BAY OF PLENTY DISTRICT HEALTH BOARD GOOD TO GREAT - MĀORI HEALTH

Transcription

1 BAY OF PLENTY DISTRICT HEALTH BOARD GOOD TO GREAT - MĀORI HEALTH

2 Contents Page Page No. 1. One page summary of Good to Great - Key messages Priority Actions Maori Health Plan Focus - Good to Great Action Plan Maori Health Steering Group Terms of Reference /17 Maori Health Plan Good to Great Presentation 50.

3 One page summary of Good to Great: Maori Health 1. Improving Maori Health is good for all 2. Improving Maori Population Health is every one s responsibility 3. We will operate from a strengths based philosophy and build on the positive achievements in Maori Health 4. We recognise partnering effectively with Iwi is fundamental to a Maori Health strategy and plan 5. There will be a deliberate focus on accelerating the achievement of equity for Maori by focusing on mainstream responsiveness. 6. Our mainstream responsiveness approach will prioritise the implementation of the Maori Health Plan priorities as these are evidenced based and this is where we will get the greatest health gain. 7. We have set explicit goals which are: a. there will be no MHP indicators in the red by 18 months b. all the indicators will be in the yellow and green in 3 years. 8. Leadership and oversight of this will be through the Maori Health Plan Steering Group which comprises primary care, NGO, clinical and BOPDHB executive representatives 9. We will have a much stronger focus on delivering on the Maori Health Plan priorities through the consistent application of Institute of Health Innovation and PDSA quality improvement methodology 10. In line with our commitment to Pae Ora we recognise the importance of the broader determinants and the need to work with other agencies and stakeholders however we will leverage the MHP priorities to undertake this intersectoral work. 11. We are promoting an ownership rather than an accountability leadership culture. Our experience shows us the most effective champions/change agents are those individuals who step up to take ownership rather than wait for it to be imposed or assigned 12. We acknowledge there are also other important measures for Maori Health such as Mauri Ora, Whanau Ora and Wai Ora. We know implementing the MHP will contribute to the achievement of these broader Pae Ora measures 3

4 August Board/Runanga endorsement of Priority Actions NO RED PDSA 3. MAINSTREAM RESPONSIVENESS OWNERSHIP EQUITY EQUITY 4

5 MAORI HEALTH FOCUS WAY FORWARD Strategic Objectives: ACTION PLAN 1. To improve maori population health to achieve equity 1 through focusing on the Maori Health Plan 2. Accelerate the achievement of equity through an increased focus on mainstream responsiveness Key themes/actions Impact to reducing the disparity gap Timeframe Accelerating Maori Health Equity through the following actions 1. Systems A. Dedicated resource and support Provide dedicated resource and support to accelerate mainstream responsiveness; and to support the current equity clinical champions. Exec. Sponsors, Service Improvement Unit High By 28 February 2017 The following key areas will need dedicated service improvement resource: - ASH (Provider Arm & Primary Care) - Breastfeeding - Screening Breast and Cervical - Smokefree -2 week Post Natal - Oral health preschool enrolment in a dental clinic B. Quality Service Improvement Apply consistent quality improvement processes. High By 28 February Utilise Service Improvement Unit (SIU) resource to support change management / service improvement initiatives and dedicated resource to the MHP priorities. - Refocus TTHW resource to have a greater change management/service improvement approach as part of the core function of the team. - Partner with Ko Awatea and Te Tumu Whakarae to provide peer review and support of existing equity focused service improvement initiatives. - Utilise Clinical Equity Champions such as the Toi Te Ora Public Health Unit, Regional Maori Health Services and Service Improvement Unit (SIU). - Consistently apply IHI methodology/heat Tool Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health Inequities therefore involve more than inequality with respect to health determinants, access to the resources needed to improve and maintain health or health outcomes. They also entail a failure to avoid or overcome inequalities that infringe on fairness and human right norms. World Health Organization 5

6 C. Health Equity Performance: Set Equity targets for the DHB MHP. - No red indicators in 18 months - All yellow and green in 3 years High - By February By August 2019 Refer to the - Maori Health Plan 16/17 - Trendly Performance Reports - 6

7 2. Leadership A. Demonstrating Executive Leadership Increase frequency of MHSG meetings from quarterly to bimonthly and Maori health dashboard report to be submitted quarterly to Executive, Board and Runanga. B. Greater ownership. Confirm indicator champions focusing on the top 5 indicators. Executive Sponsors assigned to the top 5 indicators. Champions are change agents. High High Immediate Immediate MHPSG will be the new mechanism to report at a governance level To improve line of sight and accountability of the MHP to the Board and Runanga. MHPSG provides leadership and oversight, because composition of group is whole of system, with strong executive, primary care and clinical leadership. There will be an added emphasis on the following national key priorities as this is where we have greatest disparity between Maori and non Maori: ASH Breastfeeding Maori Health Plan Champions Phillipa Jones & Pete Chandler Viv Edwards & Tracey Johnson MHSG Sponsor Pete Chandler & Simon Everitt Janet McLean C. Set equity KPI s These are inherent within the Maori Health Plan and includes evidence based targets High By February 2018 Screening Breast and Cervical Smokefree -2 week Post Natal Oral health- preschool enrolment in a dental clinic Kiri Peita & Michelle Murray Brian Pointon, Stewart Ngatai and Marg Norris Martin Steinmann Janet McLean Janet McLean Pete Chandler & Janet McLean There will still be a drive to improve DNA as this is a local priority. Establish equity KPI s for each executive member. 7

8 3. Mainstream Responsiveness Key themes/actions A. Improve Mainstream responsiveness through partnering Impact/amenability to reducing the disparity gap High impact in the short term. Once the key performance indicators and culture changes within the organisation then there should be a significant impact in addressing equity. Timeframe 31 August 2017 /Ongoing Accelerating Maori Health Equity through the following actions Service Level Agreements Planning and Funding and the Provider Arm will agree on the Maori Health Adjuster being passed on only under the achievement of agreed Maori Health targets Planning and Funding will work closely with key stakeholders to ensure they understand the key actions adopted by BOPDHB to accelerate Maori Health equity and the rationale. Relevant agreements will have incentive payments on the achievement of the key priority indicator Agreements will need to be adjusted to change how the funding is attributed. Incentive payments will correlate in an immediate effect. Equity KPIs Introduce incentives for the achievement of equity e.g. longer term contracts, penalise for non- performance withhold % of payments. Underpinning the success of achieving equity is the ability to align proportionate resources to the areas of greatest priority if there are to be significant shifts to achieve equity. DHB Job Descriptions All Job descriptions have an agreed standard terminology which emphasizes personal responsibilities under the Treaty of Waitangi to underpin mainstream responsiveness Mainstream Emotional Connectedness Determine appropriate ways for operational/service teams to connect with Iwi (e.g. the Runanga) to allow open discussion about Maori Health improvement, obstacles and barriers. Actions: - Align Maori Health Plan priorities into all relevant mainstream contracts - Link contract performance payments to the attainment of equity performance targets - Build equity indicators into all mainstream agreements targeted to priority indicators where those providers have influence - Provide incentives for providers who deliver on equity targets such as longer term contracts, - Target resources to implement changes (a cost-effectiveness 8

9 3. Mainstream Responsiveness metric could be used to assess potential projects and contracts, such as cost per units of equity achieved) - He Ritenga completed - Audit recommendations implemented 4. Maori Health Plan Performance Improvement Key themes/actions A. Maori Health performance data needs to be visible, accessible and translated into information and stories that compel action Impact to reducing the disparity gap Moderate High As with many communications and messaging it will take time to and socialize amongst the workforce and community to drive change. Timeframe Ongoing Immediate- Communication Plan Accelerating Maori Health Equity through the following actions As highlighted there are key tools and information that can be utilised to better prepare and develop a communication strategy or mediums to create a greater awareness of achieving these indicators by using client stories and the real time impact - Regular Trendly reporting - Dashboard report - Patient Whanau stories - Media and article publications - CEO newsletter, check up 9

10 5. Pae Ora Key themes/actions A. Pae Ora and He Pou Oranga Implement measures that address the wider determinants of health Impact/amenability to reducing the disparity gap High impact Timeframe 24 months plus/ongoing Accelerating Maori Health Equity through the following actions This is very similar to the intent and outcomes of working towards achieving the IHS Pae Ora shifts the focus towards the broader determinants of health. - Pae Ora summit in collaboration with interagency leadership group - Build in strength-based population health outcomes that sit above Trendly target reporting (could present in a driver diagram) to better reflect Pae Ora future state. - Could also consider other targets outside of Trendly such as Whanau Ora outcomes - Start with the Whanau Ora partnership Group s better public service Whanau Ora indicator. Build on these to include outcome measures from the Whanau Ora Needs Assessment report. B. Mauri Ora: Healthy Individuals Every health intervention provides an opportunity to shift a mauri from languishing to flourishing. Treating the health problem can be associated with encouraging self-management, fostering healthy lifestyles, increasing health literacy, strengthening identity and restoring dignity. A good outcome reflects health gain and strengthened mauri. [this is not really an action but a statement] High/Medium impact 24 months plus/ongoing Phased implementation in agreements to link health literacy outcomes and services 10

