BOARD MEETING AGENDA. 9.45am. Wednesday 22 August Items to be considered in public meeting VENUE

Transcription

1 BOARD MEETING Wednesday 22 August am 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 22 August 2018 Venue: Waitemata DHB Boardroom, Level 1, 15 Shea Tce, Takapuna Time: 9.45am WDHB BOARD MEMBERS Judy McGregor WDHB Board Chair Max Abbott - WDHB Board Member Edward Benson-Cooper WDHB Board Member Kylie Clegg WDHB Board Deputy Chair Sandra Coney - WDHB Board Member Warren Flaunty - WDHB Board Member James Le Fevre - WDHB Board Member Matire Harwood - WDHB Board Member Brian Neeson WDHB Board Member Morris Pita - WDHB Board Member Allison Roe - WDHB Board Member WDHB MANAGEMENT Dale Bramley - Chief Executive Officer Robert Paine - Chief Financial Officer and Head of Corporate Services Andrew Brant - Deputy Chief Executive Officer and Chief Medical Officer 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 Nicole Song - Board Secretary APOLOGIES: Allison Roe 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 9.45am 2.1 Confirmation of Minutes of the Meeting of the Board (11/07/18) Actions arising from previous meetings 3. CHAIR REPORT 4. EXECUTIVE REPORTS 9.50am 10.00am 10.10am 10.15am 10.20am 10.25am 4.1 Chief Executive Officer s Report 4.2 Health and Safety Performance Report 4.3 Communications Report 5. DECISION ITEM 5.1 Board Plan 5.2 Appointment to healthalliance NZ Limited Board of Directors 5.3 Fundraising and Sponsorship Policy 6. PERFORMANCE REPORT 10.35am 6.1 Financial Performance 7. COMMITTEE REPORTS 10.45am 7.1 Minutes from the Hospital Advisory Committee Meeting (01/08/18) 7.2 Minutes from the Hospital Advisory Committee Meeting (20/06/18) 8. INFORMATION PAPERS 10.50am 10.55am 11.00am 11.10am 11.15am 11.20am 8.1 Health and Safety Marker Report 8.2 Legislative Compliance 2017/ CARE Project Progress Report 8.4 Values Programme Update 8.5 National Programme for CALD Cultural Competency Courses for Health Care Workers 8.6 Car parking charges at Waitemata DHB 11.25am 9. GENERAL BUSINESS 11.30am 10. RESOLUTION TO EXCLUDE THE PUBLIC 3

4 1.1 Waitemata District Health Board Board Member Attendance Schedule 2018 NAME Mar Apr May Jul Aug Oct Nov Dec Judy McGregor (Board Chair) NA NA NA Max Abbott Edward Benson-Cooper Kylie Clegg (Deputy Chair) 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 Judy McGregor (Board Chair) Max Abbott Edward Benson- Cooper Kylie Clegg (Deputy Chair) Sandra Coney Warren Flaunty Dr Matire Harwood Involvements with other organisations Head of School, Social Science and Public Policy - Auckland University of Technology Associate Dean Post Graduate - Faculty of Culture and Society Member - AUT s Academic board New Zealand Law Foundation Fund Recipient Consultant - Asia Pacific Forum of National Human Rights Institutions Media Commentator - NZ Herald Patron - Auckland Women s Centre Life Member - Hauturu Little Barrier Island Supporters Trust 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 Chiropractor - Milford, Auckland (with private practice commitments) Trustee - Well Foundation Director - Auckland Transport Director - Sport New Zealand Trustee and Beneficiary - Mickyla Trust Trustee and Beneficiary - M&K Investments Trust (includes a share of less than 1% in Orion Health Group). Orion Health Group has commercial contracts with Waitemata DHB and healthalliance Director of High Performance Sport New Zealand Limited Board member, Counties Manukau District Health Board Member - Waitakere Ranges Local Board, Auckland Council Patron - Women s Health Action Trust Member - Portage Licensing Trust Member - West Auckland Trusts Services Member - Henderson Massey Local Board Auckland Council Trustee (Vice President) - Waitakere Licensing Trust Shareholder - EBOS Group Shareholder - Green Cross Health Director - Life Pharmacy Northwest Chair - Three Harbours Health Foundation Director - Trusts Community Foundation Ltd Senior Lecturer - Auckland University Director - Ngarongoa Limited, which is contractor providing services to National Hauora Coalition GP at Papakura Marae Health Clinic Advisory Committee Member - State Foundation NZ (Maori Health) Last Updated 28/06/18 19/03/14 07/12/16 15/08/18 15/12/16 06/06/18 10/05/18 5

6 1.2 REGISTER OF INTERESTS Board/Committee Member James Le Fevre Brian Neeson Morris Pita Allison Roe Involvements with other organisations Member Te Ora, Maori Medical Practitioners Step-daughter is a surgical registrar at Waitemata DHB Board Member - Auckland District Health Board Emergency Physician - Auckland Adults Emergency Department Trustee - Three Harbours Foundation Member - Medical Protection Society Member - ACEM Hospital Overcrowding Subcommittee Member - Northern Regional Clinical Practice Committee Shareholder - Pacific Edge Ltd DHB Representative (Auckland and Waitemata DHBs) - Air Ambulance Co-design Procurement Governance Board James wife is an employee of the Waitemata DHB, Department of Anaesthesia and Perioperative Medicine and a Medico-Legal Advisor for the Medical Protection Society Member - Upper Harbour Local Board Member - Human Rights Review Tribunal Member - Auckland District Licensing Committee Managing Director - BK & VS Neeson Limited Managing Director - Apollo Property Investments Limited Property Development Consultant Brian s son-in-law is employed by the Housing Corporation and is undertaking work for Unitec related to its Mt Albert site development. Owner/operator - Shea Pita and Associates Limited Shareholder - Turuki Pharmacy Limited Member - Eden Park Trust Board Shareholder and Director of Healthcare Applications Limited Morris wife is a: Board member - Northland District Health Board Board member - Auckland District Health Board Director - Healthcare Applications Limited Chairperson - Matakana Coast Trail Trust Member - Rodney Local Board, Auckland Council Last Updated 20/06/18 18/04/18 18/06/18 02/11/16 6

7 Confirmation of Minutes of the Board meeting held on 11 July 2018 Recommendation: That the Minutes of the Board meeting held on 11 July 2018 be approved. 7

8 2.1 BOARD MEMBERS PRESENT: Minutes of the meeting of the Waitemata District Health Board Judy McGregor (Board Chair) Max Abbott Edward Benson Cooper Kylie Clegg Sandra Coney James Le Fevre Warren Flaunty Dr Matire Harwood Brian Neeson Morris Pita Allison Roe ALSO PRESENT: Wednesday, 11 July 2018 held at Boardroom, Level 1, 15 Shea Tce, Takapuna, commencing at 11.02am PART I Items considered in public meeting Dale Bramley (Chief Executive Officer) Robert Paine (Chief Financial Officer and Head of Corporate Services) (in attendance from item 4.2) Cath Cronin (Director of Hospital Services) Debbie Holdsworth (Director, Funding) Jocelyn Peach (Director of Nursing and Midwifery, Emergency Systems Planner) Tamzin Brott (Director of Allied Health, Scientific and Technical Professions) Fiona McCarthy (Director Human Resources) Karen Bartholomew (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: WELCOME Sue Claridge, Auckland Women s Health Council Simon Maude, New Zealand Doctor The Board Chair welcomed the Board members and all those present at the meeting. She noted that this was her first meeting as new Board Chair and thanked the Board and staff for the welcome received and orientation provided. The Board Chair requested that the Chief Executive give an update on the proposed nurses strike on 12 July

9 2.1 APOLOGIES: An apology was received from Andrew Brant and for early departure from Kylie Clegg. DISCLOSURE OF INTERESTS There were no declarations of interest relating to the open section of the agenda. There were no additions or other amendments to the Interests Register. 1 AGENDA ORDER AND TIMING Items were taken in same order as listed in the agenda, except item 8.6 was considered after item BOARD MINUTES 2.1 Confirmation of Minutes of the Meeting of the Board (30/05/18) (agenda pages 7-24) Resolution (Moved Matire Harwood/Seconded Allison Roe) That the Minutes of the Board meeting held on 30 May 2018 be approved. Carried Actions arising from previous meetings (agenda pages 25) Noted. 3 CHAIR REPORT (agenda pages 26-27) The Board Chair noted her report. 4 EXECUTIVE REPORTS 4.1 Chief Executive s Report (agenda pages 28-51) Dale Bramley welcomed new Board Chair, Judy McGregor. He summarised the report presented and said that an update would be provided on the proposed nurses strike once more information was available. Matters covered in discussion and response to questions included: The Chief Executive noted the inaugural Waitemata DHB Matariki Awards held on 4 th July. Approximately 70 people attended. He acknowledged the work of MALT (Maori Workforce Alliance Leadership Team) and the award presented to the team; key data resulting from the teams work include an increase in Maori nurses of 189 across the three metro Auckland DHBs and 28 Maori doctors. The total number of Maori nurses is now 582 (with Waitemata DHB increasing by 37 Maori nurses in the last quarter) and 85 doctors; an incredible change in a short space of time. 9

10 2.1 The Chief Executive noted the addition of a Maori scorecard; at this time data is not available to replicate all areas of the full scorecard, but ethnic reporting is being increased across the DHB. In response to a question, the Chief Executive noted that there is a 30 per cent increase for Maori nurses and doctors year on year. The overall total percentage for Waitemata DHB is 5 per cent of nurses are Maori (17 per cent of Northland DHB s nurses are Maori). In response to a question about the Telehealth Pilot, the Chief Executive advised that the pilot is a reform of the outpatient process and driven by clinicians; primary care is also involved with the pilot. The pilot includes steps such as determining whether a patient needs to come back for a follow-up appointment or whether the follow up can be held at home, via link into the home or a centre in primary care. There is the ability for people to self-book appointments at a time that suits them and family, reducing DNAs (did not attend). A SoS card system is also being trialled providing priority booking straight into a service if required. It was noted that rehab in the home environment is the most beneficial for patients. The stroke rehabilitation programme was acknowledged as a successful example of this. In response to a question regarding cancer survival rates, the Chief Executive advised that the DHB has seen a 17 per cent reduction in deaths for its population, however, there more could be done. With regard to children in this area, the number of deaths is small. The DHB is on track for smoking cessation. From a public health perspective there are legislative areas around smoke free environments that the DHB could promote. It was suggested and the Board Chair agreed that a focus session on smoking cessation be held with the Board. The report was received. 4.2 Health and Safety Performance Report (agenda pages 52-70) Fiona McCarthy (Director of Human Resources), Michael Field (General Manager, Occupational Health and Safety) and Nigel Ellis (General Manager, Facilities) were present for this item. Michael Field noted that a review of international research best-practice for health and safety targets as it relates to setting a target for the metro Auckland DHBs has been completed. He summarised the update in the report (page 54 of the agenda) on the lost time frequency rate, noting that healthcare has more lost time injury per hour of work than any other industry. Board approval is sought to move the lost time frequency rate to a 12 month average trend, which will provide an optimal view of the rate. Matters covered in discussion and response to questions included: In response to a query about the 50 per cent target rate for significant hazards reviewed by managers, it was noted the rate was set as historically the DHB was not reaching 50 per cent. This target will be reviewed as part of the Board s health and safety workshop. It was requested that a paper on addressing aggression related incidents towards DHB staff in the workplace be prepared and include the most at risk areas and training for staff where aggression incidents occur. Noting that the Community Work Alarm Project pilot evaluation has been completed and a business case is being prepared as the next step. That a lot of work has been undertaken in the HSNO area (hazardous substances and new organisms); trials have been set up with orderlies to assist in identifying issues. 10

11 2.1 There has been a focus on transferring the HSNO register to an online platform allowing each area to create HSNO tracking with what is coming into the organisation and what is allowed in each area identified. Work is now underway on the HSNO disposal aspect. The Board health and safety workshop will also include leading and lagging indicators as they relate to aggression related incidents. A DHB staff member assaulted has to call the police themselves if required and the DHB s policy related to aggression incidents states that the DHB will support and enable staff to do this. Aggression incidents related to the use of drug or alcohol are recoded as such. It was noted that the graph presented on page 64 of the agenda aggression incidents includes additional incident categories from April Therefore the data from April 2018 cannot be compared to data prior to April 2018 [secretarial note: this was also identified during the discussion of item 8.2 where the same graph includes a line defining the date where data cannot be compared with that prior]. More granular information for pay equity was requested including age and gender. Resolution: (Moved: James Le Fevre/Seconded: Sandra Coney) 1. That the Board receives the report. 2. That the Board approved the new Lost Time Injury Frequency Rate (LTIFR) rolling 12 month average target. Carried 4.3 Communications Report (agenda pages 71-81) Matthew Rogers (Director of Communications) summarised this item, noting the reported DHB website and social media statistics. In addition the statistics related to Official Information Act (OIA) requests received by the DHB were noted with 107 received to date, which is in line with the previous year. He advised that the six month (January to June 2018) OIA performance report shows that the DHB has not breached the Act in terms of response time for the 93 OIAs received during that period. Matthew provided an update on the DHB s preparation as it relates to communications for the proposed nurses strike, advising that a comprehensive package of material had been provided to primary care providers (including GPs, urgent care and community pharmacies) about managing demand. In addition the DHB has also liaised with aged residential care services and maternity care services. There is also communication directed at patients and their families, along with public communications via news media and social media. There is a post on the DHB s social media about attending the emergency departments. The report was received. 5 DECISION ITEMS 5.1 Establishment of Waitemata DHB Consumer Council (agenda pages ) Carol Hayward (Community Engagement Manager), Jarrard O Brien (Associate Director Institute of Innovation and Improvement), Dr Penny Andrew (Associate Director of Institute of Innovation and Improvement) and Janine Pratt (Project Director) were in attendance. 11

12 2.1 Carol Hayward summarised the paper, she acknowledged the work of the Health Links and the support provided. She noted that the Ministry of Health had provided guidelines and encouraged the set up of consumer councils. A consultation process was carried out with the Health Links and a number of workshops held. Matters covered in discussion and response to questions included: The Board Chair noted that the Board felt that the Consumer Council should be accountable to it rather than the Hospital Advisory Committee. Janine Pratt advised that when undertaking the process of proceeding to establishing a Consumer Council, focus areas for the Council were on patient, clinical safety levels via the Clinical Governance Group and then to the Hospital Advisory Committee. If it was more wide-ranging then the Board would be an appropriate level of reporting. In response to a question about whether funding would continue for Health Links as now in place, it was noted that the role of the Health Links would change slightly and this would be further explored once a decision as made on the Consumer Council. The one year term for a Consumer Council member was queried as one year may not be sufficient; Carol Hayward noted that it is a standard term for advisory groups, but a term could be renewed. The difference between options 2 and 3 for the establishment of a Consumer Council were clarified, with option 2 preferred as it is based on clinical safety and the safety of services. Option 3 was the breadth of the community, patient and whanau care and the values programme. Option 2 was identified as having a gap that needed to be addressed. Longer term there would be greater breadth for the Council, but health and safety was a key area of work at this time. It was noted that other Consumer Councils have been more successful where there is a specific focus of work. The Health Links have reviewed and endorsed the paper submitted. The Board agreed to approve the establishment of a Consumer Council, but requested further discussion about accountability and the Council s terms of reference. Consequently, recommendations c) to f) remain unchanged and recommendation a) was amended to note that the Board approves the establishment of a Consumer Council and recommendation b) was amended to note a further report to the next scheduled meeting about accountability issues and the terms of reference. Resolution (Moved Judy McGregor/Seconded Max Abbott) That the Board a) Approves the establishment of a Consumer Council. b) That a further report be submitted to the Board for discussion on accountability issues and the proposed terms of reference for the Consumer Council. c) Notes the Consumer Council will give advice and make recommendations in the design, planning and delivery of high quality, safe and accessible health care services for the Waitemata community. d) Notes the establishment of the Consumer Council supports Waitemata DHB s commitment to comply with the 2017/18 DHB annual plan guidelines commit to either establish or maintain a consumer council (or similar) to advise the DHB. e) Notes the costs expected to be incurred by the Consumer Council, ie $72k, will be included in the DHB s operational budget for 2018/19. 12

