approach to green space is not consistent with international evidence and development of health related spaces and salutogenic and human centred design principals feedback from Allied Health Therapy Group. Research and develop a process including a review questionnaire to screen apps based on business/clinical relevance, quality, functionality and security. To implement an evidence based quality programme to promote excellence in the delivery of safe consistent high quality patient care. Work with Primary Healthcare Organisation and staff within practices to provide quality improvement support and facilitation. Develop a Strategy Paper that delivers evidence of why this is required, who will be involved and how to deliver this concept at an organisation level. Bloomfield Robyn Whittaker Stuart Bloomfield Robyn Whittaker Dale Bramley Cath Cronin Kelly Bohot Jeanette Bell Ongoing Ongoing Comment Stuart Jenkins (Auckland DHB /Waitakere DHB) Neil Houston Kelly Fraher Ongoing Jay O Brien No allocation On hold: Strategy document with Jay O Brien, ESC document on hold pending 4.3 Cancer Support Centre Develop proposal for a cancer support/wellness centre in association with Maggie s Centre. Delivery of an options paper seeking ELT approval for development of a full business case. Jay O Brien Sue French Delayed: Options Paper completed July 2017; ELT presentation November 6 th 134

141 Support Requests Current Support Requests Project Name Sponsor/ Requestor Organisation wide/multiple Divisions Waitakere Clinical Expansion Planning Planning and Funding Child Women and Family Service Medical Gastroenterology Service Model of Care Closed Support Requests Patient Focused booking (gynae service) Closed since last report Project/Work/Request Orthogeriatrician Business Case Chronic Pelvic Pain Model of Care Minimally Invasive Gynaecology Diagnostic and Surgical Services Cath Cronin Karen Bartholomew Debbie Eastwood, John Scott Carol Harris Sponsor/Request or Bill Farrington Matt Walker John Scott Dr Fiona Connell Stephanie Doe Description Care of complex and deteriorating patients at Waitakere Quality Improvement (QI) support for Maori Alliance leadership team process improvement for ethnicity data in HR systems Support development of new model of care (an acute gastroenterology service; and improved elective gastro service) and business case Implement patient focus booking for assessments for the gynaecology service (MoH funded elective improvement project) Request received Scoping Completed Approved date Assigned to Comment 10 May In progress 7 August In progress 25 May N/A N/A 24/07/2017: latest version agreed by Daniel Wong. Debbie Eastwood requested delay. Expected date of response not provided 30 June N/A N/A Closed: non i3 Project manager resource assigned Overview Outcome Close out / summary report location Improve outcomes and experience for the older adult following an acute fracture Define a new Model of Care for women with chronic pelvic pain that will achieve international best practice standards Determine a new model of care and develop a business case with or model to be implemented Business case for Orthogeriatric Service Business case for new Chronic Pelvic Pain Pathway Business case Business Case with service to finalise and present to SMT Project closed. Further development to be undertaken by service Project closed. Further development to be undertaken by service when new consultant commences December

142 Patient Deterioration Programme (PDP) Progress Summary Opportunity / Problem Statement: Our processes and systems to support safe, consistent, effectivee 24 hour care for the clinically deteriorating patient are not always adequate, presenting an on going risk to patientt 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. Waitemata 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 patientt deterioration programme to promote a structured and systematic approach towards improving the management of deteriorating patients at Waitemata DHB. Status Update: Overall Programme scoping, planning, and resource allocation completed. Bimonthly Northern Regional Alliance meetings continue. Recognition and Response Systems (note: separate progress summary reports) Planning: Local Implementation of National vital signs chart and early warning system. Planning: Response teams escalation mapping exercise and horizon scan in progress. Clinical Lead confirmed Dr Jonathan Casement. Execution: Standardised Communication ISBAR now embedding. Korero mai: Patient, family and Whānau Escalation (note separate progress summary report) Planning: Advisory and working groups established and meeting. Engagement with consumers and staff underway. Shared Goals of Care Not scoped locally. HQSC national workshop 26 October Measurement Programme measurement (national and local requirements). HQSC survey about current reporting for patient deterioration and response systems. Sponsor: S Project P Manager: Phase: P Project Risks: Large scale of programme. Clinician availability. Potential for local and national priorities and timelines to differ. Project Issues: Programme governance structure not confirmed. Next Steps: Confirm programme governance structure. Update project management plans. Await outcome of national shared goals of care workshop (October 26) and commence scoping. Deliver paper to SMT on current state and organisational impact of transition to New Zealand Early Warning Score. Timeline Recognition and Response Systems Implementation of National Vital Signs Chart and Early Warning Score Recognition and response systems: Structured Communication ISBAR Korero mai: Patient, family and Whanau Escalation Shared Goals of Care Andrew Brant, Jos Peach Jeanette Bell Initiating Milestone Planning Execution Planning Pending Status In progress In progress In progress Pending Completion December 2017 June 2018 November 2017 June 2018 September Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee Delayed Budget N/A 136

143 PDP: Standardised Communication Tool ( ISBAR) Progress Summary Sponsor: Project Manager: Phase: Jos Peach, Mike Rodgers Jeanette Bell Execution 4.3 Opportunity / Problem Statement: Poor communicationn is a significant causative factor in incidents of patient harm. A structured handover process can promote staff confidence and effectiveness in clinical conversations about patients and patientt care. The use of a standardised communication tool such as ISBAR (Identify, Situation, Background, Assessment, Recommendation) is a strategy for improving patient safetyy and is recommendedd by the World Health Organisation, the Health Quality and Safety Commission as part of the safer surgery and patient deterioration programme and the New Zealand Resuscitation Council. Presently at Waitemata DHB, ISBAR is not used consistently for referral of patients. Objective / Aim: To reintroduce ISBAR as a standardisedd approach to communication for patient referral across Waitemata DHB inpatient settings Status Update: Organisational tools in place lanyard prompts, stickers, phone pads, posters, training package, policy Rollout complete for medical and surgical services, child health, pharmacists, physiotherapists; adaption for maternity and maternal mental health in progress Post implementation ward follow up and evaluation in progress Education and Sustainability plan drafted ISBAR format rolled out on Smartpage 19 October 2017 Project Risks: Potential lack of clinical engagement across disciplines making use of ISBAR difficult to imbed Sustaining use of ISBAR at completion of project Project Issues: Nil Next Steps: Continue to promote and support areas with frequent follow up Additional resources local video, incorporation of ISBAR into local teaching, update website Post implementation auditing and evaluation Finalise plan for handover to business as usual Closure report Timeline Milestone Initiating Planning Status Complete Complete Estimated Completion Date December 2016 March 2017 Executing Closure In progress Planning November 2017 (was July 2017) December 2017 (was July 2017) Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee Extended to December 2017 Budget N/A 137

144 PDP: Kōrero mai: Patient, Family and Whānau Escalation Progress Summary 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 a report 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 around 42% of complaints. It is thought that an escalation process for patients, family and whānau will help reduce r adverse events occurring in response to reports of patient deterioration. There is no such system currently in place at Waitemata DHB. The Health Quality and Safety Commission (HQSC) are sponsoring Waitemata 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 Waitemata DHB. Status Update: Sponsor: Project Manager: Phase: Project Charter finalised and lodged with Awhina. Awhina have requested HDEC review to confirm exemption from ethics approval. In process. Two consumer interviews completed. First webinar with Lynne Maher and HQSC held, with other DHB sites. Waitemata DHB onn track with planning and execution timelines. Hui established for 1 st November at Waitakere Marae. Māori health team assisting with planning p and facilitation. Approvals sought for staff interviews. Staff information sheets and consent forms and discussion guides being approved through Co design working party, ncluding consumer review. Seven consumers have applied to join the Consumer Advisory Group. Teleconference with HQSC and Synergia held to discuss measurement. Synergia will conduct an on site visit in the coming months to work with us directly on measurement. David Price Olivia Anstiss Planning Project Risks: Talking with consumers about their experiences may prompt further complaints to Health Disability Commission (some have taken our interest in their stories as an indication that something went wrong). Project Issues: Next Steps: Staff Advisory Group to be held Friday 20 October, 2017 Apply to HDEC for ethics approval exemption Elevator pitch to be designed by co design working party Consumer Advisory Group to be established Timeline Milestone Initiating Planning Executing Closure Status In progress In progress Pending Pending Estimated Date 29 August October June 2018 Completion 4.3 Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 138

145 PDP: Recognition and Response Systems Sponsor: Jonathan Casement Project Manager: Sue French Phase: Initiating Opportunity / Problem Statement: Project Risks: 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 reversee 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 Engagement from existing clinical teams. Current IT systems may not exist or be able to support processes required for safe escalation systems. Human resource resistance to organisation wide change process. length of stay and associated health costs. Evidence demonstrates that patients exhibit many signs Project Issues: and symptoms of deterioration for a reasonable period of time before cardiac arrest or unplanned Availability of Senior Medical Officer, Registered Nurse and Registered Medical admission to intensive care occurs. Evaluation of our current systems indicates that there is Officer improvement leads to attend meetings. inconsistent processes and pathways and an absence of processes and mechanisms to support safe, consistent, effective 24 hour care for the deteriorating patient. Next Steps: Bring together simulation work, current state data and outcome measures from Objective / Aim: simulation data base to underpinn options paper. Complete research process to assess international and national response options To deliver and deploy a robust strategy for the implementation of a Waitemata Recognition and against Waitemata data and resource availability. Response program that will reduce the harm associated with unrecognised deterioration and its subsequent delayed treatment for all adult in patient care areas. Circulate potential implementation options to key stakeholders in anticipation of writing SMT Options paper. Status Update: Consideration of engaging UniServices to undertake statistical modelling for Nursing lead for project governancee group not yet notified further discussion with Jos Peach. outcomes of agreed options. Outcome measures discussed and planned for at regional planning meeting led by Health Quality Safety Commission (29 September 2017). Timeline Estimated Completion Presentation to Clinical Governance Board outlining impact of new Early Warning Score (EWS) Milestone Status Date and opportunities to capture deterioration. Initial focus groups for Escalation mapping completed (nursing, house officer, registrar, Initiating In progress September 2017 consultant, resuscitation team members and Critical Care Outreach Team) and collated. Planning In progress November 2017 Current state work near completion. Awaiting measures data from simulation group outcomes. Executing Pending January 2017 Closure Pending 30 June Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 139

146 Survive Sepsis Improvement Collaborative Progress Summary Sponsor: Dr Penny Andrew, Dr David Grayson, Shirley Ross, Kate Gilmore and Dr Matt Rogers Innovation and Improvement 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. Next Steps: S Work stream 1: Best Practice Guidelines Waitemata DHB does not reliably recognise and treat patients with sepsis in a timely Complete maternity guidelines. Confirm plan for Paediatric guidelines. manner. Work stream 2: Improvement Activities Aim: To reduce the rate of inpatient sepsis mortality to less than 15% by August 31, Review change package with sponsor group Confirm change process for evitals Work stream 3: Education program Status Update: Work stream 1: Best Practice Guidelines Explore integration of sepsis guidelines into Acute Care Training courses Work stream 2: Improvement Activities Explore options to create sepsis video education resource Work stream 4: Evaluation Change package under development Post Implementationn Review underway Work stream 3: Clinical education program Project Timeline Work stream 4: Measurement and Evaluation Activities Status Timeline Qlik dashboard under development Phase Develop adult suspected sepsis Complete July November guidelines Complete baseline measurement Complete July November 2016 Recruitment of improvement leads Complete September December 2016 Kick off event for improvement leads Complete January 2017 Phase Groups 1 4: Setting Aims Complete February March 2017 Project Risks: 2 Groups 1 4: Understanding the Complete Availability of staff members from medical and nursing teams to participate in system April May 2017 Phase 2. Groups 1 4: Generate ideas and test Complete June July 2017 PDSAs will continue beyond planned project lifecycle. Business As Usual transition Groups 1 4: Make ideas happen Complete August September 2017 plan required. Phase Underway Group 5 8: Develop guidelines and December 2016 Project Issues: 1 and complete improvement activities September 2017 Availability of RN and RMO improvement leads to attend sepsis improvement 2 meetings. Develop change packages Underway September 2017 Proportion of e Vitals sepsis screens incomplete. More information required about form use. e Vitals education video may aid adoption. Continue to monitor. 4.3 Scope On track Timeline Extend end November Budget N/A 140

147 Patient Reported Outcome Measure s (PROMs) Progress Summary Sponsor: Project Manager: Phase: Jay O Brien N/A Initiating 4.3 Opportunity / Problem Statement: Data collection for patient reported and clinician assessed outcome measures and patient experience of service is currently fragmented and lacks transparency for clinical providers andd service funder and planners. Learning from this clinical data requires extensive resource commitment from all service users and the Health Intelligence Group; reducing efficiencies and capacity to make improvements in real time for patients and whānau. Health Outcomes Prediction Engineering (HOPE) tool will provide clinical staff with unique predication capacity to guide patient potential, this will be used in addition to data obtained from universal Quality of o Life measures and condition specific PROMs. Objective / Aim: Triangulate patient reported outcomes, patient experience and clinical outcomes data to provide a meaningful and reliable dataset for clinical providers about an individual patients potential to achieve improved quality of life throughoutt their condition and treatment. To create a synthesis between PROMs, PERSy and HOPE project aims and outcomes for greater efficiency and improvement opportunities for service providers and end user application. Project Risks: High volume of requests for PROMs commencement at service level creates burden for PERSy programme writing team. Cost/acquisition of electronic devices for individual services to carry out surveying with patients. Project Issues: None Next Steps: Return contract to EuroQol. Confirm Intelecta and Mulesoft processes on track for completion. Confirm arrangements and communication of PROMs symposiumm for November 2017 at Whenua Pupuke. Status Update: EuroQol licensing agreement received and reviewed by Amanda Mark, Peter Sandiford and Jay O Brien. Questions raised regarding Stryker contract and consideration of 3 rd party agreement requirements sent to EuroQol 03 October Response due. Privacy Impact Assessment completed. Timeline Milestone Initiating Status Complete Estimated Completion Date July 2017 Planning Complete August 2017 Executing Pending March 2018 Closure On track September 2018 Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 141