11 5. Pae Ora C. Whanau Ora: Healthy Whanau Every service offered or funded by the DHB should seek to transfer knowledge and skills to whanau that empower whanau to understand, self-navigate and manage their own health conditions. High impact 24 months plus/ongoing Phased implementation in agreements to link health literacy outcomes and services D. Wai Ora: Healthy Environments Health interventions must take into account the nature and interaction between people and their surrounding environments. Health interventions should avoid or reduce risk factors and strengthen protective factors. Moderate impact in the near future 24 months plus/ongoing Health in All Policies 2 Refer - Integrated Health Strategy work plan HiAPs - Pae Ora work plan E. Board and Runanga leadership to sponsor an equity summit Establish an equity fund sponsored by both the Board and Runanga inviting proposals to test new models, out-ofthe-box thinking and approaches to promote equity for Maori and other high need groups. High 24 months plus The equity summit will have a high impact in creating a shift at a community level. This will also have positive impacts in working towards achieving equity at a population level. The approach adapted to this could be similar to the Maori Health Excellence Seminars and the top four indicators could be breakout sessions. Bring in other top performers who have achieved successful outcomes so we can learn from their experience Establish an equity fund partner with organisations to help fund initiatives. - The current policy environment (Productivity Commission s Report) has an increasing focus on the 20% of the population who are missing out and the report recommends the need to fundamentally change the way 2 (HiAP) is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP emphasises that government objectives are best achieved when all sectors include health and wellbeing as a key component of policy development. This is because the causes of health and wellbeing lie outside the health sector and are socially and economically formed. 11

12 5. Pae Ora we deliver and fund services to this cohort. - Invite expert international, national and local speakers to present and show case excellence and innovation in equity. Speakers could include experts like, Mason Durie speaking on Pae Ora, Graham Scott on the Productivity Commission report international indigenous speaker. 12

13 Māori Health Plan Steering Group Terms of Reference ROLE Māori Health - Achieving equity is one of the Board and Runanga four key priorities. The long-term goal is for Māori within the Bay of Plenty to have the same level of wellness as non-māori. Achieving equity will mean that by 31 December 2017 every indicator that is in the red (20% or more disparity gap between Maori and non-maori) will have closed the gap to within 10%. By 2019 every indicator will be either the same if not better than the performance for non-maori. There are 14 indicators in the Māori Health Plan (MHP), with 11 national and 3 local. Within the 14 indicators, as a DHB we have identified five with the highest priority for Māori Health. The top five are: 1. Ambulatory sensitive hospitalisations (ASH) hospital admissions that could have been averted through interventions delivered via primary care 2. Oral Health - Māori pre-school Dental clinic enrolment rates 3. Maternal Health - Full and exclusive breastfeeding (6 weeks, 3 mths, 6 mths) 4. Smoking - Māori women who are smokers at 2 weeks post-natal 5. DNA (Did not attend) rates The role of the Maori Health Plan Steering Group (MHPSG) is to ensure these top five priorities continue to be standing items on the MHP Steering Group meeting agenda to support the monitoring, accountability and emphasis on achievement. MEMBERSHIP Membership of the MHPSG comprises members of the BOPDHB Exec team, Toi Te Ora, PHOs and Māori Health Planning and Funding team members as follows: General Manager, Māori Health Planning and Funding General Manager, Planning and Funding Public Health Medical Leader Toi Te Ora (Chair) Chief Operating Officer Chief Medical Officer Director of Nursing Director of Allied Health CEO of Nga Mataapuna Oranga PHO CEO of Western Bay of Plenty PHO CEO of Eastern Bay Primary Health Alliance PURPOSE The purpose of the MHPSG is to drive the achievement of equity by closing the gap between Maori and non-maori by 2019; to provide leadership and ownership achieving the targets for each of the 14 indicators; and to oversee the work of the Māori Health Plan Champions. The 13

14 Champions have the full support of the MHPSG and will attend the Bi-monthly meetings as requested. A full list of Champions, project management support and Exec sponsors is attached as Appendix 1. MĀORI HEALTH PLAN CHAMPIONS The Board and Runanga have endorsed the importance of having champions leading activity, as one of the key contributors to success. While it is important that we have MHP champions to lead and coordinate work in this area, it is equally important to stress that it is a shared responsibility and that it requires a whole of system response. By focusing, as an organisation, on achieving equity for Māori, we can make a difference. Consistent with the proportionate universalism concept the DHB recognises that to reduce Māori inequalities maximum impact will be gained by not just focusing on funding programmes targeted at Māori in isolation but also funding universal interventions at a scale and intensity that is proportionate to the level of need. This will be a key focus moving forward. Ownership and leadership by our champions will involve the following: allocation of sufficient time to undertake the champion role and if need be improve performance utilising tools such as the Plan, Do, Study, Act methodology; having an overview of work being undertaken in the MHP indicator area and encourage a coordinated approach with the key stakeholders; have shared accountability and access to mechanisms that support achievement in the MHP indicator area; operate at the coalface driving service improvements and change; collate and analyse relevant data; and provide monthly progress reports and attend the quarterly MHP Steering Group meetings as requested to report progress. Progress reports will outline the following: 1. results against targets, highlighting reductions in inequalities; 2. key learnings; and 3. For any measures not achieving target 3-4 key actions being undertaken to lift our performance, and with an indication of when an improvement is likely. MEETINGS The MHPSG meets bi-monthly. REPORTING Each quarter the MHPSG will report back to the Board, Runanga and Exec Council using the Māori Health Plan Dashboard report as a vehicle to report on the latest progress on the health targets as outlined in the latest Māori Health Plan 16/17. Please see Appendix 2 for an example of the reporting template. 14

15 Appendix 1 Maori Health Plan Champions List 2016/17 National Priorities Indicators Status as at 30 June 2016 Champion Champions Project Team Exec Sponsor Access to care Maternal health Cancer Immunisation 1. Accuracy of ethnicity reporting in PHO registers Gareth Hudson-BOPDHB PHO Data/IT leads Simon Everitt 2. Percentage of Maori enrolled in PHOs and GP Clinics (Reporting only) 3. ASH rates per 100,000 (2010 calculations) 4. Full and exclusive breastfeeding (6 weeks, 3 mths, 6 mths) 5. Breast screening rate (50-69 years) 0-4 yr Philippa Jones - WBOP yr PHO 6 weeks 3 months 6 months Gareth Hudson-BOPDHB PHO Data/IT leads Simon Everitt Andrea Baker Jackie Davis Tim Slow Viv Edwards- Plunket Connie Hui Tracey Johnson Te Manu Martin Steinmann Toroa Marg Norris Kiri Peita- BOPDHB Michelle Murray-EBPHA 6. Cervical screening rate (25-69 years) Lynne Dobbs - BOPDHB 7. Percentage of 8 month olds fully immunised 8. Percentage of the population (>65 years) who received the seasonal influenza immunisation Andrea Baker- BOPDHB Janice Kuka - NMO Brian Pointon- BOPDHB Smoking 9. Maori women who are smokers at 2 weeks post-natal Brian Pointon- BOPDHB George Gray Carliza Patuawa Jeane Rossiter Philippa Jones George Gray Carliza Patuawa Jeane Rossiter Philippa Jones Roger Taylor Michelle Murray Jackie Davis Jackie Davis Andrea Baker Stewart Ngatai Marg Norris Pete Chandler Simon Everitt Janet Maclean Janet Maclean Simon Everitt Janet Maclean Simon Everitt Simon Everitt Pete Chandler 15

16 Rheumatic Fever 10. Reduction in rheumatic fever rates Brian Pointon BOPDHB Connie Hui Sandra Ball Lesley Watkins Mental Health 11. Mental Health Sue Mackersey BOPDHB Kiri Peita Eileen Hughes Janet Maclean Pete Chandler Oral health 12. Maori pre-school Dental clinic enrolment rates Martin Steinmann Connie Hui Tim Slow Janet Maclean Sudden Unexpected Death of an Infant (SUDI) 13. Lower rates of SUDI among Maori infants Raewyn Lucas/Martin Steinmann Connie Hui Tim Slow Pete Chandler Local Priorities Indicators Status Champion Project Team Exec Sponsor Did Not Attend (DNA) 14. Did-Not-Attend (DNA) outpatient appointments (% per year) Bronwyn Anstis- BOPDHB Service Improvement Unit Jewelz Taylor Jen Boryer Pete Chandler Target attained Within 10% of target Indicator Legend ASH Legend National rate for Other(non-Maori, non-pacific) ethnic group attained 1-1.5x ASH rate for Other ethnic group 10-20% away from target 1.5-2x ASH rate for Other ethnic group Greater than 20% away from target Indicates top four target with greatest inequality gap Greater than 2x ASH rate for Other ethnic group Not applicable to ASH 16