13 2.1 f) Notes the Health Links contracts are due to expire in June The establishment of the Consumer Council will inform the future functions and contributions included in the community engagement contracts. Carried 6 PERFORMANCE REPORTS 6.1 Financial Performance (agenda pages ) Robert Paine (Chief Financial Officer and Head of Corporate Services) summarised this item, noting the improvement against budget and that the DHB is on track to meet budget at yearend. The Board Chair acknowledged the Chief Executive and Chief Financial Officer and their teams for the work to achieve the budget result. The report was noted. 7 COMMITTEE REPORTS 7.1 Minutes from the Hospital Advisory Committee (09/05/18) (agenda page ) James Le Fevre (Chair, Hospital Advisory Committee) summarised the minutes. The minutes of the Hospital Advisory Committee (09/05/18) were noted. 8. INFORMATION PAPERS 8.1 Governments Expectations on Employment Relations in State Sector (agenda pages ) Fiona McCarthy (Director of Human Resources) was present for this item. The Board Chair noted the clear expectation from the Government on closing the gap between lower and higher paid workers. She requested information on how that will be implemented. In addition she asked in what way contractors are bound by the Government expectation in the employment sector. Fiona McCarthy advised that clarification is being sought on the Government s expectation in this area and will be reported to the Board, along with the KPMG report released in this area. It was noted that on page 128 of the agenda where gender pay gap is referenced at 2% for the Waitemata DHB, it should read that This is the lowest gap in the country (not largest). The report was received 8.2 Equity Framework (agenda pages ) Dr Karen Bartholomew (Director Health Outcomes, Waitemata DHB and Auckland DHB), 13

14 2.1 Aroha Haggie (Manager Māori Health Gain, Waitemata DHB and Auckland DHB) and Catherine Jackson (Public Health Physician) were present for this item. The Chief Executive introduced the item. He noted that the Minister of Health had announced three significant priorities for health: mental health, equity and community and primary care. Work streams are being developed nationally to respond to these priorities. With regard to equity Dale noted that he had been asked to lead this work for the metro Auckland region. He referred to figure 1 (page 134 of the agenda) showing the link between Maori health and equity; it was noted that Maori health overall is a much wider issue then just equity and that the Treaty of Waitangi is a foundation point. The second point highlighted by the Chief Executive was that the proposed overall outcome is to achieve the same life expectancy for significant population groups. Life expectancy groups are the sum total of all mortality and morbidity. He advised that there has to be room for self-determination of outcomes to be achieved, there can be a Health Board life expectancy outcome, but what do Iwi leaders see as the primary outcome? Thirdly, the Chief Executive summarised the proposed Waitemata DHB equity framework with requires governance and leadership; figure 2 of the agenda (pages ). The proposed framework includes: 1. Health equity as a strategic priority Governance and Senior Leadership 2. Ongoing investment in partnership approach 3. Develop structures and processes to support equity work 4. Ensure that equity is a key component of quality in delivery of care 5. Deploy specific strategies It was noted that an aim included under point 5 deploy specific strategies included increasing professionalisation and living wage for all low paid staff by the end of The Chief Executive advised that the metro Auckland DHBs are in strong support of a paper to the Regional Governance Group on this issue. The Chief Executive acknowledged Karen Bartholomew and Riki Nia Nia for their work in the area of equity. Max Abbott congratulated the Chief Executive on his role in leading this work for the region for the Minister of Health. Matters covered in discussion and response to questions included: Sandra Coney noted the she would like to see a more specific focus for women; she also queried the outcome being life expectancy. The Chief Executive said that the other options are quality of life, measures of quality of life or health life expectancy. The reason life expectancy was chosen is that it is the sum degree of these other options. Matire Harwood noted a comprehensive and evidence based paper Major fundamental changes required to achieve health equity. A copy of this will be forwarded to the Board. The Board Chair acknowledged the WHO definition adopted for health inequities (being differences that re avoidable, unfair and unjust) and noted that she would like to see a right to health embedded in the document. The Board Chair said that she would like to see the connection between the equity framework presented and other Maori Health plans. 14

15 2.1 The report was noted. 8.3 Car Parking Charges at Waitemata DHB (agenda pages ) Robert Paine (Chief Financial Officer and Head of Corporate Services) summarised this item. The Board Chair noted that she had acknowledged receipt of the correspondence received from Waitakere Health Link and Grey Power. She reminded the Board of the social benefits of people who visit patients in hospital and the work that they do. Sandra Coney expressed her concern that the paper did not answer some of the questions raised by Waitakere Health Link; Waitakere Hospital serves a community that is not particularly wealthy. She also noted that the paper does not address the query raised about the discrepancy in parking costs between the metro-auckland DHBs. She noted that patients attending the Manukau Superclinic do not incur any parking costs. In response Robert Paine advised that the Waitemata DHB maximum payment ($20) is reached after a four hour period and that is reached earlier then the other two metro-auckland DHBs. However, the DHB has a lower first hour rate and may need to try and balance that if required to be fiscally neutral. It was noted that 64% of visitors to the DHB s hospital sites do not pay anything or pay a charge of $4. It is acknowledged that those staying longer than four hours pay a higher rate; rates can be reviewed by the Audit and Finance Committee prior to seeking Board approval. Robert Paine clarified the Crown loan agreement obtained at the time of developing the North Shore Hospital car park building. The Board Chair noted that a paper would be submitted to the Audit and Finance Committee for consideration before Board approval is sought. Resolution (Moved Warren Flaunty/Seconded Edward Benson-Cooper) That the Board: a) Receives the paper, noting that the Waitemata DHB Chair has recently received two letters regarding car parking charges at the DHB s hospital campuses. b) Notes Management s comments regarding the issues raised. c) Notes that once further investigations are complete these will be considered by the Audit and Finance committee with a final recommendation coming back to the Board. Carried 8.4 Health and Safety Marker Report - Update (agenda pages ) Fiona McCarthy (Director of Human Resources) summarised this item. The Board Chair noted that the aggression incident graph (page 149 of the agenda) identifies that data prior to April 2018 cannot be compared with data from that month onwards as additional incident categories were identified for review and are now included in reporting. This also relates to the same graph that was presented in item 4.2 of this agenda. 15

16 2.1 The report was received. 8.5 Engagement Strategy (agenda page ) Carol Hayward (Community Engagement Manager) and Jarrard O Brien (Associate Director Institute of Innovation and Improvement) were present for this item. Carol Hayward summarised the report, noting the South Kaipara needs assessment recently carried out provides an opportunity to understand current healthcare and needs in the area. In addition, Carol noted the health literacy symposium (with 150 attendees) held in May 2018 as reported. Jarrard O Brien provided an update on two examples of engagement with patients as reported being the Outcomes Measurement Programme and consumer representatives now part of the PROMS governance groups. In response related to system level measures and an intersection with increasing chlamydia rates and thinking around get checked messages, Catherine Jackson (Public Health Physician) advised that data for chlamydia in the first year was low as it was not available. She advised that the New Zealand Sexual Health Society guidelines are endorsed by the Ministry of Health. There will be a focus on all young people being checked next year. The report was received. 8.6 Statement of Performance Expectations (agenda page ) This item was received after item 8.7. Wendy Bennett (Planning and Health Intelligence Manager, Auckland and Waitemata DHB) introduced this item. She queried whether the Board would like to still receive comparisons with Counties Manukau Health in this report; the Board requested the comparisons continue for metro Auckland DHBs. The report was received. 8.7 System Level Measures (agenda page ) This item was received before item 8.6. Wendy Bennett (Planning and Health Intelligence Manager Auckland and Waitemata DHBs) Tim Wood (Funding and Development Manager Primary Care Auckland and Waitemata DHBs) and Catherine Jackson (Public Health Physician) were present for this item. Karen Bartholomew introduced the report, noting that it is a regular report presented to the Board and is an evolving programme of work. The report was noted. 9. GENERAL BUSINESS The Board Chair acknowledged and thanked the Board Secretary for her work, noting that this would be her last meeting before she finished with the DHB on 20 July. The Board wished her well for her next role. 16

17 RESOLUTION TO EXCLUDE THE PUBLIC (agenda pages ) Resolution (Moved Warren Flaunty/Seconded Edward Benson-Cooper) That, in accordance with the provisions of Schedule 3, Sections 32 and 33, of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below: General subject of items to be considered 1. Minutes of Meeting of the Board - Public Excluded (30/05/18) 2. Recommendations from the Audit and Finance Committee Public Excluded (20/06/18) 3. Minutes of the Audit and Finance Committee Public Excluded (09/05/18) 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)] 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. [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 17

18 2.1 General subject of items to be considered 4. Minutes of the Hospital Advisory Committee Public Excluded (20/06/18) /19 Annual Plan Financial Budget 7. Review of Provisions and Accounting Treatments 8. Business Case Substance Misuse Prevention Service 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)] 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 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)] 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)] 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)] 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)] 18

19 2.1 General subject of items to be considered Reason for passing this resolution in relation to each item [NZPH&D Act 2000 Schedule 3, S.32 (a)] 9. Deed of Settlement 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 Draft 2018/19 Annual Plan 11. Infrastructure as a Service [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)] 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 Obligation of Confidence The disclosure of information would not be in the public interest because of the greater need to protect information which if made available: i) would disclose a trade secret; or ii) would be likely to unreasonably prejudice the commercial position of any person who supplied, or who is the subject of, such information. [Official Information Act 1982 S.9 (2) (b)] Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] 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)] 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 greater need to enable the board to carry 19

20 2.1 General subject of items to be considered Reason for passing this resolution in relation to each item Ground(s) under Clause 32 for passing this resolution on, without prejudice or disadvantage, negotiations. 12. After Hours and Overnight Services 13. Mental Health NGO Sustainability 14. Facility development Mission Homeground 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)] 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)] 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)] 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)] 15. Facilities update Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Board to carry 20

21 2.1 General subject of items to be considered Reason for passing this resolution in relation to each item Ground(s) under Clause 32 for passing this resolution out, without prejudice or disadvantage, commercial activities. [Official Information Act 1982 S.9 (2) (i)] Max Abbott and James Le Fevre advised that they would need to leave the meeting at 4pm (Kylie Clegg had at the commencement of the meeting given her apologies for early departure and would be leaving the meeting at 3.50pm). The open meeting concluded at pm. SIGNED AS A CORRECT RECORD OF THE MEETING OF THE WAITEMATA DISTRICT HEALTH BOARD - BOARD MEETING HELD ON 11 JULY 2018 CHAIR 21

22 2.1 Actions Arising and Carried Forward from Previous Board Meetings as at 10 August 2018 Meeting Date Agenda Ref Topic 30/05/ Civil Defence Auckland review of response to major storm in Auckland overnight 10 April 2018 Board members to be provided with a copy of the review Terms of Reference 30/05/ Government Inquiry into Mental Health and Addiction 2018 Board members to be provided with a copy of the Waitemata DHB s stocktake report. 11/07/ Health and Safety Performance Report: -Paper requested on aggression related incidents towards DHB staff in the work place, including the most at risk areas and training for staff where aggression incidents occur. -More granular information for pay equity was requested including age and gender 11/07/ Government s Expectations on Employment Relations in State Sector - more information/clarification to be provided on how the Government s expectation of closing the gap between lower and high paid workers will be implemented. Person Expected Responsible Report back Comment Jocelyn Peach Actioned Terms of reference ed to the Board. Susanna Galea Actioned A copy of the report has been provided in the resource centre of Diligent Boardbooks. Fiona McCarthy Fiona McCarthy Board 22/08/18 Comments included in Health and Safety Marker Report on August Board agenda Information will be circulated shortly. Awaiting national clarification will report to the Board when received. 22

23 2.1 Meeting Date Agenda Ref Topic 11/07/ Equity Framework copy of the paper Major Fundamental Changes Required to Achieve Health Equity to be forwarded to the Board. Person Responsible Karen Bartholomew Expected Report back Comment Actioned. 23

24 3. Waitemata District Health Board - Chair s Report 3 Recommendation That the report be received. Prepared by: Professor Judy McGregor (Board Chair) Health Directions Forum: 9 August, These Wellington-based meetings are organised through the tripartite Health Sector Relationship Agreement process by DHBs, Ministry of Health, and CTU-affiliated Health Unions. There were four presenters, one zooming from Australia, and the following is a summary of points which may be of interest to Board members. Prior to the presentations, the chair Cee Payne from the NZNO, observed that the recent nurses negotiation had turned traditional bargaining processes on their head, particularly the need for more responsive and proactive communications from the union to, and with, members. Drivers of health demand and unmet need- Lyndon Keene, ASMS Director of Policy and Research General consensus based on evidence about the drivers of current health demand such as ageing populations and increase in chronic conditions, a range of new technology, the expectation of users, and determinants such as poverty, poor housing, racial inequality etc. In addition to the agreed factors there was the more controversial issue of poor access to effective health care and unmet needs. The NZ Health Survey shows 29% of adults and 24% of children with unmet needs for health care. Government was signalling the need for better primary health care and health prevention to balance the pressure on hospital services. But a meta analysis of domestic and international evidence on this point (UK NHS health checks, acute inpatient discharge rates in NZ between etc) says the evidence that one relieves the other is problematic. Why? The complexity of health care, the challenges of human behaviour, the need for social and economic context to be properly integrated into analysis etc. Evidence-based policy should dictate that a whole of system approach requires both primary care and hospital services. He expressed astonishment that the current health review doesn t emphasise hospital services in its published terms of reference. DHBs need to address this in their submissions. A Dutch study of over 40 barriers to preventative primary care found lack of time, confidence to provide the right advice, patient compliance and reimbursement to be issues for GPs and others. An Australian study of 150 primary health care interventions indicated that many of the most effective occurred outside the health system with a limited number having demonstrable impact- taxes on tobacco and alcohol and a mandatory limit on salt. Research evidence point to the central role of efficient and effective clinical leadership in integrated care which needed to be bottom-up, multi disciplinary, adaptive and distributive. 24