148 Patient Safety Survey Progress Summary Opportunity / Problem Statement: Waitemata DHB has been using the internationally recognised Safety Attitude Questionnaire (SAQ) as a tool to measure the safety climate of wards and services on an ad hoc basis for several years. While several groups and services including the Ward Accreditation Programmee would like to use of the SAQ, there is system that enables access to the validated surveys (questionnaire) and reporting of results. In addition there are currently no guidelines outliningg the purpose, use, timing, reporting, and follow up required when using the SAQ. Objective / Aim: To introduce a standardised tool and process to support the use of the Safety Attitude Questionnaire at Waitemata DHB Status Update: 3rd meeting held with working group Test phase of e survey completed with i3 staff report of same in progress currently withh associated radar graphs and reporting format for working group to view. Reporting mechanisms in progress to be confirmed with development of step by step guide for stafff utilising the e survey tool. Supportive toolkit pack in progress How To Guide completed for staff/departments utilising the e survey. Will be ready by end of October for accreditation process for ICU and Lakeview departments. Emergency Department will also run survey as a repeat request from staff. Sponsor: Maggie O Brien Project Manager: Carolyn Czepanski Phase: Initiating Project Risks: Competition with other staff surveys may impact engagement Project Issues: Existing demand to use survey now from one service and one programme Next Steps: Continue developing support toolkit E survey to be sent to ED for pilot following meeting with leadership team. Next working meeting to be held following ED results/report completed estimated November 2017 On track in line with the October Patient and Whānau Centered Care Standards Timeline Milestone Status Estimated Completion Date Initiating In progress 31 September 2017 Planning In progress 31 September 2017 Executing To be confirmed 31 October 2017 To be confirmed Closure To be confirmed Nov end 2017 To be confirmed 4.3 Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee Extend end of November Budget N/A 142

149 ICNet Optimisation Progress Summary Opportunity / Problem Statement: ICNet (electronic infection control surveillance system) went live at Waitemata DHB on 28 March This is a shared system with Auckland DHB. The system was implemented out of the box and needs to be configured in order to deliver the benefits highlighted in the business case. The technical implementation of ICNet is managed by heathalliance. Objective / Aim: (Time boxed for 3 months 1 st May to July 31 st 2017) To operationalise the ICNet solution 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 Status Update: Extended properties (XPs) for Blood Stream Infections (BSI) in progresss Extended properties for Clostridium difficile (C.diff) configured and socialised with stakeholders for feedback. Tested in UAT and ready for deployment to live Previously failed functionality in ICNet has now been enabled by vendor System upgrades , and signed off by Operational Group. Vendor and heathalliance preparing deployment to live heathalliance progressing work on delivering end to end UAT environment Trendcare ICNet interface roadblocks cleared. Work now progressing between heathalliance, vendor and DHB Waitemata DHB reviewing Lab rules in preparation for mass migration to live scheduled tentatively for 10 th Nov i3 Project manager resource extended until November 17 Budget Nil Spend to Date N/A Forecast to Complete N/A Variance $0 Sponsors: Matthew Rodgers and Stuart Bloomfield Project Manager: Arti Chandra Phase: Executing Project Risks: Project time boxed for three months. Not sufficiently progressed to hand over to service too manage under BAU. Project extended until end of November. Review checkpoint in September with Sponsors to assess. Project Issues: Vendors found to make changes directly in live environment. Escalated to healthalliance. Surveillance on going Incomplete testing and validation in UAT before going live. Lack of confidencee in data integrity. End to end UAT testing environment unavailable from healthalliance. Progressed by healthalliance Project Manager. healthalliance project budget overrun. Managed by healthalliance Project Manager. Next Steps: S Complete Lab rules review Plan end to end testing following delivery of environment by heathalliance Finalise testing and standard operating procedure for BSI Complete speed testing in Live environment when version upgrades have been deployed Timeline Milestone Initiating Planning Executing Closure Scope On track Status Estimated Completion Date Complete June 2016 Complete June 2016 Extended November 17 Extended November 17 Timeline Budget Extended until November 30 th N/A

150 Tracheostomy Service Project Progress Summary Opportunity / Problem Statement: Intensive Care Unit (ICU) Senior Medical Officers and Critical Care Outreach staff have identified a gap in the management of patients with tracheostomies on general wards at Waitemata DHB. There is an increasing number and complexity of patients being admitted to wards at Waitemata DHB with a tracheostomy in situ, and care of these patients is not well coordinated. There is no formal tracheostomy service in place and there is no formal referral or tracheostomy management process in place. As a result, referral to ICU and other services is inconsistent, ad hoc, and uncoordinated. Currently medical teams are responsible for the management of patients with tracheostomies. However, most teams have limited experience in leading, coordinating and making key clinical decisions. The overall number of inpatients with tracheostomies is small, making it difficult for nursing and a medical staff to maintain confidence and skill in caring for a tracheostomy patient. This presents a significant clinical risk for this patientt group. There is no centralised system for collecting data on inpatients with tracheostomies, so the activity associated with this cohort of patients is not readily available. Objective / Aim: To introduce a multidisciplinary tracheostomy outreach service to improve the experience and outcome for patients with a tracheostomy being cared for on general wards at Waitemata DHB. Status Update: Phone call interviews to patients commenced Budget Nil Staff surveys complete. Over 120 respondents. Dataa being analysed Project Charter completed and forwarded to wider project group for review Project timeline extension requested by service. Project manager resource extension approved by i3 until March 18 with close out by May 2018 Spend to Date N/A Forecast to Complete N/A Variance $0 Sponsor: Project Manager: Phase: Project Risks: Nil Project Issues: Nil Next Steps: Continue engaging with stakeholders. Plan retrospective patient reviews. Plan for third working group meeting scheduled for 17 October Timeline Milestone Initiating Planning Executing Closure Dr Jonathann Casement/ Jocelyn Peach Arti Chandra Planning Scope On track Status Complete Extended On track On track Timelinee On track Estimated Date June 2017 January 2018 March 2018 March 2018 Completion Budget N/A

151 ED Urine Progress testing process improvement Summary Sponsor: Project Manager: Phase: Matthew Rogers Dina Emmanuel Execution 4.3 Opportunity / Problem Statement: No clear understanding of end to end process of Mid Stream Urine (MSU) testing (from presentation of patient in ED with Urinary tract infections (UTIs) to prescribing appropriate antibiotic treatment). There is no clear decision support pathway for the best time and method of collection to achieve a good quality urine sample in ED. There no clear accountability process of reviewing samples and test results in the laboratory. There are gaps in the process of flow of information on complete microbiology test results to the respective medical team for decision review. Objective / Aim: To establish a lean end to end process for MSU testing thatt is aligned to best practice to achieve accurate and timely diagnosis and treatment of patients presenting with UTIs in ED Status Update: Continue progressing the work packages identified at the start of the project (UTI bundle, MSU sample quality, Point of care testing, further testing requirement, MSU sample accuracy). Continue with the integration of the new pathway into UTI bundle. The new proposed pathway reduces the overall amount of testing required. Data analysis to establish the financial benefits of the new process. Work in progress - Confirm the new process with reduced lab testing requirements. - Improve mid stream urine sample poster layout; include things that can go wrong with the sample and the correct process of collecting sample. This will be used as part of communication hand outs to patients. - Improve communication method by translating poster text into different languages to make it easier for patient with different backgrounds to understand, the main common languages are Korean, Mandarin, Maori and Samoan (mandarin and Korean by far the most common ones). - Identified number of bathrooms, patients can use to provide urine sample. Ensure they all will have the new updated How to take mid stream urine sample poster. - Communicationn quality (quality of poster drawings and text). Project Risks: None Project Issues: Two of our team members who are responsible for the integration of the new pathway into the bundle are away from work on emergency matters. That could potentially delay rolling out the new process Next Steps: Continue with data analysis and measure current system performance Initial capability Continue working on packages with relevant team members and identify improvement areas for each package Confirm methods and communication languages with patients Work with the team to implement the suggested improvements Finalise the Integration of the new pathway into UTI bundle Measuree the impact of the new process throughh PDSA cycle Measuree final capability and confirm financial savings Timeline Milestone Initiating Planning Executing Closure Status Complete Complete On track TBC Estimated Completion Date 18 August 30 September 17 November 30 November Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 145

152 Acute Assessment and Admission Documentation Project Progress Summary Sponsor: Project Manager: Phase: Andrew Brant, Laura Chapman, Cecilia Rademeyer Renee Kong ON HOLD 4.3 Opportunity / Problem Statement: The order (or lack of order) of presentation of information in the acute assessment and admission documentation causes confusion and frustration for staff in the Assessment and Diagnostic Unit (ADU) and poses a risk to patient care. Objective / Aim: To improve the staff satisfaction in the order of acute assessment and admission documentation by identifying and implementing a solution by July Project Risks: None Project Issues: Next steps pending decision at Clinical Governance Board. Next Steps: Review of funding in mid October. Status Update: Clinical Governance Board endorsed option 2c in the paper, the roll out of larger ring binders to the Emergency Department (ED) and the Assessment and Diagnostic Unit (ADU) in both North Shore and Waitakere Hospitals, pending the sourcing of finance. Sponsor has put the project on hold as it is too early in the new financial year to determine funding. Decision to be made in mid October Timeline Milestone Initiating Planning Status Completed Completed Estimated Completion Date July 2016 August 2016 Executing On hold May 2017 Closure On hold July 2017 Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee ON HOLD Budget N/A 146

153 Assessment and Diagnostic Unit Boards (Patient Progress Board) Sponsor: Laura Chapman, Alex Boersma/Robyn Steinbeck Project Manager: Kelly Bohot Problem Statement: Our Assessment and Diagnostic Unit (ADU) doctors and nurses are currently unable to track referrals or progress of consults in ADU, have oversight of which patients are receiving different streams of care or visualise the amount of time a patient has been in the unit. The ability to visualise, track and communicate such information is important as it impacts how patients move through ADU and how different professions interact about patient care. We propose to design, build and implement a solution ADU Boards, which will allow ADU nurses and doctors to view and interact with information including patient location, alerts, nurse, doctor, time in ADU, stream, allied health referrals, pharmacy and ward consults. We anticipate the following benefits: Driver Patient flow Data availability and flow Communication Expected benefits improved visibility of patient streams improved interdisciplinary working better communication and care co ordination improved tracking of patient streams improved tracking of ADU consults improved tracking of Allied Health role on ADU better communication and care co ordination reduced need to telephone/page colleagues to follow up about patient consults and referrals Project Risks: Limited resource to complete phase 2 software updates will limit realisation of expected benefits. Explore resource options. Project Issues: Scaled back funding plan for North Shore Hospital but Waitakere Hospital may have to wait up to 18 months for hardware which could delay implementation and engagement. Workflow requirements may have changed as part of ADUcare project. Review requirements to understand variation from original scope if any. Next Steps: Review next steps in context of ADUcare project Complete PIR Phase: Closing 4.3 Status Update: Boards and software implemented Updates published (bed booking and status), (AH pop up and option to add expected patient) Patient Progress Board available via ADU generic logins on desktop via staffnet link Increase in patient allocation of streams since board implementation. Streams important to facilitate ADU care/francis Group work Milestone Setting aims Understand the system Generate ideas and test Make ideas happen Close out Status Completed Completed Completed On track underway Estimated Completion Date March 2017 May 2017 July 2017 August 2017 October 2017 Budget Capex $ Spend to Date N/A Forecast to Complete N/A Variance $0 Scope On track Timeline delayed Budget Software resource 147

154 Gastroenterology Mortality and Morbidity Meeting Progresss Summary Sponsor: Project Manager: Phase: Dr Zoë Raos Sue French Execution 4.3 Opportunity / Problem Statement: Learning from Mortality and Morbidity (M&M) outcomes for this service is currently achievedd once a year at the General Medical M&M; this severely restricts staff capacity to attend and reduces learning to 1 2 relevant cases per year. Selection of cases to this format involves significant impact events and learning and not about continuous improvement at a local level. Senior clinicians are aware that the team culture is fragmented and divided; creating barriers to improvement. This is underpinned by an absence of team cohesion. The team wish to improve the culture in the work place. Objective / Aim: Introduce an M&MM model that meets international best practice recommendations and fits this service s needs. Provide a platform for increased team cohesion through shared learning andd exposure to creating solutions to service issues, challenges and constraintss Status Update: Pilot extendedd for further three months Project lead preparing first quarter outcomes report and recommendations for Clinical Director, General Manager and Head Of Division. Project sponsor/lead to present outcomes to Clinical Director forum. Plan for invite Nov Project Clinical lead aware that I³ have completed agreed time frame and outcomes for project. Project lead will complete final actions with clinical team. Project Risks: Reduction in patient scheduling capacity on chosen day. Potential loss of 8 12 scheduling points at each site during this time. Potential risk for service to maintainn key performance indicator achievement. Project Issues: Establishing an agreeable date and time where North Shore and Waitakere can come together for one meeting with all staff for one hour. Securing rooms with video conferencing capacity on a reoccurring bases. Next Steps: Project lead to complete project outcomes with local team. No further input from i³. Timeline Milestone Initiating Planning Executing Status Complete Complete Complete Estimated Completion Date January 2017 March 2017 July 2017 Closure Complete October 2017 Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee Complete Budget N/A 148