17 Appendix 2 Maori Health Champions Reporting Template Please find below a template for you to input the information needed to be addressed by the Maori Health Plan Steering Group (MHPSG) 1. The below template is to be used for ALL INDICATORS EXCEPT ASH rates; and Maternal Health Breastfeeding (See second template (second page) below for those) Priority # Indicator Baseline Maori Target Result Maori Result Non Maori Commentary : -has there been a reduction in inequalities -If so what are the key learnings; and -If not why not, include 3-4 key actions being undertaken to lift performance and when improvement is likely to be seen <Champion to enter and to consider the 3 questions below for their response> <INSERT INDICATOR PRIORITY> <INSERT INDICATOR> i.e. Maori women who are smokers at 2 weeks post-natal <To be inserted by Administration> <Champion to enter> <Champion to enter> <Champion to enter> 1. has there been a reduction in inequalities 2. If so what are the key learnings; 3. If not why not; and 4. Include 3-4 key actions being undertaken to lift performance and when improvement is likely to be seen 17

18 2. The below templates are for ASH rates and Breastfeeding Priority # Indicator Baseline Maori Target Result Maori Result Non Maori Commentary : -has there been a reduction in inequalities -If so what are the key learnings; and -If not why not, include 3-4 key actions being undertaken to lift performance and when improvement is likely to be seen Access to Care ASH rates per 100,000 (2010 calculations) Maternal Health Full and exclusive breastfeeding: 6 weeks 3 mths 6 mths) 0-74 yrs. 0-4 yrs yrs. 6 weeks 3 months <Admin to do> <Admin to do> <Admin to do> <Admin to do> <Admin to do> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter> <Champion to enter and to consider the 3 questions below for their response> 1. has there been a reduction in inequalities 2. If so what are the key learnings; 3. If not why not; and 4. Include 3-4 key actions being undertaken to lift performance and when improvement is likely to be seen <Champion to enter and to consider the 3 questions below for their response> 1. has there been a reduction in inequalities 2. If so what are the key learnings; 3. If not why not; and 18

19 Priority # Indicator Baseline Maori Target Result Maori Result Non Maori Commentary : -has there been a reduction in inequalities -If so what are the key learnings; and -If not why not, include 3-4 key actions being undertaken to lift performance and when improvement is likely to be seen 6 months <Admin to do> <Champion to enter> <Champion to enter> <Champion to enter> 4. Include 3-4 key actions being undertaken to lift performance and when improvement is likely to be seen 19

20 BAY OF PLENTY DISTRICT HEALTH BOARD MĀORI HEALTH PLAN 2016/17 20

21 Contents Overview Abbreviations Māori Population: Profile and Health Needs National Indicators Accuracy of ethnicity reporting in PHO registers Percentage of Māori enrolled with PHOs Ambulatory sensitive hospitalisation rate (0-4, 45-64, 0-74 years) Full and exclusive breastfeeding rates at 6 weeks, 3 months, and 6 months Breast screening rates (50-69 years) Cervical screening rates (25-69 years) Smoking cessation in pregnancy Percentage of infants fully immunised by eight months of age Seasonal influenza immunisation rates (65 years and over) Reduction in rheumatic fever rates Oral health Mental health Sudden Unexpected Death of an Infant (SUDI) Local Indicators Did-Not-Attend (DNA) rate for outpatient appointments Appendix A Methodology for Local Indicator Selection References Version This document is subject to ongoing updates. Readers are encouraged to refer to the BOPDHB website for the latest version of the plan. Please direct correspondence related to this plan to george.gray@bopdhb.govt.nz 1 21

22 Overview This plan describes Bay of Plenty District Health Board s (BOPDHB) priorities in Māori health for the time period. This plan aligns with the requirements of the New Zealand Public Health and Disability Act (2000) which directs District Health Boards (DHBs) to reduce disparities and improve health outcomes for Māori. The format of this plan and the indicators listed within it follow the direction given in the 2016/2017 Māori Health Plan Guidance from the Ministry of Health. This plan aligns with the BOPDHB s Annual Plan (AP) and the Midland DHBs Regional Services Plan. Over the coming year we will continue to take a population health approach to Māori health. We will continue to work with other organisations to address the primordial causes of health inequality and to address the indicators listed in this plan. As in the past, we will monitor progress through our Māori Health Plan Steering Group (MHPSG); this quarterly forum comprises representatives from the various organisations involved in achieving the targets listed in this plan. The group includes representatives from primary care, secondary care, regional public health services, community providers, and the DHB. The Māori Health Plan gives a one-year subset of actions and aspirational targets related to Māori health; longer term activities (2-5 years) to improve health for Māori and non-māori are described in the BOPDHB Annual Plan. The methods used to determine the local indicator listed in this plan is summarised in Appendix A. In addition to the Māori Health Plan Steering Group, quarterly performance results for the Māori Health Plan indicators will be disseminated to four key audiences. First, results will be submitted to the Board for review and discussion in the same manner that Annual Plan and Health Target results are presented. Second, quarterly performance reports will be reviewed by the DHB Runanga. Third, quarterly performance results will be presented at the DHB s executive management meetings. These three dissemination groups represent both operational and governance levels of the organisation. Fourth, the DHB s Māori Health Plan performance will be presented in our Annual Report. We look forward to progressing the objectives described in this plan. 2 22

23 Abbreviations ABC ACS AP ARF ASH BFHI BOP BOPDHB CME COPD CVD CVRA DAR DHB DHBSS DMFT DNA EBPHA ENT GM HbA1C IGT IHD ISP ISDR MHPSG MOH NCHOD NMO NSU NZ NZHS PHO POPAG RR WBOPPHO An approach to smoking cessation requiring health staff to ask, give brief advice, and facilitate cessation support. Acute Coronary Syndrome Annual Plan Acute rheumatic fever Ambulatory sensitive hospitalisation Baby friendly hospital initiative Bay of Plenty Bay of Plenty District Health Board Continuing medical education Chronic obstructive pulmonary disease Cardiovascular disease Cardiovascular risk assessment Diabetes annual review District Health Board DHB Shared Services Diseased, Missing, or Filled Teeth Did not attend (used in the measurement of outpatient clinic attendance) Eastern Bay Primary Health Alliance Ear, nose and throat General Manager Glycosylated haemoglobin Impaired glucose tolerance Ischaemic heart disease Independent service provider Indirectly standardised discharge rate Māori Health Steering Group Ministry of Health National Centre for Health Outcomes Development Nga Mataapuna Oranga (Primary Health Organisation) National Screening Unit New Zealand New Zealand Health Survey Primary Health Organisation Population Health Advisory Group Rate ratio Western Bay of Plenty Primary Health Organisation 3 23

24 Māori Population: Profile and Health Needs 1. Geographic Distribution BOPDHB s population was 215,000 at the 2013 Census. 25% of BOPDHB s population identified as Māori (53,700 people) at the Census, compared with 14% nationally. 1 BOPDHB comprises five territorial authorities. In 2014 the majority of the population were based in western areas, 56% lived in Tauranga City with a tapering population count towards the east; Absolute numbers of Māori reflect the total population s pattern, tapering from west to east. However Māori make up a greater proportion of each district s population toward the east. Table 1. Bay of Plenty (BOP) population distribution by territorial authority. 2 District Western BOP Tauranga Whakatane Kawerau Opotiki Total Popn. 45, ,800 34,300 6,600 8,830 Māori Popn. 8,795 21,734 15,167 4,043 5,262 Māori (%) Health Service Providers Key health service providers in BOPDHB include: Two public hospitals: Tauranga (349 beds) and Whakatane (110 beds). Three PHOs. Multiple local and national non-profit and private health and social providers. 3. Iwi within BOPDHB Multiple Iwi lie within or across BOPDHB s borders including: Ngai Te Rangi Ngāti Ranginui Te Whānau ā Te Ēhutu Ngāti Rangitihi Te Whānau ā Apanui Ngāti Awa Tūhoe Ngāti Mākino Ngāti Whakaue ki Maketū Ngāti Manawa Ngāti Whare Waitahā Tapuika Whakatōhea Ngāti Pūkenga Ngai Tai Ngāti Whakahemo Tūwharetoa ki Kawerau 4. Age Distribution of the Māori Population In 2013, BOPDHB s over-65 population was proportionately larger than the national average (17.5% vs. 14.3%), with both the BOPDHB and national populations getting older; The BOPDHB Māori population is skewed towards younger age groups, one-third of Māori are aged under 15. In comparison just 17% of non-māori are aged under 15; Only 7% of Māori are aged over 65, whereas 22% of non-māori are over the age of 65. Table 2. Age distribution of the BOPDHB population. 3 1 "District Health Board Māori Health Profiles 2015, Research..." Mar < 2 Statistics NZ infoshare, Population Estimates at 19/11/2014. Baseline 2013 Census 3 "District Health Board Māori Health Profiles 2015, Research..." Mar < 4 24

