BOARD MEETING AGENDA. 1pm. Wednesday 27 September Items to be considered in public meeting VENUE

Transcription

1 BOARD MEETING Wednesday 27 September pm AGENDA Items to be considered in public meeting VENUE Waitemata DHB Boardroom Level 1, 15 Shea Terrace Takapuna 1

2 Karakia E te Kaihanga e te Wahingaro E mihi ana mo te ha o to koutou oranga Kia kotahi ai o matou whakaaro i roto i te tu waatea. Kia U ai matou ki te pono me te tika I runga i to ingoa tapu Kia haumie kia huie Taiki eee. Creator and Spirit of life. To the ancient realms of the Creator Thank you for the life we each breathe to help us be of one mind As we seek to be of service to those in need. Give us the courage to do what is right and help us to always be aware Of the need to be fair and transparent in all we do. We ask this in the name of Creation and the Living Earth. Well Being to All. 2

3 1 MEETING OF THE BOARD 27 September 2017 Venue: Waitemata DHB Boardroom, Level 1, 15 Shea Tce, Takapuna WDHB BOARD MEMBERS Lester Levy - Chair Max Abbott - WDHB Board Member Edward Benson-Cooper WDHB Board Member Kylie Clegg Deputy Chair Sandra Coney - WDHB Board Member Warren Flaunty - WDHB Board Member James Le Fevre - WDHB Board Member Dr Matire Harwood - WDHB Board Member Brian Neeson WDHB Board Member Morris Pita - WDHB Board Member Allison Roe - WDHB Board Member APOLOGIES: Matire Harwood Time: 1pm WDHB MANAGEMENT Dale Bramley - Chief Executive Officer Robert Paine - Chief Financial Officer and Head of Corporate Services Andrew Brant - Chief Medical Officer Debbie Holdsworth - Director Funding Jocelyn Peach - Director of Nursing and Midwifery Cath Cronin Director of Hospital Services Tamzin Brott Director of Allied Health Fiona McCarthy Director Human Resources Roger Perkins Executive Head Peta Molloy - Board Secretary REGISTER OF INTERESTS Does any member have an interest they have not previously disclosed? Does any member have an interest that may give rise to a conflict of interest with a matter on the agenda? PART 1 Items to be considered in public meeting AGENDA 1. AGENDA ORDER AND TIMING 2. BOARD MINUTES 1pm 2.1 Confirmation of Minutes of the Meeting of the Board (16/08/17) Actions arising from previous meetings 3. EXECUTIVE REPORTS 1.05pm 1.10pm 1.20pm 3.1 Chief Executive Officer s Report 3.2 Health and Safety Report 3.3 Communications Report 4. PERFORMANCE REPORT 1.30pm 4.1 Financial Performance 5. COMMITTEE REPORTS 1.40pm 5.1 Minutes from Hospital Advisory Committee (26/07/17) 6. INFORMATION PAPERS 1.40pm 1.50pm 6.1 Health and Safety Marker Report 6.2 Statement of Performance Expectations (SPE) Performance Report : Quarter four 2016/ pm 7. RESOLUTION TO EXCLUDE THE PUBLIC 8. GENERAL BUSINESS 3

4 1.1 Waitemata District Health Board Board Member Attendance Schedule 2017 NAME Mar Apr May Jul Aug Sep Nov Dec Dr Lester Levy (Chair) Max Abbott Edward Benson-Cooper Kylie Clegg Sandra Coney * Warren Flaunty James Le Fevre Matire Harwood Brian Neeson Morris Pita Allison Roe Apologies given *Attended part of the meeting only # Absent on Board business ^ Leave of Absence 4

5 1.2 REGISTER OF INTERESTS Board/Committee Member Lester Levy - Board Chairman Max Abbott Involvements with other organisations Chairman Auckland District Health Board Chairman Counties Manukau District Health Board Chairman Regional Governance Group, northern region DHBs Chairman Auckland Transport Chairman Health Research Council Independent Chairman Tonkin + Taylor Professor of Leadership University of Auckland Business School Lead Reviewer - State Services Commission, Performance Improvement Framework (current review Ministry for the Environment) 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 Last Updated 17/08/17 19/03/14 Edward Benson-Cooper Chiropractor Milford, Auckland (with private practice commitments) 07/12/16 Kylie Clegg Trustee - Well Foundation 17/08/17 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) Sandra Coney Member Waitakere Ranges Local Board, Auckland Council 15/12/16 Patron Women s Health Action Trust Member Portage Licensing Trust Member West Auckland Trusts Services Warren Flaunty Member Henderson Massey Local Board Auckland Council 06/12/16 Trustee (Vice President) - Waitakere Licensing Trust Shareholder - EBOS Group Shareholder Green Cross Health Director Life Pharmacy Northwest Director Westgate Pharmacy Ltd Chair Three Harbours Health Foundation Director - Trusts Community Foundation Ltd Dr Matire Harwood Senior Lecturer Auckland University 09/12/16 Board Director Health Research Council Director Ngarongoa Limited, which is contractor providing services to National Hauora Coalition. GP at Papakura Marae Health Clinic Advisory Committee Member State Foundation NZ (Maori Health) Member Te Ora, Maori Medical Practitioners James Le Fevre 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 05/05/17 5

6 1.2 REGISTER OF INTERESTS Board/Committee Member Brian Neeson Morris Pita Allison Roe Involvements with other organisations 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 15/12/16 06/12/16 02/11/16 6

7 Confirmation of Minutes of the Board meeting held on 16 August 2017 Recommendation: That the Minutes of the Board meeting held on 16 August 2017 be approved. 7

8 2.1 Minutes of the meeting of the Waitemata District Health Board Wednesday 16 August 2017 held at Waitemata DHB, Boardroom, Level 1, 15 Shea Terrace, Takapuna, commencing at am BOARD MEMBERS PRESENT: Lester Levy (Board chair) Max Abbott Edward Benson-Cooper Kylie Clegg (Deputy Board chair) James Le Fevre Matire Harwood Brian Neeson Morris Pita Allison Roe ALSO PRESENT: PART I Items considered in public meeting Dr Dale Bramley (Chief Executive Officer) Robert Paine (Chief Financial Officer and Head of Corporate Services) Dr Andrew Brant (Chief Medical Officer) Dr Debbie Holdsworth (Director Funding) Tamzin Brott (Director of Allied Health, Scientific and Technical Professions) Cath Cronin (Director Hospital Services) Fiona McCarthy (Director Human Resources) Karen Bartholomew (Acting Director Health Outcomes) 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: APOLOGIES: Molly Neilson (Maternity Services Consumer Council) Sue Claridge (Auckland Women s Health Council) Kath Tse (i3) Annabel Farry (i3 and midwife) Paula Ryan (Midwife, Birthcare) Ann Hanson (Birthcare) Adith Stoneman (Maternity Services Consumer Council) Emma Ryburn (Maternity Services Consumer Council and Mothers Milk NZ) Kashka Tunstall (North Shore Times) Apologies were received from Warren Flaunty and Allison Roe and for late arrival from Sandra Coney. 8

9 2.1 WELCOME The Board Chair welcomed the Board members and all those present at the meeting. DISCLOSURE OF INTERESTS Kylie Clegg advised that she was now a Director of Sport NZ. There were no declarations of interest relating to the open section of the agenda. 1 AGENDA ORDER AND TIMING Items were taken in same order as listed in the agenda. 2 BOARD MINUTES 2.1 Confirmation of Minutes of the Meeting of the Board (05/07/17) (agenda pages 7-20) Resolution (Moved James Le Fevre/Seconded Max Abbott) That the Minutes of the Board meeting held on 05 July 2017 be approved. Carried Actions arising from previous meetings (agenda pages 21) Noted. 3 EXECUTIVE REPORTS 3.1 Chief Executive s Report (agenda pages 22-48) The Chief Executive introduced the report. He thanked the Board members who were available to attend the opening of Te Aka (a 15-bed facility at the Mason Clinic site) on 4 th August The Chief Executive also noted a number of DHB staff being recently recognised nationally in various awards. He thanked the Director Funding and her team for their work on the bowel screening national pilot being recognised at the Deloitte IPANZ Awards and winning the Poster Award for Excellence in Design of Supporting Poster category. He also warmly acknowledged the recipients of awards won as reported. The report was received. 3.2 Health and Safety Performance Report (agenda a pages 49-65) Fiona McCarthy (Director of Human Resources) and Michael Field (General Manager, Occupational Health and Safety) were present for this item. Fiona and Michael summarised the report. Morris Pita thanked the Fiona and Michael and those involved with the Board member health and safety site visits held to date. He queried health and safety IT systems and what the driving concern would be for the organisation in this area. In response it was noted that there are four platforms of operation and that work is required around system integration 9