155 ED SWIFTCARE Progress Summary Sponsor: Project Manager: Phase: Willem Landman Dina Emmanuel Executing 4.3 Opportunity / Problem Statement: Currently all ED patients go through one clinical assessment process. It has been identified that not all patients need to go through the same process. Patient presenting with primary care conditions can be assessed differently to patients presenting with an acute condition. Additionally more conditions can bee seen in front of house in consult rooms rather than occupying beds unnecessarily Objective / Aim: Enhance ED capacity and patient flow while providing the most appropriate care. The project will analyse, process map and implement changes to improve patient flow in front of house i.e. waiting room, triage and consult area. Key Performance Indicator measurement will be comparing before and after dwell time, LOS and number of patients who would normally have been sent to the Flight Deck were seen at the front of house. Status Update: Continue with pilot runs as part of the PDSA cycle. Update process map to include the new learnings Introduced focussed communicationn meeting on the mornings of each pilot day. Feedback very positive in engaging the team Work in progress (WIP) to complete the setup of cliniciann consult rooms aiming to be one stop shop providing them with what they need to perform the work North Shore Hospital updates Very positive results when running the pilot with doctors having the right mind set. Percentage improvement on patients seen in front of house (would otherwisee gone to the flight deck) on pilot days varies between 17 50% of the total patients seen on the pilot. This depends highly on the patient case presented on the day in addition to the doctor mind set Median Dwell time range 38 mins 170mins, LOS range 41mins 149mins Waitakere Hospital updates Variable pilot results depending largely on the doctor on the day running the pilot Median Dwell time range 78 mins 286mins, LOS range 52mins 316mins. Big time ranges suggest improvement opportunities It has been suggested to change the name Fast track as its creating confusion to staff by interpreting it as giving privilege to less acuity patients by seeing them faster than others. Few name were suggested and Non Emergent name has been chosen by majority to replace the old protocol Fast track Created two new triage locations for Non Emergent patients. WRANE= Waiting Room Adult Non Emergent and WRPNE= Waiting Room Paediatric Non Emergent. This is currently in use at all times (pilot and non pilot days). Those locations will be used as part of measurement system analysis and will replace the old protocol fast track Started 12 days challenge led by shift CNS, the aim is to ensure triage nurse choosing the newly created locations if appropriate Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Project Risks: Lack of engagement and not accepting the new process as it s a change to the current operation Project Issues: Doctors completing the mandatory screening section (family violence and child protection) need to complete eight hours training course. Next Steps: Completee consult rooms set up (both North Shore Hospital and Waitakere Hospital) Continue with process map updates following pilot runs to include the new learnings Investigate options allowing doctors to complete mandatory screening without attending the 8 hours training course. May be shorter version training? For Waitakere Hospital pilots, measure dwell time, LOS improvement for nontrials. Audit emergent patients comparing to the initial state before the start of the measurement system analysiss For North Shore Hospital additionally measure the percentage of patients seen in front of house during the pilots which otherwise will be occupying beds at the flight deck unnecessarily Continue with pilot runs as part of the PDSA cycle Measure Waitakere Hospital challenge results Timeline Milestone Status Estimated Completion Date Initiating Complete July 2017 Planning Complete July 2017 Executing In progress August 2017 Closure TBC 31 October 2017 Scope Timelinee Budget On track On track N/A 149

156 Family/Whānau Centered Feeding Tube Management Project Progress Summary Sponsor: Project Manager: Phase: Susan Peters Olivia Anstiss Executing 4.3 Opportunity / Problem Statement: Following on from a project completed in 2016, which investigated a perceived lack of coordination with the insertion of feeding tubes, several recommendations emerged for bothh adult and paediatric services. In the paediatric service, there was strong support for a more family and whānau focused patient pathway, and greater wrap round psychosocial/ multidisciplinary care. There is yet to be any implementation of the recommendations, and redesign of services in response to this. Objective / Aim: The current project aims to co design a family and whānau centred tube feeding and weaningg management pathway with staff and service users, to be completed by December Status Update: Project Risks: Competing priorities of staff in redesigning service provision. Project Issues: Funding for any potential support solutions to be determined. Next Steps: Transcription of interviews. Thematic analysis. Hold Co design workshop. Timeline Milestone Status Estimated Completion Date Initiating Complete 30 August 17 Planning Complete 15 October 2017 Seven consumer and one staff interview completed. Initial themes emerging. Funding secured for transcriptionist. Co design Workshop with staff and consumers booked for 16 November 2017 to review results and overlay consumer experience on tube feeding and weaning pathway Family and Whānau Centred Tube Feeding and Weaning Symposium to be held in Whenua Pupuke on 26 October Project to be launched at the Symposium. Executing Closure In progress Pending 30 November 2017 December 2017 Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget $1,500 approx (transcriptionist fundedd via revenue from Symposium) 150

157 Cancer Support Centre Progress Summary Presently emotional, psychological and psychosocial care for patients and whānau affected byy cancer is either scattered across multiple different government and non government agencies, or do not exist in New Zealand. International evidence confirms long held beliefs that supporting patients and whānau to be in control of their cancer journey through acquisition of o knowledge and support for their emotional and social needs will reduce the burden of the disease and its related treatments. Maggie s United Kingdom is an evidenced based programme of support that nurtures people affected by cancer to live well through cancer, to enhance their life through and beyond cancer and to not lose the joy of living in the fear of dying. This programme is offered in a purpose built b centre of architectural significance and surrounding landscaped designed to create hope and resilience. Sponsor: Jay O Brien Project Manager: Sue French Discrete work: Options Paper Opportunity / Problem Statement: Risks: Competing priorities for the DHB to establish ambulatory cancer treatment centre Issues: Further consultation required on other Tasman options for a cancer support model and impact on changing face of cancer treatments. This has delayed return of paper to Executive Leadership Team. Next Steps: Tabled for Executive Leadership Team week commencing 6 November Objective / Aim: To seek agreement from the Chief Executive Officer and Chairman of the Board to enter into a formal relationship with Maggie s United Kingdom to build the first Maggie s Centre in the Southern hemisphere on the Waitemata Site. Status Update: Options paper agreed by Cath Cronin for presentation at Executive Leadership Team. Timeline Milestone Setting aims Understand the system Generate ideas and test Make ideas happen Status Completed Completed Completed Pending Estimated Completion Date January 2017 February 2017 February 2017 TBC Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee Delayed Budget N/A 151

158 Healing Green Space Progress Summary Sponsor: Project Manager: Jay O Brien Nil at present 4.3 Discrete work: Executive request for approval Problem Statement: There is an absence of human centred design in the approach to healing and therapeutic green space inside the hospital site perimeters; this affects both current and intended in door and outdoor spaces and negatively impacts on therapeutic outcomes and the experience of our patients and their whānau. The DHBs current approach to green space is not consistent with international evidence and development of health related spaces and salutogenic and humann centred design principals. Project Risks: Challenges to strategic overview of non clinical outdoor space. Project Issues: None. Next Steps: To be confirmed with Project sponsor. Aim: Develop a Strategy Paper that delivers evidence of why this is required, who will be involved and a how to deliver this concept at an organisation level. Status Update: Further development with Project Sponsor. Project management support redirected. Timeline Milestone Status Estimated Completion Date Setting aims Complete April 2017 Understand the system Complete June 2017 Generate ideas and test Complete July 2017 Make ideas happen Delayed TBC Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee delayedd Budget N/A 152

159 Orthogeriatrician Progress Summary Sponsor: Bill Farrington, Matt Walker, John Scott Project Manager: Nil Discrete work: Business Case Opportunity / Problem Statement: Risks: Absence of a geriatrician specialist knowledge in the management of fragility fractures from front door to admission to rehab or discharge, in particular # NOF, is compromising short and Model could identify expenditure in Allied Health may be required. This is not currently budgeted for. long term health outcomes and patient and whānau experience of health care in Waitemata. Issues: None. Objective / Aim: Improve acute and long term health outcomes through reduction in morbidity and mortality Next Steps: associated with the complex health needs of patients over 65 who sustain a fracture. To improve the older adult experience of acute fracture management in Waitemata. Status Update: Project and business case with General Manager and Head of Division Specialist Medicinee and Health and Older Adult. I 3 Director confirmed that any further work to be completed by the service and advanced through the respectivee General Managers. Timeline Milestone Status Estimated Completion Date Business case awaiting finance workings. Both services informed by Penny Andrew. Setting aims Complete January 2017 Understand the system Complete March Generate ideas and test Make ideas happen Complete Closed July 2017 August 2017 udget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee Closed Budget N/A 153

160 General Surgery Clinical Pathways Progress Summary Sponsor: Project Manager: Discrete Work: Richard Harman Angie Hakiwai Mentorship Renee Kong 4.3 Opportunity / Problem Statement: The Department of General Surgery has identified an opportunity to quantify ways to improvee patient outcomes and experience, and reduce health care costs within General Surgery. The focus of this work is the development and implementation of protocols for three presentations abscess, appendicitis and cholecystitis, which account for around 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 August 2018 Status Update: Acute arranged cholecystectomies a theatre was offered to the group on Friday of weekk four from October to February, presenting the perfect opportunity to trial the process. Budget Capex $ Opex $ - First trial took place 13 October with threee patients. - Fantastic engagement from perioperative nurse coordinators, registrars, house officers, and anaesthetic group. - Data modelling and support provided by Auckland University Services. - Patient experience interviews to be conducted as input for next trial on 10 th November. - Criteria refined for next trial. Criteria Led Discharge developing proforma to reduce duplication. Reduce time to resolve simple abscess sourcing items for an abscess kit and developingg process to trial. Appendicectomy and Cholecystectomy Pathway Explorers developed and ready for testing. Work continuing on project plan and governance structure. Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Project Risks: Nil Project Issues: Nil Next Steps: Conduct patient experiencee interviews Prepare for next trial of acute arranged cholecystectomies Develop proforma for criteria led discharge initiative Finalise abscess kit for trial Test Pathway Explorers Complete project plan Agreement on governance structure. Timeline Milestone Initiate Plan Execute Close Scope On track Status Estimated Completion Date In progress September 2017 In progress October 2017 On track December 2017 On track August 2018 Timelinee Budget Delayed N/A 154

161 Patient and Whānau Centred Care Standards and Ward Accreditation Programme Sponsor: Dale Bramley Cath Cronin Project Manager: Jeanette Bell Phase: Ongoing Opportunity / Problem Statement: Project Risks: In 2014, feedback from patients, staff, and hospital audits indicated variability in the delivery of fundamental aspects of patient care. Ward processes and systems required for wards to achieve ward accreditation difficult to achieve without home based ward teams. The Patient and Whānau Centred Care Standards (PWCCS) programme was implemented in Project Issues: 2015 to increase visibility of care and promote safe, consistent high quality care. A ward accreditation has been introduced to promote and recognise sustained excellence in the Nil PWCCS programme and ward leadership. Next Steps: Objective / Aim: To implement an evidence based quality programme to promote excellence in the delivery off safe consistent high quality patient care. Status Update: PWCCS Review mental health benchmarks. Plan November 2017 PWCCS round six and ward accreditation round two. Continue monthly ward accreditation executive meetings. Programme planning for Post June review panel meetings for ward teams completed. Timeline Project manager handover to Clinical Nurse Specialist Meg Smith and Associate Director of o Nursing Lucy Adams complete. Estimated Milestone Status Mental healthh review tools reviewed as planned. Completion Date Post Review 6 scheduled for November. Ongoing Business as usual for Ward accreditation: PWCCS Inpatient wards inpatient wards Review 6 Nov Intensive Care Unit / High Dependency Unit (ICU/HDU) and Lakeview Cardiology Centre are a 2017 the first two wards eligible for ward accreditation, and will pilot ward accreditation package. Accreditation portfolios submitted by both areas and panel assessment to take PWCCS expansion to day stay, place 26 and 31 October. Outcomes of reviews will be known by 31 October. outpatients, community Pending November 2018 Implementation of ward On track for new accreditation 1 st wards accredited timeline October Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 155

162 Safety in Practice Progresss Summary Opportunity / Problem Statement: Project Risks: Safety in Practice is designed to enhance quality improvement capability of general practice Sustainability risk with programme going forward. teams within the Auckland region, by focusing on patient safety. In order to achieve this goal, a Project Issues: range of tools and resources (adaptedd from the Scottish Patient Safety Programme in Primaryy Project team incomplete. Care), alongside support from improvement and clinical experts are provided to general practice teams to foster a patient safety culture. For this year (year 4), we are also working with community pharmacy to develop pharmacy Lack of team visibility on project planning. Six practices withdrawn. bundles to help improve patient safety. Next Steps: Objective / Aim: Finalise planning for next round of learning sessions. To develop more reliable practice systems and to promote a safety and improvement culture Continue evaluation discussions. within general practices and community pharmacies. Continue GP practice and pharmacy visits/support. Status Update: Due to the spread of the programme this year and increased uptake we are working across both Auckland DHB and Waitemata DHB to recruit participants and run centralised learning sessions. Timeline Sponsor: Stuart Jenkins Project Manager: Kelly Fraherr (Improvement Advisor role) Phase: Ongoing Teams involved: 59 general practices and 20 community pharmacies. Milestone Status Learning Sessions: Two General Practice Learning Sessions held (17 and 22 August) and Pharmacy Learning Session held (26 September) with positive feedback. Planning for nextt Setting practice specific aims On track round of sessions underway. Understandd the system On track Expert Advisory/Reference Group Pharmacy: Audit bundles for pharmacy finalised and Generate ideas and test On track data collection tools finalised. Make ideas happen On track Evaluation: Progressing evaluation of previous, current, and upcoming year(s). GP Practice visits and pharmacy visits started. Year 4 closure On track Estimated Completion Date October 2017 January 2017 April 2018 July 2018 August Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 156

163 Connecting Journeys Progress Summary Opportunity / Problem Statement: The orderly IT system at Waitemata DHB, Task Manager, is the primary method of task allocation and management for the orderlies, some cleaners and transit care team. In 2016, 393,889 jobs were created in Task Manager. It is a very busy system trying to cope onn old, unsupported software and any delays in use of the system can result in orderly delays. Objective / Aim: To implement an improved orderly task management system (SmartPage) to improve workflow, efficiency, patient flow, reduce wasted resources and improve communication and visibility across services. Status Update: Project progressingg well and aiming for implementation of system at Waitakere Hospital before end November with North Shore to follow shortly after. System configuration has started and is almost complete. System testing in progress. Device set up started. Stakeholder Engagement has started. Training plan started. Planning started for go live including contingency planning. Data collection and evaluation planning initiated. Sponsor: Project Manager: Phase: Project Risks: Nil Project Issues: Nil Next Steps: Finalise system configuration and obtain configured system from vendor. Continue system testing. Complete requirements for device set up. Continue stakeholder engagement. Finalise planning, scheduling and carry out training plan. Prepare for go live, including finalisation of contingency planning. Carry out data collection and evaluation plan. Timeline Milestone Initiating Planning Execution Closure Leith Hart Kelly Fraherr Planning Status Complete On track On track On track Estimated Completion Date October 2017 October 2017 December 2018 February Budget Capex $ Opex $ Spend to Date N/A N/A Forecast to Complete N/A N/A Variance $0 $0 Scope On track Timelinee On track Budget N/A 157