25 Responding to Māori health need- Joanne Baxter, Associate Professor of Māori Health and Associate Dean (Māori) Otago University This was a hugely impressive and sobering presentation and I will send around the power point when it becomes available. The absence of Māori in the room when health science research priorities were discussed and funding allocated is of concern. The failure of representation meant that when age-related health funding (falls, incontinence etc) was distributed the fact that Māori died at a much younger age meant that their needs were not necessarily being addressed and they were excluded from inquiry. Māori health workforce. Analysis showed that for Māori to become 20% of the health sector workforce we would need: 13,000 more nurses; 2510 more doctors; 380 more dentists and 320 more midwives. The barriers in the education system meant that Maori had lower levels of university entrance and were not accessing the right science subjects. Under-representation at tertiary level meant that on graduation there were few role models, Māori were marginalised and invisible, suffered from greater community expectation and burnout, patient concordance was a problem, and there were higher expectations on a small number. The capacity for Māori-led health provision needed to be adequately resourced and that Māori were weary and wary of pilot programmes which weren t continued. We always get the pilots never the airplane or the airport Paparangi Reid. 3 Vision and priorities for the health sector- Ashley Bloomfield, Director General Health Five years of no increase in per capita funding meant the balloon is bulging. Pressure on health workforces and on DHBs with caps on administrative staff which restrains clinical innovation. Need for clinicians with management and leadership skills as change managers and project managers. As DG he is committed to leadership for the sector (convening and collaborating, not always agreement) and stewardship (direction and future focus) and a strong and equitable public health system. The Minister had a very keen appetite for innovation in models of care. A mental health and addictions directorate has been established in the Ministry to enhance capability and capacity. Asked about a Maori health directorate he was still working through whether an aggregated group or dispersed membership was best and how to organise capability and capacity at the Ministry level. He agreed that three people were too few. In discussion about Māori and iwi providers there was comment that funding needed to be adequate so that they could afford trained Māori workforce. The DHB Performance Framework had in the past been too weighted towards financial performance. While there had been enormous value from the targets the Minister wanted a broader suite. For example, elective care targets based solely on surgery alone maybe too limited, if it could be undertaken in an outpatient s clinic (not counted). Capital and asset management. Big backlog of deferred maintenance and aged infrastructure. DHBs face triple whammy with capital charging as well. Treasury doing work on this. Health workforces need to respond to emerging issues and he believes that the Ministry should have a lot more leverage with tertiary providers re training needs and be more strategic about future needs. Areas of shortage- radiology and midwifery- were trained in the public sector and then went to the private sector creating significant issues for both workforces. 25

26 Shared responsibility for training was questioned given the leverage that DHBs and ACC might have. The DG said he was frustrated at the continuing shortage situation. Natural tension between whole of system national needs versus local considerations dictated in part by the current configuration of DHBs. Greater collaboration between DHBs and communities, and inter-dhbs at a regional level required. Questions over whether current decision rights by individual board were best serving regional service configurations. 3 Northern Regional Governance Group: 2 August, Five items were discussed including IS Governance, Laboratory Services (Audit and Finance), Equity, DHB Annual Planning Debrief and the NRLTIP progress. By the time the Board meets the NRLTIP communications outreach programme is expected to have started. Of interest to the Board is the commencement of a Primary and Community Care Deep Dive and we were asked to identify key areas of focus. The Chairs asked that the work: 1. Increase its Māori and Pacific representation on the Project Steering Group 2. Note the need for allied health workforce and nursing workforce participation in the project 3. A focus on how inequalities in access to, and outcomes of, primary and community care can be addressed and the gaps closed. The background paper provided has a wealth of information about the region, its needs, current services etc and is a substantial piece of work in its own right. The chair of the Auckland DHB, Pat Snedden, has been talking to a wide range of stakeholders about a sharper and more focused regional equity agenda and this discussion is ongoing. Counties Manukau chair Mark Gosche spoke of the need to respect the differences in health access and outcomes between Māori and Pasifika in the region. The Primary and Community Care work is clearly a focus of equity work. The Northern region could also commit to the ACCORD settlement for nurses by recommending that Māori and Pasifika nurses are prioritised in recruitment. Judy McGregor 26

27 4.1 Chief Executive s Report 4.1 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 CEO Series: The Minister of Health, Hon Dr David Clark, delivered a CEO Lecture Series address at North Shore Hospital s Whenua Pupuke auditorium on 1 August where he discussed the progress the Government is making toward priority areas in the public health sector. The lecture included a 15-minute Q&A session with staff. We look forward to welcoming former prime minister of New Zealand, Rt Hon Helen Clark, at a special CEO Lecture on 28 August. Welcoming the Minister: Board Chair Judy McGregor, Hon Dr David Clark and CEO Dr Dale Bramley Hepatitis C trial: A potentially life-saving Waitemata DHB-funded Hepatitis C screening programme is now being trialled at seven west and north Auckland pharmacies. Around 500 participants in higher-risk categories will undergo a simple finger-prick test as part of the pilot study the first of its kind to ever take place in New Zealand pharmacies. Results will indicate whether further testing is required to diagnose the potentially fatal liver disease, Hepatitis C - putting patients who ultimately test positive on the pathway to treatment and, in most cases, a full cure. An estimated 8,000 people with Hepatitis C live within Waitemata DHB boundaries and approximately 5,000 of them are undiagnosed. 27

28 A number of major news outlets covered the story including Newshub: Waitemata DHB wins public sector award: Dr Eleri Clissold was named Young Professional of the Year at the Institute of Public Administration New Zealand Awards. The award recognises young health professionals who have achieved excellence through their work within the public sector. Dr Clissold, who joined Waitemata DHB as a Medical Education Fellow in 2015, has designed and implemented an innovative medical education programme for junior doctors. This is also acknowledgment of the excellent work that started in our Medical Education and Training Unit as the programme continues to enhance training experiences and better outcomes for patients. This is a significant achievement for Dr Clissold who has quickly established herself as an emerging talent. Dr Clissold s role has been part of the Fellows Programme within the Institute of Innovation and Improvement, which has already produced a number of promising young clinicians. Promising future ahead: IPANZ Young Professional of the Year, Dr Eleri Clissold. HRC Grant: The Health Research Council has awarded Dr Karen Bartholomew and the Health Gain Team $65,000 in funding under the Breast Cancer Register Initiative. The funding will enable her team to complete qualitative research that will fill gaps in our knowledge about why many eligible New Zealand women particularly Maori and Pacific women as well as those from rural areas and lower social-economic groups do not complete radiotherapy as part of standard treatment for early breast cancer. Waitemata and Auckland DHB will fund the second phase of the research, involving focus groups and interviews with patients. Record hand hygiene audit: Waitemata DHB is leading the country when it comes to hand hygiene, having achieved a record compliance score of 90.3% and highest number of moments monitored (14,657) in the National Hand Hygiene Compliance Report for April- June We now have a wider spectrum of medical staff, including doctors, trained as auditors and it is wonderful to see their hard work coming into fruition. Maintaining the highest levels of hand hygiene is now business as usual for us and it ensures we provide a safe environment for all of our patients. 28

29 National Health Target DHB performance data: this was published for the third quarter of 2017/18 by the Ministry of Health on 10 August (Appendix 1). The results showed Waitemata DHB exceeded the requirements of four of the national targets faster cancer treatment, raising healthy kids, improved access to elective surgery and shorter stays in ED. I want to take this opportunity to acknowledge the hard work by so many of our people that has gone into achieving these results. They demonstrate that we are performing at a high level and providing the best care possible to our community across a range of important healthcare indicators. We have further work to do in two indicators increased immunisation and help for smokers to quit in primary care. The results for quarter four are expected later in August. The data can be viewed here: Matāriki Awards: Our inaugural Matāriki Awards were a huge success. The awards recognise staff who showcase our values in their work as they strive to better health outcomes for Māori within Auckland. We received a high number of nominations for four major awards and the winners were: "Everyone Matters" - Te Hine-ngaro Tuterangiwhiu, a new graduate physiotherapist at Waitakere Hospital, uses her knowledge in te reo and tikanga to enhance the experience of many patients. "With Compassion" - Hiria Nepe, public health nurse who works within schools that have a high Māori population, provides health education and early intervention in schools with a high Māori population. "Better, Best, Brilliant" - The HPV Self-Sampling feasibility study research team for boosting the number of Māori women screened for HPV by reducing the barriers to seeking treatment. "Connected" - Danielle Tahuri, coordinator of the Healthy Babies, Healthy Futures programme with Waitemata DHB s community partner, Healthwest. Danielle was nominated for her fantastic work addressing Māori childhood obesity by promoting healthy lifestyle choices among our Māori mothers

30 4.1 Connected: Stephen Anderton, Danielle Tahuri, Waitemata DHB Chair Professor Judy McGregor and Dame Rangimarie Naida Glavish. Focus on the future: The Digital Innovations Expo, hosted by our Institute for Innovation and Improvement, showcased over 20 systems, programmes and apps which are being used by our clinicians to ensure that, through smart and innovative use of technology, we can continue to deliver better health outcomes for all in our hospitals. It also gave clinicians a chance to talk to those behind the projects and give their own feedback and views. The event was so successful that a similar event is being considered for Waitakere Hospital. We created a short video to highlight the event: Nurses Week Awards: This year, a new Maori Nurse Leader award, the Kauae Raro Maori Nurse Leader Award, was introduced under the leadership of Clinical Nurse Director Dianna McGregor. Coral Skipper, Maori Clinical Nurse Specialist Diabetes Service, was awarded the korowai, which will be passed to the next recipient in Coral s contribution to the DHB has included mentoring and supporting the next generation of Maori nurses. Within the Diabetes service she has tailored services to the community as part of her dedication to reducing inequities within the health system. 30

31 4.1 Leading by example: Clinical Nurse Director Dianna McGregor (left) awarding the korowai to Maori Clinical Nurse Specialist Coral Skipper. Expansion of the values programme: As part of our ongoing roll-out of our values work at the DHB, the #hellomynameis campaign highlighted the importance of introducing ourselves when working with patients and their families. The campaign was started by Dr Kate Granger in the UK when she was diagnosed with cancer before passing away in Dr Granger believed taking the time to say your name was not just a common courtesy but more about making a human connection with someone who is suffering and vulnerable. I, too, believe that introducing yourself to a patient can help build and gain trust in difficult circumstances and I encourage all staff to support this campaign that is truly about patient-centered and compassionate care. More than 350 pictures were sent to the patient experience team from staff demonstrating their active engagement during the campaign. The public communication and reach via social media has been very successful. Hello everyone: More than 350 pictures were received during the #hellomynameis campaign Nursing: Approximately 140 non-clinical staff, Waitemata DHB volunteers and St John volunteers worked alongside clinical staff to ensure there was no disruption to patients or the smooth running of our hospitals during the national nursing strike on 12 July. 31

32 Collaboration, team work and good planning ensured patient care and safety remained at high standards. The Patient Experience team managed volunteers who provided non-clinical support such as assisting at meal times, answering call bells, welcoming visitors to the ward, conversing with patients and assisting with making beds. An agreement has now been reached with nurses and our focus is on implementing this. Creating a culture where all staff feel valued is very important and we will continue to look for new ways to show our nursing staff how important they are to us. Extra nurses will be coming as part of the agreement and a paper will go to Board regarding this. 4.1 Visit by Minister of Social Development and Disabilities: We had the pleasure of hosting the Minister of Social Development and Disabilities, Hon Carmel Sepuloni, when she met staff from our Adult Mental Health Services and Addictions Services. Ms Sepuloni, who is also the Associate Minister for Arts, Culture and Heritage and Pacific Peoples, was at North Shore Hospital on 12 July to discuss the Individual Placement and Support (IPS) Employment model assisting those who experience serious mental health conditions into employment. This pilot programme is being undertaken in partnership with the Ministry of Social Development. Special guest: Minister of Social Development and Disabilities, Hon Carmel Sepuloni Expansion of services at Waitakere Hospital: Another important milestone in the expansion of our radiology facilities at Waitakere Hospitals took place when kaumataua and staff gathered for a dawn blessing on 27 July. As the population of our district grows, so too does the demand on our services and facilities. Work on the expansion of this area started last year, with more space created for a new CT scanner that was installed in October The blessing marked the completion of a separate project stage that will now allow for a second CT scanner to be installed later this year. Going green: Furthering our commitment to sustainability, the Cityhop car fleet used by staff at North Shore and Waitakere Hospital will be swapped from petrol to electric-powered as part of a Government initiative to reduce emissions. This will result in six cars at North Shore and three at Waitakere going green. National Bowel Screening Programme Review welcomed: The National Bowel Screening Programme Independent Assurance Review was released on 8 August. Pleasingly, the review acknowledged the effectiveness of Waitemata DHB s pilot - noting that it was of higher quality than a number of other international pilots - a tribute to the work of those Waitemata DHB staff who had ensured its success. The document also recognised the significant effort Waitemata DHB had invested in supporting other DHBs as they went through the national bowel screening programme s implementation phase, including the willingness to share expertise gained as a result of running the pilot. We are now focused on 32

33 working closely with others across the health sector to manage the complexities of implementing a national population screening programme in a consistent manner to ensure maximum benefit to the health of New Zealanders. 4.1 Creating a culture of appreciation A further 55 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: Marie Arellano - Clinical Support Coordinator, Research and Knowledge Centre. Nominated by Rose Smart. Marie is a compassionate and hardworking team member who is always a pleasure to work with. Marie recently completed an exceptional piece of work using her coding skills to deliver new functionality to the CeDSS site. Maria Lourdes Escandor Cleaner, Clinical Support Services. Nominated by Medeline Viana. Maria works every day in our ward to keep our working environment clean, safe and hygienic. Nothing is too much for Maria and she s always willing to help all the staff as well as the patients and relatives in any way she can. Keshena Bennetts and Jessica Klippenstein - Social Workers, Marinoto Youth and Child North. Nominated by Heloise Pilling. Keshena and Jessica have done an amazing job connecting with our community. They are delivering an anxiety group from a community facility allowing increased access to families who would struggle to attend the hospital site. Anne-Marie Jeffries - Occupational Therapist, Inpatient North Therapies. Nominated by Sonya Wilson. For Anne-Marie's excellent work as a casual Occupational Therapist at Waitakere - she is much appreciated! Michelle Theyers - Social Worker, Methadone Services. Nominated by Soulisone Sayarath. Michelle s compassion and empathy for the complex clients that she works with is clearly evident in the work that she does. She is a true embodiment of the Waitemata DHB values with compassion and everybody matters. Albert Renaldi Engineer, Biomedical Hospital Operations. Nominated by Michael Smith. Albert is very pleasant, approachable and reliable. He delivers an outstanding service and shows great understanding about how the equipment is required back to the department in a timely fashion. On several occasions, he has come through to ensure the service gets what it needs and ultimately, that the patient receives the optimal care. Paul Sullivan Healthcare Assistant, Ward 10. Nominated by the Ward 10 team. Paul is our go to guy on our ward for any issues we have. Anything that needs fixing, changing or getting. You name it and he will endeavour to do it or get it done. Nothing is too much trouble and he does it with a smile, every time. Paul, we really appreciate your connectedness and your compassionate nature. 33