10 2.1 between the platforms. It was requested that a paper would be provided to the Board at its meeting in November on getting a more integrated data response as it relates to IT. Edward Benson-Cooper queried under section 5 staff reported incidents of the report the reference to 11 instances of staff shortage, in response Michael noted that staff shortages are reports as incidents and it may be a number of staff on sick leave and not related to an injury or such. The report was noted. 3.3 Communications Report (agenda pages 66-73) Matthew Rogers (Director of Communications) summarised this item. He acknowledged the attendance of Kashka Tunstall (a new health reporter for the North Shore Times) at the Board meeting. The Board Chair noted that requests under the Official Information Act continue to increase; Matthew Rogers advised that the majority of requests are from political parties and that the volume received is expected to drop as the general election period nears. The report was received. 4 DECISION PAPERS 4.1 Immunisation Health Target Statement (page 74-78) Ruth Bijl (Funding and Development Manager Child, Youth and Women s Health), Natalie Desmond (Senior Programme Manager - Child Health), Dr Tim Jelleyman (Community Paediatrician) and Jesse Solomon (Senior Programme Manager) were present for this item Dr Jelleyman summarised the paper, noting that immunisations work effectively and safely with a body s natural system to prevent diseases in the community. The paper before the Board is about helping children and communities and aligns with the medical practice of putting patients first. He also noted the importance of respecting individual choice and gaining an understanding of a patient and their family s position about immunisation when engaging on a Ward and then linking that with the medical professions scientific model. Dr Jelleyman advised that his responsibility is to provide the right advice to the family and to advocate for a child s best treatment and prevention options. It was noted and agreed that the first bullet point in the recommendation be amended to note that achieving 95% immunisation coverage for eight month olds to be fully immunised is a national health target, but no longer a better public service target. Morris Pita acknowledged the paper presented and noted his support for the purpose of the paper and the position being recommended to the Board. James Le Fevre also endorsed the paper presented noting that immunisation remains the greatest public health prevention. The Board Chair also acknowledged the paper noting the recent increase of immunisation rates reported. He also referenced getting a wider sense of communicable diseases (referencing the recent typhoid outbreak), noting the number of movements of people in 10

11 2.1 terms of international arrivals and the difference of regimes in different countries around immunisation of communicable diseases. He noted the responsibility of the Board, management and clinicians in ensuring the best care for its population. Matire Harwood noted the importance of also achieving health equity; she noted her role as a GP in the South Auckland area and that a lot of work had been to improve immunisation rates. Resolution (Moved Morris Pita/ Seconded James Le Fevre) That the Board: Note that achieving 95% immunisation coverage for eight month olds to be fully immunised is a national health target. Note that evidence supports the need for high rates of immunisation coverage to protect both individuals and the population as a whole, hence the 95% target. Note that immunisation is an effective strategy to reduce inequity in health outcomes for Maori and Pacific, and those living in areas of economic deprivation. Note that there is abundant, high quality evidence regarding the efficacy and safety of the New Zealand immunisation schedule and programme. Endorse the proposed position statement on immunisation, Immunisation is a safe and effective way to protect individuals and the community from serious vaccine preventable diseases. The Waitemata District Health Board actively supports and encourages immunisation in line with the New Zealand National Immunisation Schedule and World Health Organisation recommendations. Carried [Note: subsequent to the discussion of this item and during the public excluded meeting the following was raised: The Board Chair noted that Allison Roe (who was absent from the meeting) had sent an mid-morning regarding item 4.1 Immunisation Health Target Statement of the open agenda and requested that it be noted that she did not endorse recommendation e) Endorse the proposed position statement on immunisation, Immunisation is a safe and effective way to protect individuals and the community from serious vaccine preventable diseases. The Waitemata District Health Board actively supports and encourages immunisation in line with the New Zealand National Immunisation Schedule and World Health Organisation recommendations. It was also noted that the Board Secretary had acknowledged receipt of Allison s and advised her of the Board s decision.] 5 PERFORMANCE REPORTS 5.1 Financial Performance (agenda pages 79-93) Robert Paine (Chief Financial Officer and Head of Corporate Services) summarised this item. Resolution (Moved Brian Neeson/Seconded Max Abbott) That the Board: a) Note the content of this report 11

12 2.1 b) Receive the following reports: Carried 1 Executive Summary and key themes 2 Financial Overview of the 2016/17 result 3 Financial Performance - DHB Arms 4 Financial Performance - Other Indicators/Trends 5 Capital Expenditure 6 Financial Position 7 Cash flow Position 6 COMMITTEE REPORTS 6.1 Minutes from the Community and Public Health Hospital Advisory Committee (21/06/17) (page ) The draft minutes were noted. 7 INFORMATION PAPERS 7.1 Health and Safety Marker Report - Update (agenda pages ) Fiona McCarthy (Director of Human Resources) was present for this item. The Board Chair thanked Fiona for the work being undertaken in this area and noted that similar reporting had now been implemented at Auckland DHB, he requested that Fiona liaise with the new Director of Human Resources at Counties Manukau DHB about implementing the same reporting to its Board. James Le Fevre commented on the reference to the health of workers and the orientation towards the physical aspect of roles and queried whether areas such as resilience are considered. Fiona advised that the work reported relates specifically to hazards and that there are sections related to resilience. The DHB does provide resilience and mindfulness sessions; more information will be provided to the Board about this. The report was noted. 8 RESOLUTION TO EXCLUDE THE PUBLIC (agenda pages ) Resolution (Moved Kylie Clegg/Seconded Max Abbott) 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: 12

13 2.1 General subject of items to be considered 1. Minutes of Meeting of the Board - Public Excluded (05/07/17) 2. Recommendations from the Audit and Finance Committee Public Excluded (26/07/17) Reason for passing this resolution in relation to each item 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)] 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 the resolution(s) from the open section of the minutes of the above meeting, in terms of the NZPH&D Act. Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] 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. 3. Minutes from Three Harbours Health Foundation (12/04/17) 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)] 4. Facilities 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)] [Official Information Act 1982 S.9 (2) (j)] Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] Negotiations The disclosure of information would not be in the public interest because of the 13

14 2.1 General subject of items to be considered 5. Programme Development Reason for passing this resolution in relation to each item 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 greater need to enable the board to carry on, without prejudice or disadvantage, negotiations. [Official Information Act 1982 S.9 (2) (j)] Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] 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. 6. Contract 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)] 7. Draft Plans 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 [Official Information Act 1982 S.9 (2) (j)] Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] 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)] Obligation of Confidence The disclosure of information would not be in the public interest because of the greater need to protect information which is subject to an obligation of confidence. [Official Information Act 1982 S.9 (2) (ba)] [NZPH&D Act 2000 Schedule 3, S.32 (a)] 14

15 2.1 General subject of items to be considered Reason for passing this resolution in relation to each item 8. Facilities 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)] 9. Facilities 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)] 10. Project Update 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 Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] GENERAL BUSINESS There were not items of general business. The Chair thanked those present. The open meeting concluded at 11.08am. SIGNED AS A CORRECT RECORD OF THE MEETING OF THE WAITEMATA DISTRICT HEALTH BOARD - BOARD MEETING HELD ON 16 AUGUST 2017 CHAIR 15

16 2.1 Actions Arising and Carried Forward from Previous Board Meetings as at 21 September 2017 Meeting Date Agenda Ref Topic 16/08/ Health and Safety Performance Report Provide report to the board on the health and safety IT systems and getting a more integrated data response. Person Responsible Fiona McCarthy/ Michael Field Expected Report back 08/11/17 Comment 16

17 Chief Executive s Report Recommendation: That the Chief Executive s Report be received. Prepared by: Dr Dale Bramley (Chief Executive Officer) 1. News and events summary A number of events of significance took place across the DHB over the past six weeks: The TransforMED project has begun its roll-out on the general medicine wards at North Shore Hospital. One of the key projects within TransforMED is the creation of home-based wards, allowing clinical staff members to work together in one place as a regular team, as opposed to across multiple wards with a changing mix of patients and colleagues. This is resulting in improved patient outcomes as a result of better communication and teamwork and a higher level of streamlined care. From early August to early September, there has been a 12-hour (or 13%) reduction in average length of stay across North Shore Hospital s general medicine wards. On the trial ward (Ward 3) alone, the length of stay is down by 29 hours (28%) compared to the 12-month average. There has been a 58% increase in daily discharges from Ward 3 and more patients are being discharged before 12 noon. This has been achieved without impacting on the seven-day readmission rate. These improvements have helped drive an overall 8%, or 15-bed, reduction in occupied acute general medicine beds compared to 12 months ago. Congratulations to the TransforMED team on realising these benefits for our patients. TransforMED is led by the Division of Medicine. Other workstreams include improvements to the identification and acute care of frail elderly patients through an interdisciplinary assessment process and planned implementation of new models of care in the Assessment and Diagnostic Unit (ADU). 17

18 3.1 The TransformedMED team on Ward 3 at North Shore Hospital (L-R): Indira Wickramasinghe. Sheila Kaur Tina Chang Steven Miller (consultant) registered nurse Kurt Navarro. Events celebrating Maori Language Week from September proved very popular, with a range of free lunchtime seminars from special guest speakers and opportunities for our staff to attend Maori pronunciation and waiata workshops. Our Maori Health team did a wonderful job of injecting a sense of colour and fun into these events. By far the most popular feature of the week was the regular online performances by the Ako Ako Girls, Kaiaia Hawke and Rawinia Morehu. Videos of the girls introducing Maori Language Week and presenting Maori words of-the-day throughout the week were posted on the DHB s Facebook page and generated a huge level of interest. The initial post had reached an audience of more than 40,000 people as of 14 September, with the video watched more than 16,000 times. Updated figures will be provided at the Board meeting. Well done to all involved particularly the Ako Ako Girls for devising such an engaging, entertaining and informative programme to celebrate the importance of Maori culture. 18