164 6. Safe Care 6.1 Infection Prevention and Control (IP&C) IP&C Surveillance Overview and Audit Results for Q3 July September) 2017 [Full report see Appendix 2] Division Total ESBL (Def) Total ESBL (Prob) Total HABSI Total C.diff (HO HCA) Average MRO Screening Rate Total National Hand Moments % National HH Moments Passed (Ave %I&PC Facilities Standards Met Overall (Ave) % Commodes Clean Waitemata DHB Q3 (Jul Sep) % % 98% 96% Acute and Emergency Medicine % % 96% 98% Child, Women and Family % 99% Elective Surgery Centre % 98% 99% Mental Health % 98% 100% Speciality Medicine + HOP % % 98% 88% Surgical and Ambulatory % % 99% 99% 4.3 By Month Month Total ESBL (Def) Total ESBL (Prob) Total HABSI Total C.diff (HO HCA) Average MRO Screening Rate Total National Hand Moments % National HH Moments Passed (Ave %I&PC Facilities Standards Met Overall (Ave) % Commodes Clean January % 4,156 84% 97% 98% February % 4,208 87% 98% 96% March % 5,223 86% 97% 90% April % 5,099 86% 98% 96% May % 5,261 87% 98% 97% June % 5,513 85% 98% 97% July % 5,023 88% 97% 94% August % 5,497 88% 98% 97% September % % 98% 97% RAG Rating Legend % National HH Moments Passed % I&PC Facilities Standards Met % of Clean Commodes 80% 99% 99% 70% 90% 90% < 70% < 90% < 90% 158

165 6.2 Surveillance Extended Spectrum Beta Lactamase (ESBL) ESBL Definitions 1) Hospital Acquired ESBL (HA ESBL) A. Definite Isolation of ESBL from clinical or screening specimen after 48 hours of admission in either a high risk patient (as per MRO report) and not previously colonised and with a negative ESBL admission screen or a low risk patient not meeting the criteria for admission screening. 4.3 B. Probable Isolation of ESBL from clinical or screening specimen after 48 hours of admission in high risk patient not previously ESBL colonised and ESBL admission screen not done. C. Possible: Isolation of ESBL from clinical or screening specimen on admission in community patient not previously known to have ESBL, admitted to a Waitemata DHB acute care facility within the last 30 days (NB: if previous admission one month ago then community acquired. If referral from a Rest Home or Private Hospital other health care facility (HCF) acquired) D. Infection in known ESBL colonised Isolation of ESBL from clinical specimen after 48 hours hospitalisation in previously known ESBL colonised or infected patient. 2) Community Acquired ESBL (CA ESBL) Isolation of ESBL from clinical or screening specimen within 48 hours of admission in a low risk patient with no exposure to an acute or long term care facility in the last 30 days (NB: such patients will not be routinely screened on admission) 3) Other Healthcare Facility onset ESBL (Other HCF ESBL) Isolation of ESBL on admission screen or clinical isolate within 48 hours admission in patients not previously colonised, admitted to Waitemata DHB acute care from a rest home, private hospital or other acute care facilities ESBL Q Overview No update from the Infection, Prevention and Control team as there has been no significant changes in the ESBL data Jan Sep 2017 North Shore Hospital Waitakere Hospital Counts Rates Counts Rates HA Definite HA infection HA Probable CA* ESBL (incl.) September 2017 October 2017 North Shore Hospital Waitakere Hospital North Shore Hospital Waitakere Hospital Counts Rates Counts Rates Counts Rates Counts Rates HA* ESBL HA Definite HA infection HA Probable CA* ESBL (incl.)

166 50 40 Hospital Acquired (HA) ESBL (Overall) Rate per 10,000 Bed Days HA ESBL NSH HA ESBL WTH 0 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct Hospital Acquired (HA) Definite ESBL Rate per 10,000 Bed Days Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 HA Def NSH HA Def WTH 160

167 20 15 Hospital Acquired (HA) Probable ESBL Rate per 10,000 Bed Days HA Prob NSH HA Prob WTH 0 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct Hospital Acquired ESBL Infection Rate per 10,000 Bed Days 10 HA Infection NSH 5 HA Infection WTH 0 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct Community Acquired (CA) ESBL Rate per 10,000 Bed Days Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 CA ESBL NSH CA ESBL WTH 161

168 6.2.2 Methicillin Resistant Staphlococcus aureus (MRSA) Current Waitemata DHB MRSA surveillance Definitions 1) Community onset MRSA: New MRSA identified from either clinical isolate or screening within 48 hours of admission in a patient with no contact with acute healthcare or contact>30 days prior to identification 2) Health onset MRSA: A) New healthcare onset (hospital acquired HA) MRSA identified after 48 hours of hospital stay B) Previous Waitemata DHB admission (Ex Waitemata DHB) MRSA identified <48 hours after admission in a patient with prior contact in the last 30 days with NSH/WTH C) Other healthcare facility (other) MRSA identified <48 hours of admission and attributable to other healthcare facilities 4.3 MRSA Q Overview 2015 (January December) NSH/WTH Total MRSA isolates 160/111 (total 271) A passive surveillance programme for MRSA (i.e. no high risk patient screening on admission) makes it difficult to assign accurate attribution especially with regards to hospital acquired MRSA Community acquired MRSA from January September 2017 is high for both North Shore Hospital and WTH compared to Total of 27 new healthcare associated MRSA. The majority of the new healthcare associated MRSA were isolated in Q1 and Q2 of this year Overall healthcare attributions together with community acquired MRSA are higher compared to previous years and may eventually require more analysis to understand the reasons. There have been no outbreaks of hospital acquired (HA) MRSA Vancomycin Resistant Enterococcus (VRE) 2016 (January December) NSH/WTH 181/223 (total 304) 2017 (January September) NSH/WTH 144/114 (total 258) Community MRSA (new isolate on admission) 105/80 (185) 121/93 (214) 91/94 (185) Community MRSA (known on admission) 24/12 (36) 31/17 (48) 20/10 (30) New New healthcare onset 22/6 (28) + 22/11 (33) 21/6 (27) Health care onset (known on admission 13/9 (22) 8/4 (12) 10/4 (14) Waitemata DHB surveillance definitions for VRE VRE burden total number of new and previously known VRE colonised/infected patients seen at North Shore Hospital/Waitakere Hospital during the month. VRE incidence newly identified VRE colonised or infected patients during a particular month. Definite hospital acquired: if admission screen was negative and subsequent screening cultures >48hrs after admission confirm VRE. Probable hospital acquired: if admission screen not performed and subsequent screening cultures >48hrs after admission confirm VRE. Other: if VRE isolated on admission screen or within 48hrs of admission to North Shore Hospital/Waitakere Hospital. VRE Infection: any infection diagnosed either on admission to, or during, hospital stay. 162

169 VRE Q Overview Identification of new VRE colonisation or infection remains low which could be due to enhanced IPC measures including automated environmental decontamination. Total of seven hospital acquired (HA) VRE isolated at North Shore Hospital from January June 2017; three of these were isolated in Q1 due to a VRE cluster on Ward 14. No new VRE identified in Q2 or Q No infections occurred from new HA acquired VRE colonisation in 2017 (YTD). 4.3 Rate per 10,000 occupied bed days Waitemata DHB VRE rate per 10,000 bed days (Exc: all mental health, well baby and haemodialisys units Burden Incidence Infection C. difficile Infections (CDI) Waitemata DHB Surveillance Definitions for CDI Healthcare facility Onset (HO HCA) CDI symptom onset more than 48hrs 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 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. 163

170 Waitemata 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. Waitemata DHB has an active feedback process for all cases of HO HCFA (definitions below) where root cause analysis is undertaken by the ID physician/microbiologist and 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. 4.3 The CDI working group in conjunction with AMS/I&PC will continue to focus on early recognition, improving diagnostic testing requests, isolation practice and antimicrobial stewardship as the key areas. CDI Q Overview A total of 91 CDI cases were isolated between January September 2017 (including recurrence) 12 CDI cases were isolated in September (including recurrences); and a further 12 in October (including recurrences) The proportion of healthcare facility onset (HO HCA) infections for the year to 30 September 2017 was 56% in September, and 75% in October Two HO HCA CDIs isolated in September were avoidable; a further two cases were similarly identified in October (WTH) The overall CDI rate for 2017 is 3.9/10,000 bed days; the rate for September was 5.4 and October was 4.3 Rate per 10,000 Bed Days Waitemata DHB Total CDI Rate per 10,000 Bed Days (YTD) 164

171 6.2.5 Influenza Surveillance January September 2017 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) There is an ongoing high influenza burden in the Waitemata community and hospital attendances continues at both North Shore Hospital and Waitakere Hospital The trend is downwards from a spike in levels in June, July and August 2017; only three healthcare associated were identified in September (two at North Shore Hospital and one at Waitakere Hospital) Influenza Data at NSH Jan Sep 2017 Actual Volume Jan 17 Mar 17 May 17 Jul 17 Sep 17 Influenza at NSH Influenza A Influenza at NSH Influenza B Influenza at NSH Community Acquired Influenza at NSH Healthcare Acquired 150 Influenza Data at WTH Jan Sep 2017 Actual Volume Jan 17 Mar 17 May 17 Jul 17 Sep 17 Influenza at WTH Influenza A Influenza at WTH Influenza B Influenza at WTH Community Acquired Influenza at WTH Heatlhcare Acquired 165

172 6.2.6 Communicable Diseases/Cluster/Outbreak September 2017 Disease Pertussis (whooping cough) N (Neisseria) meningitidis (Meningococcal Disease) Haemophilus Influenzae October 2017 Total # of cases 2 Ward/Unit Emergency Department WTH # of Patients requiring tracing # of Staff requiring tracing 0 10 Outcome All staff were followed up by the Occupational Health and Safety team. Both patients had not been placed into droplet precautions on admission. 1 Ward N meningitis isolated in sputum. Staff and inpatient contacts were given prophylaxis. 1 Titirangi Ward 10 0 H. influenza was isolated from blood cultures. Contact tracing was recommended by the Auckland Regional Public Health Service (ARPHS) as unable to identify the type of influenza until confirmation from Institute of Environmental Science and Research (ESR). 4.3 Disease Pertussis (whooping cough) Total # of cases 1 Ward/Unit Emergency Department Waitakere Hospital + Rangatira (Paeds) Ward Mumps 2 Emergency Department Waitakere Hospital # of Patients requiring tracing # of Staff requiring tracing 0 30 Outcome All staff were followed up by the Occupational Health and Safety team; all found to have either had their Pertussis vaccination or a Pertussis booster in the last four years. 0 6 Occupational Health and Safety team contacted all staff informing them of exposure and checking their immune status. 166

173 6.2.7 Clusters and Outbreaks September Disease Confirmed Norovirus Total # of cases Ward Ward Closure Lost bed days # of Patients with disease # of Staff with disease Sept Sept Outcome Widespread gastroenteritis (five multi bedded rooms) cause by norovirus for both Wards 14 and 15. Wards were closed to admission throughout the duration of the outbreak. Unable to establish the index case for outbreak as several patients and staff developed symptoms at the same time. Both wards were reopened after both were completed decontaminated using a Deprox 1 machine. The outbreak was contained with no new cases identified due to: Increased infection, prevention and control (IP&C) auditing. Increased cleaning. Limiting staff to essential staff only to the wards. Limiting visitors. Limiting patient movement to essential services. October 2017 Disease Total # of cases Norovirus Cluster 1 14 Ward Ward Closure Lost bed days Room closed to admission 8 # of Patients with disease Three symptomatic patients # of Staff with disease 0 Outcome IP&C to following up on remedial work. 1 Deprox is a regulated vaporisation system for bio decontaminating 167

174 7. Patient and Whānau Care Centered Care 7.1 Patient Experience Feedback National Inpatient Survey The third national patient experience survey for 2017 was conducted from Tuesday 22 August to t Friday 7 October for inpatient experiences in late July and early August. Previous quarter reports are summarised in the table below. Patient Experience System Level Measure targets for each domain are 8.5 in 2017/18. Result highlights for this quarter response rates lower than average and all domains up in comparison to last quarter. Waitemata DHB ranking nationally has improved significantly from the last quarter. Year and Quarter Total Surveys Communication Partnership Coordination Needs Jul Sep 2017 Apr Jun 2017 Jan Mar 2017 Overall 2016 Oct Dec 2016 Jul Sep 2016 Apr Jun 2016 Jan Mar Table 1: National Survey Results Friends and Family Test During September 2017 we received feedback from 1,182 people through the Friends and Family Test (FFT). The Net Promoter Score (NPS) for September was 74, well above the DHB target of 65 and continuing the high recent NPS trend. Friends and Family Test Overall Results Figure 1: Waitemata DHB overall NPS 168

175 4.3 Graph 1: Waitemata DHB overall FFT results Table 2: Waitemata DHB FFT resultss (each question) Net promoter scores (NPS) in September across the organisation for all Friends and Family Testt questions have met target. The care and respect and welcoming and friendly continue to be our highest scoring questions. 169

176 Net Promoter Score over time Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 WDHB Target Net Promoter Score 4.3 Graph 2: Waitemata DHB Net Promoter Score over time Waitemata DHB continues to score well above target with the overall NPS. Over the last four months, three of the highest scores have been achieved (June 78, August 76, September 74). Total Responses and NPS to Friends and Family Test by ethnicity Sep 17 Maori Overall Asian Overall Pacific Other Responses NPS Table 3: NPS by ethnicity All ethnicities identified have met the overall Waitemata DHB NPS target. Work will continue in each service to increase response rates and explore any specific comment themes. Friends and Family Test Comments The care, attitude, attention, detail and friendliness of the doctors, nurses and staff is exceptional. Ward 10 North Shore Hospital Each time myself or family/friends have been here things have improved you feel like you are being looked after by a caring friend for all needs not only medical. Waitakere Hospital ADU Staff were prompt and very professional attending to mum s every needs. Very friendly and thorough. Thank you to all the staff in Muriwai ward. Well done. Muriwai Waitakere Hospital 170