25 5. Population Growth Projections Māori are projected to comprise a consistent 25% of the DHB s population to However, the median age for this group will continue to be significantly younger than the total population of BOPDHB. Table 3. Age distribution projections of the BOPDHB population to Deprivation Distribution Māori in BOPDHB are more likely to be in the two most deprived NZDep categories than non-māori in the DHB or nationally. Over 50% of BOPDHB were found in NZDep 9 and 10 in 2013; 17% of non-māori were found in the same deciles. 4% of Māori are within NZDep deciles 1 and 2 compared with 15% of non-māori. Figure 1. NZDep distribution of the BOPDHB Māori and non-māori populations. 5 4 ibid. 5 ibid. 5 25

26 7. Primary Care - PHO Enrolment In Q the highest number of Māori were enrolled with Eastern Bay Primary Health Alliance (EBPHA), followed by Western Bay of Plenty PHO (WBOPPHO), and finally Ngā Matapuna Oranga PHO (NMO). Table 4. Enrolled populations in BOPDHB PHOs as at Q PHO EBPHA WBOPPHO NMO Total Enrollees 45, ,466 11,385 Māori 21,232 18,864 8,107 Māori (%) "Enrolment in a primary health organisation Ministry of..." Mar < 6 26

27 National Indicators Accuracy of ethnicity reporting in PHO registers Outcome we seek: How will we know if we have been successful? Target: Māori: Non-Māori: Greater accuracy of ethnicity data in PHO enrolment databases. Ethnicity data accuracy will increase as measured through implementation of the Ministry of Health s primary care ethnicity data auditing tool. n/a - a target will be determined once baseline data has been collected Clinics and PHOs were introduced to the Ethnicity Data Audit Tool in will be used to gain baseline data, work with PHOs to set targets, and monitor performance improvement. n/a What we are planning to do: By 31 July 2016 By 30 November 2016 By 31 December 2016 By 28 February 2017 By 28 February 2017 By 31 January 2017 Milestone 1 - Appoint an indicator champion to oversee the completion of the tasks described here for this indicator. This will help improve ethnicity data quality by ensuring that the tasks described here are implemented and monitored through the year and that a key person is accountable for activity completion. Milestone 2 - Assess the level of implementation of the ethnicity data auditing tool (EDAT) among BOPDHB clinics. This will help improve ethnicity data quality by determining the level of implementation across PHOs and clinics; it will also help to identify the resources, training, and support required to implement the tool in all remaining clinics. Milestone 3 - Collate EDAT scores and ethnicity data accuracy for 80% of clinics in BOPDHB. This will help improve ethnicity data quality by ensuring that the EDAT has been implemented in a sufficiently high number of clinics. Milestone 4 - Facilitate sharing of best practice processes from high scoring clinics to others with low EDAT results within the three BOPDHB PHOs. This will help improve ethnicity data quality by accelerating organisational learning among clinics; the resources and processes used in the best performing clinics will be shared with clinics performing less well on this measure. Milestone 5 - Complete a register of clinic EDAT scores in order to track current implementation across clinics along with a repeat audit in 1-3 years (depending on initial results). This will help improve ethnicity data quality by identifying the clinics that have implemented the EDAT and setting a reminder date for the tool to be repeated. This will ensure that ethnicity data quality is repeatedly checked and improved. Monitoring will be performed through the quarterly meeting of the Māori Health Plan Steering Group. This group comprises representatives from each of the PHOs in BOPDHB. This forum will be used to collaborate with the PHOs on ways to improve the baseline results. Audit results will be provided to all general practices in keeping with the current performance feedback activities already performed by PHOs. 7 27

28 Percentage of Māori enrolled with PHOs Outcome we seek: How will we know if we have been successful? Increased access for the Māori population to primary health care services. 100% of Māori in BOPDHB will be enrolled with a PHO. Target: 100% Māori: 91% (Jan-Mar 2016) Non-Māori: 99% (Jan-Mar 2016) What we are planning to do: By 1 July 2016 By 1 July 2016 Finalise a champion for this indicator. Work with the Ministry of Health to incorporate additional patients into the PHO enrolment estimate who are engaged with a clinic that is not registered with a PHO (e.g. Te Kaha). This will improve access to care for Māori by giving a more accurate picture of primary care access and utilisation. By 1 July 2016 Compare the anonymised PHO enrolment demographics (numerator) with the 2013 Census (denominator) to identify enrolment gaps stratified by geography, ethnicity, gender, and other variables. This will improve access to care for Māori because it will help to identify the demographics of the 4,413 Māori who are not enrolled (as at February 2016) in PHOs. This will help BOPDHB and the PHOs to tailor enrolment initiatives towards these groups. By 31 August 2016 Ongoing By 31 December 2016 Provide PHO enrolment deficit analyses to PHOs in BOPDHB in order to help PHOs target enrolment improvement initiatives to specific populations. This will help improve access for Māori by helping PHOs to understand where enrolment gaps are in their communities. Track PHO enrolment on a quarterly basis. Complete an audit of ethnicity data accuracy in 80% of BOPDHB clinics (see previous indicator: Accuracy of ethnicity reporting in PHO registers). The audit will enable the Māori Health Planning and Funding Team to reconcile the impact of underreported or misclassified Māori ethnicity on reported PHO enrolment rates. Multiple studies have reported misclassification rates as high as 35%. 7 8 Ongoing Monitor indicator performance on a monthly basis through the Māori Health Planning and Funding Team. Monitor indicator performance on a quarterly basis through the Māori Health Plan Steering Group. 7 Bramley, Dale, and Sandy Latimer. "The accuracy of ethnicity data in primary care." Journal of the New Zealand Medical Association (2007). 8 Swan, Judith, Steven Lillis, and David Simmons. "Investigating the accuracy of ethnicity data in New Zealand hospital records: still room for improvement." New Zealand Medical Journal (2006). 8 28

29 Ambulatory sensitive hospitalisation rate (0-4, years) Outcome we seek: How will we know if we have been successful? Reduced ambulatory sensitive hospitalisation (ASH) rates in the 0-4 and age groups Indirectly standardised ASH rates for Māori will be the same as those for the total population of New Zealand. Targets (Māori): Māori: 0-4 years: 113 Māori: years 144 Baseline Māori (year to 31 Mar 2016): Baseline total population (year to June 2015): What we are planning to do: 0-4 years: years: years: years: 102 For the years age group: By 30 June 2016 Develop a test of change project focussed on reducing Māori ASH years and submit to the Alliance Leadership Team (ALT) for approval. Commence socialisation of the test of change in ED working with all stakeholders to develop a pragmatic innovative model to enable primary care or home based management of ED presenting ASH conditions. All Māori individuals presenting at ED will also be followed up by a primary care nurse to increase education and selfmanagement skills with the aim of reducing reoccurrence. Bi weekly meetings with Primary Care ASH champion and secondary care ASH cochampion plus secondary care managers to be established. Committed support and resource of the BOPDHB Service Improvement team and GPL to support reduction in ASH rates for Māori to be confirmed. This will ensure the tests of change are well supported from within the hospital environment and from general practice. Working party to look at heart failure self-management (SM) established within the Midlands cardiac network. Performance measure: Test of change approved by ALT Working party for heart failure SM established By 31 July 2016 Provision of CME and CNE education facilitated by DHB SMO s to support primary care management of commonly presenting ASH conditions affecting Māori. This will include heart failure, COPD, cellulitis and DVT All commonly presenting ASH conditions to be supported by a pathway visible on Bay Navigator. Funding secured to ensure that ASH conditions and related interventions can be managed at general practice at no cost to Māori patients. Funding also secured to support nursing support and intervention if a higher level of support is required or if home based services are required. Increase ASH visibility through the development of a shared data platform identifying ASH by condition, ethnicity, hospital site and PHO. Provision of a more detailed level of data identifying ASH conditions by practice to be provided to each PHO. Data to be refreshed monthly. Performance measures: 9 29

30 Bay Navigator pathways in place for all main ASH conditions Funding secured to support reduction of Māori ASH conditions Visible shared ASH data shared monthly By August 2016 Test of change within Tauranga ED completed, this will be supported by utilisation of a primary care nurse to assist with the identification of Māori patients who may be suitable for primary care management rather than admission. Heart failure self-management program availability within primary care. The selfmanagement program to be underpinned by the living with heart failure resource developed by the heart Foundation. Self-management may be in groups or on an individual basis and may be delivered in a home environment, Marae, Hauora or community clinic. Performance measures: Test of change implemented and completed in Tauranga. Number of Māori individuals who were referred to primary care instead of admitted to hospital for an ASH condition Number of eligible individuals accessing primary care delivered heart failure selfmanagement programs in WBoP. Reduction in Heart failure readmission rate By 30 Sep 2016 Employment of a full-time community advanced nurse to provide in-reach Māori advanced nursing support within specific Eastern Bay geographical locations to enable home based management of ASH presenting conditions rather than inpatient admission. Develop Baywide health promotion to manage skin infections and respiratory infections specifically targeting Māori. Usage of Tauranga Moana radio plus the free newspapers will support the promotion. The health promotion messages will be developed collaboratively with Toi Te Ora and will support Early presentation at general practice - Promotion of diabetes self-management group attendance for Māori, this will include continued support for provision of courses to be held on Hauora and Marae. - Promotion of self-management groups for heart disease including heart failure Performance measures: Advanced primary care nurse employed to support ASH reduction in EBoP Reduced ASH length of stay Full write up of the test of change in Tauranga and recommendations submitted to ALT. Decisions on next steps made. By October 2016 Explore the possibility of primary care undertaking the interface into ED. Write a test of change and submit this to ALT for consideration. Performance measure: Test of change submitted to ALT By January 2017 Referral to primary care of all suitable Māori ASH presentations who present at Tauranga ED. Performance measure: 15% Reduction of Tauranga ASH admissions 20% Reduction in Tauranga ASH length of stay Ongoing Monitor the ASH indicator on a quarterly basis through the Māori Health Plan Steering Group. What we are planning to do: By June 2016 For the 0-4 years age group: Establish Secondary Care paediatrician ASH lead and linkage with GP liaison Implement new dashboard for Māori children which gives clear visibility of 10 30