19 3.1 Chief Advisor Tikanga Naida Glavish with the Ako Ako Girls during the filming of one of their popular Maori Language Week videos. Our DHB is among the finalists in two categories at the 2017 New Zealand Innovation Awards. Waitemata s Leapfrog programme has been named a finalist in the Innovation Systems and Performance Improvement category, while our Precision-Driven Health partnership with Orion Health and the University of Auckland is among the finalists in the Innovation in Health and Science category. Being announced among the finalists is itself an achievement, considering the high calibre of projects judges selected from. Our DHB has excelled in awards over recent months, winning two Auckland Transport awards, the Research and Business Partnership Award at the KiwiNet Research Commercialisation Awards (with Orion Health and the University of Auckland) and the Hospital Pharmacy Performer of the Year Award. Innovation award-winners will be announced at an event on 19 October. A Waitemata and Auckland DHB led national pilot programme providing additional rehabilitation services to employed people who experience a mild stroke is expected to begin by the end of this calendar year. Reablement from Stroke Obtained via a Rehabilitation and Employment Service (RESTORES) will begin with a pilot of 20 participants and then gear up for a randomised controlled trial of 300 people. It will see those who have experienced a mild stroke given rehabilitation support aimed at helping them return to work and remain in the workforce. The trial will inform a potential wider roll-out of the programme, based on evidence of sustained employability and financial outcomes. In the near-term, it offers the potential to change the lives of people in the Waitemata district who have experienced stroke and their families and dependents. At the time of preparing this report, the ROI process for the pilot stage only was entering the final stages, with an anticipated contract start date of late October-early November. 19

20 3.1 New national data confirms Waitemata DHB has one of the highest rates of hand-hygiene best practice compliance in the country. Effective hand-washing can significantly reduce the risk of patients acquiring healthcare-associated infections. The data reflects our DHB s prioritisation of hand hygiene education for staff, patients and visitors, with around 5,000 moments each day where hand-cleaning opportunities are taken to protect the safety of our patients. On 5 September, the State Service Commission (SSC) released 2016/17 data on Official Information Act (OIA) compliance by Government agencies. This is the second time agency OIA performance information has been compiled and released, giving the public the opportunity to understand how agencies are living up to their responsibilities under the Act to conduct themselves in a transparent and accountable manner. I am delighted that the SSC found that Waitemata DHB had the second-highest OIA on-time response rate of all DHBs across New Zealand. During 2016/17, we received 181 OIA requests and 180 of these were responded to within the 20-day timeframe outlined in the Act. This resulted in a 99.5% on-time compliance rate, the second-highest of any DHB in New Zealand. Over the same period, the SSC noted one complaint to the Ombudsman about our OIA responses and that there were no findings issued against the DHB. Data is to be reported at six-monthly intervals in future. In late August, our DHB launched a new platform allowing us to communicate better with our colleagues in primary care. The new platform, known as Medinz, is the product of close collaboration with Healthpoint to develop a communications system that is easy-to-use and responsive to the needs of primary care. The initial roll-out is aimed at general practices, community pharmacies and urgent care clinics. It allows recipients to select how they receive critical and urgent information (fax, , text message) without charge from Waitemata DHB that will assist them in the care of their patients. The platform creates a single source of accurate information for everyday use but will be of particular value in the event of a major incident or emergency where it is important to get information to the primary care audience rapidly. A key function of Medinz is that it allows recipients to give feedback about how useful they have found the information, which allows us to manage our quality control processes to ensure we are only sending information that is useful and relevant. Just over two weeks after the launch of Medinz, we had more than 800 individuals who had activated their accounts across more than 40 community pharmacies, five urgent care clinics and more than 30 GP practices operating under the umbrellas of four primary health organisations. While the rate of uptake of Medinz across our district continues to grow, the new platform also creates the capability to push critical and urgent messages to all primary care providers across our district should the need arise, including those who have not yet activated their Medinz accounts. Auckland Regional Public Health Service and Labtests are also publishing to Medinz and it is expected that other DHBs will also take on publishing rights in the near-future. Main road signs directing patients and visitors to both of our hospitals were replaced in August as part of our ongoing wayfinding project, which aims to enhance the patient and visitor experience. The new look is consistent with a fresh design agreed on by the DHB after public consultation and a review of all external signage in Our wayfinding committee is now looking at internal signage based on further feedback from the public, patients and DHB volunteers. We would like to acknowledge and thank Healthlinks for their contribution to our signage improvements. 20

21 3.1 The new Waitakere Hospital external signage on Lincoln Road makes navigation easier for the public. A 14-strong delegation from China s National Health Development Research Centre visited North Shore Hospital on 25 August. Funding models and potential areas of collaboration were among agenda items discussed at Whenua Pupuke before a tour of the hospital. The delegation was led by Dr Wei Fu, who is keen to have follow-up conversations on health policy and other areas of mutual interest. Dr Fu is also interested in the day surgery concept and was impressed with the efficiency of our Elective Surgery Centre (ESC). 21

22 3.1 Chief Medical Officer Dr Andrew Brant with DHB staff and members of the Chinese delegation Congratulations to Dr Eleri Clissold for receiving an Open for Leadership Award from the Health Quality and Safety Commission (HQSC) on 18 August. The award recognises her efforts in developing and enhancing training experiences for post-graduate year two and junior doctors as a Fellow of our Institute for Innovation and Improvement (i3). It also acknowledges her part in trialling virtual reality technology as a learning tool. Eleri is now employed in the urgent care department of Apollo Medical but continues to work part-time at i3. Her example epitomises our organisational goal to be better, best and brilliant in all that we do and the award recognises the high value we place on training and developing a workforce that puts its patients first and makes us a national leader in healthcare delivery. 22

23 3.1 Dr Eleri Clissold with Associate Minister of Health Peter Dunne and i3 Director Dr Penny Andrew. Five Waitemata DHB staff were selected for this year s Rotary Youth Leadership Awards programme. They were among 120 participants from a number of organisations who started the eight-day initiative with a week-long series of team-building exercises and inspirational lectures from visionaries including Sir Ray Avery. They completed the final three-day testing phase of the course in tough conditions at a remote location. The testing phase is designed by DHB medical scientist and former full-time soldier Jon Atkinson. It is based on the New Zealand Army s officer selection standards. A number of DHB staff, aged between 20 and 28, have participated in this programme over the past few years and brought their new-found skills and boosted confidence back to the workplace. 23

24 3.1 Waitemata DHB staff selected for the Rotary Youth Leadership Awards: (L-R): Albert Delorino, Ashley Kim, Nikki Renall, Jon Atkinson, Rebecca Watkin. Front: Kellin Pungatara Creating a culture of appreciation A further 40 staff have been recognised in the CEO Awards, launched in mid-2014 to celebrate those staff, nominated by their colleagues and patients, who demonstrate our organisational values through their work. Each staff member whose nomination is considered worthy of acknowledgement receives a personalised letter of thanks, a certificate of appreciation and a small gift. Staff acknowledged with a CEO Award since the last Board meeting include: Phillip Insull, Orthopaedic Consultant - Orthopaedic Surgery, nominated by Rupert Murch Mr Insull s communication with our team has been of the highest order. Hayley Brown, Registered Nurse - Waitakere Emergency Department, nominated by Robyn Dangen Hayley has been Acting Charge Nurse for the past two weeks and she has been calm, reassuring, professional and always positive during this period. Nicole Broodkoorn, Community Mental Health Nurse - Acute Mental Health Team, nominated by Fiona McCarthy (on behalf of a patient) For helping a patient for over two years in their battle with mental health illness. Annie Menzies, Midwife - Waitakere Maternity, nominated by Susan Cluitt Annie is very generous in sharing her knowledge with colleagues, and makes the day fun with a good bit of humour. 24