177 Made to feel welcome and safe. Doctor and nursing staff both professional and very friendly. You should be proud of the quality of service you provide Surgical Unit Waitakere Hospital The service is outstanding. The nurses are very caring and I can t fault the service at all. North Shore Hospital Haematology Day Stay I am more than pleased with the effective treatment and rehabilitation I have received at North Shore Hospital.. AH Outpatients Physiotherapy North Shore Hospital 4.3 Friends and Family Test by ward Division Service Responses NPS AH AH Community Adults North 3 67 AH AH Community Adults Rodney 4 75 AH AH Community Adults West 4 25 AH AH Community Child Health North 7 86 AH AH Community Child Health West AH AH EDARS AH AH Outpatients Physiotherapy North Shore Hospital AH AH Outpatients Physiotherapy WTH 7 86 AH AH Renal Dietitian Dialysis 1 0 AH AH Renal Dietitian Outpatients 6 83 A&EM North Shore Hospital ADU A&EM North Shore Hospital ED SMHOP North Shore Hospital Haematology Day Stay S&A North Shore Hospital Hine Ora Ward S&A North Shore Hospital ICU/HDU A&EM North Shore Hospital Lakeview Cardiology Centre CWF North Shore Hospital Maternity Unit S&A North Shore Hospital Outpatients Mains S&A North Shore Hospital PACU Short Stay Ward SMHOP North Shore Hospital Renal Unit CWF North Shore Hospital SCBU S&A North Shore Hospital Short Stay Ward 9 67 A&EM North Shore Hospital Ward A&EM North Shore Hospital Ward

178 Division Service Responses NPS S&A North Shore Hospital Ward A&EM North Shore Hospital Ward A&EM North Shore Hospital Ward S&A North Shore Hospital Ward S&A North Shore Hospital Ward A&EM North Shore Hospital Ward A&EM North Shore Hospital Ward SMHOP North Shore Hospital Ward SMHOP North Shore Hospital Ward A&EM WTH ADCU A&EM WTH Anawhata Ward A&EM WTH ED 9 22 A&EM WTH ED Waiting Room A&EM WTH Huia Ward CWF WTH Maternity Unit SMHOP WTH Muriwai Ward S&A WTH Outpatients Mains 8 50 CWF WTH Rangatira Ward SMHOP WTH Renal Service 4 50 CWF WTH SCBU S&A WTH Surgical Unit A&EM WTH Titirangi Ward A&EM WTH Wainamu Ward Table 4: FFT results by ward Just over half (53%) of wards and services met their response targets and of these wards and services, the majority score above the Waitemata DHB target for NPS. Outpatients Physiotherapy at North Shore Hospital have recorded a high response rate following a promotion of the use of FFT data recently. North Shore Hospital Haematology Day Stay, Hine Ora ward and ward 15 all rate highly, with patients reporting a great service and friendly, caring and professional staff. North Shore Hospital ED and ward 11 achieved low NPS, with patients reporting long wait times, poor experiences with staff and delayed call bell answering. To increase FFT response rates, the volunteer programme will trial regular surveying over the weekend by high school student volunteers from October

179 7.1.3 Happy or Not Results 4.3 Figure 2: Happy or Not results Happy Or Not terminals are a simple way of collecting high volumes of feedback so that hospital staff and services can get a snap shot of patient and visitor experience. Happy or Not terminals have been used alongside service improvement work in the Outpatients department at North Shore Hospital. Five terminals are attributed to outpatients and have asked questions about wayfinding and wait times to coincide with touch points in the Experience Based Questionnaires that are being completed in the Outpatients Department. A review of the Happy or Not system was completed and is due to be presented at SMT Real Time Feedback Mental Health (July 2017 September 2017) Real Time Feedback (RTF) is used as part of the organisational goal to collect information about people s experiences and Mental Health and Addiction Services have used the HDC endorsed electronic system as part of gather feedback from people accessing services and their family/whānau. Mental Health are currently reviewing the use of Real Time Feedback and how the data could be better utilised when hosted by the PERSy (Patient Experience Reporting System). A strategic management decision is required before this progresses, therefore data for this quarter is limited. 173

180 Reporting Device Scores Appointment Expectations Respect Involved Communication 4.3 Culture Family Recommend Support Reviewed Graph 3: Child Youth and Family 3 surveys completed Appointment Expectations Culture Respect Involved Communication Family Recommend Reviewed Support Graph 4: Forensics1 18 surveys completed 174

181 Expectations Respect 5 Involved 4.3 Appointment Communicati on Culture Family Recommend Support Reviewed Graph 5: CADS 14 surveys completed Expectations Appointment Culture Recommend Reviewed Respect Support Involved Respect Involved Communicati on Family involved Graph 6: Takanga A Fohe 60 surveys completed 175

182 Expectations Respect 4 3 Involved 4.3 Appointment 2 1 Communication 0 Culture Family Recommend Support Reviewed Graph 7: Waiatarau 8 surveys completed Appointment Expectations Respect Involved Communication Recommend Family Reviewed Support Graph 8: Waimarino 3 surveys completed 176

183 Service Score Comparisons Taharoto Rd Waimarino 3 Takanga A Fohe Whitiki Maurea 2 1 CADS Rodney CYF Total average Graph 9: Total averaged score per service 7.2 Patient Experience Activity Highlights Volunteer Recruitment Update Green Coats Volunteers (FOH) Other activities volunteers allocated to Shop volunteers Ward Health and Safety Weekend Service Assistance with projects Other allocated Volunteers Volunteers on boarded awaiting allocation Total volunteers available Total Volunteer resignation in Table 5: Volunteers Recruitment 177

184 Reason for resignation Retirement = 9.09 % (1) Move out of area = % (3) Health status = % (3) Change of circumstance (found job, increase in work with previous commitments.)= 36.36% (4) 4.3 Volunteers awaiting interviews Volunteers awaiting police checks Volunteers awaiting orientation/onboarding Volunteer Withdrawal Total Volunteer Applications in Table 6: Volunteers withdrawal/onboarding Reason for withdrawal Long wait for onboarding = 7.27 % (8) No further contact post application = % (54) Lost details=3.63% (4) Change of circumstances (Health status, find job, issue with visa) = 39.09% (43) Police record= 0.90% (1) Volunteer Activity Highlights Volunteer Recruitment Update Two recruitment drives conducted in February and June this year have led to a high number of enquiries but an average retention of people. With a regular advertisement on Seek website and the Waitemata DHB recruitment website, we are receiving a regular flow of enquiries (approximately 4 6 per week on average) which peaked during the recruitment drive attracting various candidates such as job seekers, visitors and international students who don t tend to proceed further with their application or volunteer for long time. The creation of a new database highlights these findings and will enable us to improve recruitment and retention of volunteers. Volunteer Events Two meetings, one at each site, are planned in October to update volunteers about the programme and seek their feedback In December we will be celebrating International volunteer day and Christmas celebration for all volunteers (on the 5th for North Shore & 11th For Waitakere Hospital Volunteer Initiatives Two Health and Safety volunteers have commenced orientation with the facilities team to complete weekly health and safety inspections/audits across North Shore and Waitakere Hospitals. The tea trolley recently introduced in Outpatients at North Shore Hospital managed by Red Cross Volunteers is going well and it is planned to support this service with Waitemata DHB new recruits. Likewise, new recruits are to be introduced to Short Stay Ward at North Shore Hospital. Five ward volunteers are working on a roster in Titirangi Ward to provide societal service to patients and their family. Volunteers are assisting the ward with non clinical duties such as help with puzzle, crossword, reading to patients etc. A young man with intellect disability started working last month once/week with the Hospital Auxiliary at Waitakere, assisting with putting magazines in waiting area and assisting with wheelchair management. 178

185 A roster will be introduced for weekend volunteers to complete the Friends & Family Test from October 7 on all wards two volunteers with ipads will be rostered from 12pm 3pm every Saturday and Sunday. Waitakere Emergency Department Experienced Based Survey was conducted with the support of volunteers. Other roles such as sleep packs, ward support are currently being scoped with input of Charge Nurses Mangers. 4.3 Patient Experience Team Highlights Hello my name is. Chris Pointon Visit Chris Pointon (husband of the late Kate Granger) spoke to staff at a guest lecture which was video conferenced across most Waitemata DHB sites. Chris spoke about Kate s global campaign to ensure people understood how important the basic common courtesies are when providing care. A doctor herself Kate quickly learnt what it was like on the other side of the stethoscope. Staff were clearly touched by Chris story with many tears shed. Chris is currently on a global tour, due to requests across the world and the promise to Kate to continue her great legacy in sharing her story. Pastoral Care Pastoral Care Activity for Chaplains North Shore Hospital (September) No. of visits to patients 879 No. of visits to family 152 No. of visits to staff 86 Worship services (regular and special) 16 No. of call out to serious condition 13 No. of after hours call out 5 No. of room blessings 1 No. of deaths attended 6 No. of funerals taken 0 Pastoral Care Activity for Chaplains Waitakere Hospital (September) No. of visits to patients 375 No. of visits to family 64 No. of visits to staff 267 Worship services (regular and special) 6 No. of call out to serious condition 1 No. of after hours call out 0 No. of room blessings 3 No. of deaths attended 5 No. of funerals taken 0 179

186 Pastoral Care Activity for the Chaplains Mason Clinic (September) No. of visits to patients 267 No. of visits to family 1 No. of visits to staff 92 Worship services (regular and special) 37 No. of room blessings 0 No of training sessions provided The graph below summarises the activity of the Chaplains in Overall, there is a high number of staff support especially at Waitakere Hospital whilst at Mason Clinic, due to the nature of the work, family visits are uncommon. There also seem to be a surge in total visitation in Waitakere Hospital. Graph 10: Waitemata DHB Chaplain activity 180

187 Pastoral Care Activity for the Voluntary Chaplains Assistants (VCAs) across Waitemata DHB No. of visits to patients No. of visits to family No. of visits to staff Hours volunteered (Waitakere) (Mason Clinic) (North Shore) 4.3 There is one Volunteer Chaplain Assistant (VCA) at Waitakere Hospital, one VCA at Mason Clinic and 17 VCAs at North Shore Hospital. Every 3 rd Thursday of the month a training session is held for the VCAs. For September, the North Shore VCA had training on Verbatim. Summary of chaplaincy after hour call out activity The graph below summarises the number of after hour call outs at North Shore and Waitakere Hospitals (please note: Mason Clinic does not have an after hour call out service). In September, there has been no call out in Waitakere hospital and also see a decrease in the North Shore hospital call out. 14 No. of After Hours Call Out North Shore Waitakere 0 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Month Graph 11: Chaplain Oncall Record 181

188 7.3 Patient Experience Activity Overview Project Name Project Summary Patient Experience Lead Organisation wide / Multiple Divisions Happy or Not Machine Review Sleep Programme Kōrero Mai Whānau/Patient led escalation Patient Stories Programme Strategy Patient Story Production Waitemata DHB have nine Happy or Not Machines collecting patient data across the organisation. A review is to be conducted to ensure data collected by these machines are utilised to inform patient experience quality improvement activity. Poor sleep in hospitals is one of the biggest patient complaints to Waitemata DHB. A working group has been established to address the issue and implement improvements. A research partnership with Auckland University, Canterbury University and Massey University has been formed to measure success of specific interventions on Ward 7 North Shore Hospital pilot ward. Kōrero Mai (Talk to Me) aims to co design a patient/family/whānau led escalation system for patients whose condition is deteriorating (getting worse). Strategy to set patient story acceptance guidelines, funding responsibilities and process flow. Capturing patient stories on video for internal and external audiences. The purpose is for staff Update Domain Status Lara Cavit Happy or Not review and report completed. Awaiting presentation to Senior Management Team (SMT). Current use of machines changes to facilitated specific patient experience measures linked to quality improvement work in Outpatients at North Shore Hospital. David Price Ravina Patel David Price Olivia Anstis Sleep packs price comparison complete. Sleep pack items have been ordered. 5,000 packs will be made and distributed to wards at North Shore Hospital and WTH in January Sound measurement study to gain baseline ward noise levels in partnership with Auckland and Canterbury University in progress. Light study completed with Massey University, with specific recommendations implemented Collaboration with acoustic engineers to outline potential acoustic interventions. Patient Experience Director is Executive Sponsor. All working/steering groups formed First co design workshop held Volunteers engaged to assist with transcription of patient/staff interviews. Ravina Patel Work will start on the Patient Story strategy in Octo.ber Ravina Patel Lara Cavit On track Generally on track minor issues/delays Surgical site infection patient story is complete and has been signed off by Measurement and Evaluation Practice + Physical Environment Patient and Community Participation Patient and Community Participation Patient and Community Off track/not started

189 Project Name Project Summary Patient Experience Lead Consumer Council Patient Exp. online e learning programme Listening Event Strategy Mystery Shopper Programme to learn from experiences and assist with providing the best level of support and care to our patients. As part of the annual planning DHB priorities guidelines for 2016/17 an expected focus for improving quality at Waitemata DHB is to commit to either establish or maintain a consumer council (or similar) to advise the DHB. Waitemata DHB is a unique position with key stakeholders (Waitakere Healthlink and Healthlink North), contracted to support consumer engagement activity. An elearning module is to be developed to replace the current workshops held in the Patient Experience space. The elearning module solution will be highly engaging to appeal to all staff. Story telling, gamification and humour and play will be used. Various requests are made to the Patient Experience team to support and fund listening events with the aim of using co design methodology to support redesign of services or inform future quality improvement priorities. A strategy is required to provide a consistent process for organising these events as well as utilising the feedback generated to influence change. To ensure high level customer service is consistently performed with face to face interaction with our patients and consumers a mystery shopper programme is to be introduced. The aim of the programme is to interact with staff via telephone or face to face to regularly evaluate current interactions. David Price Carol Hayward David Price Jake Du Toit Update Domain Status patient. Video to be shared at a medical conference in October. Two bariatric patient stories underway, both at editing stage. Patient story recommendations to be actioned in October. Smokefree and SCBU story completed, awaiting for publishing on website. Currently working with both Health Link Boards to finalise a Consumer Council option for Waitemata DHB. The function, make up and implementation of a consumer advisory board are being considered with the aim of presenting a paper to the Board by the end of First review of e learning complete. To be tested with users for 2 nd review feedback in late October. David Price On hold to be commenced in early David Price On hold to be commenced in early Participation Governance People and Leadership Practice Measurement and Evaluation Patient and Community Participation People and Leadership Measurement and Evaluation