31 opportunity areas (splitting out ED, split by geography and presentation reason, PHO) Embed focus in mainstream service improvement priorities Establish secondary care led 0-4 ASH multi-disciplinary working group Performance measure: 1. Dashboard designed and circulated widely each month 2. Framework to support a two year improvement programme in place By 31 July 2016 All commonly presenting ASH conditions to be identified and a timetable produced for associated pathway development on Bay Navigator. ASH data refined to allow targeted action on opportunity areas to be listed on the dashboard with a quarterly improvement plan schedule developed Develop political linkages with local councils and MPs through Toi Te Ora and Board members to contribute to growing local discussions on solution to homelessness in Tauranga Include ASH measure in hospital balanced scorecards First defined target area improvement workstream commenced Establish mechanisms to follow up frequent fliers for follow up in appropriate clinic under the coverage of Regional Māori Health Services Performance measures: 1. Visible shared ASH data shared monthly across primary and secondary care teams 2. Clinical opportunities identified and prioritised for targeted improvement plan (one opportunity per quarter) 3. Initial sessions arranged with local council and MPs to share child ASH data 4. Defined first improvement area workstream commenced, with reporting through MHPSG to BOPALT By August 2016 For each high ASH presentation reason, determine from analysis whether this can be attributed to housing, geography, clinical decision making, GP access etc in order that each presentation type where there is a notable Māori-Non-Māori disparity has a primary reason determined. Commence a review of the ED component and establish a waiting time improvement target for 0-4 year olds which is less than three hours. Ensure that breaches are documented as relating to either clinical risk management or system capacity. Commence improvement programme on system capacity component Performance measures: 1. Reasons are specified for the most common ASH disparity presentations 2. ED presentation waiting time improvement plan developed for work over next three months By Sep 2016 By October 2016 By January 2017 Revision of dashboard to include information on what we know and what we need to determine pointers GP liaison to commence GP education programme on asthma action plans Commencement of prioritised opportunity area 3 improvement workstream Commencement of prioritised opportunity area 4 improvement workstream. Implement opportunistic ward immunisation protocol, INR status check on all admissions Performance measure: 15% Reduction of Tauranga ASH admissions (including ED 3+ hour waits) Ongoing 1. Monitor the ASH indicator on a quarterly basis through the Māori Health Plan Steering Group 2. Monitor the ASH indicator monthly through hospital balanced scorecards and Board reports 3. Monitor 0-4 year old ED wait times as a new internal target 11 31

32 Full and exclusive breastfeeding rates at 6 weeks, 3 months, and 6 months Outcome we seek: How will we know if we have been successful? Targets: Higher rates of breastfeeding for Māori infants at 6 weeks, 3 months, and 6 months. Māori infants will have attained breastfeeding rates consistent with the age-related targets set by the Ministry of Health in the Well Child Tamariki Ora Quality Improvement Framework. 75% at 6 weeks (full or exclusive) 60% at 3 months (full or exclusive) 65% at 6 months (full, exclusive, or partial) Māori (Jul-Dec 2015): 59.3% at 6 weeks (full or exclusive) % at 3 months (full or exclusive) 54.9% at 6 months (full, exclusive, or partial) NZ European/Other (Jul-Dec 2015): What we are planning to do: 75.3% at 6 weeks (full or exclusive) % at 3 months (full or exclusive) 70.3% at 6 months (full, exclusive, or partial) The factors influencing breastfeeding for Māori women have been identified in past research The barriers identified in the research include: difficulty establishing breastfeeding within the first six weeks; poor or insufficient professional support; perception of inadequate milk supply; and returning to work. The interventions listed below are aimed at addressing some of these factors by supporting initiation and delaying cessation of breastfeeding. 13 We will continue to achieve high initiation rates through continuation of the World Health Organization s Baby Friendly Hospital Initiative (BFHI) in BOPDHB hospitals. By 31 July 2016 Breastfeeding forum in the Western Bay of Plenty will be meeting regularly and have agreed on makeup of attendees and Terms of Reference. Key activities of this group to include a stocktake of breastfeeding promotion and support currently available to consumers, discuss trends where decline is evident, and strategise for improvement. This group will have representation at affiliated projects and groups in the DHB including Toi te Ora obesity steering group and Maternity Safety and Quality Governance Group. Monthly meetings will evaluate breastfeeding rates for Māori and trends occurring. This forum would also provide support for Baby Friendly Hospital Initiative (BFHI) in BOP DHB Hospitals and community events such as The Big Latch. This forum will evaluate the Baby Friendly Community Initiative for relevance to this community (BFCI) and BFHI maintenance as a universal activity. By 31 August 2016 Breastfeeding forum will work in collaboration with Māori Health, DHB, PHO, LMC and WCTO providers to provide planning for a service suitable for Whānau Access to receive improved support and education to increase breastfeeding rates. - This is envisaged as a targeted home-visit service where Marae-based support could also be successful, as has been implemented in Lakes DHB. Current data shows inequality with the earlier cessation of breastfeeding from Māori clients at the 3-month age band as compared with other ethnicities. This has been identified as an increasing trend across the past 3 quarters. Total population has exceeded the current target of 60% at each quarter. 9 Source: Ministry of Health. Data supplied April ibid 11 Manaena-Biddle, H, J Waldon, and M Glover. "Influences that affect Māori women breastfeeding." Breastfeeding Review 15.2 (2007): Glover, Marewa et al. "Barriers to best outcomes in breastfeeding for Māori: mothers' perceptions, whānau perceptions, and services." Journal of Human Lactation 25.3 (2009): Dyson, Lisa, F McCormick, and Mary J Renfrew. "Interventions for promoting the initiation of breastfeeding." Cochrane Database Syst Rev 2 (2005)

33 - Ensure pathways are developed for health professionals and clients to access timely lactation services. - Evaluate need for increased lactation service following stocktake of current level of service - If need is agreed upon, progress to business planning. By 31 March 2017 Well child providers to build on capacity and capability of evidence based lactation support. Assess WCTO Activity to support Breastfeeding support through measuring performance through care delivery components from individual well child practitioners for their caseload. Evaluate use of Mama Aroha talk cards within WCTO environment, assess for need of refresher training and practice development. Ongoing Monitor the breastfeeding indicator on a quarterly basis through the Māori Health Plan Steering Group

34 Breast screening rates (50-69 years) Outcome we seek: How will we know if we have been successful? Lower breast cancer morbidity and mortality among Māori women through better utilisation of the national breast screening programme for women aged years. 14 Screening rates for Māori women (50-69 years) in BOPDHB will have reached the national target of 70%. Target: 70% Māori (baseline): 59.9% (Q3 2016; Jan-Mar 2016) Non-Māori (baseline): By 31 July 2017 By 31 July 2016 By 31 July 2016 By 31 July 2017 Ongoing 73.5% (Q3 2016; Jan-Mar 2016) ISPs to implement recruitment strategies, 3 months prior to the scheduled breast screening mobile unit visit, for priority women to access the breast screening mobile unit specifically in the Katikati, Waihi, Te Puna region through a hapu approach to ensure maximum utilisation of allocated appointments, such as promoting the mobile screening unit on the local Tauranga Moana iwi radio station programme (Moana AM Māorivation), working with the Runanga, adopting Mana Wahine Champions from the hapu to promote mobile unit visits, working with local GP Practices. Performance Measure: Increase in the number of Māori women screened with the breast screening mobile unit. The ISPs will implement the Waikato DHB s Mammogram project which aims to focus on using daughters to encourage and support their mothers to get a mammogram, and to be a conduit of good information for their mothers. The approach also adds to the knowledge younger women have about breast screening for when they reach the 45+ age group. Performance Measure: Increase in the response rate (increased number of enquiries for enrolment or bookings). Results (increased number of bookings converted to completed mammograms). Awareness (feedback and overall assessment of campaign, plus follow-up survey of sample if required. Review the Institute of Healthcare Improvement project that was implemented in 2015/16 to understand bottlenecks in the patient journey, and make iterative changes to the intervention based on results from using a part-time patient navigator. Once iterative changes are identified work with PHOs to ensure data matching with BSM and apply the strategy to another GP clinic with low enrolments of eligible Māori women to the breast screening programme. Performance Measure: Increase in the number of Māori women who enrol to the national breast screening programme. ISPs, Planning and Funding, Primary Care and Colposcopy will participate in the regional planning process with BSA providers. Performance Measure: Participation in two regional coordination meetings per annum. Monitor performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team. Monitor screening performance on a quarterly basis through the MHSG. Performance Measure: Screening performance is monitored monthly and quarterly and key actions to lift performance are identified. 14 It is acknowledged that the national breast screening program facilitated by the NSU provides coverage for women aged The BOPDHB Māori Health Plan 2014/15 refers to the year age group in keeping with existing performance reporting for this indicator