34 Simone Marsh - Health Care Assistant, Emergency Care Centre. Nominated by Sinead O'Malley. I love the way Simone is always available and willing to help when needed. She has a calm and gentle presence with our patients and it seems that nothing is too much trouble for her. She s such a valued member of the team and I know this sentiment is shared by all who work with her. Thank you so much Simone for all you do! 4.1 Gitaben Patel Cleaner, Clinical Support Services. Nominated by Trixina Smith. Our area has been cleaned efficiently. Gita vacuums the whole area and works at this task so the carpet is cleaned thoroughly. It is great to have a pleasant person doing this valued work. Theresia Bottema - Patient Care Assistant, Outpatients North Shore. Nominated by Diane Leithead. Theresia always works extra-time in her own time to ensure the clinics are set up in a timely manner which enables clinics to start on time and run smoothly. Theresia s time management and organisational skills are exemplary and she is a great support to the nursing team and doctors. Colleen Jagger - Patient Care Assistant, Outpatients North Shore. Nominated by Diane Leithead. Colleen s skills and flexibility between clerical and patient care are above and beyond those expected and desired of her role. Colleen s clinical knowledge-base means that many tasks are completed on time every time. Colleen is able to adapt to a variety of situations and roles that may be required of her during the day and ensures the clinics run smoothly and efficiently. Jasmin O'Sullivan - Clerical Worker Clinical, Clinical Records. Nominated by Danielle Hacking. Jasmin goes above and beyond to ensure people receive the clinical records that they have requested. She works part-time and has the entire research and audit community to respond to. She is friendly and polite and must be a huge asset to her team. Thank you Jasmin for doing your job so efficiently with such a friendly manner, you really are a star! Dr Chandra Ramanathan Psychiatrist, Community MH West 1. Nominated by Ambi Cherian. Dr Ramanathan is a humble psychiatrist who is compassionate, caring and kind. He has an outstanding willingness to spend time educating patients and their families about diagnosis and recommended treatments. He always goes above and beyond to provide the best care possible. Mags Ross Manager, CADs Central. Nominated by Jason Cabral-Tarry. Mags is supportive, friendly, approachable, always positive and pragmatic during meetings and projects with colleagues. She has brought valuable knowledge and experience to improve quality at CADS and strongly 'lives the values' through her leadership and collegiality with everyone here. Vicky Brackstone - Social Worker, North Therapies. Nominated by Petra Fowler. Vicky has gone so many extra miles for months to assist a client s safety and well-being, regularly weighing up his vulnerability and risks with his abilities to care for himself. She has showed a great ability to balance compassion, ethical decisions and professionalism in response to the client s needs. Rachel Prasad, Cathrene Orot, Micheline Habarugira, Michelle Soppitt, Brittany Fraser and Jinky Cos - Health Care Assistants, Bureau. Nominated by Dr Jacqui Gore. For showing such high levels of compassion and care to our patient while an inpatient on the medical wards. Their commitment and dedication was a crucial element to our patient s full recovery. 34

35 Neroli Blight - Specialty Nurse, Urology. Nominated by Susan Rae. Neroli is performing above and beyond what I would expect given such a short timeframe. She uses her initiative, anticipates issues and escalates these as required. She also works quickly to defuse upset patients and their families. Neroli embodies the DHB values of 'Better Best Brilliant', 'With Compassion' and 'Connected'. 4.1 Stephanie van Zyl - Operations Manager, Department of Anaesthesia and Perioperative Management. Nominated by Charles McFarlan. Stephanie leads with a clear dedication to her role and a calm approach to maintaining crossdiscipline relationships. Stephanie also simply looks after the people around her. Ciska Kritzinger - Senior Physiotherapist, Community West Therapies. Nominated by Mary Ellen Powdrell. Ciska is consistently caring, knowledgeable, fair and approachable for both staff and patients. Her enthusiasm and dedication is unwavering and infectious! We are so lucky to have you in the team. Karen Jansen-Stephenson - Management Accountant, Corporate. Nominated by Simon Watts. Karen has successfully led the PO First Oracle project that has gone live this week. She has undertaken a comprehensive project roll-out including the provision of training, troubleshooting, support and guidance to a large number of oracle users across the Waitemata DHB. A real great example of being 'Connected'. Racheal Perry - Registered Nurse, Child and Family West. Nominated by El Mann. Racheal supported our mutual client to have his vital treatment during the school holidays and in my absence. An awesome supportive colleague and much more than that, she also cares for his siblings when they also need unexpected care and attention. She s an amazing RN, a pocket rocket and such a fantastic example of collaborative support for our young clients in the community! Dr Mike Ang - Clinical Director, Adult Mental Health Services. Nominated by Cat Railey. Mike has been an unwavering support to us, offering to run clinics on top of his already massive workload to ensure that we are able to offer the best to our community. His recognition of our work and the challenges we face by jumping in alongside us is humbling. Kim Barker - Health Care Assistant, Clinical Support Services. Nominated by Susan Ching. Kim is a highly-organised and energetic staff member who follows a task or project through to completion. Kim has put in time and effort to develop an efficient stock ordering system which has saved ECC money and Waitakere Hospital has benefited from Kim s commitment to developing an efficient and organised environment. Catherine Smith - Psychologist, Rata Unit. Nominated by Chris McCloughen. Catherine does great work with the clients providing one-on-one counselling and this is reflected in the feedback given by other people in the teams that she is an integral part of. We are fortunate to have employed such a skilled person who is able to work with care recipients who have complex presentations and challenging needs. Wayne Forsyth - Clinical Centre Leader, OT, Maternal Mental Health. Nominated by Gill Graham. In response to unfilled vacancies and orientation to new staff, Wayne has held a higher than optimal case load with significant acuity. While obviously stressful, Wayne has continued to provide great care to the clients and continued support to his colleagues. We truly appreciate him on the team. 35

36 Donna Enoka - Administration Clerk, Kia Ora Hauora. Nominated by Natalia Valentino. Donna is supportive and always positive with colleagues. Recently Donna re-organised and refurbished our staff kitchen; we have now a nice area to have our meals and to share our stories. Thank you Donna for your support! 4.1 Maria Lafaele - Project Manager, Funding. Nominated by Leanne Catchpole. Maria demonstrates our values in her work, particularly connected where she frequently uses her personal networks to help connect the DHB with the Pacific community. Her relationships with the Pacific community and health professionals led to their valuable and extensive input into the recent development of our Effective Stop Smoking Conversations with Pregnant Women online training. Netini Vaeau - Team Manager, Takanga a Fohe. Nominated by Epenesa Olo-Whaanga. Netini provides consistent care and fairness for our staff while demonstrating a high regard for their physical and psychological safety when dealing with clients who have a range of mental health and addiction issues. Genevieve Dalseide - Ward Clerk, Dependant Haemodialysis. Nominated by Rachel Le Maitre. Genevieve continually shows enormous compassion towards the dialysis patients. She works above and beyond her role and working hours, ensuring everyone arrives at the right destination. She always puts in the extra effort to recognise patient s birthdays, special events and milestones. Patients appreciate her, as do all her colleagues. Linda Mackenzie Clemmett and Danielle Fernandes - Developmental Coordinators, Child Development Services. Nominated by Olivia Murton. Over the last couple of months Linda and Danielle have made a fantastic effort in organising a fundraising event for one of the charities we make referrals to. They organised a Scottish Celidih, sold over 100 tickets, decorated and prepared a great array of food on the night and raised around $1200 for the Children s Autism Foundation! They also ensured it was a really enjoyable event! Dr Vicki MacFarlane - Medical Officer, CADs Regional Administration. Nominated by Diane Leithead. "Vicki truly represents the DHB values: 'Everyone matters' she is kind, compassionate and takes the time to listen; 'With compassion' she is attentive and professional to patients and colleagues; 'Better, best, brilliant' she is actively involved in quality improvements and making the detox services for the region better; 'Connected' she remains connected with her team and patients at all times." Lee Ann Strahan - Ward Clerk, Emergency Care Centre. Nominated by Adriana Carlucci-Hercun. For going above and beyond for a patient needing help to sort out their ACC and organise a sick note. Lee evaluated what needed to be done and started the process before being asked. Lee provides 'best better brilliant' care to our patients. Jeong Lee - Occupational Therapist, Inpatient West Therapies. Nominated by Marieke Dijk. Jeong embraces all work thrown at her, absorbed half a case list from a leaving colleague and just dealt with it. She brings great skills, knowledge and experience. We are so lucky to have Jeong in our team. Barbara Latta - Administration Clerk, Youth Services. Nominated by Kate Doswell. Barbara is the backbone of our team support. From the small to the big things, she is always willing to help out, always greets us with a smile and keeps our team on track. She welcomes our clients and their families/whānau and makes them feel important and comfortable prior to their appointments. Barbara is truly 'better, best, brilliant'. 36

37 Ruth MacBain - Registered Nurse, Intensive Care Unit. Nominated by Marcelle Mafi. For going far above and beyond her normal role recently with a very tragic and sensitive situation in ICU. Ruth showed compassion, professionalism and a truly caring attitude in all she did for one of our patients that day. We appreciate all she did and I for one am very glad she was here that shift. We are truly grateful. 4.1 Loreen Hira - Social Worker, Adult Community Mental Health Team. Nominated by Catherine Deeney. Loreen is a committed social justice practitioner and champion of the vulnerable. She provides a first-class service to her clients, their families and to other social workers as an exemplary colleague and extremely competent supervisor. She is very skilled and very humble about her contribution, despite how great it is. Jo-Anne Benjamin - Information Analyst, Information Systems. Nominated by David Grayson, Stuart Bloomfield and Lara Hopley. Jo-Anne saved us today with a critical access issue for one of our doctors. Her speed and efficiency in dealing with the problem meant care was able to be given without delay. Jo-Anne s expertise is vital for us living our value of being connected and I m glad we have her here! Hannah Coombridge - House Officer, Kingsley Mortimer Unit (Ward 12). Nominated by Lee Roberts. Hannah is a fantastic doctor who is confident, yet caring. She gets the job done quickly and safely, she seeks assistance and has a fantastic bedside manner which matters immensely. She makes you feel your patients are in very safe hands. Jake Watson - Enrolled Nurse, Waitakere Ward 1. Nominated by Ivy John. Jake is very compassionate, energetic and caring towards his colleagues and clients, it is always a pleasure to work with him. Dominique Walker - Registered Nurse, Kingsley Mortimer Unit (Ward 12). Nominated by Sabia Hussaini. Dominique has had to manage a particularly difficult and challenging case recently and maintained a high level of professionalism at all times and has shown great resilience. She has demonstrated courage and strength to speak up, so that she is able to deliver care to the highest standard. Dominique is always supportive of her colleagues and it s always a pleasure to work with her. Eileen Mills-Newman - Recruitment Administrator, Recruitment Centre. Nominated by Antonietta Heath. Eileen ensures that each candidate's paperwork is submitted for loading by payroll. Every day she chases hiring managers and candidates for copies of registrations, APC s, NZPV s and paperwork to confirm eligibility to work in New Zealand. Without Eileen s hard work, no one would get paid. Thank you Eileen - you re a legend. Ian Gotty - Health and Safety Manager, Facilities and Development. Nominated by Lara Halligan. Ian is extremely helpful and always goes the extra mile to help any staff or contractors who require advice or assistance. With an unfailing positive attitude and passion for his area of expertise, he is a great asset to the team. Maree Bertinshaw - Health and Safety Coordinator, Quality and Improvement Team. Nominated by Jason Cabral-Tarry. 37

38 Maree has a wealth of knowledge and experience. She is approachable, kind, always willing to share her time with us and is an excellent resource for all health and safety related matters. She helps us provide better, best, brilliant care to our staff and clients and is a champion for improving health and safety standards. 4.1 Carol Holmes - Administration Clerk, Medical Subspecialties. Nominated by Pat Henley. Carol has faced constant challenges in her work especially during TransforMED. She has always been willing, considerate, and conscientious while maintaining a calm and cheerful demeanour and generally coping wonderfully with the thankless task of finding last minute solutions in an everchanging landscape. Her efforts indeed deserve acknowledgement. Suzanne Morris - Speech-Language Therapist, Inpatient North Therapies. Nominated by Michael Parker and Gavin Pilkington. Suzanne has completed an incredible course of swallowing rehabilitation with a patient on Ward 12, which has probably been lifesaving and has contributed significantly to recovery. Suzanne is a pleasure to work with and her dedication has been inspirational to other ward staff. Ursula Viljoen and Nathan Ellitts - Consultants, Recruitment Centre. Nominated by Michael Field. Both Ursula and Nathan have been absolutely amazing in their recruitment support for my team, going well and truly above and beyond what anyone could reasonably expect. Their dedication to their roles, and of supporting managers, is clear to see and they are always positive and proactive. It is a genuine pleasure to deal with them and know they are right behind me, offering their expertise, experience, support and guidance. Anne-Marie Hall - Clinical Charge Nurse, Emergency Care Centre, WTH. Nominated by Sarah Timmis. Anne-Marie showed real connectedness and compassion for our team during a recent emergency. Her ability to problem solve and support us during a difficult time is so valued and appreciated. 2. Upcoming events Looking toward the upcoming months, we can expect to see: The CEO Lecture Series continues with former prime minister Helen Clark on 28 August. Dr Helen Wihongi will host a clinic about Te Ara Tika - Guidelines for Māori research ethics, 4 September. Continued progress on the Patient Engagement System project using ipads, with design prints producing some great ideas for what the app might look like. Plans for Maori Language Week (10-16 September) including the grand launch of the Ake Ake cultural app coming together. 3. 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. 38

39 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. 4.1 The eorders system for laboratory testing has been adding in some clinical decision support measures ('soft stops') to prompt staff to think again before ordering tests and is proving to be successful. The next phase will introduce 'on demand' blood tests in ADU - as opposed to the daily phlebotomy rounds on the wards - removing the possibility of any tube labelling errors. The Outpatient Flow Tools are progressing well with address collection and validation in collaboration with Auckland DHB, and the proposal for a digital postage solution nearing completion. Meantime, work is progressing on clinic profiles as well as mapping out the processes and systems used in booking, scheduling and managing clinics. General Surgery, ORL and Orthopaedics are using SOS cards for patients who are not booked for a follow-up appointment but are able to get one if needed within a defined period. 4. Outcomes discussion This month, I have asked Penny Andrew (Director of the Institute for Innovation and Improvement) to provide a summary of the Executive Briefing reports for the 12 months to March The Health Roundtable (HRT) has published Executive Briefing reports for the 12 months to March The reports cover the relative stay index (RSI) trend; the top 10 diagnostic related groups (DRGs) opportunities for bed-day savings; ED target comparisons; Hospital Diagnosis Standardised Mortality Ratio (HDxSMR); and a summary of hospital KPIs. Highlights from the reports are: North Shore Hospital adjusted mortality continues to drop (see graph below). Adjusted length of stay (RSI) remains far lower than 2016 level, although it appears to have leveled out. Change has been achieved largely through reduction in long-stayers (>21 days stays). We now have the lowest proportion of long-stayers of all peer hospitals (see graph below). The hospital-acquired complication rate is low, although not lower than Counties Manukau DHB. The conditions with the greatest potential to save bed days are consistent with previous reports: respiratory conditions; acute myocardial infarction (AMI, aka heart attack) with invasive investigative procedure (this can be related to waiting for angiogram or waiting for transfer to ADHB for even more invasive procedure); heart failure; fractured neck of femur; stroke; urinary tract infection (UTI); cellulitis; and chest pain. Waitakere Hospital has similar conditions, and has reduced length of stay. Waitemata DHB hospitals have seen the greatest drop in RSI of all NZ hospitals over the last year. This is in part due to the TransforMED Programme and the excellent work that has been done on our wards. North Shore Hospital RSI dropped to 97% in the latest period. 39

40 Adjusted mortality

41 Long-stay share of beds North Shore Hospital: Waitakere Hospital: Board performance priorities 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 National Patient Experience Survey Results Year and Total Communication Partnership Coordination Needs Quarter Surveys Apr Jun Jan Mar Overall *Oct - Dec n/a n/a n/a n/a Jul Sep Apr Jun Jan - Mar National Survey Results (non-weighted results) *Anomaly with survey methodology In the second quarter, Waitemata DHB improved in most domains. Our response rate of 31% is 6% higher than the National Average of 25%. 41