190 Project Name Project Summary Patient Experience Lead Website/Intranet Update Waitemata DHB wide Christmas Month Pastoral Care Services Review Patient Information Booklet To enhance both the public and staff understanding of the patient experience team s role, function and activity, the current information available via the Waitemata DHB website and staff intranet requires updating. Waitemata DHB loves celebrating Christmas! An opportunity for staff to reflect on the year and the great achievements that have been made as an organisation to serve our community. A month programme of events and activity is planned to acknowledge staff during the festive season. In addition, community events/activities are also planned. Waitemata DHB with the support of the Interchurch Council for Hospital Chapliancy provides chaplaincy services across North Shore Hospital, Waitakere Hospital and Mason Clinic for patients, whānau and staff. A review of current service provision to develop an overarching chaplaincy services strategy is to be completed to raise the profile within the organisation and the community. Patients and staff have consistently requested the availability of information related to their inpatient stay. The provision of a patient information booklet was endorsed by local community groups as a solution to this challenge. David Price Ravina Patel Lara Cavit Update Domain Status On hold to be commenced in early David Price Staff Christmas barbeque dates booked. Christmas Day Staff lunch/dinner booked. Christmas tree and decoration donations from local businesses confirmed. Steering group meeting schedule to prepare monthly calendar of events and communications. David Price Two guidance papers have been written by current chaplains to influence the strategy. Strategy session/workshop held with all chaplains and some volunteer chaplains in September. Draft strategy to be written by late October for further consultation. Lara Cavit North Shore Hospital Booklet finalised and circulated throughout the organisation. Large quantity of feedback (both positive and constructive) received. Waitakere Hospital Booklet in final draft stages, however it has been decided to combine both the North Shore Hospital & Waitakere Hospital booklet due to similar information. Consumer Health Literacy groups are to review in October. Final booklet to be circulated in late Communication and Information People and Leadership People and Leadership Communications and Information

191 Project Name Project Summary Patient Experience Lead Volunteers Ongoing Recruitment/ Onboarding Uniform Update Weekend Volunteer Programme Quarterly Corporate Volunteer Programme Ward Volunteer Programme An increased demand for volunteers to support activity throughout the organisation has led to two recruitment campaigns in Volunteers have requested a change of uniform which is more professional and stands out, and one that aligns with Auckland DHB. Many new volunteers are only available on weekends. Waitemata DHB currently does not have a programme of work that can be completed on weekends. Various requests are made to Waitemata DHB by corporate organisations to complete volunteer work on a specific day each week as part of their community support programmes. Waitemata DHB hopes to accept these requests formally, by creating an annual quarterly calendar with specific corporate groups. Waitemata DHB aims to have volunteers working on all wards throughout the 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. Genevieve Kabuya Update Domain Status Volunteer numbers have increased and an onboarding process has been developed to orientate and train volunteers in various roles. Spreadsheet to record candidate recruitment to be finalised by mid October. Ravina Patel Well Foundation endorsed funding the Waitemata DHB volunteer uniform polo shirts. David Price Pilot patient experience volunteer work completed in August. (120 surveys completed by four volunteers with three hours). Roster of 16 volunteers to complete specific patient experience surveying over weekend created and commenced in October. Communication to divisions/services to highlight other activity that can be completed by volunteers on weekend. David Price Fiona McCarthy Genevieve Kabuya Ravina Patel Fact finding to determine Health and Safety requirements and potential options for activity of large volume of volunteers on specific days of year. Request for Volunteer Service form sent to Charge Nurse Managers on 22 September to understand future demand on wards. All responses due back by 31 October. Short Stay Ward allocated two volunteers. Negotiations with St John to support ward volunteer programme on Ward 14 and 15. Patient and Community Participation People and Leadership Patient and Community Participation Patient and Community Participation Practice

192 Project Name Project Summary Patient Experience Lead Outpatient Tea Trolley St John Volunteer Relationship Volunteer Guidebook Hospital Operations Food Services Medical MHOPS / A&EM Renal Emergency Department (ED) Swiftcare Waitakere Many patients wait for long periods within outpatients for their appointment. A tea trolley is to be introduce to provide refreshments and support other patient needs while waiting. St John provide and support the Emergency Department and Ward 2 volunteers five days a week at North Shore Hospital. We hope to expand this service to other wards through the hospital to ensure sustainability and sharing the responsibility. Project to update the volunteer guidebook which will be shared with all current and new volunteers. Food is very important for patient recovery and high source of feedback for patient feedback. To improve food services at Waitemata DHB, the patient experience team will work with our current provider to continually evaluate the service and focus quality improvement activity to improve patient satisfaction with food. Project to seek patient feedback about their experience with the renal service and social workers. Enhance ED capacity and patient flow while providing the most appropriate care. This project will analyse, process map and implement changes to improve patient flow in front of house i.e. waiting room, triage and consult area. Genevieve Kabuya Genevieve Kabuya Ravina Patel Genevieve Kabuya Update Domain Status Red Cross volunteers introduced tea trolley in outpatients in September, two shifts per week. Other volunteers to be sourced to support a five day week roster. Preliminary meetings held with St John and a plan for 2018 to be finalised by end of October with costings and process. Quote and timeline received. Approval to proceed sent to consultant on 29 September. Project completion date, end of November. David Price Food services completed with volunteers. Support of a heat retaining equipment upgrade. Review of current maternity service provision with an increase in beverage services from one to five, spoken menu introduced and negotiate of roles for Health Service Assistants and Food Services staff. Ravina Patel Patient interviews currently being conducted with three out of 15 completed David Price Experienced Based Design Survey Developed and administered by volunteers with ED patients. Phone interviews completed by volunteers to discharged ED patients. Further data collection to be completed including theming of current results. Physical Environment Patient and Community Participation Practice Physical Environment Measurement and Evaluation Measurement and Evaluation

193 Project Name Project Summary Patient Experience Lead Home Warding Ward 6 Patient Experience Child Woman and Family Auckland Regional Dental Service (ARDS) Patient Experience paediatric measurement Maternity Patient Experience Workstream Improving communication and multi disciplinary team working by creating ward based teams. Patient and Staff experience study completed focused on Ward 6 with the support of the HQSC and research group Sapere. 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. From a recent review of maternity services various themes from mothers have been identified for improvement to enhance the patient experience. A workstream group has been formed to progress quality improvement activity. Update Domain Status David Price Development of patient experience measures to evaluate the success of the strategy. David Price Research completed comprising of staff interviews, patient interviews, patient surveys, staff and patient listening events. Report presented to SMT. Recommendations from the study to be planned and implemented with ward staff. Lara Cavit Ravina Patel Patient Experience team completing presentation of research and feedback options to individual ARDS teams. Last presentations to be completed towards the end of October. Overarching Patient Experience measure to be developed for measuring paediatric patient experience for ARDS as well as local measures. David Price Top three issues for mother s identified as: Food, Partners/support people staying overnight and parking. Three small groups formed with workstream to focus on these areas. Compassionate parking policy updated to include day of birth as a consideration for parking pass. Researching solutions for partners staying overnight with current ward space restrictions + reviewing current policy. Changes made to current maternity food services that have increased beverage services, increased portion size and enable increased choice in meals. Measurement and Evaluation Practice Patient and Community Participation Measurement and Evaluation Practice

194 Project Name Project Summary Patient Experience Lead Surgical ORCA Patient Feedback Review Ambulatory EDARS Review Outpatients Allied Health Friends and Family Test Overview Mental Health Co Design Programme High level of patient feedback identifying areas of improvement for the provision of orthopaedic services. Comparative study to understand how the EDARS service delivery has evolved over the first year of implementation. Outpatient Patient Experience project aimed at understanding the patient journey through outpatients and the current touch points. Allied Health response rates with the Friends and Family Test has been low. Engagement with key Allied Health services to increase response rates and supporting the use of the feedback generated by the test. A six month co design programme has been developed for mental health and addictions staff. Over the six months staff will complete various service improvement projects utilising co design methodology. Update Domain Status David Price Experience Based Survey with patients completed Patient stories collated Interviews with Pre Admission Clinic staff and Orthopaedic staff. Orthopaedic Surgeon meeting attended. To meet with surgical management team to develop a programme of worked aimed at a consistent patient experience process for ORCA services. Ravina Patel All patient interviews are complete. Staff In our shoes session complete. Report to be completed. Lara Cavit Patient journey mapping being completed at present using Experience Based Questionnaires and Happy or Not machines. Lara Cavit All Allied Health outpatient and community services have been visited to highlight current challenges. Report completed and forwarded to Allied Health to progress action plan. Awaiting confirmation on Allied Health targets for response rates and specific timing of FFT completion within patient journey. David Price Two workshops have been completed with up 25 attendees at each session. Five project groups have formed and completed the initial scoping of each project. Six hourly coaching sessions are to be set up to assist with the progression of the co design projects. People and Leadership Practice Measurement and Evaluation Measurement and Evaluation Measurement and Evaluation People and Leadership Patient and Community Participation

195 Other Work In Progress Overview Involvement Patient Experience Resource Annual Patient Experience Week Values Programme Health Literacy Programme Waitemata DHB celebrate Patient Experience week each year. Creating awareness of current patient experience activity and celebrating success and performance, as well as highlighting areas of improvement. Waitemata DHB values programme is a highly successful programme that highlights staff values and the expected behaviours. This programme has been re established with the ambition on taking the values work to the next level. The Auckland and Waitemata DHB Health Literacy Steering Group has developed a Project Charter to guide the programme s implementation. The following strategies are included in the Project Charter, along with timeframes for implementation: Health literacy goals are included within both Auckland and Waitemata DHBs Annual Plans. Health literacy policy and guidelines are developed and implemented for both DHBs. Services are challenged and supported to integrate health literacy objectives into service design. In addition, the programme aims to ensure there is a common understanding of health literacy across both organisations and it is aligned with national MOH health literacy programme guidelines. April 2017 Patient Experience Week held, report presented to SMT in June For 2018, planning will commence in early Key members of the steering committee with key Patient Experience activities from the Values programme to be led by patient experience these activities are yet to be determined. Steering Group Member. Supporting the streamlining of processes for Patient Information to be developed to ensure consistency and that consumers are integral to development of our patient information. Ravina Patel Lara Cavit David Price David Price Ravina Patel David Price 4.3 Way Finding Frail Elderly Patients Steering group established to review and provide advice on wayfinding signage and issues in accordance with the wayfinding policy guidelines. Programme to encourage frail elderly patients to Get up, get dressed, get moving! Patient Experience is assisting with seeking patient feedback about the programme and their experiences. Monthly meetings to review wayfinding signage and discuss signage issues Survey loaded in Survey Monkey. Patient feedback underway. Ravina Patel Ravina Patel Partners in Care Project to assess the role that nominated support people can play to achieve better health outcomes for patients Community engagement is complete with feedback from Health of Older People, Breast Cancer Support and others. Ravina Patel 189

196 Other Work In Progress Overview Involvement Patient Experience Resource System Level Measures Patient Experience Annual system levels have been developed in conjunction with the Ministry of Health to monitor DHB performance in patient experience. Regional DHB Patient Experience representative on steering group. Communicate outcomes to other DHBs. Support community engagement work in relation to measure evaluation. Patient Gowns Working group to improve hospital patient gowns. Consumer rep involvement. Feedback provided on proposed hospital gown options Awaiting new options. Pacific Health FFT Responses Recent Pacifica Responses to the FFT have been low and consistently the Net Promoter Score has not met target. Working with the Pacifica Health Team to increase response rates. ipads allocated to four Pacifica team members with Friends and Family Test available. Report of last quarter s data compiled and presented to the team. David Price Ravina Patel David Price Pulmonary Rehab Support provided in development of patient survey. Lara Cavit Patient Safety Week Steering Group set up to plan for Patient Safety week. Basic plan and structure for Patient Safety week Lara Cavit completed. Meal tray mat design completed. Happy or Not terminals booked for event and strategy developed for their use in evaluating intervention. Curtains Curtains across North Shore Hospital and WTH will be replaced. Samples have arrived. Ravina and Kath to seek patient Ravina Patel feedback on the design October HINZ Conference Joint abstract accepted at HINZ conference with Healthpoint Developing presentation and presenting on 1 st of David Price Presentation for keynote presentation. November Family meeting (complaint management) support David Price Waitakere Chapel Extension Lactation clinic Divisions and services request patient experience team support with managing complaints and mediating at family meetings. On average two requests a week received. On average three s a week received directly from patients. Waitakere Chapel to be extended and refurbished via community donation and Well Foundation funding ($450,000) Lactation team are seeking patient feedback on their lactation service. Director of Patient Experience attending family meetings and supporting complaint resolution, including formal response review and linking patients in with quality improvement activity, where their feedback can be used to influence change. Attending planning meetings and liaising with community groups to donate to the project. Supporting the development of the patient experience measures. David Price Ravina Patel

197 Closed in August/September Project/Work Service Overview Outcome Renal Options Survey Medical Request to create survey for renal services to evaluate different options available for dialysis patient treatment. Volunteer Update Report to SMT Patient Exp. Full report providing volunteer programme update submitted to SMT. Henderson School Report to SMT Patient Exp. Outcome report of the Henderson School visit submitted to SMT. Completed, results collated and sent to renal services. Presented to SMT. Presented to SMT