35 Cervical screening rates (25-69 years) Outcome we seek: How will we know if we have been successful? Lower cervical cancer morbidity and mortality among Māori women through better utilisation of the national cervical screening programme for women aged years. 15 Cervical screening rates for Māori women will have reached the national target of 80%. Target: 80% Māori: Non-Māori: 65.3% (at Q2 2016, year age group) 86.6% (at Q2 2016, year age group) What we are planning to do: By 30/06/2017 The Taku Wahine Puroto programme (provision of outreach and after hours cervical screening services for eligible Māori women) to be extended and delivered by Western Bay of Plenty PHO, Nga Mataapuna PHO and Eastern Bay Primary Health Alliance. Performance Measure: Number of women screened at the outreach clinics By 31/12/2016 Toi Te Ora will assist PHO s with the use of the National Screening Unit s monthly electronic data-matching reports to identify women who have slipped through the General Practice recall systems Performance Measure: Number of practices supported to identify and recall unscreened and underscreened Māori women By 31/12/2016 Te Kupenga Hauora o Tauranga Moana will establish regular cervical screening clinics at Tauranga Hospital specifically targeting Support Services where there are high eligible Māori women employed. Eligible women will also be encouraged to enrol and book a breast screening appointment at the time of screening Performance Measure: Number of women screened at the clinic By 30/06/2017 Strengthen the communication skills of Primary Care Provider staff to enable improved cervical screening health literacy and improved access to cervical screening services particularly for Māori women Performance Measure: Number of training sessions delivered on taking a best practice health literacy approach to cervical screening By 31/12/2016 ISPs and Colposcopy to undertake a quality initiative to review and improve the relevant administration processes so Māori women receive timely colposcopy treatment Performance Measure: Māori women receive timely colposcopy treatment Ongoing Monitor performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team. Monitor screening performance on a quarterly basis through the MHSG. 15 It is acknowledged that the national cervical screening program facilitated by the NSU provides coverage for women aged The BOPDHB Māori Health Plan 2014/15 refers to the year age group in keeping with the indicator guidance listed on page 154 of the 2014/15 Operational Policy Framework on the National Service Framework Library website

36 Performance Measure: Screening performance is monitored monthly and quarterly and key actions to lift performance are identified

37 Smoking cessation in pregnancy Outcome we seek: How will we know if we have been successful? More Māori women who are smokefree at two weeks postnatal. The percentage of Māori women who were pregnant and were offered smoking cessation advice and support and who are smokefree at two weeks postnatal will increase over 2016/17 as a result of our efforts. Target: 95% Māori: 61% (Jan-June 2014) Non-Māori: 80% (Jan-June 2014) What we are planning to do: By 30 September 2016 Enhance referral pathways from LMCs, DHB midwives and ante-natal education providers to national and local smoking cessation providers, taking into account new providers and programmes funded by the Ministry following the Realignment of tobacco control services RFP process. By 31 December 2016 Provide training appropriate to providers and DHB staff on engaging with Māori pregnant women (and their whanau) and their smoking behaviours. Training will differ for staff depending on whether they are carrying out ABC and referring, or delivering a regular supportive quit smoking programme for Māori smoking pregnant women. By 1 April 2017 Increase the proportion of smoking Māori pregnant women who accept cessation support from 15.8% (Q2 2015/16 result) to 40%. Ongoing Work with the MoH to improve reporting on this indicator. Monitoring of the target at two weeks postnatal is not timely with a long lag period for results. It is not useful therefore for monitoring results changes quickly following introduction of new activities. Maternity tobacco data collected at registration with LMC is reported quarterly but does not reflect smoking status at two weeks postnatal. Ongoing Monitor smoking cessation advice provision performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team. Monitor smoking cessation advice provision and smokefree rates at two weeks postnatal on a quarterly basis through the Māori Health Plan Steering Group

38 Percentage of infants fully immunised by eight months of age Outcome we seek: How will we know if we have been successful? Reduced immunisation-preventable morbidity and mortality. 95% of Māori infants will be fully immunised by eight months of age (by 31 December 2014). Target: 95% Māori (Q2 2016): 86.2% Non-Māori (Q2 2016): 88.6% What we are planning to do: By 30 June 2017 By 30 September 2016 By 30 June 2017 Ongoing We will have met with at least 50% of Lead Maternity Carers (LMCs) in the Bay of Plenty by 30 June 2017 and agree a way forward to refer all expectant Mother s information to their respective GP at an earlier stage (when antenatal bloods available) so the practice can set up immunisation notifications. We will report progress on this initiative to the Māori Health Plan Steering Group on the following four dates: 1) 30 September 2016, 2) 31 December 2016, 3) 31 March 2017, and 4) 30 June We will conduct a review of the immunisation outreach services (OIS) contracts with PHOs to ensure the different models currently used are meeting the 95% target by 31 July We will explore with PHOs the potential benefits for the co-location of immunisation outreach staff and customise our approaches in order to reach 100% of nonimmunised babies by 30 September We will report to the Māori Health Plan Steering Group on interventions that will increase integration between the OIS, immunisation facilitators at the DHB and PHOs, and the NIR. We will report on the completion of these initiatives to the Māori Health Plan Steering Group by 30 September We will work closely with our PHOs to ensure that immunisation information relayed to parents, GPs, Nurses and the general public is consistent. We will work closely with individual PHOs to implement at least 3 immunisation promotional activities each by June We will report progress on this initiative to the Māori Health Plan Steering Group on the following three dates: 1) 31 December 2016, 2) 31 March 2017, and 3) 30 June Monitor immunisation performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team and via the BOPDHB Planning and Funding immunisation champion. Monitor immunisation performance on a quarterly basis through the Māori Health Plan Steering Group

39 Seasonal influenza immunisation rates (65 years and over) Outcome we seek: How will we know if we have been successful? Reduced influenza morbidity through increased seasonal influenza vaccination rates in the eligible population (65 years and over). 75% of Māori in the eligible population will have received the seasonal influenza vaccination in the period January to July Target: 75% Māori (Q ): Non-Māori (Q ): 62.6% (High-needs population) 69% (Total population) What we are planning to do: By 31 May 2017 By 31 May 2017 By 31 May 2017 Ongoing Promotion of the seasonal influenza vaccination through PHOs, Māori Women s Welfare League, Koroua and Kuia health service providers, Whanau Ora providers, and other Hauora providers, using the locally developed te reo resource. N.B. There is no national strategy for increasing uptake in Māori, nor any national health education resources produced in te reo. Promotion of the seasonal influenza vaccination through Māori media such as the Māorivation programme on Moana FM Tauranga. Enhanced recall processes in general practice for Māori patients aged 65+. This would involve more proactive engagement with whanau following the standard patient recall systems. Coverage rates are available by PHO by ethnicity through national data collections for primary health. This data is available on a quarterly basis only and is derived from practice payment claims. Data is also available from the NIR for vaccinations delivered in general practice and probably by 2017 winter from pharmacies, DHB staff and perhaps from other occupational health nursing services. The NIR data would be available monthly through datamart. Monitor immunisation performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team and via the BOPDHB Funding and Planning immunisation champion. Monitor immunisation performance on a quarterly basis through the Māori Health Plan Steering Group