42 Friends and Family Test In June, we achieved a net promoter score (NPS) of 80, our highest score since the survey was introduced in July The response rate for the Friends and Family Test (FFT) remains high, with feedback from 1,099 people. The NPS was up seven points on the previous month and continues to track well above the DHB target of Waitemata DHB Friends and Family Test question breakdown Net Promoter Score over time Total Responses and NPS to Friends and Family Test by ethnicity Waitemata DHB Net Promoter Score over time June-18 Māori Overall Asian Overall Pacific Other Responses NPS Net promoter score by ethnicity We have exceeded our target of 65 across all ethnicities. 1.3 Volunteer Update Green Coats Other allocated Volunteers Volunteers (Front of House) (B) (A) Volunteers on boarded awaiting allocation (C) Total volunteers available (D) (A) + (B) + (C) =(D) Volunteer Recruitment Volunteer numbers increased by 12 from May. In addition to these numbers, 24 students from Westlake Boys High School commenced volunteer work on 30 June. These students are independently managing the weekend volunteer service and supporting patient experience surveying. 42

43 Facilities Major capital projects need strong regional support and alignment. The Northern Region has developed 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. 4.1 The Waitemata DHB capital projects programme has been reviewed to identify projects that can be delivered under the DHB s funding, with the remainder forming part of a programme of projects requiring Government funding. Ministerial Program Business Cases are being developed and are anticipated to be: ECIB, Sustainable Inpatient Services (North Shore), Sustainable Outpatient Services, Infrastructure, Waitakere Hospital Development and Mason Clinic. Projects that cannot be delivered under DHB funding have been placed on-hold pending review for inclusion in the Ministerial Programme Business Cases. The Board will be regularly updated on this work going forward. Better Outcomes Progress: On track Achieving the health targets June 2018 Shorter waits in Emergency Departments 96% (target 95%) Improved Access to Elective Surgery 109% (target 100%) Increased immunisation (eight-month-old) 92% (target 95%) Better help for smokers to quit - Maternity 93% (target 90%) Raising healthy kids 99% (target 95%) Faster Cancer Treatment (62 days) 94% (target 90%) Health Quality and Safety Markers May 2018 Falls Falls risk assessment audits that inform the Health Quality and Safety Commission data are conducted monthly. Overall, Acute and Emergency Medicine completed 95% of falls risk assessments; Specialist Medicine and Health of Older People completed 100% and Surgical and Ambulatory completed 97% on admission. Hand Hygiene Waitemata DHB s Hand Hygiene Compliance Audit result for July 2018 is 89%; this exceeds the national target of 80% compliance. See the News and events summary for our record score in the National Hand Hygiene Compliance Report for April-June Healthcare-associated infections The CLAB insertion bundle was used in ICU on 100% of occasions in July. The insertion bundle compliance meets the national target of 90%. 43

44 Māori Health Māori Alliance Leadership Team Waitemata DHB is exceeding targets to increase the proportionality of Māori represented in our workforce. We are currently sitting at 6.7% against a target of 6%. There are 483 Māori staff employed across WDHB. 4.1 Waitemata DHB Quarterly Performance Scorecard Maori workforce March 2018 Te Wiki o te Reo Māori 2018 The theme for Maori Language Week (10-16 September)/Te Wiki o te Māori Reo 2018 is Kia Kaha te Reo Māori, which translates to: Let s make the Māori language strong. We are currently developing a programme of activity across both North Shore and Waitakere sites to enable basic Te Reo Māori practice across our organisation, this will include the launch of our new Āke Āke mobile application (app). The first of its kind, Āke Āke is a tool that staff can use on a daily basis to enhance and improve cultural interactions with patients and each other. Tumu Whakarae submission to Mental Health Inquiry Tumu Whakarae (National Reference Group of Maori Health Strategy Managers within DHBs) has been working collectively on a robust submission to the Mental Health inquiry. This has been a labour-intensive piece of work. However, the opportunity to propose much needed changes and improvements to our current approach in this area warranted such an effort. Pacific Health Tanoa: Pacific Allied Health forum All staff were invited to attend a Tanoa symposium on 3 August that explored ways to improve health outcomes for Pacific patients. The event also provided an opportunity to celebrate our Pasifika staff across the DHB and foster a sense of belonging across the workforce as staff discussed ways to celebrate, boost and support our team to help better-serve our community. Approximately 150 staff members attended the event. We shared the event into our wider community via a short Facebook video: 44

45 Workforce Development Finau Talanoa and Maggy Mase, both majoring in health promotion as part of the Bachelor of Health Science degree at AUT, have joined the Pacific Health Projects team as interns. Encouraging and supporting the next generation of Pacific health workers is part of the DHB commitment to providing the best care for our patients and it is wonderful to have them on board

46 4.1 Appendix /18 Health Target Results Data - Quarter Three Health Target: Faster cancer treatment DHB Name Target % Achievement % Auckland 90.0% 91.3% Bay of Plenty 90.0% 96.7% Canterbury 90.0% 91.3% Capital & Coast 90.0% 91.3% Counties Manukau 90.0% 94.7% Hawke's Bay 90.0% 91.0% Hutt Valley 90.0% 90.1% Lakes 90.0% 92.3% MidCentral 90.0% 94.0% Nelson Marlborough 90.0% 85.8% Northland 90.0% 86.0% South Canterbury 90.0% 93.1% Southern 90.0% 90.2% Tairawhiti 90.0% 90.2% Taranaki 90.0% 97.3% Waikato 90.0% 96.5% Wairarapa 90.0% 95.3% Waitemata 90.0% 93.2% West Coast 90.0% 81.3% Whanganui 90.0% 81.3% All DHBs 90.0% 91.4% 46

47 /18 Health Target Results Data - Quarter Three Health Target: Raising healthy kids DHB Name Target % Achievement % Auckland 95.0% 100.0% Bay of Plenty 95.0% 97.9% Canterbury 95.0% 98.4% Capital & Coast 95.0% 95.4% Counties Manukau 95.0% 100.0% Hawke's Bay 95.0% 97.8% Hutt Valley 95.0% 91.1% Lakes 95.0% 100.0% MidCentral 95.0% 98.8% Nelson Marlborough 95.0% 86.5% Northland 95.0% 100.0% South Canterbury 95.0% 97.1% Southern 95.0% 99.1% Tairawhiti 95.0% 97.0% Taranaki 95.0% 98.2% Waikato 95.0% 100.0% Wairarapa 95.0% 100.0% Waitemata 95.0% 99.0% West Coast 95.0% 100.0% Whanganui 95.0% 96.3% All DHBs 95.0% 98.5% 47

48 /18 Health Target Results Data - Quarter Three Health Target: Better help for smokers to quit - Primary care DHB Name Target % Achievement % Auckland 90.0% 89.4% Bay of Plenty 90.0% 90.2% Canterbury 90.0% 90.6% Capital & Coast 90.0% 89.9% Counties Manukau 90.0% 90.0% Hawke's Bay 90.0% 88.9% Hutt Valley 90.0% 83.3% Lakes 90.0% 84.0% MidCentral 90.0% 86.8% Nelson Marlborough 90.0% 86.6% Northland 90.0% 83.1% South Canterbury 90.0% 91.8% Southern 90.0% 90.9% Tairawhiti 90.0% 90.0% Taranaki 90.0% 88.9% Waikato 90.0% 87.6% Wairarapa 90.0% 89.6% Waitemata 90.0% 87.5% West Coast 90.0% 89.8% Whanganui 90.0% 90.7% All DHBs 90.0% 88.6% 48

49 /18 Health Target Results Data - Quarter Three Health Target: Improved access to elective surgery DHB Name Target % Achievement % Auckland 100.0% 94.0% Bay of Plenty 100.0% 111.2% Canterbury 100.0% 97.0% Capital & Coast 100.0% 101.8% Counties Manukau 100.0% 98.7% Hawke's Bay 100.0% 96.4% Hutt Valley 100.0% 112.3% Lakes 100.0% 99.4% MidCentral 100.0% 103.7% Nelson Marlborough 100.0% 94.8% Northland 100.0% 103.0% South Canterbury 100.0% 99.4% Southern 100.0% 98.7% Tairawhiti 100.0% 99.6% Taranaki 100.0% 119.7% Waikato 100.0% 105.4% Wairarapa 100.0% 104.0% Waitemata 100.0% 110.2% West Coast 100.0% 104.0% Whanganui 100.0% 107.4% All DHBs 100.0% 102.3% 49

50 /18 Health Target Results Data - Quarter Three Health Target: Shorter stays in emergency departments DHB Name Target % Achievement % Auckland 95.0% 89.5% Bay of Plenty 95.0% 93.3% Canterbury 95.0% 94.5% Capital & Coast 95.0% 90.3% Counties Manukau 95.0% 89.7% Hawke's Bay 95.0% 89.0% Hutt Valley 95.0% 90.8% Lakes 95.0% 97.7% MidCentral 95.0% 80.8% Nelson Marlborough 95.0% 94.6% Northland 95.0% 91.6% South Canterbury 95.0% 98.1% Southern 95.0% 89.6% Tairawhiti 95.0% 95.7% Taranaki 95.0% 90.7% Waikato 95.0% 85.8% Wairarapa 95.0% 93.6% Waitemata 95.0% 96.4% West Coast 95.0% 97.5% Whanganui 95.0% 91.5% All DHBs 95.0% 91.3% 50

51 /18 Health Target Results Data - Quarter Three Health Target: Increased Immunisation DHB Name Target % Achievement % Auckland 95.0% 94.0% Bay of Plenty 95.0% 88.5% Canterbury 95.0% 94.9% Capital & Coast 95.0% 94.5% Counties Manukau 95.0% 93.4% Hawke's Bay 95.0% 94.3% Hutt Valley 95.0% 93.4% Lakes 95.0% 91.3% MidCentral 95.0% 91.4% Nelson Marlborough 95.0% 86.8% Northland 95.0% 85.0% South Canterbury 95.0% 95.0% Southern 95.0% 93.7% Tairawhiti 95.0% 83.5% Taranaki 95.0% 87.6% Waikato 95.0% 88.5% Wairarapa 95.0% 89.5% Waitemata 95.0% 91.5% West Coast 95.0% 80.6% Whanganui 95.0% 89.3% All DHBs 95.0% 91.7% 51

52 CEO Scorecard 4.1 Health Targets Waitemata DHB Monthly Performance Scorecard CEO Scorecard June /18 Actual Target Trend Patient Experience Actual Target Trend a. Better help for smokers to quit - maternity 93% 90% p Complaint Average Response Time 11 days <14 days p i. Better help for smokers to quit - primary care 88% 90% p Net Promoter Score FFT p Improved Access to Elective Surgery - WDHB 109% 100% p Shorter Waits in ED 96% 95% HQSC Quality and Safety Markers - Quarterly Trend Faster cancer treatment (62 days) 94% 90% q Older patients assessed for falling risk 94% 90% q Increased immunisation (8-month old) 92% 95% Older patients assessed sig. fall risk with care plan 96% 90% p Raising Healthy kids 99% 95% Good hand hygiene practice 90% 80% p Occasions insertion bundle used - ICU 99% 90% Provider Arm - Service Delivery Occasions maintenance bundle used - ICU 91% 90% q e. Surgical site infection rate per 100 procedures 0.9 <0.8 q Waiting Times Actual Target Trend b. Antibiotic in the right time 96% 100% q ESPI ESPI 1-90% OP Referrals processed w/n 10 days Compliant Improving outcomes ESPI 2 - % patients waiting > 4 months for FSA Compliant Better help for smokers to quit - hospitalised 99% 95% ESPI 5 - % patients not treated within 4 months a. Compliant Ambulatory Sensitive Hospitalisation rate (ASH) q Diagnostics f. Annual amenable mortality rate (per ) p % of CT scans done within 6 weeks 66% 95% q Population coverage/access Trend % of MRI scans done within 6 weeks 65% 90% p Cervical Screening 71% 80% q Urgent diagnostic colonoscopy (14 days) 98% 90% p a. Breast screening 66% 70% Diagnostic colonoscopy (42 days) 71% 70% p c. Bowel Screening Participation Surveillance colonoscopy (84 days) 67% 70% q - Round 3 48% 60% q Treatment Patient Flow a. HSMR (Source: Health Round Tables) 0.81 <1.04 p Elective Surgical Discharges (YTD) a. Surgical intervention rates (per 10,000 pop) Elective Discharges - Total 20,695 20,806 q - Angioplasty q Elective Discharges - Provider Arm 14,298 14,322 q - Angiography q Elective Discharges - IDF Outflow 6,397 6,484 p - Major joints q Efficiency - Cataract q Outpatient DNA rate (FSA + FUs) 7% <10% p g. # NOF patients to theatre (48 hours) 86% 85% a. Average Length of Stay - Electives 1.50 days <1.5 days ST elevation MI receiving PCI (120 mins) 70% 80% q a. Average Length of Stay - Acutes 2.73 days <2.5 days p AT&R referrals assessed (2 working days) 98% 90% p Best Care Managing our Business Staff Experience Actual Target Trend Major Capital Programmes Time Budget Quality Sick leave rate 3.3% <3.6% Elective Capacity and Inpatient beds (TBC) d. Turnover rate - external 13% 8-12% CT scanner Waitakere - Stage 1 - complete Lost time injury frequency rate (per hours worked) 9 <2 p CT scanner Waitakere - Stage 2 Mason Clinic Tanekaha replacement Financial Result Trend Ward 6/7 renovation - complete Expense/Revenue (YTD Total) 1,724,732 k 1,724,750 k q Maori Scorecard Health Targets - Monthly Actual Target Trend Health Targets - Quarterly Actual Target Trend Shorter Waits in ED 97% 95% a. Better help for smokers to quit - maternity 87% 90% q Increased immunisation (8-month old) 86% 95% i. Better help for smokers to quit - primary care 88% 90% p Better help for smokers to quit - hospitalised 100% 95% p Raising Healthy kids 100% 95% Faster cancer treatment (62 days) 92% 90% p Quality and Safety Markers - Monthly h. Quality and Safety Markers - Quarterly Older patients assessed for falling risk 100% 90% Surgical site infection rate per 100 procedures Older patients assessed sig. fall risk with care plan 100% 90% g. # NOF patients to theatre (48 hours) 100% 85% 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 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. Key notes a. Reported quarterly - Mar Q3 17/18 b. Dec Q2 2017/18 prelim (latest HQSC data available). c. Bowel Screening Round 3 data Dec Q (participation rate for invites Jan - Dec 2017). d. Employees taking positions outside of the hospital/dhb e. Prelim data Mar Q3 17/18 f. Annual data - latest available 2015 g. Coding dep, rolling 3 mths - May 2018 h. Reported quarterly - latest available, Sep Q1 17/18 i. Jun 18 - prelim PHO data A question? Contact: Victoria Child - victoria.child@waitematadhb.govt.nz - Reporting Analyst, Planning & Health Intelligence, Planning, Funding and Health Outcomes, Waitemata & Auckland DHBs Team 52