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199 Highlights: Monthly Report for Hand Hygiene October 2017 The overall Waitemata DHB hand hygiene compliance for the month of October 2017 is 88%. This is an equal record all time high result in line with previous months this year. Congratulations to the clinical units with 100% compliance rate: o Maternity NSH o Haemodialysis - WTH o Kahikatea-Mason Clinic o Kauri-Mason Clinic o Pohutukawa-Mason Clinic o Rata-Mason Clinic o Tane Whakapiripiri-Mason Clinic o Te Aka - Mason Clinic o Totara-Mason Clinic Congratulations to the professional groups with the highest compliance rate: o Phlebotomy Invasive Technician = 93% o Administrative and Clerical Staff = 93% 4.3 Areas of concern: Healthcare worker (HCW) groups performing below the 80% benchmark are: o Student Doctor = 78% o Medical Practitioner = 76% Clinical Units performing below the 80% benchmark are: o Ward 3 = 79% o Interventional Radiology NSH = 79% o CCU NSH = 79% o Emergency Department NSH = 73% o Ward 4 = 71% o Endoscopy NSH = 68% o Wilson Centre = 64% o Theatre WTH = 72% Major achievements by WDHB: Waitemata DHB has consistently exceeded the national hand hygiene compliance target of 80 percent since August WDHB has the largest hand hygiene auditing program in New Zealand! Our nearest rival ADHB has an auditing program half the size of WDHB (by total number of moments audited). WDHB achieved the fourth highest compliance rate in New Zealand (April to June 2017) but by statistical power our result would be the highest compliance for New Zealand!! Hand hygiene program update WDHB hand hygiene working party membership We have welcomed several new members to the hand hygiene working party. Thank you for your support! We are aiming to increase representation from Waitakere Hospital and also the medical profession. Reporting changes The format of monthly hand hygiene reporting has changed. The WDHB hand hygiene working party, quality department, Director of Nursing and Infectious Diseases / Microbiology doctors were consulted. Monthly reporting will now occur in two methods: o A short DHB level report (this report). WDHB Hand Hygiene Monthly Report October

200 o Monthly Report for Hand Hygiene October 2017 Individual ward level reports that will be available from the shared drive: G:\Nurses\AUDITS PROGRAM\HAND HYGIENE REPORTS (these can be printed and displayed in each clinical unit s quality boards). 4.3 Number of moments required by clinical units Inpatient medical, surgical, maternity, paediatric units = 100 moments per month Outpatient units (including outpatient haemodialysis units) = 50 moments per month Inpatient mental health / detox units = 25 moments per month Hand hygiene auditor training The December 2017 Hand Hygiene Auditor Training Session has 5 spaces till open. Clinical units with 2 or more trained auditors will not be considered for training. We only require a clinical unit to have 2 hand hygiene auditors. Fri 15th Dec :30am-4:00pm Waitakere Conference Room, Ground floor, Snelgar Building, Waitakere Hospital Open for applicants 5 spaces still open for training Recommendations for improving compliance: It is recommended that the inpatient units that are below the 80% compliance benchmark and the 100 moments per month target work together with their department hand hygiene auditors to improve their results. Department hand hygiene auditors need to be provided with dedicated time to enable the required moments to be collected. It is recommended that each of the hand hygiene auditors from these areas investigate the issues and liaise with the WDHB Hand Hygiene Coordinator (Graham Upton Mobile: ). These issues will be discussed by the WDHB Hand Hygiene Working Party at their monthly meeting. A plan for improvement will be created in discussion with the relevant line managers. Hand hygiene program dates for 2018 New hand hygiene auditor training days Friday 23 rd March 2018 Waitakere Conference Room, Snelgar Building, Waitakere Hospital, 55 Lincoln Road, Henderson Friday 15 th June 2018 Waitakere Conference Room, Snelgar Building, Waitakere Hospital, 55 Lincoln Road, Henderson Friday 14 th September 2018 Waitakere Conference Room, Snelgar Building, Waitakere Hospital, 55 Lincoln Road, Henderson Existing hand hygiene auditor refresher session hours hours hours Wednesday 21 st February 2018 Waitakere Conference Room, Snelgar Building, hours Waitakere Hospital, 55 Lincoln Road, Henderson Tuesday 20 th February 2018 Rata Room Whenua Pupuke NSH hours WDHB Hand Hygiene Monthly Report October

201 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Hand Hygiene Compliance % Graph 1: Monthly Report for Hand Hygiene October % 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% Waitemata DHB Hand Hygiene Compliance in past 12 months 87% 87% 87% 86% 86% 86% 86% 85% 85% 88% 88% 87% 88% Table 1: Overall WDHB hand hygiene compliance by facility Name Correct Moments Total Moments Compliance Rate Elective Surgery Centre % North Shore Hospital % Waitakere Hospital % Waitemata DHB % Table 2: Overall WDHB hand hygiene compliance by professional group Name Correct Moments Total Moments Compliance Rate Phlebotomy Invasive Technician % Administrative and Clerical Staff % Student Allied Health % Nurse/Midwife % Student Nurse/Midwife % Cleaner & Meal staff % Health Care Assistant % Other - Orderly & Not Categorised Elsewhere % Allied Health Care Worker % Student Doctor % Medical Practitioner % WDHB Hand Hygiene Monthly Report October

202 Monthly Report for Hand Hygiene October 2017 Table 3: Overall WDHB hand hygiene compliance by moment 4.3 Name Correct Moments Total Moments Compliance Rate 1 - Before Touching A Patient % 2 - Before Procedure % 3 - After a Procedure or Body Fluid Exposure Risk % 4 - After Touching a Patient % 5 - After Touching A Patient's Surroundings % Table 4: North Shore Hospital hand hygiene compliance by department Name Correct Moments Total Moments Compliance Rate Maternity NSH % Haemodialysis - NSH % ICU % CVU-NSH % Ward % Hine Ora Ward % Ward % Ward % SCBU NSH % Ward % Haematology Day Stay NSH % Ward % He Puna % Ward % Ward % Haemodialysis - Apollo % Ward 12 KMU % Ward % Out Patients Department NSH % Short Stay % Ward % PACU 1 & % Radiology % Ward % Ward % Interventional Radiology % CCU NSH % Emergency Department NSH % Ward % Endoscopy - NSH % Wilson Centre % WDHB Hand Hygiene Monthly Report October

203 Monthly Report for Hand Hygiene October 2017 Table 5: Waitakere hospital hand hygiene compliance by department 4.3 Name Correct Moments Total Moments Compliance Rate Haemodialysis - WTH % Kahikatea-Mason Clinic % Kauri-Mason Clinic % Pohutukawa-Mason Clinic % Rata-Mason Clinic % Tane Whakapiripiri-Mason Clinic % Te Aka - Mason Clinic % Totara-Mason Clinic % Titirangi % Muriwai Ward % Rangitira Unit % Huia % Anawhata % SCBU WTH % Emergency Department WTH % Wainamu % CADS % Maternity WTH % ADU - WTH % Out Patients Department WTH % Theatre WTH % Table 6: Elective Surgery Centre hand hygiene compliance by department Name Correct Moments Total Moments Compliance Rate Cullen Ward % ESC PACU % Table 7: Overall WDHB hand hygiene compliance, glove usage and product used When gloves are taken OFF, the percentage of Moments that were MISSED is: 3.1% When gloves are put ON, the percentage of Moments that were MISSED is: 14.8% Of all Moments where glove use is recorded, the percentage of Moments that were MISSED is: 10.4% The percentage of correct Moments where alcohol based hand rub was used is: 79.2% The percentage of correct Moments where soap and water was used is: 20.8% WDHB Hand Hygiene Monthly Report October

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205 KEY POINTS: Waitemata DHB Infection Prevention and Control September This report includes analysis of any significant trends during the July-Sept 2017 quarter. The following are the highlights: Overall low HABSI rate 0.18/1000 bed days for current quarter compared to 0.40 in 1 st quarter. However, the HABSI rate for Sept was high, and 5/13 (38%) HABSI s in current quarter were related to CAUTI. HCA-BSI cases with 2 following port catheter insertion and 1 post TRUS biopsy. A significant reduction in HA-ESBL was noted in July-Sept across both sites with 29 HA-Def (compared to 116 in the 1 st half) at NSH, and 12 HA-Def (compared to 38) at WTK. There were no outbreaks in the quarter. Increase in overall and HO-HCFA CDI rate with 12 CDI in Sept only 1. Healthcare Associated Bacteraemia (HABSI) Note: Excludes well babies, Mason clinic, Wilson centre, Taharoto, Waiatarau CADS and all Haemodialysis unit HABSI is defined as 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 hrs of admission is categorized as HABSI. Total Number of x HABSI for Sept 2017 Rate = Jan Feb March April May June July August Sept Total No. HABSI Rates/1000 Bed Days HABSI Jan - Sept 2017 n = 53 TOTAL NUMBER DEVICE RELATED POST PROC. /SURGICAL OTHER (inc. non CAUTI) UNKNOWN CAUTI IVL CLAB 197

206 HABSI Analysis for September 2017 Source Total Ward Organism Comments CAUTI 2 Ward 15 PAER Indication for IDC appropriate to manage deterioration in patients condition after MCA Muriwai Kleb. Pneumonia & Proteus mirabilis Other 3 ICU/HDU Citrobacter Koseri Hospital acquired pneumonia Indication for IDC was appropriate for management of urine output 4.3 Muriwai ESBL EC Bilary sepsis secondary to blocked CBD stent and dislodged PTC stent Titirangi H influenza Patient died on the day bacteraemia was identified, from respiratory failure due to severe pneumonia (likely aspiration) Unknown 2 Ward 4 E coli 4 days after Total Nephrectomy. Unable to identify source of HABSI. Muriwai E feacium Possible source spontaneous gut bacterial translocation due to GI bleed Wards with highest attribution and device related HABSI Jan Sept 17 Comments: Total of 53 HABSI identified in last 9 months (compared to 71 HABSI for the similar time period in 2016). 17/53 (32%) HABSI related to devices- 10 urinary catheter and 7 vascular devices. Overall 13 cases of HABSI for July-Sept quarter compared to 25 cases in Jan-Mar 17. However, 7 HABSI cases in Sept, and 5/13 (38%) HABSI s in current quarter were related to CAUTI. Root cause analysis of all cases revealed that indication of IDC was appropriate but duration despite being excessive in some cases was also appropriate in view of the medical conditions. An audit is planned at the end of 2017 to reinforce Quit CAUTI prevention bundle and the ANTT technique/monitoring of IDC insertion and maintenance practice. Majority of vascular device related were identified in first 6 months (3 IVL, 3 PICC and 1 CVL). CVL and PICC line related HABSI did not identify any breaches in maintenance and insertion bundle. 12 post procedure/surgical HABSI attributed to various procedures with no specific trend Healthcare Associated Staphylococcus Aureus Bacteraemia New HQSC SAB defination SAB defination implemented 27th August 2017 Case type Numerator definition Denominator defination Inclusions: When to identify SAB as healthcare associated Exclusions: When SAB is not healthcare associated Wards with highest HABSI cases Ward 8- Total 8 (2 CLAB, 2 CAUTI) Ward 15- Total 7 (2 CAUTI) Muriwai - Total 5 (1 CAUTI) Healthcare associated SAB is isolation of S. aureus from one or more sets of blood cultures and: a. the patient acquired it while they were hospitalised in a DHB facility and it was not present or incubating on admission b. the first positive blood culture was collected more than 48 hours after admission or 48 hours or less after discharge OR it satisfies at least one of the following criteria (see page 4 for further detail): a. It is a complication of an indwelling device (eg, vascular catheter, urinary catheter). b. It occurs within 30 days of a surgical procedure or within 90 days of surgery involving implanted devices and is related to the surgical site. c. It is diagnosed within 48 hours of a related invasive instrumentation or incision. d. It is associated with neutropaenia (< 1.0 x 109/L) contributed to by cytotoxic therapy Do not count a SAB that recurs within 14 days of the original event as a new episode, as it qualifies as the same infection. Maternally acquired infection: This is an infection that a neonate acquires from the mother during delivery. Unless strong evidence suggests otherwise, classify an infection that appears less than 48 hours after birth as acquired from the mother. Monthly inpatient admission and discharge data from the National Minimum Dataset is used to calculate the number of inpatient bed days in the quarter Well babies, mental health patients, and boarders (e.g. parent staying with a child) are excluded from the admission and discharge data used to calculate the number of inpatient bed days. If an episode of SAB does not meet any of these criteria, then classify Healthcare Associated S.aureus Bacteremia ( ) WDHB rate per 1000 bed days versus National Rate WDHB 0.04 National Oct'15-Dec'15 Jan'16-Mar'16 Apr'16-Jun'16 Jul'16-Sep'16 Oct'16-Dec'16 Jan'17-Mar'17 Apr'17-Jun'17 Jul'17-Sep'17 198

207 Comments Includes both HCA- BSI and HABSI Staph aureus bacteraemia. 16 SAB (includes 1 MRSA) isolated from Jan Sept 2017 (4 HCA and 10 HA) 8/16, 50% of SAB were attributed to vascular device (3 IVL & 5 CLAB). HCA-BSI (unlike HABSI) is generally incubating at the time of admission and is therefore diagnosed within 48 hours of admission. However, they are attributable to recent healthcare contact with surgical or invasive procedures performed within 30 days of bacteraemia, or in patients with long term Health Care Associated BSI (HCA- BSI) 4.3 Distribution of HCA BSI from Jan Sept 17 Source Total Ward Organism Comments CLAB 12 Haemodialysis Unit Assortment of organisms Majority of CLAB attributed to renal dialysis patients with permanent tunnel line. 3 Medical / Surgical Staph Aureus Line used for patients receiving TPN Two patient had Portacath inserted in AIR, received chemotherapy at ACH Post-surgical procedure 2 Haemodialysis Unit E coli and Staph aureus Renal Outpatients patient with permanent AV fistula 2 Ward 4 E coli and Staph aureus Post TRUSS biopsy and post ERCP Other 1 Ward 10 Staph aureus Readmitted post chest drain removal Unknown 1 Maternity Strep pyogenes Unable to identify source of BSI, patients were admitted within 30 days post discharge after having had a procedure 1 Haemodialysis Unit Staph aureus Unable to identify source of BSI, patients were admitted within 30 days post discharge after having had a procedure 2. Extended Spectrum Beta Lactamase (ESBL) Bacteria Case type Hospital Acquired ESBL HA-ESBL Definition A. DEFINITE Isolation of ESBL from clinical or screening specimen after 48 hrs. Of admission in either High risk patient (as per MRO report) and not previously colonised AND with a negative ESBL admission screen OR Low risk patient, not meeting the criteria for admission screening. B. PROBABLE Isolation of ESBL from clinical or screening specimen after 48 hrs. Of admission in High risk patient, not previously ESBL colonised AND ESBL admission screen NOT DONE. C. POSSIBLE Isolation of ESBL from clinical or screening specimen on admission in community patient, not previously known to have ESBL, admitted to WDHB acute care facility within last 30 days (NB: if previous admission >1 month ago then community acquired. If referral from RH/PH then other HCF acquired) D. INFECTION IN KNOWN ESBL COLONISED Isolation of ESBL from clinical specimen after 48 hrs. hospitalisation in previously known ESBL colonised or infected patient Community Acquire ESBL CA-ESBL Other Healthcare Facility Onset OTHER HCF-ESBL Isolation of ESBL from clinical or screening specimen within 48 hrs. Of admission in a low risk patient with no exposure to acute or long term care facility in last 30 days. (NB: such patients will not be routinely screened on admission) Isolation of ESBL on admission screen or clinical isolate within 48 hrs. Admission in patients, not previously colonised, admitted to WDHB acute care from rest home, private hospital, or other acute care facilities. ESBL rate Jan-17 ESBL rate/10,000 bed days at NSH Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 HA ESBL HA Def HA Prob CA ESBL 199