40 Reduction in rheumatic fever rates Outcome we seek: How will we know if we have been successful? Target: Reduced rates of acute rheumatic fever. The admission rate for an initial case of acute rheumatic fever in BOPDHB will reach the target for BOPDHB established by the Ministry of Health, as part of the national two thirds reduction in hospitalisations by Reduction of first episode ARF cases in total population to 3 over the 2016/17 year. Reduction of first episode ARF rate in total population to 1.3/100,000 over the 2016/17 year. What we are planning to do: Detailed actions are documented in the Bay of Plenty Rheumatic Fever Plan Key activities are described below: By 31 December 2016 By 31 December 2016 By 31 July 2016 (ongoing) By 1 July 2016 and ongoing Ongoing Planning and implementation of a sustainable healthy housing programme across the BOP incorporating existing community projects in Western BOP District Council, Murupara township and Opotiki. Development of a funding strategy for 2017/18 that will allow the continuation of evidence-based sore throat management programmes in schools, community, and general practice that reach the priority populations. Carry out systems failure analysis of all new notifications of acute rheumatic fever, and put into place all recommendations arising from that analysis. Delivery of an effective, quality Bicillin preventative programme through district nursing primarily across the BOP district. Reconciliation of regulatory notifications to the Medical Officer of Health with admission records to obtain current numbers of cases and rates. Oversight of all healthy housing activity in the BOP (and lakes) DHB districts by a multiagency Healthy Housing Forum to be established by 30 September Completion of 2015/16 Bicillin programme audit using the BOP rheumatic fever register, and utilise the data to inform ongoing quality improvements. Undertake a case review of all cases of first episode acute rheumatic fever, and complete any actions determined from those case reviews. Use information and recommendations from the national evaluation of the cost effectiveness of all school-based sore throat management programmes to determine the future of these programmes. By 1 July 2017 Ongoing Implementation of a sustainable programme in primary and community care for easy access for sore throat management of priority populations outside of school-based programmes. Priority populations are 4-19 year old Māori and Pacific living in Quintile 5 neighbourhoods. Monitor performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team. Monitor screening performance on a quarterly basis through the Māori Health Plan Steering Group

41 Oral health Outcome we seek: How will we know if we have been successful? Improved oral health outcomes for Māori children. 95% of Māori preschool children will be enrolled in a dental clinic. Target: 95% by 31 December 2016 Māori (December 2015): 67% Non-Māori (December 2015): 88% What we are planning to do: By 31 December 2016 By 30 September 2016 Ongoing A 95% enrolment rate for preschool Māori by 31 December 2016 will be achieved by: Commencing a data matching project between July-September 2016 to match client data between NIR and Titanium through BOPDHB Data Intelligence Service. This will identify children not enrolled Community Dental Services (CDS). CDS to commence contacting these families of non-enrolled children by leveraging and utilising the existing networks of NGO providers, Wellchild and Hauora Māori in the BOPDHB region from October Continue to work with Māori Regional Health Services to have greater reach into communities through the CDS Oral Health Promotion Team. Target regions will be the East Coast from Opotiki Whangaparaoa and Murupara due to rurality, isolation and deprivation. The aim will be to deliver lift the lip training for the under 5yr olds as an early intervention tool to Kaupapa Māori Organisations, Marae and Kohanga/Kura. The Oral Health promotion team will also deliver healthy cooking and oral health nutrition programmes within these settings. These initiates will be delivered between July 2016 and March Continue to track referral sources for pre-enrolment requests from July 2016 and to review this information monthly to determine where additional focus needs to occur. The Oral Health Promotion team is to develop the train the train programme for oral health promotion to ECC s into a resource for Kohanga Reo that is translated into Te Reo by September This resource is to be used for: To train Kohanga Reo Kaiako (Teachers) to deliver this programme to increase awareness of good oral health nutrition and practices for the children and their families. Promotion and Training to commence from October To enable Te Kohanga Reo to adopt further good oral policies and practices based on this programme and for this to be ongoing. To work collaboration with Kohanga Reo to gain more participation in World Oral Health Day (March) and National Oral Health Day (November) each year. Oral Health Promotion Team to measure participation and effectiveness of this programme by 30 th June Monitor dental clinic enrolment performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team and via the BOPDHB Funding and Planning oral health champion. Monitor dental clinic enrolment performance on a quarterly basis through the Māori Health Plan Steering Group

42 Mental health Outcome we seek: How will we know if we have been successful? Appropriate rates of use of Section 29 of the Mental Health Act (community treatment order). To be determined in collaboration with the MoH. Target: No targets set for 2016/17 Māori (Q1 2016): Non-Māori (Q1 2016): 196 per 100,000 per year 37 per 100,000 per year What we are planning to do: By 31 August 2016 Identify variance in use of Section 29 across BOPDHB by establishing consistent data collection processes for this indicator. By 30 September 2016 Analyse the degree of variance in use of Section 29 within the DHB by reviewing the rationale for its use in samples of Māori patients seen by different practitioners in different parts of BOPDHB. Compare Māori and non-māori patients. By 30 October 2016 Report findings of analyses to practitioners and a clinically-led multidisciplinary mental health forum. Develop guidelines and regular auditing processes to support standardised application of Section 29 throughout BOPDHB. By 1 November 2016 (Ongoing) Monitor the impact of the implementation of guidelines and auditing processes. Ongoing Monitor indicator performance on a quarterly basis through the Māori Health Plan Steering Group

43 Sudden Unexpected Death of an Infant (SUDI) Outcome we seek: How will we know if we have been successful? Māori (baseline): Lower rates of SUDI among Māori infants. The rate of SUDI among Māori infants will be 0.4 cases per 1,000 live births or less. 1.93/1,000 live births, compared with 1.75/1,000 live births for all Māori in New Zealand, and 0.38/1,000 live births for non-māori. Five year annualised rate of SUDI Data supplied by the Ministry of Health. 46.7% of Māori infants had a caregiver provided with SUDI information at Core Contact 1 in Targets: 0.4 cases per 1,000 live births or less. 70% of caregivers of Māori infants are provided with SUDI information at Well Child Tamariki Ora Core Contact 1. What we are planning to do: Ongoing By 30 June 2016 By 30 June 2016 By 30 September 2016 BOPDHB to continue to fund the Pepi Pod program and wahakura wananga Improve the number of infants receiving all Well Child Tamariki Ora (WCTO) core contacts in their first year of life, along with SUDI provision, by ensuring the WCTO Quality Improvement Plan includes the following actions: Complete Core Contact one before 49 days of age Provide SUDI information at core contact 1 Improve the number of infants enrolled with LMCs and WCTO providers, by ensuring the WCTO Quality Improvement Plan includes the following actions: a confirmed newborn enrolment process a triple enrolment form at birth having a focus on early referral to WCTO Ensure that safe sleep practices are implemented in healthcare settings as follows: Key BOPDHB staff, WCTO and Antenatal Parenting providers will receive mandatory education and resources that promote safe infant sleeping practices and SUDI prevention, including ways of communicating risk to parents and caregivers, and families / whanau. Each BOPDHB service will be responsible for providing safe sleeping arrangements for infants up to one year of age who sleep within BOPDHB facilities. All parents/caregivers with infants up to one year of age will be informed about safe infant sleeping and SUDI prevention. BOPDHB staff will advise and role model only safe infant sleeping, safe night feeding and safe settling practices within BOPDHB facilities (and when relevant in community settings) and promote these as strategies to use at home. Infants who are exposed to any smoking, alcohol or drug use during pregnancy, who are born before 36 weeks gestation or less than 2500gm birthweight will be assessed as being vulnerable to SUDI. This assessment will be documented as part of routine health care for all infants up to one year of age that are placed to sleep within BOPDHB facilities. A care plan for infants vulnerable to SUDI will include smoking cessation action and discharge planning by staff to support safe infant sleeping arrangements at home, e.g. referral to the Pēpi-Pod Programme for infants 0 6 weeks, SUDI risk information will be included in the discharge summary to primary health care. All BOPDHB facilities that provide sleeping arrangements for infants up to one year of age will be supported by Safe Sleep Champions

44 Monitoring of safe infant sleeping in BOPDHB facilities will be achieved by regular audit using an approved audit tool. By 30 June 2016 Review and evaluate Antenatal and Parenting services for effectiveness, efficiency and consistency. A report on this review/evaluation will be provided to the Māori Health plan Steering Group by 31 July By 1 July 2016 Ensure that all the Antenatal and Parenting education programs delivered from 1 July 2016 must include information about safe infant sleeping and SUDI prevention. Prior to 30 June 2016, the champions will meet with all Well Child Tamariki Ora, LMC and Plunket providers to ensure they understand the requirements of the target from 1 July 2016 to 30 July LMC, Well Child Tamariki Ora, and Plunket providers have an early intervention approach to SUDI prevention and refer vulnerable infants to the Pepi-Pod Programme. 70% of referrals to the Pepi-Pod Programme will be made by LMCs (currently <50%). Ongoing Monitor indicator performance on a quarterly basis through the Māori Health Plan Steering Group

45 Local Indicators Did-Not-Attend (DNA) rate for outpatient appointments Outcome we seek: How will we know if we have been successful? Lower did-not-attend (DNA) rates by Māori in outpatient appointments clinics. The DNA rate for outpatient appointments for Māori will reach 5%. Target: 5% Māori (YTD): 15.6% Non-Māori (YTD): 4.4% What we are planning to do: By July 2016 By July 2016 By July 2016 By August 2016 By October 2016 By November 2016 By December 2016 By February 2017 Plan of specific initiatives based on stakeholder (internal and external) meetings about current and previous work, enablers and barriers to attendance is in place. Organisational monthly reporting dashboard available to these stakeholders to document progress. For clinics with DNA rates >12% there is specific senior management intervention. Reporting progress through to the Hospital Advisory Committee. Dedicated resource from Māori Health management teams to work within the Service Improvement Unit as the Māori DNA lead Establish partnerships at Executive level with six Iwi across the Bay as a means to understanding the varying local issues communities face and to better understand how the system is not working for Māori. Ensure learnings are publicised on our intranet for future reference Provide DHB website information to support literacy, access and other information for Māori which addresses issues that Iwi have raised as barriers to attendance Implement new systems to ensure specific patient populations have systems in place to reduce barriers to attendance e.g. patients from Matakana Island have appointments which fit within barge transport times, potential to provide community group hospital appointments on the same day - use IHI Methodology and small tests of change to trial Expand the Patient Information Centre to include a member of staff who speaks Te Reo. Ensure PIC processes/practices document and meet cultural requirements to reduce barriers to attendance. Work with Ko Awatea to transition the informal DHB DNA network started by BOPDHB to the proposed national Innovation Hub to share national successes and learnings in Māori DNA improvements Communications Plan in action to ensure organisational knowledge about initiative achievements and focus of future improvements shared with internal and external stakeholders. Move outpatient appointment services closer to home for renal patients living in Whakatane