53 4.2 Health and Safety Performance Report Recommendation: 4.2 That the Board receives the report. Prepared by: Michael Field (Group Manager, Occupational Health and Safety Service) Endorsed by: Fiona McCarthy (Director, Human Resources) 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 health 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. 3. Overview of current health, safety and wellbeing activity for July Guidance on Healthy Sleep The DHB has recently released guidance on healthy sleep. A copy will be made available at the Board meeting for members. 3.2 Health and Safety Site Visits The first site visit will be advised at the Board meeting. 53

54 3.3 Safe Way of Working (SWoW) Annual Self-Assessment Audit The annual Safe Way of Working (SWoW) self-assessment audit commenced on 6 April 2018 and closed on 1 June The self-assessment audit, completed by each service and ward manager for the 194 areas of Waitemata DHB, measures performance against the twelve elements contained in the Safe Way of Working system, which includes: employee participation; incident management; hazard management and risk assessment; contractor management; security and emergency preparedness. Below is an overview of the self-assessment performance scores for each Division. 4.2 Division % Self-Assessment Achievement 2017 % Self-Assessment Achievement 2018 % Change Acute and Emergency Medicine 79% 94% +15% CEO 71% 85% +14% Child, Women and Family 81% 93% +12% Corporate Services 54% 83% +29% Hospital Operation 77% 89% +12% Hospital Services 71% 87% +16% Human Resources 72% 94% +22% Speciality Medicine and Health of Older People Specialist Mental Health and Addiction Services 70% 88% +18% 86% 94% +8% Surgical and Ambulatory 80% 92% +12% Planning and Funding 96% 94% -2% Facilities and Development 52% 89% +37% In comparison to 2017, the results of the 2018 SWoW audit achievements show a significant improvement in performance across all Divisions, which is a credit to the commitment to service system improvement. This result is particularly impressive, as additional/new questions were added this year, to ensure a continued level of improvement across the Services, meaning these results demonstrate that many managers are proactively improving their own area s Health and Safety performance. Recommendations for further improvement, based on the 2018 results, are being sent to each manager for implementation and OH&SS will track this. Any areas scoring less that 70% are also being contacted directly to ensure we are providing all the support and guidance they require. 3.4 Update on the health and safety request for proposal The Request for Proposal (RFP) has been released as a closed tender, with the nine successful suppliers from the Expressions of Interest (EOI) process being invited to submit a final retailed tender response. 54

55 The RFP closes on 4 September 2018 and it is expected that we will require three weeks to review all tender submissions. Once this is complete, the three highest scoring suppliers will be invited to demonstrate their systems during workshops and two suppliers will be chosen at this point for a two week proof of value, requiring them to upload real data and for both Waitemata DHB and healthalliance to check performance and functionality matches with the suppliers promise. 4.2 A recommendations paper can be expected to the Board in November. 3.5 Performance Scorecard * The target at end of flu campaign is 60% Indicators in red Pre-employment screening completed prior to commencement 59% compared with target of 70% Comment A number of staff commenced employment prior to the completion of the pre-employment health screening and each manager has been followed up and reminded of the required process. Preemployment screening is not currently mandatory across Waitemata DHB, with a trial for Specialist Mental Health and Addictions Division and Corporate having been completed. The evaluation of the trial will be tabled at the Executive Health, Safety and Wellbeing Committee in August for a decision and plan on whether the DHB adopt mandatory preemployment health screening across the DHB. 55

56 4. Work related injury Claim Data for June 2018 Outlined below is our injury claim data for June. Work injury claim data is for all work injuries currently managed by the DHB, including injuries that may have been incurred in previous years, up to and including injuries for June High accident events account for approximately 55% of the claims as follows: Manual handling - 28% Slips, trips and falls - 17% Aggression - 10% Lost days Number of lost days for month Treatment cost $ total for month INJURY CLAIM DATA Total: Injury Claim Report for June 2018 Weekly compensation costs (80% of salary) $ total for month Staff cover cost $total cover cost for month Total Total $ cost for month $36, $29, $36, $101, 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, our performance level and any actions to address issues. Key Risk is well managed all significant actions complete Risk is well managed - some minor actions to be completed Risk is being managed and has some significant actions underway Risk is being managed and has some significant actions yet to progress Approximately 11 actions have been in progress for over 12 months, although some of these (e.g. rostering solutions) have a long lead in timeframe. Of these, four are Facilities and Development projects with approved CAPEX, all of which are now actively progressing. Eight actions have been in progress and are due to complete by December Risk: Aggression-physical and verbal Previous Report Action Community Worker Alarm Project: Pilot evaluation has been completed and a recommendations paper is being drafted. Complete: 100% In depth data study to review aggression: Study has commenced and will now complete in June. Complete: 20% Current Action Community Worker Alarm Project: Pilot evaluation paper to ELT by September. Pilot complete: 100% Evaluation complete: 0% In depth data study to review aggression: Study has commenced; however due to increased workload, completion has been delayed and will now complete in August. Complete: 20% 56

57 Risk: Aggression-physical and verbal Previous Report Action Online security and safety training in development. Due May Complete: 60% Current Action Online security and safety training has been implemented (CALM training) and online foundation training is also complete and in testing prior to rollout. Complete: 100% 4.2 Complete pilot course to help staff thrive in challenging work situations. Due June 2018 Complete: 50% ED workplace safety work streams: Complete: 30% Pilot closed in favour of considering specialist face to face training. ED workplace safety work streams: Complete: 50% Risk: Blood and Body Fluid Incidents (BBFA) Previous Report Action Needleless Systems: Data reviewed on areas with Blood and Body Fluid Events (BBFE) and needless systems. Two areas identified for follow up via the OH&SS team. Work has commenced with BD (Becton Dickinson), our supplier of sharps bins and needleless systems, to audit high incident areas. Any work streams identified will be reported through this section. Complete: 85% Current Action Needleless Systems: Data reviewed on areas with Blood and Body Fluid Events (BBFE) and needleless systems. Two areas identified for follow up via the OH&SS team. Work has commenced with BD, our supplier of sharps bins and needleless systems, to audit high incident areas in August. Work has commenced to develop a sharps safety week, scheduled to run late Complete: 90% Risk: Hazardous Substances and New Organisms (HSNO) Previous Report Action Current Action HSNO audits: Focus has shifted onto newly HSNO Audits: Review of new Act has been released legislation and the resulting changes to completed and audits of 33 high risk areas (67 policies and procedures. HSNO audits will physical locations) have recommenced. recommence once all policy changes have been Audits completed: 45% finalised. Audits completed: 43% The business case for the Dangerous Goods store will be presented to the Board in An interim facility is due for installation in 2019, and interim management process has been developed. Complete: 25% The DHB is discussing how best to transfer internal hazardous waste to the dangerous goods store (North Shore Hospital) and the dangerous goods cabinets (at Waitakere Hospital). Paper to pilot an internal transfer system is due to the senior management team in May. Complete: 20% Not due yet. Trial on transferring HSNO waste within the main hospitals is being progressed, with training and dedicated trolleys currently being arranged. It is expected that the trial will commence early September and run for 6 weeks. Complete: 30% 57

58 Risk: Health and Wellbeing (stress, fatigue, depression) Previous Report Action Current Action Healthy Workplaces: Healthy Workplaces: 4.2 The review of the new toolkit on bullying has been complete and we are due to add these to templates and circulate for review by July. Complete: 80% Work on safe and healthy rostering is in progress for 15 Resident Doctor rosters to comply with the MECA; and centralisation of ward nursing rosters: Centralisation of nursing rosters: Complete: 70% (Due 2019) RMO rosters: Complete: 60% (Due December 2018) Mindfulness: Discussion on scoping an integrated and multimedia approach to mindfulness training is underway. Complete: 30% Shift work, sleep and fatigue: Work on introduction of general guidance for managing sleep and fatigue is in draft. Meetings with professions are planned throughout March to understand what shift work and afterhours materials would be of value to staff. General guidance on sleep has been published. Complete: 100% The toolkit is complete and templates are in design phase. Due to complete in August. Complete: 80% Centralisation of nursing rosters: Complete: 70% (Due 2019) RMO rosters: Complete 73% (Due December 2018) An area on Ko Awatea LEARN has been created for all participants past and present with a range of resources and recordings for them to access and utilise for themselves and their teams. Complete: 50% Healthy Sleep Guide for individuals developed, waiting quality sign off before distribution. Once complete, this will be promoted and put on website. Meetings with professions are planned to understand what shift work and afterhours materials would be of value to staff. Fatigue and shift work information will be developed at later stage after Massey University s (Philippa Gander) recommendations are received later this year. Meetings postponed due to cancellation by groups and planned leave. Complete: 30% New for August Wellbeing framework in draft and due to the Board in November. Risk: Manual and Patient Handling On-going actions Meetings with managers will continue to be held to discuss moving and handling requirements including training, to provide support to services. Additionally, where services are unable to release resources, due to workload, special training sessions are being scheduled via OH&SS. 58

59 Risk: Physical environment (ventilation, lighting, equipment) Previous Report Action Current Action Helipad: CAPEX is approved. Work commences in Helipad: Work commences on 20 August for late June to replace lighting and helipad painting. painting and lighting, including visual and audible Installation imminent. buzzers when helicopters are landing. Pedestrian Complete: 80% crossing to be installed shortly thereafter. Complete: 85%. 4.2 Loading Docks: In progress: CAPEX has been approved to finalise the design and tender stage. A Business Case is due to the Executive Leadership Team in July. The construction has an estimated start date of August/September subject to building consent. Planning complete: 85% Pedestrian Crossings: The CAPEX for the Design of the North Shore Hospital pedestrian crossings programme of works has been approved on 25 June with a business case due to the Executive Leadership Team in July. The Waitakere roading/pathway design tender is due in June/July for an estimated commencement in August subject to consent. Planning complete: 75% Additional Security Door Access, North Shore Hospital: A CAPEX has been approved and an order for the new door completed. Estimated completion of the project is September/October Long lead items (door) will be received by August Planning complete: 100% Installation complete: 10% Loading Docks: CAPEX has been approved to finalise the design and tender stage. A Business Case is due to the Executive Leadership Team in August. The construction has an estimated start date of September subject to building consent. Planning complete: 85%. Pedestrian Crossings: The CAPEX for the Design of the North Shore Hospital pedestrian crossings programme of works has been approved on 25 June with a business case due to the Executive Leadership Team in August. The Waitakere roading/pathway design tender is due in August for an estimated commencement in September subject to consent and timing of approval. Planning complete: 75%. Additional Security Door Access, North Shore Hospital: A CAPEX has been approved and an order for the new door completed. Estimated completion of the project is September/October Long lead items (door) will be received by August Planning complete: 100%. Installation complete: 10%. Risk: Contractor and Procurement Management Previous Report Action Asbestos Register: This project has one stage to complete: Stage 2: A volunteer is due to commence the transfer of information into the database this month. Due by May Complete: 40%. BIEMS Upgrade: No Change as not yet due. Upgrade progressing with final delivery expected in July A mobile app is being developed to enable submission of BEIMS away from the office. This is due to roll out end Procurement Complete: 100% Current Action Asbestos Register: This project has one stage to complete: Stage 2: A volunteer has commenced for the transfer of information into the database. This is a large piece of work, so is expected to continue until completion in October/November. Complete: 50% BIEMS Upgrade: Stage 1 Upgrade is progressing with final delivery expected in August 2018, one month delay due to technical issues implementing the new server software. A mobile app is being developed to enable submission of BEIMS away from the office. This is 59

60 Risk: Contractor and Procurement Management Previous Report Action Delivery Complete: 25% Contractor management process alignment: No Change as not yet due. This work has now been fully scoped and a resource assigned to progress alignment of current contractor procurement policies, processes, project management and performance practises, which will be implemented between May and July Processes will be re-assessed every six months to ensure continuous quality improvement. The processes will be embedded over the following 12 months with the first audit planned for 2019/20. Complete: 65% Current Action due to roll out by end of Procurement Complete: 100% Delivery Complete: Stage 1 80% Stage 2 10% Contractor management process alignment: This work has now been fully scoped and a resource assigned to progress alignment of current contractor procurement policies, processes, project management and performance practises, which will be implemented between May and July Processes will be re-assessed every six months to ensure continuous quality improvement. The updated Project Management guidelines processes will be embedded over the following 12 months with the first audit planned for 2019/20. This will be published in August These define the contractor management requirements for the facilities team. Complete: 70% 4.2 Risk: Slips trips and Falls On-going actions Communications continue to be developed and released regarding Slips, Trips and Falls hazards, focussed heavily on staff rushing to complete tasks. Ongoing. Each incident of this type is followed up by OH&SS, with any corrective actions tracked to completion. Ongoing. 6. Stakeholder feedback 6.1 healthalliance Collaboration We continue to work closely with healthalliance to ensure that processes are in place and in use, including Waitemata DHB specific inductions, for healthalliance contractors carrying out work on our sites. We continue to share information and take collaborative corrective actions where required for areas of Waitemata DHB premises that healthalliance operate from (i.e. Inwards Goods etc.). healthalliance is actively participating in the RFP for dedicated Health and Safety software. 6.2 Regional Collaboration With the commencement of the new Health and Safety Manager for Auckland DHB, work in aligning our reporting, especially relating to statistics, is underway. We are also sharing information, reporting and toolkits with regional and national teams. 60

61 6.3 Facilities and Development Related Contractor Incident Reporting May 2018 The Facilities and Development department maintains a record of the key contractor and trades staff performance monitoring indicators as KPI s. These KPI s are graphed below and provide an oversight of the department s adherence to work monitoring, contractor management and health and safety performance. The key KPI s are commented on below followed by the graphs Injuries and Accidents: Incidents and accidents are monitored across all DHB sites and include data for staff and contractors. In May a contractor received a small laceration above the right eye while using a drill in cramped ceiling space. An investigation was completed by the main contractor and sub-contractor identified opportunities for improvement in the planning stages of these tasks, and ensuring better bracing techniques used when operating in awkward and restrictive overhead spaces. All actions/opportunities for improvement identified in reports now completed, with supporting evidence provided to the Waitemata DHB for future record and auditing purposes Near Miss / Incidents: Near Miss and Incidents are monitored across all DHB sites and include data for staff and contractors. We are pleased to see increased reporting in this area. As the data grows we will be able to show lead indictor trends to highlight areas of focus to improve work practices. There were four near miss events recorded for this period relating to; a blown fuse, inappropriate use of a power cord, care to be taken when carrying work equipment and ensuring equipment is fit for purpose. 61

62 6.3.3 Safety Inspections: Random safety inspections are expected to be completed weekly during the construction period for all projects. Key comments are: A strong focus continues on projects meeting and exceeding the KPI s for safety inspection. All corrective actions completed, with supporting evidence provided to Waitemata DHB for future records and auditing purposes. Facilities Operational team regularly conduct safety inspections, however they have not been recording the findings in a manner that provides data for reporting (see graph below). Additional support and training has been provided during May with Facilities and Development Health and Safety Manager accompanying Facilities Maintenance staff as they complete the required inspections and documentation. A workgroup meeting was run by the District Facilities Manger to discuss the training the staff had received and to ensure all those involved are comfortable and confident in completing the inspections Health and Safety Toolbox meetings: All contractors and staff are expected to attend one health and safety / toolbox meeting per construction week for projects. Facilities maintenance staff are expected to attend fortnightly health and safety / toolbox meetings. Health and Safety meetings continue to be conducted across all projects and Facilities Operational team Contractor site inductions: All contractors are expected to attend site inductions. This indicator notes the number of new contractor staff on site and will vary significantly with construction project work load. 62