208 ESBL rate/10,000 bed days at WTH 4.3 ESBL rate HA ESBL HA Def HA Prob CA ESBL Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Wards with highest attribution in HA-Definite ESBL cases Jan -Sept 17 Ward Muriwai Anawhata Titirangi CCU Wainamu HA-DEF Jan June 2017 NSH WTH No Rate No Rate HA-DEF (A) HA-PROB (B) HA-inf. (D) CA-ESBL July Sept 2017 NSH WTH No Rate No Rate HA-DEF (A) HA-PROB (B) HA-inf. (D) CA-ESBL Sept 2017 NSH WTH No Rates No Rates HA- ESBL HA-DEF (A) HA-Prob (B) HA-inf. (D) CA-ESBL ESBL HA EC from clinical isolates Jan -Sept number MSU CSU BSI Site Sputum Wound number ESBL HA KP from clinical isolates Jan - Sept 2017 MSU CSU BSI Site Sputum Wound 200

209 Comments A significant reduction in HA-ESBL occurred in July-Sept quarter across both sites with 29 HA-Def (compared to 116 in 1 st 6 mths) at NSH, and 12 HA-Def (compared to 38) at WTK. The low numbers of HA-probable ESBL also indicate that screening compliance has improved. There were no ESBL outbreaks in this quarter. Improved awareness of the significance of ESBL cross transmission prevention through Take Charge and other educational programs is likely to be contributory to the success. Sustainability and efforts to standardise auditing and feedback procedures is essential to ongoing success of the program Central Line associated bacteraemia (CLAB) - including PICC lines Key point: Target Zero CLAB - a National Quality Initiative, lead locally at Waitemata DHB by ICU/HDU, is well and truly embedded across the DHB. A standardised checklist for insertion of all central lines, and maintenance list for inpatients is required and audited periodically. CLAB rates at Waitemata DHB remain very low as shown in tables below. Most wards have very long CLAB free periods due to both good compliance and infrequency of patients with central lines CLAB free days January to Sept 2017 CLAB free days ICU Ana Wain. Titir H Ora Huia SCBU WTH ICU/HDU CLAB report Sept17 Total # of central lines (centrally & peripherally) inserted = 28 Average # of lines per day for the month of September = 2.5 Compliance data for the month of September 2017 o INSERTION = 100% o MAINTENANCE = 95% CLAB RATE for the month of September = 0.86 per 1000 line days Patient: Total of CLAB attributed to Renal Services. These are from dialysis patients with long term tunnel line in-situ Renal Services Tunnel line CLAB rate Jan Aug 17 (includes both HCA and HABSI) 2016 June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Line days NA Average/day CLAB CLAB rate per 1000/L. Days = 0.64 In addition to the CLAB cases mentioned above, there were 2 additional patients who developed Port Cath infections from S.aureus within 1 month of Port insertion in advanced interventional radiology. Although insertion compliance was 100%, a meeting with the service is organised to determine any other potentially correctable factors. 4. Clostridium difficile Infections (CDI) Case type Healthcare Facility Onset HO-HCA Community Onset health care facility associated CO-HCA Community Onset Community Associated CO Indeterminate Recurrent Definition CDI symptom onset more than 48hours after admission (3rd calendar day). Discharged from a healthcare facility within previous 4 weeks. No admission in the last 12 weeks. Discharged from a healthcare facility within the previous 4 to 12 weeks. Episode of CDI that occurs eight weeks or less after the onset of a previous episode provided the symptoms from the prior episode resolved. 201

210 4.3 Comments Total of 91 CDI cases isolated between January September 2017 (including recurrences) - Total of 12 CDIs in September (including recurrences) - The proportion of HO-HCA infections for year to date is 60% and for September was 75% - There were 2 avoidable HO-HCA CDIs in September - The overall CDI rate for 2017 is 3.9 per 10,000 bed days, the September rate was 5.4 Waitemata has an active feedback process for all cases of HO-HCA and for all recurrent infections, where a case review in undertaken by the ID physician/microbiologist and AMS pharmacist at the time of diagnosis of CDI. A letter outlining the causes and corrective actions is sent to the responsible clinician if the case is considered avoidable. CDI working group in conjunction with AMS/IPC will continue to focus on early recognition, improving diagnostic testing requests, isolation practice and antimicrobial stewardship in key areas. 5. Methicillin Resistant Staphylococcus Aureus (MRSA) MRSA definitions 1) 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 2) Healthcare onset MRSA (see below) A) Hospital Acquired (HA) = New MRSA identified after 48 hours of hospital stay B) Healthcare associated (HCA) = Previous WDHB admissions and NEW MRSA identified in a patient admitted for <48 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 48 hours of admission Definition 2016 (Jan-June ) NSH/WTH Total MRSA isolates 98/73 (total=171) 2016 (July- Dec ) NSH/WTH 83/50 total= (Jan Sep ) NSH/WTH 144/114 Total = 258 Community MRSA and other HCF (new cases) 65/57 (122) 56/36 (92) 91 / 94 (185) Community MRSA (known on admission) 14/10 (24) 17/7 (24) 20 /10 (30) New healthcare onset (hospital acquired) 13/5 (18) 8/6 (14) 21 / 6 (27) Health care onset (known on admission) 6/1 (7) 2/3 (5) 10/4 (14) Comments: A passive surveillance program for MRSA (i.e. no high risk patient screening on admission) makes it difficult to assign accurate attribution, especially with regards to hospital acquired MRSA. Community acquired MRSA from Jan September is high for both NSH and WTH compared to 2016 Total of 27 new health care associated MRSA. Majority of the new health care associated MRSA was isolated in 1 st and 2 nd quarter Overall healthcare attributions together with community acquired MRSA are higher compared to previous years and may eventually require more analysis to understand the reasons. No outbreaks identified with HA MRSA. 6. Vancomycin Resistant Enterococcus (VRE) Active VRE surveillance (similar to ESBL) is performed since May 15 after ward outbreaks were identified at NSH in Identification of new VRE colonisation or infection remains low due to enhanced IPC measures including automated environmental decontamination. 202

211 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 patients during a particular month. A: Definite hospital acquired If admission screen was negative and subsequent screening cultures >48 hrs after admission confirm VRE 4.3 B: Probable hospital acquired If admission screen not performed and subsequent screening cultures >48 hrs after confirm VRE. C: Other If VRE is isolated on admission screen or within 48 hrs of admission to NSH/WTK. VRE infection Any infection diagnosed either on admission to or during hospital stay. Includes infections in previously colonised Graph: VRE rate per 10,000 bed days at Waitemata DHB (excluding all mental health and well-baby units, haemodialysis) Axis Title Burden Infection Incidence 2 0 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Comments: Identification of new VRE colonisation or infection remains low which could be due enhanced IPC measures including automated environmental decontamination. Total of 7 HA VRE isolated at NSH from January June 2017 with 3 isolated during first quarter due to a VRE cluster in Ward 14. No new VRE identified in 2 nd and 3 rd quarter of No infections have occurred from new HA acquired VRE colonisation in Surgical Site Infections (SSI) for knee and hip arthroplasties In scope procedures for SSI surveillance are primary and revision hip and knee arthroplasty performed at either NSH or elective surgical centre (ESC), in accordance with the National Surgical Infection Improvement (SSII) program. Surveillance criteria are for 90 days post-operative for deep infection and 30 day for superficial infection. WDHB met performance targets for compliance with process measures involving prophylactic antibiotics and anti-septic skin preparation. Therefore, other factors including acuity of surgery, perioperative wound care, risk of bleeding post operatively etc. may be contributory. IPC planned initiatives included undertaking a quality improvement project to determine any additional perioperative risk factors for SSI s (e.g. wound care, drains) which has been abandoned now after resignation of the IPC quality improvement lead. Other initiatives include improved real time feedback process after an event, reporting all deep SSI s as SAC-2 events and expansion of surveillance procedures after improved ICNET functionality. SSI s per 100 procedures (July Sept 2017) WDHB Quarter 2014 Q2 Q3 Q Q2 Q3 Q Q2 Q3 Q Q2 Q3 WDHB total procedures No. of SSIs NA 203

212 WDHB SSI Rate versus National SSI Rate WDHB rate National rate SSI Rate Jan-Mar 14 Apr-Jun 14 Jul- Sept 14 Oct-Dec 14 Jan-Mar 15 Apr-Jun 15 July-Sept 15 Oct-Dec'15 Jan-Mar'16 Apr-Jun'16 Jul-Sep'16 Oct-Dec'16 Jan-Mar'17 Apr-Jun'17 Jul-Sept'17 Types of SSI WDHB 4 3 number of SSI Jan- Mar 14 Apr- Jun 14 Jul- Sept 14 Oct-Dec 14 Jan-Mar 15 Apr-Jun 15 July- Sept 15 Oct- Dec'15 Jan- Mar'16 Apr- Jun'16 Jul- Sep'16 Oct- Dec'16 Jan- Mar'17 superficial hip deep hip superficial knee deep knee Apr- Jun'17 Jul- Sept'17 Comments: Total of 893 in scope procedures performed from Jan Sept 17 with 10 SSI to date. Risk Pro completed for 4 SSI graded as SAC-2 for more transparent investigation to understand and improve other potentially modifiable risk factors. Analysis of discrepancy in the SSI rate between ESC and NSH, patient and perioperative risks is underway. WDHB in process of finalising pre-operative S.aureus decolonisation strategy as part of the HQSC initiative to further reduce SSI rate. 8. Influenza Surveillance 2017 WDHB had a busy Influenza season which peaked in June to August and now seems to be declining sharply. In addition to much higher than national average of community Influenza like illness presentations, the number of confirmed Influenza presentations to ED and those admitted to hospital (up to 50% of all confirmed cases) was also high. Graph below shows the number of both Inf A and Inf B cases across both acute care hospitals. 204

213 Number of positive inpatient cases Number of positive inpatient cases NSH total = 502 cases NSH influenza A and B 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 flu B flu A WTH total = 406 cases WTK influenza A and B Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 flu B flu A Number of confirmed Influenza patients at WDHB Community vs Healthcare* (HCA) acquisition Mar- Sept NSH 71 HCA cases WTK 27 HCA cases Mar Apr May Jun July Aug Sept Mar Apr May Jun July Aug Sept Community Healthcare Note: includes only confirmed patient cases where ILI symptoms developed 48 hours after admission. Source of acquisition variable (HCW, patient, visitors). 205

214 10. Communicable Diseases, Clusters and Outbreaks Contact tracing Sept 2017 Disease Total cases Ward No of patient contacts traced No of staff contact traced Comments Pertussis 2 EDWTH 0 10 All staff followed up by OCH&S. Both patients were not in droplet precautions on admission 4.3 N meningiditis 1 Ward N meningitis isolated in sputum. Staff and inpatient contacts were given prophylaxis Haemophilus influenzae 1 Titirangi 10 0 H influenza isolated from blood cultures. Contact tracing recommended by ARPHS as unable identify type of H influenza until confirmation from ESR. Outbreaks Sept 2017 Disease /MRO Total no of outbreaks Ward Ward closure Lost bed days No of patients with disease /MRO No of staff with disease Comments Confirmed Norovirus 1 Wards Ward Widespread gastroenteritis caused by norovirus spread across 5 multi bedded rooms for both ward 14/15 both wards.ward was closed to admission for duration of outbreak. Unable to establish index case for outbreak as several patients and staff developed symptoms at the same time. Both wards were reopened after entire ward was Deproxed cleaned. The outbreak was contained with no new cases with heightened IP&C auditing, increased cleaning, limiting staff and visitors to ward to essential staff and limiting patient movement to essential services 11. Environmental issues Area Issue Follow-up Outcome CCU NSH Ceiling vents throughout going to be put on a roster for cleaning. Toilet brushes being ordered to replace old ones Very clean, tidy and well maintained ward. ED WTH Dust found on several surfaces and equipment in ED. Faecally stained commodes. Maintenance issues identified odour? drains A follow up Environmental Review is scheduled take place 3 weeks from date of this review. BEIMS logged Clinical support service delivery coordinator to report back to IPCNS and Rangatira CNM when cleaning issues identified have been addressed 12. Projects ESBL FAST Project: Meet held to discuss progress with ESBL FAST project, post intervention auditing component still outstanding to complete project. ICNET project: planned re-launch of ICNET is for 10 th November Building, Renovations and other issues IP&C input: ESC expansion planning continues IP&C involvement on hold Ideal ward project IP&C and Clinical Microbiologist involvement WDHB Kitchen renovation Ward 7 refurbishment Wainamu refurbishment continues ED Waitakere expansion reopened with IP&C input NSH Theatre refurbishment continues Surgical Pathology refurbishment IP&C involvement in ANTT implementation Evaluation of new products. Maintenance of Jupiter P 1 Respiratory Equipment 206

215 4.3 National Orthopaedic Surgery Report January to March 2017 Hip and knee arthroplasties Surgical Site Infection Improvement Programme SSII Programme National Orthopaedic Surgery Report Page 1 of