25 3.1 Dale Stewart, Patient Care Assistant - Outpatients Waitakere, nominated by Margaret Rhind Nalina Naidu, Patient Care Assistant - Outpatients Waitakere, nominated by Margaret Rhind Dale and Nalina worked tirelessly to make Medical Day Stay (MDS) safe, and as user friendly as possible within the set guidelines given to them. Liz Pitney, Charge Nurse Manager - North Shore Short Stay Unit, nominated by Rosemary Kumu Liz showed kindness and a willingness to help us solve a Health and Safety problem. Amy Offermans, Registered Nurse - Child and Family West, nominated by Donald Taylor For Amy's care shown to a patient and family in the community. Pat Sullivan, Psychiatric Assistant - Kauri Unit, nominated by Graham Bastow Pat is one of those guys that quietly gets on and does an excellent job every day with a huge presence/mana and a fantastic work ethic. Cate Wallace, Programme Manager - Planning and Funding, nominated by Trish Palmer Cate make an essential contribution to service development and service delivery with a keen focus on the tangata whaiora at the centre of decisions and actions plans. Clarice Yabut, Therapy Assistant - AH Inpatients West, nominated by Sonya Wilson Clarice is always happy to help and takes genuine pleasure in the progress of the patients in her care. Usha Chand, Dental Assistant - ARDS, nominated by Carol Hall Usha combines integrity, attention to detail, a calm manner and intuitive assistance. Tanith Butler, Registered Nurse - ESC Surgical Ward, nominated by Chrissy Howley Tanith is a wonderful nurse who is always willing to do extra shifts especially the last few weeks when staff have been sick. Louise Jamieson, Charge Nurse Manager - Waiatarau IPU, nominated by Sarah Gray Louise always has a smile to share and a willingness to listen even at the most stressful of times. Robyn Harper, NASC Coordinator NASC - Special Med and HOP, nominated by Dianne Cooke People matter to Robyn. She is compassionate and unfailingly caring, her interventions are effective and she is both humble and brilliant. Margaret McAleer, Clinical Nurse Specialist - Home Health Support West nominated by Sally Monk For going above and beyond for her patients and displaying incredible collegial support when working with MDT. Karen Pollock, Clinical Nurse Specialist - General Surgery, nominated by Xu Cui Karen is very professional. She delivers the highest standard of care to patients and always finds ways to improve the service. Teresa Wingate and Angela Makwana, Clinical Nurse Specialists - General Surgery, nominated by Xu Cui Teresa and Angela are truly wonderful role models and highly valued and respected by the entire hospital! Kristine Zheng, Registered Nurse - Discharge Lounge, nominated by Sandie Davis-Roberts Amid all the attention and people surrounding her, Kristine got on with the infusion with patience and without fuss. She was extremely professional. Filbert Lim, Bureau HCA - Bureau Nursing Waitakere Hospital, nominated by John Garner Patient care above and beyond the call. Tess Gatchalian, Social Worker - Allied Health, nominated by Sonya Wilson "For her hard work and enthusiasm each day." Marieke Dijk, Occupational Therapist - Allied Health, nominated by Amy Stonestreet "Marieke is a fountain of knowledge and support for her team in the face of on-going high workload demands, and she provides excellent support and care to her clients." 25

26 3.1 Petra Fowler, Social Worker - Allied Health, nominated by Robyn Gibson "I have been astounded by the amount of hard work and commitment Petra has shown. She exemplifies best practice in healthcare." Nicole Renata, Social Worker - Child Development Service, nominated by Sarah Timmis "Nicole always works to reduce health disparities for our children and their families/whanau. She is an outstanding support for our team and always goes the extra mile. Wendy Jessup, Dietician - SCBU North Shore Hospital, nominated by Karen Boyle "Wendy has shown compassion, been connected with the family and strived for best possible outcomes and brilliant care." Dr Jye Lu, Clinical Lead - Gynaecology Services, nominated by Susan Rae, Gwyneth Capes and Nikki Cole "Dr Lu is the epitome of our DHB motto Best care for Everyone and our DHB values of Everyone Matters, Connected and With Compassion. Priscilla Philip, Executive Assistant - Planning and Funding, nominated by Scott Abbot "Priscilla is always going above what is required of her to help others, is very quick at solving issues and is just generally great to work with!" Jacqui Finch, Nursing Consultant - Corporate, nominated by Sharon Fisher Jacqui epitomises all the DHB values, but particularly around Everyone Matters. She makes time, all the time, to support her team and is always present for us. Sue Christie, Workforce Development Manager - Corporate, nominated by Vanessa Aplin For consistently supporting the Recruitment Team and the business by facilitating the Assessment Centres. Mike Aislabie, Traffic Co-ordinator - Traffic and Fleet, nominated by Norman Bond Duncan Glover, Parking Attendant - Traffic and Fleet, nominated by Norman Bond Feedback received from a member of the public: I wanted to write to say how impressed I was at the professionalism and kindness shown by Mike and Duncan. Their courtesy made the transaction very pleasant and I left with a smile. Sam Brens, Programme Coordinator - Mason Clinic, nominated by Shivika Singh "Sam has diligently worked towards developing programmes for staff at Mason Clinic around motivational interviewing." Jim Van Rensburg, Psychologist - Tane Whakapiripiri, nominated by Shivika Singh "Jim is dedicated, organised, and a hard worker. He is a real team player and he often offers to help others on top of his own responsibilities." Kim Beckford, Registered Nurse - Detox Centre, nominated by Astrid Smith "Kim has taken on the massive work of encouraging CADS to recycle and does a lot of the work herself. She is simply amazing." Sasha McKinlay, Registered Nurse - Health Support West, nominated by Alison Cunningham Sasha's commitment to her patients is admirable; her energy is endless and her ability to hold a team together is very appreciated." Maria Casale, Outpatient Dietician - Nutrition and Dietetic Services, nominated by Elize van Drimmelen Maria always goes above and beyond for her patients in a diligent and friendly manner. Victoria Yanez, Registered Nurse - Waitakere Day Surgery, nominated by Fleur Boxall For her long standing commitment, dedication and improvements to our unit as the Infection Control Representative." Tingting Zhang, Cultural Worker - Asian Health, nominated by Sonya Wilson 26

27 3.1 "For her hard work with our patients and her valuable insights into the cultural aspects of our patient's care." Awhina Brockbank, Administration Co-ordinator - Outpatients North Shore, nominated by Mandy Carn-Bennett Andrea Bond, Charge Nurse Manager - Outpatients North Shore, nominated by Mandy Carn- Bennett "Both Awhina and Andrea went out of their way to support HDS due to staff sickness. Both demonstrated WDHB values Everyone Matters, With Compassion and Connected." 2. Upcoming events Looking toward the upcoming months, we can expect to see: World Mental Health Day event co-sponsored with AUT on 10 October. A special guest lecture by international digital patient experience advocate Dave debronkart on 30 October. Continuation of the 2017 CEO Lecture Series in the Whenua Pupuke auditorium, with the likely visit of Lord Victor Olufemi Adebowale CBE in November. Lord Victor is the Chief Executive of the social care enterprise Turning Point and a member of the House of Lords. Chair Dr Lester Levy will also deliver a CEO Lecture Series presentation later in the year. Further progress on the replacement of CT scanners at Waitakere Hospital, with the first of two new scanners scheduled to be installed late this month. The installation of the second new scanner at Waitakere Hospital is scheduled for August Future Focus The Leapfrog programme was established as a means to support a focused, intensive burst to take a large leap in moving the DHB from where we are to where we want to be. The programme consists of a small number of strategic organisation-wide projects that are resourced to achieve significant change and impact on health outcomes and patient/family experience. The intended benefits are to move these projects along at a faster pace with top-level support for the significant changes required, giving greater visibility and attention to those projects identified as being important in achieving the DHB s priorities and purpose as well as instilling the culture of improvement and innovation. As per the News and Events Summary, the Leapfrog Programme has been announced as a finalist in the NZ Innovation Council Awards - Innovation Systems and Performance Improvement category. This award celebrates excellence in performance improvement, process improvement, accelerator programs, innovation and idea programs. The awards will be announced on 19 October. Across the DHB, 95%+ laboratory tests for all inpatient scheduled blood collections are now ordered electronically. Refinements are being finalised as the elabs project is closed. This has resulted in an average reduction of seven minutes from the time an eorder is received in the Lab to when it is acknowledged in the Laboratory Information System (LIS) for analysis. With time freed- 27

28 3.1 up, resources have been re-allocated to avoid calling-in additional resources and overtime during peak periods. Other benefits include better allocation of phlebotomy staff, no collects being missed and it is almost impossible to mismatch form and label. The team are working on the potential next steps for eorders and will present to the Board on these in the near future. In the Best Facilities Design stream, the team continues to have input into the ESC extension ward design, potential innovations for SCBU, research into patient/caregiver input for an Integrated Stroke Unit, feasibility of locations for ward mock-ups and proposals around improving sleep in hospital. The Outpatient FollowUp project has been trialling and evaluating a new eoutcomes form in rheumatology and the SOS (follow-up only if required by the patient) implementation in General Surgery. The regional RFP for telehealth technology continues, with trials planned for later this year. A business case has been prepared for other tools to support Outpatient Flow that is being presented to the Board this month. This could provide the enablers for improved processes and flow through Outpatient Clinics (real and virtual). The QlikSense project is tracking well against its targets for one app in each division and 100 users. The Internal Referrals work is also progressing, with ward consults live in many services and surgical waitlist referrals under development. 4. Outcomes discussion This month, I have asked Kelly Bohot, Project Manager at i3, to provide an update on sepsis improvement work underway. An improvement collaborative approach to timely identification and treatment of sepsis at Waitemata District Health Board Background Sepsis is a time-critical, lifethreatening medical emergency that can be present in any patient, in any clinical setting. It is globally one of the most-common but least recognised diseases. Sepsis is more common than stroke or heart attack and kills more people annually than AIDS, breast and prostate cancer combined. Delayed treatment is associated with high mortality; mortality rate increases by 7.6% for every hour of delay in starting antibiotic. 28