63 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun Health and Safety Events June 2018 Rolling year-on-year monthly average comparison: Previous 12 months 135 (average) Current 12 months 215 (average) Current Period: The number of reported events during the month of June was 371. With the additional security incidents we are now receiving, our new monthly average for the last quarter is 355 incidents, in comparison to 135 incidents for the previous 12 months. Rolling 12 month analysis: In March we became aware of a new category of security incident which has now been made available to include in our event reporting. This has resulted in the overall number of events and near misses being made visible. Incidents at a low level are followed up by managers and incidents at a medium and high level are followed up by the Occupational Health and Safety Service. 24 Months of Reported Incidents This graph shows reported incidents from April 2016 to June 2018 The dotted line notes the timeframe where additional incident categories were identified for review as noted above. 63

64 The graphs below note all event types, including environmental and people related events: Number of Events per Division June Hospital Services Corporate Services Child, Surgical & Speciality Women & AmbulatoryMedicine & Family Health of Older People Hospital Operations Specialist Mental Health & Addiction Services Acute & Emergency Medicine Total number of events by 'Nature of Event' June 2018 BBFA- Percutaneous exposure- Needle stick- Internal Body Fluid Traffic System Issues BBFA- Splash into eye- Internal Body Fluid BBFA- Splash onto Broken skin- Blood Fall From Height Poor Maintenance Injury During Training Physical Assault (Hand Held Weapon) Contamination Poor Working Environment Exposure to Fire Exposure to Extremes of Temperature Exposure to Excessive Noise Verbal Assault (Threat of Death) Damage or Failure of Internal Structure, Tool, Equipment or Machinery BBFA- Splash into eye- Blood Non-compliance with Policies & Procedures Repetitive-Motion Injury Health & Fitness Concern BBFA- Percutaneous exposure- Surgical Instrument- Blood Damage or Failure of Building or Structure BBFA- Scratch Verbal Assault (Threat of Physical Violence) BBFA- Percutaneous exposure- Needle stick- Blood Exposure to Hazardous Substance/Material Inappropriate Behaviour BBFA-Potential Manual Handling (Object) Physical Assault (Projectile Object) Manual Handling (Patient) Slip, Trip and Fall Caught / Struck In or By Unsafe Shift Pattern & Hours of Working Safety Concern Verbal Assault (Personal) Failure to Provide Essential Service Verbal Assault (General) Physical Assault (Body Only)

65 8. Notifiable Events Month Reported to WSNZ Type of Incident Injury Sustained Outcome Recommendations Controls Investigation Laceration to lip underway. June Assault Fractured nose and June Fire Nil Investigation underway. July Electric Shock Minor burn to hand Investigation underway. On WorkSafe NZ s recommendation the DHB is implementing a change of process to introduce a requirement for any staff receiving an electric shock to get an ECG to gain an indepth health evaluation July Slip and Fall Concussion Staff member slipped on toilet paper on cubicle floor at District Court, striking her head on toilet bowl and losing consciousness Top three Incident types that cause harm Physical Assaults; Slips, Trips and Falls; and Moving and Handling 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: 9.1. Aggression Rolling year-on-year monthly average comparison: Previous 12 months 41.5 Current 12 months 81.5 June Rolling 12 month trend analysis Aggression related incidents remain of high concern, with an increase in incidents due to an additional category of security incidents being made visible. We continue to encourage staff to report incident and near misses. Physical aggression incidents were 44 in May and 108 in June. Verbal aggression incidents decreased slightly, from 90 in May to 79 in June. 14% of outcomes from these incidents resulted in physical harm, 26% nil harm, with the remainder had psychological impact. High acuity of individual patients may be responsible for this result, with individual patients triggering a number of incident reports over the time they are in our care. Analysis of this increase of reported physical aggression incidents is underway and will be reported as soon as results are available. 65

66 Apr Ma Jun- Jul-16 Aug Sep Oct- Nov Dec Jan- Feb Mar Apr Ma Jun- Jul-17 Aug Sep Oct- Nov Dec Jan- Feb Mar Apr Ma Jun- Actions Significant actions are in place to better understand and manage aggression incidents including ongoing review and improvement of clinical triage, assessment and treatment processes; new security and safety training (See section 3 for details); specific Emergency Department workstreams; review of data to better understand areas to focus workstreams; investigation of all incidents; introduction of new risk assessment templates for aggression risks and hazards; completion of reviews of all public reception areas; completion of key deep dive audits and implementation of findings. Staff impacted by aggression events are provided with appropriate support e.g. care, treatment or debrief to provide immediate opportunities to ensure medical attention/ opportunities to discuss and review the incident. 4.2 OH&SS continue to meet regularly with both the PSA and NZNO and collaborate on areas of high incidents/ risks. Aggression Incidents 24 Months This graph shows aggression incidents from April 2016 to June 2018 The dotted line notes the timeframe where additional incident categories were identified for review as noted above. Aggression Incidents by Division June Child, Women & Family Surgical & Ambulatory Hospital Operations Speciality Medicine & Health of Older People Specialist Mental Health & Addiction Services Acute & Emergency Medicine 66

67 Physical Versus Verbal Aggression Incidents June Physical Verbal 42% 58% Respiratory Effect, 1 Aggression Incidents Outcomes June 2018 Stress or Anxiety, 7 Cuts, Abrasions or Bruises, 14 Laceration, Severing Injury or Puncture Wound, 3 Musculoskeletal Injury (Soft Tissue), 9 Psychological Effect, 110 Nil, 43 The following tables show the number of physical and verbal assaults directed at 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 60% of these incidents are clinically derived and are likely due to the effects of the patient illness, or their treatment pathway. 67

68 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Verbal and Physical Assaults Directed at Staff Apr- May Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May Jun Patient Visitor Employee Community Member 1 Contractor 1 1 Student Slips, Trips and Falls Rolling year-on-year monthly average comparison Previous 12 months 13.4 Current 12 months 14.6 June month Slips Trips Falls

69 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Slips Trips Falls by Division June Specialist Mental Health & Addiction Services Hospital Services Corporate Services Child, Women & Family Acute & Emergency Medicine Speciality Medicine & Health of Older People 9.3 Moving and Handling Rolling year-on-year monthly average comparison Previous 12 months 6.5 Current 12 months 10.1 June Months Patient Handling Injuries

70 Appendix 1 Glossary for Monthly Performance Scorecard and Report 4.2 Injury Claims Lost time incidents Lost time injury Frequency Rate (rolling 12 month average) Notifiable Injury/illness Notifiable Incident Notifiable Event Pre- Employment Screening Significant Hazard (Instead of a definition, all hazards are risk rated to determine how serious they are under the new legislation) Psychosocial Risk Patients who are away without leave (AWOLs) PCBU Officer A claim resulting from a workplace injury. Any injury claim resulting in lost time. Number of lost time injuries, divided by total hours worked, multiplied by 1,000,000 hours. (a) Amputation of body part, serious head injury, serious eye injury, serious burn, separation of skin from underlying tissue, a spinal injury, loss of bodily function, serious lacerations. (b) any admission to hospital for immediate treatment. (c) any injury /illness that requires medical treatment within 48 hours of exposure to a substance. (d) any serious infection (including occupational zoonoses) to which carrying out of work is a significant factor, including any infection attributable to carrying out work with micro-organisms, that involves providing treatment or care to a person, that involves contact with human blood or bodily substances, involves contact with animals, that involves handling or contact with fish or marine mammals. (e) any other injury/illness declared by regulations to be notifiable. An unplanned or uncontrolled incident in relation to a workplace that exposes a worker or any other person to a serious risk to that person s health or safety arising from an immediate or imminent exposure to an escape, spillage or leakage of a substance; an implosion explosion or fire; an escape of gas or steam; an escape of a pressurised substance; an electric shock; a fall or release from height of any plant or substance; collapse or partial collapse of a structure; interruption of the main system of ventilation in an underground excavation or tunnel; collision between two vessels or capsize; or any other incident declared by regulations to be a notifiable incident. Death of a person, notifiable injury or illness or a notifiable incident. Health screening for new employees. A hazard with the potential to cause serious harm. Aspects of the design and management of work, and its social and organisational contexts, which have the potential for causing psychological or physical harm. Patients under the Mental Health (compulsory Assessment and Treatment) Act 1992, who leave Waitemata DHB premises without prescribed or approved leave. Person Conducting Business or Undertaking. Person occupying the position of a director of a company or includes any other person occupying a position in relation to the 70

71 Worker Reasonably Practicable HSNO OH&SS business or undertaking that allows the person to exercise significant influence over the management of the business or undertaking. An individual who carries out work in any capacity for the PCBU e.g. employee, contractor or sub-contractor, employee of the sub-contractor, employee of labour hire company, outworker, apprentice or trainee, person gaining work experience, volunteer. Means that which is or was at a particular time reasonably able to be done in relation to ensuring health and safety, taking into account and weighing up all relevant matters, e.g. the likelihood of the hazard/risk occurring; the degree of harm resulting; what the person knows about hazard/risk and how to eliminate/ minimise the risk; and the cost associated with elimination of the hazard/risk. Hazardous Substances and New Organisms. Occupational Health and Safety Service

72 4.3 Communications Report 4.3 Recommendation: That the report be received. Prepared by: Matthew Rogers (Director Communications) Communications support The communications team provided advice and support to the following projects/campaigns/issues/ events over the last six weeks: Waitakere Hospital expanded radiology department dawn blessing. IPANZ Public Sector Excellence Awards - Young Professional of the Year, Dr Eleri Clissold. Liaison with State Services Commission on publication of Official Information Act compliance data. Minister for Social Development and Disability Issues Carmel Sepuloni s visit to DHB re Individual Placement and Support pilot for mental health service-users. Promotion of Digital Innovations Expo at Whenua Pupuke. Launch of Hepatitis C Screening in pharmacies pilot programme. CEO Lecture Series address by Minister of Health Hon Dr David Clark on 1 August. Planning for 28 August CEO Lecture Series visit by former prime minister, Rt Hon Helen Clark. HPV self-sampling pilot. #hellomynameis campaign. World Head and Neck Cancer Day. Matariki Awards promotion. Compassion (Values) campaign promotion. Tanoa Pacific Fono. National nursing strike internal and external communications. Staff flu vaccination campaign. Promotion of new after-hours and overnight care arrangements. Cleaners and orderlies cultural lunch and recruitment video. Launch of Awhi Tamariki comprehensive child health checks. Recognition of long-serving DHB chaplain Father Martin Bugler upon his retirement. Implementation of national DHB agreement on proactive disclosure of OIA responses. Kōrero Mao Talk to Me campaign. National bowel screening review reactive communications. Ongoing publication of messages via the Medinz primary care communications platform. Health Heroes. Safety in Practice campaign promotion. Promotion of Inpatient Snapshot initiative. Coordination of responses to Dear Dale s to the CEO from DHB staff. Review of content for submission to health sector publications. Ongoing weekly internal communication via StaffNet and Waitemata Weekly. Ongoing management of Official Information Act responses. Liaison with Well Foundation Marketing and Communications. Ongoing liaison with Metro Auckland DHB communications leads. 72

73 Ongoing after-hours and weekend media line cover and senior management communications support. Proof-read leaflets, booklets and brochures for various departments. Ongoing compilation and distribution of proactive media material. Ongoing social media strategy, activity and issues management. Event photography. Drafting of correspondence from the corporate office. CEO Board Report. Review of copy for DHB website. Management of DHB general all-user screen saver content. Approval of all-user staff s. Weekly Board briefing. Fortnightly A Note From the CEO to all staff. Weekly National Health Targets and clinically-led metrics updated and communicated. 4.3 Waitemata DHB website Google Analytics Statistics Waitemata DHB website Number of visits July 2018 July 2017 Total visits to this site 56,521 (+10.4%) 51,166 New Zealand 26,387 24,716 Australia USA United Kingdom Top areas July 2018 July 2017 Waitemata DHB staff page 29,476 25,724 Home page 13,399 13,863 North Shore Hospital Waitakere Hospital Contact us 6,044 3,159 2,550 6,666 2,949 2,494 Traffic sources July 2018 July 2017 Search traffic 73% 73% Direct traffic 21% 20% Referral traffic 4% 6% 73

74 4.3 Social media Facebook Waitemata DHB Facebook page likes have increased by 46.5% since July 2017, with 4,030* current likes (2,751 likes - July 2017). Waitemata DHB Facebook review numbers have increased by 41% since July Waitemata DHB Facebook star rating - 4.3/5 from 295 reviews* (4.4/5 from 208 reviews July 2017). Total audience reach between 1 July 2017 and 31 July 2018 was 88,500. Top three posts between 1 July 2018 and 31 July 2018: 74

75 1. Nursing Strike Where should I go? DHB (Audience reach: 27,039)

76 2. Subsidised Care Announcement (Audience reach: 10,549)

77 3. Hello My Name Is launch (Audience reach: 4,496 Video views 2,080) 4.3 *As at 8 August Twitter Waitemata DHB Twitter followers have grown by 33.8% since July 2017, with 2,268 current followers* (1,994 followers as at July 2017). Total audience reach between 1 July 2018 and 31 July 2018 was 41,700. Top tweet between 1 July 2018 and 31 July 2018: 77

78 #HelloMyNameIs Video (5,591 reach. 951 Video Views) 4.3 *As at 8 August

79 OIAs received A total of 28 new OIA requests were received between 27 June and 8 August 2018: 4.3 K. McCallum (Mediaworks) - Questions regarding acute mental health staffing numbers, qualifications, vacancies and capacity. A. Ashley (FYI website) - Timeline of current and future projects that affect transgender care. N. Jones (NZ Herald) - Copies of any briefings/memos etc sent to the Minister of Health before meetings with the Minister since October N. Jones (NZ Herald) - Copies of briefings/memos/reports to the Director General of Health since October G. Singh - Follow-up appointment delays in ophthalmology services. M. Bull (Apex) - Information regarding radiology examination data including staffing levels, number of examinations, services and wait times. N. Akoorie (NZ Herald) - Details of any fraudulent expenses uncovered during internal auditing processes. N. Akoorie (NZ Herald) - Rates of injuries and deaths during assisted deliveries and caesarean section births. E. Ford (Stuff) - Babies born in 2017 and 2018, type of delivery, birth location and maternal age. H. Martin (Stuff) - Maternity bed numbers and average length of stay compared with January M. Alexander (Newshub) - Number of Medical Practitioners charged with sexual assault offences. C. Bruner (TVNZ) - Number of eye surgeons on-call during December - January. K. Price (NZME) - Occupancy rates for North Shore and Waitakere Hospitals. M. Grant (lawyer) - Clinical records and radiology imaging. S.Maude (NZ Doctor) - Request for breakdown of where aggression incidents toward staff have taken place (on or off DHB property), month-on-month over last 24 months. K. Brown (Radio NZ) - Costs related to nurses strike and number of elective surgeries postponed due to the strike. K. Stephenson (NZ Doctor) - Copies of any documents prepared, sent or received relating to Auckland Sexual Health Service. R. Clarke (MOH) - School oral health data (caries-free and average DMFT) for five-to-nine-yearolds. C. Wallbridge - Request for oral health data for primary school children at five Auckland schools from 1 July 2017 to 30 June B. Fountain (NZ Doctor) - Board processes regarding agenda items discussed excluding public. M. Rickerby (Multiple Sclerosis Society) - Neurologist staffing numbers. M. Rickerby (Multiple Sclerosis Society) - Neurologist waiting times. M. Rickerby (Multiple Sclerosis Society) - Neurologist appointment numbers. N. Jones (NZ Herald) - Various information regarding ED voucher scheme. K. Neve (SAFE) - Food and nutrition standards, policies and guidelines regarding food served to inpatients. H. Martin (Stuff) - Copies of resilience reports regarding mains and back-up power supply to hospitals. A. Hipkiss (NZNO) - Incident reports relating to short staffing for the last three months, including response and outcomes. J. Libbey (Auckland District Law Society) - Policies, monitoring and processes for mental health patients on breaks and leave. 79