46 Ongoing Monitor DNA performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team and via the provider arm DNA champion. Monitor DNA performance on a quarterly basis through the Māori Health Plan Steering Group

47 Appendix A Methodology for Local Indicator Selection Local indicators were developed through a five-step process involving: 1. Identification of information sources; 2. Identification of leading health issues; 3. Ranking health issues; 4. Scoring the leading health issues; 5. Review and finalisation 1. Identification of Information Sources External Information Sources The most useful source of health needs information was a 2008 Health Needs Assessment completed by the MOH. This document provided epidemiological summaries for a range of conditions stratified by age gender, and ethnicity. Health service utilisation was also presented. Internal Information Sources Epidemiological and service utilisation reports were gathered from Toi Te Ora Public Health Service, Funding and Planning, and the DHB s Population Health Advisory Group (PoPAG). 2. Identification of Leading Health Issues Health conditions and service utilisation issues were collected in a spreadsheet if they met the following criteria: a) A statistically significant difference between Māori and non-māori outcomes was present; b) There were high inequalities between Māori and non-māori in BOPDHB (a rate ratio of 1.2 or greater was used) indicating worse health outcomes for Māori compared with non-māori within the DHB; c) There were high inequalities between Māori in BOPDHB and Māori nationally (a rate ratio of 1.2 or greater was used) indicating worse health outcomes for Māori in BOPDHB than Māori in the rest of the country. 3. Ranking Health Issues Rate ratios between Māori and non-māori on BOPDHB were calculated. The list of health conditions and service utilisation options were then ranked based on the size of the rate ratio this gave a measure of inequality within BOPDHB. 4. Scoring Health Issues The issues with the highest rate ratios were scored against a list of indicator selection criteria developed by the National Centre for Health Outcomes Development (NCHOD). 5. Review and Finalisation The highest scoring options were reviewed by a public health physician from the regional public health unit, before a set of three condition related indicators were finalised with the DHB s PoPAG and the General Manager Māori Health

48 References 1. BOPDHB. Māori Health Plan Quarter 2 Update. [pdf] Tauranga : BOPDHB, Ministry of Health. Nationwide Service Framework Library: DHB trend data year to end December Ministry of Health. [Online] [Cited: 2 May 2012.] Historical Reports. District Health Boards Non-Financial Quarterly Report. [Online] [Cited: 12 March 2012.] Bay of Plenty DHB Quarter 3. District Health Boards Non-financial quarterly report. [Online] Quarterly BSA DHB Reports [Excel Spreadsheet] Wellington : s.n., Quarterly NCSP DHB Reports [Excel Spreadsheet] Wellington : s.n., Freeman, S. BOPDHB Tobacco Health Target Quarter (1 October to 31 December 2011). [pdf document] Tauranga : BOPDHB, DHBNZ. DHB Performance Scorecard. [Excel Spreadsheet] Wellington : DHBNZ, Ministry of Health. Health Targets - How is Your DHB Performing? Health Targets Quarter Two 2011/12. Ministry of Health website. [Online] Bay of Plenty DHB Health Needs Assessment. Wellington : Ministry of Health, Preschool dental clinic enrolment rates [Excel Spreadsheet] Wellington : Ministry of Health, Lowe, L. Benzathine penicillin review. Tauranga : Toi te Ora - Public Health Service, Ministry of Health. 2012/13 Operational Policy Framework. Wellington : Ministry of Health, Statistics New Zealand. District Health Board Area summary tables. Statistics New Zealand. [Online] Statistics New Zealand. Regional Summary Tables. Statistics New Zealand. [Online] 2014 hhttp:// 16. Bay of Plenty District Health Board. Hospitals. Bay of Plenty District Health Board. [Online] Ministry of Health. Primary Health Care. PHO Enrolment Demographics 20124Q1 (Jan- March 2014). [Online] Statistics New Zealand. Household Labour Force Survey: June 2011 quarter. Wellington : Statistics New Zealand, Ministry of Health. Bay of Plenty DHB - Report on the National Priorities as at February Wellington : Te Kete Hauora, National Screening Unit. Aims of the programme. Breastscreen Aotearoa. [Online] [Cited: 7 May 2011.] National Cervical Screening Programme: Targets for 2006 and National Screening Unit. [Online] [Cited: 6 May 2011.] Bay of Plenty District Health Board. BOPDHB Tobacco Health Target Report: quarter /11. Tauranga : Bay of Plenty District Health Board, Howden-Chapman, Philippa, et al. Effects of improved home heating on asthma in community dwelling children: randomised controlled trial. British Medical Journal. 2008, Vol. 337, a Jaine, R, Baker, M and Venugopal, K. Epidemiology of acute rheumatic fever in New Zealand Journal of Paediatrics and Child Health. 44, 2008, pp Loring, B. Rheumatic Fever in the Bay of Plenty and Lakes District Health Boards: A review of the evidence and recommendations for action.. Tauranga : Toi Te Ora - Public Health Service, Bay of Plenty District Health Board. ASH and BOPDHB - An Action Plan. Tauranga : 48 31

49 Funding and Planning Unit, Ministry of Health. Health Targets: How is your DHB performing? Source data and comments from the Target Champions for quarter /11. Ministry of Health. [Online] [Cited: 21 March 2011.] Massey University Wellington. Health Needs Assessment, Bay of Plenty District Health Board, For the Ministry of Health Available from: Ministry of Health. Emergency Department Use 2011/12. Key findings of the New Zealand Health Survey. Ministry of Health [online] Available from

50 29/08/2016 Improving Māori Health Performance Dialogue, it s the food that sustains the Leader 50 1

51 29/08/2016 GREAT HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness GREAT BIG HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 51 2

52 29/08/2016 GREAT HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness WHO EVERYONE S Ngāi te rangi Ngāti Ngāti Ranginui Ranginui Tūhoe Tūhoe Ngāti Whakaue ki Maketū Ngāti Ngāti Pūkenga Ngāti Whakaue ki Maketū Ngāti Manawa Ngāti Manawa Waitaha Tapuika Waitaha Tapuika Ngāti Ngāti Whare Whare Te Whānau-ā- Te Apanui Whānau-ā- Ngāti Whakahemo Ngāti Rangitihi Apanui Ngāti Mākino Ngāti Awa Ngaitai Ngaitai Te Whānau-ā-Te Ēhutu Tūwharetoa-ki-Kawerau Whakatōhea HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 52 3

53 29/08/2016? CONFRONT THE BRUTAL FACTS but keep the faith All DHBs HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness BOP NO DHB LAKES TAIRĀWHITI TARANAKI WAIKATO HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 53 4

54 29/08/2016 PRIORITISE the Our Core Business CORE Regional Services Plan Annual Plan Māori Health Plan DIRECT HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness PAE ORA (Dahlgren & Whitehead 1991) CORE HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 54 5

55 29/08/2016 MĀORI HEALTH PLAN REDUCING LONG-TERM WELFARE DEPENDENCY WHĀNAU ARE LEADING HEALTHY LIFESTYLES Wai Ora Whānau Ora Mauri Ora HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness TRENDLY... EXCELLENCE HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 55 6

56 29/08/2016 STRATEGIC POSITION STRATEGY IN ACTION STRATEGIC CHOICES Exploring Strategy: Text and Cases HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 56 7

57 29/08/2016 BREAST SCREENING GREAT BREAST SCREENING EQUITY LENS TAIRĀWHITI LAKES TARANAKI BOP WAIKATO 57 8

58 29/08/2016 IMPROVE

59 29/08/2016 CERVICAL SCREENING EQUITY LENS BOP TAIRĀWHITI HEDGEHOG NO RED PDSA MAINSTREAM RESPONSIVENESS OWNERSHIP EQUITY EQUITY HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 59 10

60 29/08/2016 GREAT HE POU ORANGA KAUPAPA (PRINCIPLES) Kaitiakitanga Stewardship; Kotahitanga Unity; Manaakitanga Hospitality; Pūkengatanga Abilities Ūkaipōtanga Origins; Rangatiratanga Leadership; Wairuatanga Spirituality; Whanaungatanga Connectedness 60 11