29 3.1 In 2016, Waitemata DHB s leadership team introduced the Survive Sepsis Improvement Collaborative (SSIC). The 18-month initiative was initiated in response to changes to the international consensus definition for sepsis and septic shock 1 and five serious adverse sepsis-related events on our adult inpatient wards in 2015/16. The primary aim is to reduce inpatient mortality to less than 15% by World Sepsis Day We aim to do this through timely identification and treatment of patients with suspected or confirmed sepsis. The SSIC consists of four work streams: development of best practice guidelines, clinical education, ward-based improvement activities and measurement. Development of best practice guidelines Waitemata DHB s adult inpatient sepsis guidelines are now available via our sepsis education page and as a screening tool in e-vitals. Paediatric and maternity guidelines are also under development. In July 2017, we added a sepsis screening tool to the evitals (PatientTrack) system. The sepsis screening tool compares vital signs to sepsis clinical indicators outlined in Waitemata DHB s inpatient sepsis guidelines. Clinical education We developed a sepsis clinical education package to support RN educators to deliver education to their ward areas and RMOs to their peers. We published the education package and guidelines on a sepsis site and have been tracking visitor numbers during the project. The increase in visitors in June is consistent with an education drive before the introduction of the sepsis screening tool in evitals. We also developed a web-based quiz via Kahoot to reinforce key learnings from our education package. In all, 285 staff members have played the Waitemata DHB sepsis quiz. We have received some positive feedback about the quiz: Sepsis one was awesome. Short and succinct and ended with a good quiz and Love the quiz. Ward-based improvement activities SSIC is based on the Institute for Healthcare Improvement s (IHI) Breakthrough Series. The approach is designed to facilitate system-wide improvements in quality by bringing multiple teams together for a short time to focus on improvements in a specific area. We recruited 21 nurse (RN) and junior doctor (RMO) teams for each of our adult inpatient ward areas. We combined teams from clinically similar areas to create four groups. Each group was supported by an 29

30 3.1 innovation and improvement project manager (i3pm) who guided the improvement process, including application of improvement tools. The RN and RMO improvement leads are currently testing four change ideas (eg a sepsis kit; sepsis escalation process) on our inpatient wards, using the model for improvement Average score 2.8 Quality Improvement Tools Knowledge: Self efficacy rating Average score 3.7 Before the project, we asked RN and RMO improvement leads to rate their confidence with 10 quality improvement tools. So far, six RMO leads have reported increased confidence with 6/10 tools. At the start of the project, mean confidence rating was 2.8 out of 5 (range 1-4) compared to 3.7 (range 2-5) after four months participation in the collaborative. 2 1 Before and patient outcomes. After Measurement We will report against the following measures to understand the impact of our improvement activities on clinical practice Outcome Process Balance Inpatient mortality Reliable screening Responsible antimicrobial ICU admissions Prompt treatment use Completeness of treatment The measures will be added to a Qlik dashboard to enable ward areas to track their management of patients with sepsis. We are also working with our health economist and data analysts to model and cost sepsis outcomes. 30

31 3.1 Summary and next steps We have realised some of the potential benefits of large-scale collaborative improvement, including strengthening relationships between RNs and RMOs, supporting clinicians to confidently apply various improvement tools and engaging a broad number of stakeholders in the improvement process. We also recognise the challenges associated with this large-scale improvement, including the amount of resource required, identifying the best ways to communicate with different stakeholders across the organisation and the flexibility required to support our clinical colleagues who are balancing clinical commitments with improvement work. Our next step is to complete project evaluation, which will include a review of the measurement set so we can better-understand the impact of this project on patient outcomes. Wednesday 13 September was World Sepsis Day and we held an event to celebrate the improvement work and raise awareness of sepsis. This includes the first Australasian screening of the movie Starfish a true story about a family thrown into turmoil when the husband develops sepsis. References Singer M, Deutschman C, Seymour C et al (2016) The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA Feb 23; 315 (8): The Breakthrough Series: IHI s Collaborative Model for Achieving Breakthrough Improvement Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers;

32 5. Board performance priorities 3.1 The following provides a summary of the work underway to deliver on the DHB s priorities: Relief of suffering Progress: Patient Experience National Inpatient Survey The third national patient experience survey for 2017 is currently being conducted and results should be available in early October. Previous quarter reports are summarised in the table below. Year and Total Communication Partnership Coordination Needs Quarter Surveys Apr Jun Jan - Mar Overall Oct - Dec Jul - Sep Apr - Jun Jan - Mar Waitemata DHB National Inpatient Survey results Friends and Family Test During August 2017, we received feedback from 1,118 people through the Friends and Family Test (FFT). The Net Promoter Score (NPS) for August was 76, well above the DHB target of 65 and the second-highest score recorded. Friends and Family Test Overall Results Waitemata DHB overall NPS Waitemata District Health Board, Meeting of the Board 27/9/17 32

33 3.1 Waitemata DHB continues to score well above target with the overall NPS. Over the last quarter, two of the highest scores have been achieved (June 78, August 76). Facilities Major capital projects need strong regional support and alignment. The Northern Region is working on a Long-Term Investment Plan (LTIP) to guide all significant future capital investments in the region. The Board will be regularly updated on this work going forward. Waitakere Hospital Radiology Replacement and Additional CT Scanner The construction team is now on-site at Waitakere Hospital Radiology Department preparing for the installation of a new CT Scanner. The Aquilon Prime is manufactured by Toshiba and uses cuttingedge technology to deliver high-quality imaging at low radiation dose. The new scanner will replace the existing Siemens CT scanner that has been in service since late We do not anticipate any disruption to services while this work is undertaken. Following the commissioning of the new CT Scanner, the team will move straight into installation and commissioning the second CT Scanner at Waitakere Hospital. This will involve significant refurbishment of the existing department to create new patient facilities and the creation of space to accommodate the second CT Scanner, due for installation in late Elective Capacity and Inpatient Beds (ECIB) business case to Capital Investment Committee (CIC) The business case was submitted to the CIC and we await the outcome of their decision. Replacement Wards Project We are going through the Investment Logic Mapping (ILM) process in developing a strategic assessment. Waitemata District Health Board, Meeting of the Board 27/9/17 33

34 3.1 Mason Clinic presentation to CIC for refurbishment of Tanekaha The CIC approved the Tanekaha business case at its meeting on 27 March subject to: 1) Agreeing the recycling of capital from the 44 Taharoto Road property. (Proposal submitted to Treasury) 2) Submission of the post-implementation review of He Puna Waiora. (Complete) 3) Receiving a progress report on the 15-bed unit at Mason Clinic under construction. (Complete) 4) Receiving the revised Business Case with updated pricing and final design to be submitted In November. (Awaiting finalisation of land procurement which affects final design and costs.) Better Outcomes Progress: On track Achieving the health targets as at 3 September 2017 Shorter waits in Emergency Departments 98% (target 95%) Improved Access to Elective Surgery 106% (target 100%) Increased immunisation 93% (target 95%) Better help for smokers to quit - Maternity 92% (target 90%) Raising healthy kids 100% (target 95%) Faster Cancer Treatment (FCT 62 days) 95% (target 90%) Health Quality and Safety Markers August 2017 Falls Falls risk assessment audits that inform the Health Quality and Safety Commission data continue and are conducted monthly. Overall, Acute and Emergency Medicine completed 100% of falls risk assessments, Specialist Medicine and Health of Older People completed 100% and Surgical and Ambulatory completed 82% on admission. Of those, Acute and Emergency Medicine completed 85%, Specialist Medicine and Health of Older People completed 87% and Surgical and Ambulatory completed 61% within eight hours of admission (against a target of 90%) Hand Hygiene Waitemata DHB s Hand Hygiene Compliance Audit result for August 2017 was 88%, exceeding the national target of 80%. This placed Waitemata DHB second-highest nationally. Healthcare-Associated Infections The CLAB insertion bundle was used in ICU on 100% of occasions in June The insertion bundle compliance exceeds the national target of 90%. Māori Health Te Wiki o te reo Māori Celebrations (Māori Language Week) 2017 From September 11-17, we celebrated te wiki o te reo māori (Māori Language Week). We enlisted two amazing Ngāti Whatua kotiro, also known as the Ako Ako Girls to help us promote and celebrate the importance of the Māori language. The theme for this year s celebration was 'Kia ora te reo Māori '. The theme also provided an opportunity for us to acknowledge the role and contribution of our Chief Advisor Tikanga and the role she has played as a champion for the Māori language. Staff were challenged to post Kia ora videos on our Facebook page. Waitemata District Health Board, Meeting of the Board 27/9/17 34

35 3.1 Te Whare Wānanga o Awanuiarangi agreed to partner with us and is providing language experts to facilitate pronunciation workshop for our staff during the week. Lunchtime seminars were also provided by Scott and Stacey Morrison, Te Hamua Nikora and Te Atawhai Tibble. Like Matāriki, Māori Language Week gives us an opportunity to expose our staff to important enablers and intelligence that will enhance our collective capability care for the whānau and families that we are here to serve. Workforce Development Ethnicity data quality improvement Improving and monitoring Māori workforce participation requires reliable, high-quality ethnicity data. Workstreams under MALT have undertaken a range of audit work to identify and improve workforce data quality, including ethnicity data. This work has identified opportunities for improvement around the collection, recording and transfer of ethnicity data. The findings of this work are very similar to other ethnicity data quality improvement activities led by Waitemata DHB, such as the Primary Care Ethnicity Data Audit Toolkit and the Cervical Screening Ethnicity Data Improvement Project, where systems issues and training were identified as key improvement opportunities. Under MALT small projects have been undertaken to investigate this further, and to update systems with correct data. For example: Project to check staff ethnicity where records display not-stated. Staff were invited to update/correct their recorded information through an online survey using the census question. This resulted in 5% of the 122 respondents in Waitemata DHB and 8% of the 727 respondents in Auckland DHB identifying as Māori. Project to cross-check staff records where iwi affiliations are noted but ethnicity is recorded as non-māori. The 166 staff paper records identified through this audit were checked and where ethnicity was provided this was updated/corrected. This resulted in 71% with Māori ethnicity identified. At the July MALT meeting it was agreed to form a data working group to progress the short, medium and long term system change activities to ensure that ethnicity data is captured according to the best practice Ministry of Health Ethnicity Data Protocols for the Health and Disability Sector. Waitemata DHB has been instrumental and refreshing the Ethnicity Data Protocols as part of a Ministry of Health Working Group; the Protocols have been recently agreed to be adopted as a formal Health Information standard by the Ministry of Health. A key element of the refreshed Protocols is to address ethnicity data issues related to electronic systems such as this. Activities to progress under the working group will include the integration into HR systems of an innovative electronic Single User Interface (SUI), co-developed by Waitemata DHB with the Ministry of Health, to allow the easy integration of electronic collection systems with system recording and storage. This will be a national first and will benefit a number of other DHBs who use the same platform. Waitemata District Health Board, Meeting of the Board 27/9/17 35

36 3.1 Pacific Health Mumps epidemic Across Auckland, mumps notifications are approaching 300 cases this year, despite Auckland Regional Public Health Service and DHBs continuing to promote the vaccination message. Many of those contracting mumps are of Pacific ethnicity. Dr Josephine Herman, Public Health Physician (of Cook Islands descent) is taking the lead for the Mumps Portfolio and organised a Pacific engagement with DHB managers, parish nurses, Procare representives on 31 August The key issues were: Immunisation critical to control outbreak and reduce burden Messages to target GPs and Pacific community Need to increase vaccinator workforce Key messages: - Consequences eg orchitis/infertility - MMR vaccination - Awareness regarding imported cases from the Pacific Promotion: Parish/outreach nurses Media outlets: radio, TV, social media Waitemata District Health Board, Meeting of the Board 27/9/17 36

37 3.1 CEO Scorecard Health Targets Waitemata DHB Monthly Performance Scorecard CEO Scorecard July /18 Actual Target Trend Patient Experience Actual Target Trend a. Better help for smokers to quit - maternity 92% 90% p Complaint Average Response Time 11 days <14 days q a. Better help for smokers to quit - primary care 90% 90% p Net Promoter Score FFT q Improved Access to Elective Surgery - WDHB 95% 100% q Shorter Waits in ED 93% 95% q a. HQSC Quality and Safety Markers - Quarterly Trend Faster cancer treatment (62 days) 91% 90% q Older patients assessed for falling risk 95% 90% q Increased immunisation (8-month old) 93% 95% p Older patients assessed as significant fall risk with care plan 96% 90% Raising Healthy kids 100% 95% Good hand hygiene practice 86% 80% Occasions insertion bundle used - ICU 100% 90% p Occasions maintenance bundle used - ICU 98% 90% p g. Provider Arm - Service Delivery Surgical site infection rate 0.90 <1 p b. Antibiotic in the right time 95% 100% q Waiting Times Actual Target Trend ESPI Improving outcomes ESPI 1-90% OP Referrals processed w/n 10 days Compliant Better help for smokers to quit - hospitalised 98% 95% ESPI 2 - % patients waiting > 4 months for FSA Non-Compliant e. Ambulatory Sensitive Hospitalisation rate (ASH) p ESPI 5 - % patients not treated within 4 months Non-Compliant f. Annual amenable mortality rate (per ) q Diagnostics Population coverage/access Trend a. % of CT scans done within 6 weeks 97% 95% p Cervical Screening 74% 80% q a. % of MRI scans done within 6 weeks 97% 90% q Breast screening 66% 70% q c. Urgent diagnostic colonoscopy (14 days) 98% 90% q Bowel Screening Participation Diagnostic colonoscopy (42 days) 77% 70% q - Round 3 53% 60% p Surveillance colonoscopy (84 days) 96% 70% q Treatment a. Patient Flow HSMR (Source: Health Round Tables) 0.92 <1.04 p e. Elective Surgical Discharges (YTD) Surgical intervention rates (per 10,000 pop) Elective Discharges - Total 1,615 1,831 q - Angioplasty p Elective Discharges - Provider Arm 1,155 1,261 q - Angiography p Elective Discharges - IDF Outflow p - Major joints Efficiency - Cataract p d. Outpatient DNA rate (FSA + FUs) 8% <10% # NOF patients to theatre (48 hours) 91% 85% q Average Length of Stay - Electives 1.57 days <1.65 days q ST elevation MI receiving PCI (120 mins) 75% 80% p Average Length of Stay - Acutes 2.61 days <2.5 days p AT&R referrals assessed (2 working days) 98% 90% p Managing our Business Best Care Staff Experience Actual Target Trend Major Capital Programmes Time Budget Quality Sick leave rate 3.3% <3.6% q Elective Capacity and Inpatient beds (TBC) Turnover rate - external 12% 8-12% CT scanner Waitakere - Stage 1 Lost time injury rate (per hours worked) 7 <2 q CT scanner Waitakere - Stage 2 Mason Clinic Tanekaha replacement Financial Result Trend Ward 6/7 renovation (Dec/Jan 2018) Net Surplus/Deficit (YTD) 650 k 2,400 k How to read Performance indicators: Trend indicators: Achieved/ On track Substantially Achieved but off target p Performance improved compared to previous month Not Achieved but progress made Not Achieved/ Off track q Performance declined compared to previous month Performance was maintained 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. Reported quarterly - June data Q b. Dec Q2 2016/17 (latest HQSC data available). c. Bowel Screening Round 2 (closed) Jun Q4 2015/16 - Round 3 commenced (participation rate for invites Jan - Mar 2017). d. June 2017 e. Reported quarterly - March data Q f. Annual data - latest available 2014 g. Prelim data A question? Contact: Victora Child - Reporting Analyst, Planning & Health Intelligence Team: victoria.child@waitematadhb.govt.nz Planning, Funding and Health Outcomes, Waitemata DHB 37

38

39 3.2 Health and Safety Performance Report 3.2 Recommendation: That the report be received. Prepared by: Michael Field (Group Manager, Occupational Health and Safety) Endorsed by: Fiona McCarthy (Director, Human Resources) Glossary ELT - Executive Leadership Team HSNO - Hazardous Substances and New Organisms OH&SS - Occupational Health and Safety Services PCBU - Person conducting business or undertaking SMT - Senior Management Team 1. Purpose of report The purpose of the Health and Safety report is to provide quarterly reporting of health, safety and wellbeing performance including compliance, indicators, issues and risks to the Waitemata DHB. 2. Strategic Alignment Community, whanau and patient centred model of care Emphasis and investment on both treatment and keeping people healthy Intelligence and insight Evidence informed decision making and practice Outward focus and flexible, service orientation Operational and financial sustainability This report comments on issues and risks that impact on patient care and organisational culture. This report comments on organisational health information via incidents, health monitoring and leave information. The report provides information and insight into workplace incidents and what Waitemata DHB is doing to respond to these and other workplace risks. The leading and lagging indicator dashboard is based on current best practise indicators and targets. Health, safety and wellbeing risks and programmes are inherently focused on staff, patients, visitors, students and contractors. All strategic and operational work programmes and policy decisions are discussed with relevant services such as site visits and approaches to reduce risks. As appropriate, programmes of work will outline how services will ensure operational or financial sustainability, how measures of success are set and value and return on investment is monitored. 38

40 Trend highlights at a glance (rolling 12 months) 3.2 Staff incidents Number of staff reported incidents is stabilising. Continues to remain steady. Pre-employment Screening Remains at a very low level. Health and Safety representative vacancies Attendance at Health and Safety Orientation Progress continues to be made with catching up on the backlog of staff orientation. Number of staff injury claims We have noted a spike in injury claims over the last two months; however the total number of staff injury claims remains steady over the previous 12 months. Key Increased performance Steady performance Decreased performance In summary, for July 2017 Stabilisation of number of staff reported incidents. Slight reduction in Lost Time Incidents and injury frequency rates Corporate orientation rates remain below target. High levels of Health and Safety representative training completed. Steady levels of pre-employment screening prior to employment. High levels of hand hygiene. 39

41 Performance Scorecard 3.2 Comment on variations Indicators in red Six Lost Time Incidents and seven Lost Time Injury Frequency Rate compared with a target of five or less for both indicators. Comment We noted the following injuries and causes in July: 1. Knee sprain patient restraint. 2. Lumbar sprain patient handling. 3. Facial contusions patient assault. 4. Wrist sprain and cut patient restraint. 5. Rib and thumb sprain patient restraint. 6. Ankle sprain slip on wet floor. The resulting injuries from most incidents can range from minor bruising, which is the most common, to fractures or breaks, which is far less common. We are continuing our focus on patient aggression, in line with incident causes. 40

42 Attendance at Health and Safety orientation (corporate orientation) 67% compared with target of 100%. Although additional sessions have been arranged, attendance at the corporate orientation continues to be an issue, with staff invited, but not always attending. As a result, Learning and Development have moved the training sessions to Whenua Pupuke, to allow for larger numbers of attendees at each session, and are currently arranging for two different week days to be available (currently only Mondays) to allow for staff who are unable to attend on a Monday to attend on a Thursday instead. Additionally, communications to all managers, stressing that attendance is mandatory, are currently being developed for distribution. An online health and safety orientation education module is also being developed to send to new staff who cannot attend the first available orientation. 3.2 In order to increase understanding regarding the cost of staff injuries, injury cost tables have now been included under each of the high incident type sections. These tables provide information relating to the total costs incurred for the reported month, including treatment costs; weekly compensation costs for the injured staff member; and the estimated cost for replacing these staff members while they are away from work recovering. It is worth noting that costs for any injury claim can span multiple months, sometimes years, so this information should not be viewed as the costs associated with injuries which were sustained in that month, but rather as the total monetary value of claim costs incurred during that month. The total cost for 2015/16 and 2016/17 financial years are included below for comparative purposes: Total: Injury Claim Report for 2015/16 Financial Year Lost days Treatment cost Weekly Staff cover cost Total compensation costs (80% of salary) (100% of salary) Number of lost days for year $ total for year $ total for year $total cover cost for year Total $ cost for year 2,375 $294, $347, $434, $1,077, Total: Injury Claim Report for 2016/17 Financial Year Lost days Treatment cost Weekly Staff cover cost Total compensation costs (80% of salary) (100% of salary) Number of lost days for year $ total for year $ total for year $total cover cost for year Total $ cost for year 2,641 $246, $486, $607, $1,340,

43 The table below provides the total costs for July 2017: 3.2 Total: Injury Claim Report for July 2017 Lost days Treatment cost Weekly compensation costs (80% of salary) Number of lost days for month Staff cover cost (100% of salary) Total $ total for month $ total for month $total cover cost Total $ cost for for month month 342 $23, $66, $82, $172, Key Health and Safety Risks The table below outlines our key health and safety risks together with commentary on the current status/issues related to that risk and any actions to address issues. We have added residual risk (the portion of risk that is left after a risk assessment has been conducted) to this table. The actions reported each month are controls in progress and the residual risks from each of these identified risk areas will vary. Waitemata DHB has attempted to note the residual risk in the context of the original risk using a traffic light after each risk below: Risk: Aggression-physical and verbal Previous Report Action Community Worker Alarms: Presentation to Executive Leadership Team (ELT) due in August. Complete: 40% Draft police complaints policy has been reviewed and feedback provided to Legal Services to complete policy. Complete: 50% Intent for aggression incidents: Following Board comments, a third category has been added to the intent guidance document, covering partial intent for board reporting purposes. This category is for the classification of aggression incidents relating to people who have knowingly taken excessive alcohol or narcotics. This has also been included within the new aggression risk assessment documents, as outlined below. Complete: 80% Aggression Risk Assessment: Initial feedback was received and documents have been fully updated. These have now been sent back to the high risk areas, as well as the Behaviours of Concern Committee members, for final feedback. Complete: 80% Current Action Paper proposing a trial of community worker alarm systems has been approved by ELT/SMT. Trial commencing 19 September Complete: 60% No change - Awaiting final version from Legal Services. Complete: 50% Complete: 100% Initial feedback received and document updated. Resubmitted to Behaviours of Concern Committee members and awaiting final feedback. Complete: 90% 42

44 Risk: Aggression-physical and verbal Previous Report Action Hospital Reception Area Reviews: Template has been finalised and rolled out to all Health and Safety representatives, as well as OH&SS staff. Areas of highest concern are being reviewed first by OH&SS directly, with Health and Safety representatives carrying out their own area reviews. Complete: 97% New incident investigation templates have been finalised and sent to various managers for initial feedback. Complete: 75% Current Action Continuing to progress. Complete: 98% Feedback has been received and adjustments made. The investigation templates will now be rolled out in October 2017 Complete: 100% 3.2 Residual Risk: As these projects are still underway, the residual risk has not changed. It is envisioned that the residual risk levels will reduce upon project delivery. Original Risk Residual Risk Risk: Blood and Body Fluid Incidents (BBFA) Previous Report Action Needleless Systems: No change - Meeting with needleless systems clinical representatives underway. Complete 70% Residual Risk: Nil change Original Risk Current Action Needleless Systems: No change - Meeting with needleless systems clinical representatives underway. Complete 70% Residual Risk Risk: Hazardous Substances and New Organisms (HSNO) Previous Report Action HSNO audits continue to progress on-target. Audits completed: 38% Current Action HSNO audits continue to progress on-target. Audits completed: 40% Dangerous goods store: Successful tender respondent has been chosen and a recommendation is being drafted for ELT endorsement. Complete: 17% Temporary hazardous goods Store: Review of hazardous goods volumes and types has been completed and it has been determined that a temporary store for Waitakere Hospital is not required, we are simply limiting the volumes that areas are able to order at any one time and hold in their own Dangerous Goods Cabinets. The only remaining issue is a lack of holding space for waste chemicals for disposal. As such, additional Dangerous Goods Cabinets will be purchased for waste chemicals and situated on the Loading Dock area, which will enable us to operate on an interim basis, until such time as the required No change: the business case for the Dangerous Goods store is being prioritised alongside other capital projects. Complete: 17% Arranging final procedures and purchasing of hazardous goods cabinets. Complete: 95% 43

45 3.2 Risk: Hazardous Substances and New Organisms (HSNO) Previous Report Action Dangerous Goods Store can be constructed. Complete: 90% Current Action Hazardous Substances Register: During recent audits, it was determined that the current register is not fit for purpose due to the fact that our current register is Microsoft Excel based and does not allow us a consolidated view across all current systems (hazard, incidents, risks and HSNO) of what chemicals and what volumes each area has against any incidents and near misses, which results in us being unable to systematically manage trigger levels and other aspects. This is unable to be rectified within our current software environment. Funding for dedicated Health and Safety software will be raised during the year with planned implementation for 2018/19. Complete: 0% Hazardous Substances Register: Approval has been provided for OH&SS to engage with healthalliance to arrange a Request For Information for dedicated Health and Safety Software. All new dedicated software systems contain compliant HSNO registers, so this item will be addressed as part of that project. Initial engagement has been made with healthalliance to begin this process. Complete: 5% HSNO policy: The new HSNO legislation has now been released, coming into force in December The HSNO policy is therefore being reviewed to align it with the new legislative requirements. Complete: 10% HSNO Policy has now been fully reviewed and updated to include new classifications and tracking requirements and is awaiting feedback from stakeholders. Complete: 90% Residual Risk: As the audit project and hazardous goods store progresses and each area becomes compliant, this residual level of risk will reduce. Original Risk Risk: Contractor and Procurement Management Previous Report Action Asbestos Coordinator: Recruitment process progressing. Complete: 75% Asbestos Register: This project has been split into two stages, as follows: Stage 1: Add a RAG (Red, Amber and Green) indicator to the existing register of reports, to allow contractors and staff to quickly identify whether asbestos is either confirmed as being present, should be assumed as being present or confirmed as not being present. This work is currently underway, with completion estimated by the end of July Complete: 100% Stage 2: Transfer of asbestos related information from the current Excel spreadsheet into the online Quality Hub version, currently utilised by Current Action Asbestos Coordinator: Recruitment process progressing. Complete: 85% Residual Risk Asbestos Register: This project has been split into two stages, as follows: Stage 1: Complete: 100% Stage 2: No change awaiting confirmation of student resource to carry out transfer of information from the current Excel spreadsheet 44

46 3.2 Risk: Contractor and Procurement Management Previous Report Action Auckland DHB. A project manager has been assigned to carry out this work, with completion estimated by the end of October Complete: 5% Waitemata DHB is currently initiating the updating of BIEMS to the most current version (similar to that currently used by Auckland DHB). This will enhance support for the facilities management processes required of a large multifacility organisation and will enable effective categorisation, job planning, recording and reporting from the system. Complete: 10% Residual Risk: Nil change. Original Risk Current Action into the online Quality Hub version, currently utilised by Auckland DHB. A project manager has been assigned to carry out this work, with completion estimated by the end of November Complete: 5% Progressing on-track. Dates and programme for updating BEIMS is currently being finalised with healthalliance, with an upgrade rollout estimated for December 2017, with final delivery in February Complete: 15% Residual Risk Risk: Manual and Patient Handling Previous Report Action Joint meetings with managers to discuss moving and handling requirements including training, is still underway, to provide support to services. Complete: 35% Original Risk Current Action Joint meetings with managers to discuss moving and handling requirements including training, is still underway, to provide support to services. Complete: 45% Residual Risk Risk: Health and Wellbeing (stress, fatigue, depression) Previous Report Action Current Action Healthy Workplaces: Healthy Workplaces: Team walking challenge: 10% (due October) Development of online healthy workplace resource still underway. Complete: 30% Work is continuing on wellbeing initiatives with Senior Medical staff. Complete: 40% Utilisation of the staff Fitness Hubs: Please note, an error was made for Waitakere Hospital usage in the last report, so historic figures have been updated accordingly. Usage rates for the last three months are as follows: Team walking challenge: The ELT has requested the DHB develop our own walking challenge programme internally. A student resource is being considered. Complete: 2% Development of online healthy workplace resource still underway. Complete: 35% Work is continuing on wellbeing initiatives with Senior Medical staff. Complete: 50% Utilisation of the staff Fitness Hubs: We continue to see very good update in Fitness Hub usage, with the North Shore Hospital Fitness Hub now approaching commercial activity levels. Usage rates for the last three months are as follows: North Shore Hospital 45

47 3.2 Risk: Health and Wellbeing (stress, fatigue, depression) Previous Report Action North Shore Hospital April: 1,052 May: 1,435 June: 1,246 Waitakere Hospital April: 731 May: 830 June: 743 Original Risk Current Action June:1,246 July: 1,268 August: 1,399 Waitakere Hospital June: 743 July: 786 August: 770 Risk: Physical environment (ventilation, lighting, equipment) Previous Report Action Helipad: Final draft plans have been completed, with work now needing to be scheduled to complete the enhancement of helipad health and safety. Complete: 75% New work on a resource kit for behaviours we wish to see is in progress using the Auckland DHB Speak Up materials as guidance. Complete: 10% New work on safe and healthy rostering is underway with Resident Doctors, Nursing and Senior Medical Officers rosters all in review. Complete: 40% New a fund for staff with impairments has been set up to fund appropriate work arrangements for staff that would not normally be able to access resources from existing support agencies, e.g. Mainstream, Blind Foundation, National Foundation for the Deaf. Complete: 100% Residual Risk Current Action Helipad: Hazard signage has been arranged and installed by OH&SS to fencing surrounding the helipad and separate signage placed outside of the doors facing the helipad from Whenua Pupuke. Final enhancement of helipad is due December Complete: 80% Loading Docks: This work is continuing, with quotes now being sought to carry out the physical works. Complete: 60% Loading Docks: Successful tender respondent has been identified and work is scheduled to be carried out in December Complete: 65% Pedestrian Crossings: Additional crossings are now being scheduled. Complete: 50% Pedestrian Crossings: No change - Additional crossings are now being scheduled across all campus. Complete: 50% Residual Risk: The residual risk remains the same at present until we complete some environmental projects and get regular environment reviews underway. Original Risk Residual Risk Risk: Slips trips and Falls Previous Report Action Current Action 46

48 3.2 Risk: Slips trips and Falls Previous Report Action All poster resources have now been distributed and being displayed on Health and Safety notice boards. It will take some time to ensure they are displayed in all locations, so completion level will not change until this is confirmed. Complete: 95% Current Action Complete: 100% Slips, trips and falls hazard reviews: Volunteers have now been sourced and clear guidance documents developed, including reporting templates. Both the lower ground floor and ground floor of North Shore hospital, identified as requiring immediate review, have been reviewed by OH&SS, with remedial actions either complete or scheduled. The review work being carried out by the volunteers will begin within the next two weeks and is likely to take up to two months to complete. Once completed, recurring walkthroughs will be scheduled once every 12 months, to ensure that any changes are noted and addressed. Complete: 10% Walkthrough s of both North Shore and Waitakere Hospitals have been completed by the OH&SS, with 11 hazards identified and scheduled for repair/replacement. Complete: 100% Residual Risk: The residual risk has dropped for entryways; however, this makes up a small proportion of overall slips, trips and falls events requiring the residual risk to remain the same. As staff communications are developed and delivered, it is expected that this residual risk will fall. Original Risk Residual Risk 4. Stakeholder feedback 4.1 Health and Safety Impacts on Waitemata DHB stakeholders Non-Clinical Contractor Induction All of the Non-Clinical Contractor online induction modules have now been finalised by OH&SS, allowing contractors to complete relevant modules online, prior to attending the on-site induction, where required. For those that do not require the on-site induction, such as couriers who are not entering any clinical areas), a certificate of completion will be required in order to obtain a security pass. healthalliance collaboration A strong working relationship has been formed with the healthalliance Health and Safety Manager, with information on incidents and hazards being regularly shared. A meeting with healthalliance to emphasis the expectations of contractor s pre and post scheduled work is due in the next month. 47

49 5. Staff Reported Incidents 3.2 Rolling year-on-year monthly average comparison: Previous 12 months 127 Current 12 months Current Period: The number of reported incidents by staff during the month of July was 164. Rolling 12 month analysis: We have seen a steady increase in staff incident reports since January 2017, in-line with historical trends. The higher number of incident reports we are currently receiving is likely due to our continued communications regarding the criticality of staff reporting incidents through RiskPro. 6. Notifiable Events One Notifiable Event (Incident) in July 2017: Burst water main pipe at North Shore Hospital. One Notifiable Event (Injury/Illness) in August 2017: Visitor slipped on wet floor and sustained a fracture to femur. 48

50 7. Top Incident types that cause harm 3.2 The main types of incidents that cause harm to our staff and the management of these hazards and risks are outlined in the following tables: 7.1 Aggression Rolling year-on-year monthly average comparison: Previous 12 months 32 Current 12 months 43 Actions: New processes for reporting intent relating to aggression incidents have been developed and awaiting final feedback from high risk areas. A template for the review of hospital based clinical reception areas has been completed and reviews have begun. Common controls in place for aggression incidents include: Area alarms Personal alarms Emergency response teams Staff training (i.e. communications, de-escalation, calming and restraint, as relevant) Hazard reviews of areas 49

51 The following tables show the number of physical and verbal assaults directed to staff and how many are generated by patients, visitors or other staff. The information below tells us that almost 100% of aggression incidents were generated by patients or visitors. This information should be viewed in the context that over 90% of these incidents are clinically derived and are likely due to patient illness, or their treatment pathway. 3.2 Rolling 12 month trend analysis Since August 2016, we have been experiencing a general downward trend in aggression related incidents; however, this trend reversed in March 2017 and continues to rise. This is likely due to the strong focus we have had, and continue to have, regarding aggression incidents and our continued calls for higher reporting of these incidents and near misses. Our new process to capture patient information relating to aggression incidents, has enabled us to recognise the impact that an individual patient can have on monthly aggression statistics. For example, 19 incident reports have been generated based on five patients for July Due to the unpredictable nature of these event types and our ability to eliminate clinically driven aggression, it is possible that we will continue to see spikes in incident numbers, generally driven by either a few incidents or a few people in our patient population. 50

52 Incidents for June 2017 In recognition that a number of incident reports can be generated by the same patient, the following table is included to enable Board members to gain visibility of the role acuity levels of patients can play in the number of incident reports generated. 3.2 Number of incidents by individual patients July 2017 Medical and Health of Older People Services Patient Number of None identified Incidents None identified Mental Health and Addictions Services Patient Number of Incidents Surgical and Ambulatory services Patient Number of Incidents Acute General Medicine Patient Patient A 6 Patient A 3 Patient A Patient 5 B Patient C 2 Number of Incidents 3 Aggression: Injury Claim Report for July 2017 Lost days Treatment cost Weekly compensation costs (80% of salary) Number of lost days for month Staff cover cost (100% of salary) Total $ total for month $ total for month $total cover cost Total $ cost for for month month 15 $1, $4, $5, $11,

53 7.2 Slips, Trips and Falls 3.2 Rolling year-on-year monthly average comparison: Previous 12 months Current 12 months Current period: The 13 Slips, trips and falls in July were caused by: Environment - 4 Faulty Equipment - 1 Inattention - 2 Other 1 (sat on stool that moved) Sport - 1 Wet Floor - 3 Work Practice - 1 Rolling 12 month trend analysis Slips, trips and falls are very much driven by changes in weather with wet period leading to higher incidents. A message for staff not to text and walk has been circulated as inattention is a high factor in falls. New posters to raise awareness of this risk have also been developed and have been distributed across Waitemata DHB. Slips, Trips and Falls: Injury Claim Report for July 2017 Lost Days Treatment Cost Weekly Staff Cover Cost Total Cost Compensation Cost (80% of salary) (100% of salary) Number of lost days for month $ total for month $ total for month $total cover cost for month Total $ cost for month 131 $2, $21, $27, $52,