80 Media Clippings (23 June 5 August 2018) Positive + Neutral 0 Negative Page no. Channel 23 George s journey in Special Care Baby Unit + 29 Rosmini perform for the Prime Minister + 32 Westlake Well Foundation Committee + Page no. Nor West News 13 DHB s bid to combat rheumatic fever cases + 45 Conversations mental health 0 54 DIY test to reduce embarrassment + Page no. North Harbour News 12 Bus network 0 17 More Shore buses, more often 0 21 Rheumatic screening + Page no. North Shore Times 6 Simplified bus network before end of year 0 9 Bid to combat rheumatic fever + 19 Mum s scary ordeal 0 35 Cheaper to park illegally on street 0 42 After-hours care targeted by DHB to decrease cost + 53 Nurses strike not about money - 57 Thank you to the hospital + 62 Hep C test offered in community + Page no. NZ Doctor 1 Govt pours $16.7m crime cash into addiction treatment + 2 Screen and treat for osteoporosis to reduce fractures 0 endocrinologist 39 Screening IT design job for Deloitte, review under wraps 0 Page no. NZ Herald / Weekend Herald 4 Caring teen critical after ute flips on sand 0 8 Use executive pay 0 40 Sideswipe number plate 0 46 From 20-year addiction to rehab boss 0 59 Small business Q & A prem babies + 61 Mason Clinic warning - 80

81 Page no. NZ Herald / Weekend Herald 68 Short & sweet North Shore Hospital parking - 69 Push to fund oxygen therapy Page no. NZ Nursing Review 25 Preventing and managing blood clots in pregnancy 0 33 Winter is coming. and so is the flu 0 Page no. Onehunga Community News 22 Barre Fit class gets tick of approval 0 Page no. Otago Daily Times 3 Seven injured on beach 0 58 Psychiatric care ordered 0 Page no. Pharmacy Today 24 Hospital pharmacists association president stands down 0 30 Society Pharmacist of the Year passionate about patient safety + Page no. Rodney Times 11 Bid to combat rheumatic fever + 15 Funding boost for unsealed roads 0 44 Beat bowel cancer + 64 Potentially lifesaving hep C test + Page no. Western Leader 14 DHB s bid to combat rheumatic fever cases + 37 What s on craft market 0 41 Mental health workshop 0 56 Tamihere: City s healthcare divide - 66 Potentially life-saving hep C test + TOTAL: Positive + 18 Neutral 0 22 Negative - 4 Total items 44 81

82 5.1 Board Plan Recommendation: That the Board: (a) Approve the concept of having a Board Plan for workshops. (b) Approve the following topics for the first four of these workshops: - Health and Safety (October 2018 Board meeting). - Treaty of Waitangi and Maori Health Equity (November 2018 Board meeting). - Conflict of Interest and Other Protocols (December 2018 Board meeting). - LTIP and Implications for Waitemata DHB (March 2019 Board meeting). (c) That the Board review/approve the schedule for the following calendar year annually in November, starting from November (d) That the Board Chair be authorised to approve any variations to the schedule, should circumstances warrant. 5.1 Prepared by: Judy McGregor (Board Chair) 1. Summary It is proposed to have an annual programme to review key areas of concern, so that each year it receives a full briefing and update and an opportunity to review and discuss the approach being taken. 2. Strategic Alignment This approach could benefit many of the Board s priorities and strategic themes, however overall the clearest link is with: Intelligence and insight Evidence informed decision making and practice By ensuring detailed annual review of key focus areas By ensuring detailed annual review of key focus areas. 3. Introduction/Background It would be worthwhile for the Board to have an annual programme of workshops reviewing key areas of importance and concern. This would help provide long term strategic focus for the Board. It is proposed that eight key focus areas be identified and annually reviewed on a rolling cycle each year. 82

83 5.2 Appointment to healthalliance NZ Limited Board of Directors 5.2 A short report is expected to be circulated prior to or at the meeting. 83

84 5.3 Fundraising and Sponsorship Policy Recommendation: That the Board approve the Fundraising and Sponsorship Policy. 5.3 Prepared by: Robert Paine (Chief Financial Officer) Reviewed by: Amanda Mark (General Counsel) Endorsed by: Senior Management Team June Executive Summary Attached as Appendix 1 is a draft policy recommended for the Board s approval. As stated at the start of the policy, the purpose of this policy is to provide a clear and cohesive approach to fundraising and sponsorships which provide additional income and support to the Waitemata District Health Board. As a large organisation with thousands of staff and many perceived needs for additional funding and/or support, the DHB requires co-ordinated, well managed and appropriate internal processes. All projects and processes must respect the priorities of the DHB. To avoid duplication of efforts and multiple requests to donors or funders, all fund raising and sponsorship requests initiated by Waitemata DHB, its departments, programmes, employees and subsidiaries will be coordinated through the Well Foundation in the first instance. 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 Operational and financial sustainability This policy enables best fundraising practice to support patient centred models of care, as a priority focus of the Well Foundation. As above Fundraising priorities are set against Waitemata DHB business cases which must cite intelligence and insights which lead to improvements to healthcare and/or patient experience. As above Fundraising priorities are set against Waitemata DHB business cases which must cite operational and financial sustainability, beyond initial fundraising injection of support. 84

85 3. Introduction/Background Waitemata DHB has ongoing need and desire for additional, external support which must be managed in a professional, cohesive manner. The Well Foundation was set up four years ago for this purpose and the proposed policy provides a revised, updated set of guidelines which reflect current and future needs Risks/Issues With close to 7,000 employees and multiple services desiring additional support, it is critical that any approaches to external supporters are managed professionally by a central, co-ordinated source. Prior to the Well Foundation being formed, Waitemata DHB had received negative feedback from some large regional corporates which were being approached by multiple DHB services seeking support. These approaches were not coordinated, nor were the projects officially prioritised by Waitemata DHB. The proposed policy lays out a clear path for Waitemata DHB prioritisation of projects to the Well Foundation, which manages all approaches to external supporters to maximum effectiveness and strength of long-term, successful donor/supporter relationships. Note that the Waitemata DHB Board Chair and Chief Executive Officer acting together will have the final right of decision as to whether a potential sponsorship partner should be approached or sponsorship accepted from a potential sponsorship partner. 5. Approach/Methodology/Analysis/Justification 5.1 Investigation/Research/Evidence The proposed policy builds on the platform created by the former North Shore Hospital Foundation but also brings in best practice as used by similar hospital foundations in New Zealand such as the Starship Foundation, Auckland Health Foundation, Middlemore Foundation, Wellington Health & Hospitals Foundation and Meia Foundation based at Canterbury DHB. 5.2 Justification/reasons for recommended option Current policy is outdated and requires revision to reflect current and future needs of Waitemata DHB. 6. Linkages/Impact 6.1 Strategic Context Funds raised by the Well Foundation represent an important portion of annual revenue to Waitemata DHB. 6.2 Impact on reducing inequalities and Maori Health Gain. Funds raised may reduce inequalities based on Waitemata DHB-prioritised projects recommended to the Well Foundation. 85

86 7. Costs/Resources/Funding Not applicable Consultation/Engagement 8.1 Consultation already undertaken Policy was presented to SMT in June 2018 and any feedback has been adopted. 8.2 Planned consultation Internal communication to take place, subject to policy being approved by the Board. 86

87 WDHB Management Executive Fundraising and Sponsorship Contents Overview Fundraising Bodies Three Harbours Health Foundation Well Foundation Accepting Donations Donation Process flow chart Funding Criteria & Processes: Well Foundation Submitting Fundraising Proposals Other Charities Access Guidelines Well Foundation Donation Reimbursement Process Sponsorship Policy Benefits of Corporate Sponsorship Management of Corporate Partnerships Starting Framework for Sponsorship Evaluation Summary Matrix Questions...9 [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 1 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 87

88 WDHB Management Executive Fundraising and Sponsorship 1. Overview 1.1 Purpose: 5.3 The purpose of this policy is to provide a clear and cohesive approach to fundraising and sponsorships which provide additional income and support to the Waitemata District Health Board. As a large organisation with thousands of staff and many perceived needs for additional funding and/or support, the DHB requires co-ordinated, well managed and appropriate internal processes. All projects and processes must respect the priorities of the DHB. To avoid duplication of efforts and multiple requests to donors or funders, all fund raising & sponsorship requests initiated by Waitemata DHB, its departments, programmes, employees and subsidiaries will be coordinated through the Well Foundation in the first instance. 1.2 Scope: The scope of this policy is DHB-wide, where all staff, services and departments adhere to this document in relation to any fundraising and/or sponsorship approach, request, proposal or idea. 2. Fundraising Bodies 2.1 Three Harbours Health Foundation: The Three Harbours Health Foundation (THHF) was established in 1995 as an independent body to administer funds donated for health care. Since the creation of the Well Foundation in 2014, the THHF will principally focus on receiving and managing funds for approved research, clinical trials and education grants. THHF manages approximately 65 sub funds, the activities of which are mostly for specific purposes as determined by the principal fund holders who are mostly clinicians. THHF is primarily a vehicle to enable and protect the interests of the DHB and third parties, namely corporate and pharmaceutical organisations. In respect of clinical research or drug trials, Waitemata DHB enters into contracts with research and pharmaceutical companies on commercial terms under which we agree to provide services by running clinical trials and the pharmaceutical companies pay us for those services. The profit from the clinical trials is then used by the services who run the trials to pay for things such as salaries for fellows or clinical trial coordinators or research nurses. Funds from research grant applications are banked and administered by THHF, principally via its Business Manager. THHF funds include the surplus amounts earned from commercial clinical trials and research projects which are preserved for future approved projects. [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 2 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 88

89 WDHB Management Executive Fundraising and Sponsorship 2.2 Well Foundation: 5.3 The Well Foundation is the official fundraising body for the Waitemata District Health Board and has been set up to manage and oversee all philanthropic fundraising and sponsorship income. It is a registered charitable trust. The foundation s role includes: 1. Seeking and receiving donations from the public, patients, their families 2. Seeking and receiving bequests (donations left through a Will) 3. Overseeing events where funds are raised by community service group partnerships eg Rotary, Lions, schools, churches 4. Managing corporate sponsorships and business partnerships 5. Seeking and receiving funds from trusts and foundations 6. Receiving gift in kind donations of goods and/or services (refer to separate Art Policy) The foundation team is made up of fundraising and administrative specialists who professionally manage all donations, including thanking and liaising with donors, securely banking donated funds, recording their intended purposes and administering the funds according to best practice and audit standards. As such, the foundation has been set up to receive and receipt all philanthropic income which is intended to benefit the DHB and its services, whether it be for a tangible piece of equipment, to enhance a service/department, or to be earmarked for a future, yet-to-be-determined/approved research project. Depending on the donor s intentions, the funds will be securely banked with the Well Foundation or the Well Foundation will grant the funds across to the THHF/DHB if specifically for research/educational purposes at the appropriate time. The foundation replaces two historical organisations - the North Shore Hospital Foundation and the West Auckland Health Services Foundation - as one unified entity that works closely with the DHB to address the most pressing health needs of its communities. Each year, the foundation will have an agreed list of projects which reflect the DHB s priorities. 3. Accepting Donations & Donation Acknowledgement All minor donations, including cash gifts under $50, specifically intended by the donor for staff treats/morning teas may be accepted directly by hospital ward staff and managed by the relevant Charge Nurse Manager. This largely relates to donations from grateful patients/families who do not desire an official tax receipt for their donation, but to show their appreciation of ward staff directly. Minor donations must be used as the donor intended. In accepting a minor donation, the Charge Nurse Manager and ward staff accept full responsibility for its use. All other donations toward WDHB divisions, departments, projects and programmes should be directed to the foundation which will manage the donor relationship, in partnership with the relevant DHB staff as appropriate. DHB staff should direct anyone asking about making a donation or fundraising to the foundation s printed brochures which are available throughout North Shore and Waitakere hospitals, as well as at various DHB [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 3 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 89

90 WDHB Management Executive Fundraising and Sponsorship community-based health services and facilities. The brochures include a secure, pre-addressed postage paid envelope which donors can detach and post directly to the foundation. It also contains the foundation s contact details. DHB staff can also direct donor enquiries to which has comprehensive information about the charity, the board and management teams, objectives, current projects, signing up for regular communications and an online donation page. 5.3 The foundation reserves the right to decline any gift that is believed to not be in the best interest of the organisation or employees, or if maintenance of a gift would result in a fiscal or legal liability for the DHB or the foundation. Effective fund raising includes the identification of prospective donors and the recognition and continued relationship/communication with donors. These activities should be managed by the foundation, drawing in relevant DHB staff as appropriate. This includes: Prospects and donors invited to campus for a group event or individual meetings Prospects and donors signaling an interest in making a donation due to the great care they/their loved ones have received The foundation will work to align the DHB s priorties to the donor s intentions and interests. 3.1 Well Foundation Donation Process: 4. Fundraising Criteria and Processes: Well Foundation The foundation has been set up to focus on projects which are sufficiently developed and endorsed by Waitemata DHB senior management as a priority for fundraising efforts. [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 4 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 90

91 WDHB Management Executive Fundraising and Sponsorship All proposals that go before the foundation must be approved by the DHB s Executive Leadership Team (ELT) and/or Centre Governance Group and be clearly categorised as either: 5.3 A. investment ready patient/whanau-centred projects which are attractive to donors (ie meets the foundation s criteria and have a robust business case including ELT/WDHB board sign off) or B. concept only where all WDHB projects have gone through the ELT/Centre Governance Group for development and screening against their criteria. The foundation may provide advice so the concept is sufficiently developed to become investment ready. All projects must meet the foundation s criteria which is available on the DHB s StaffNet website. The foundation does not fund standard, basic equipment, services or other initiatives which are normally funded through WDHB budgets. 5. Submitting Fundraising Proposals The foundation works to the same financial calendar as the DHB, from 1 July 30 June the following year. By the start of each financial year, the foundation aims to have a clear list of priority projects to work on over the next 12 months and beyond. This will likely to be mixture of smaller, tangible items (additional medical equipment) through to large campaigns. As some fundraising items will come from the Capital Expenditure (CAPEX) list, DHB services should submit their requests via the normal CAPEX projects process. For projects not covered by the CAPEX process, you may apply to the foundation for support by using the funding proposal form. The foundation will consider these requests throughout each financial year. 6. Other Charities/Causes & Access to DHB Premises/Brand Other Charities/Causes & Access to DHB Premises/Brand There is significant activity in the New Zealand market place, with hefty competition for the donor dollar. Each year many established not for profit organisations run major public appeals. These appeals appear in different formats: direct mail, telephone & electronic fundraising, street appeals, lotteries, planned giving campaigns, internet campaigns etc. The DHB and/or foundation is approached on a weekly basis for access permission from these groups to fundraise in the interior of the hospital. 6.1 Access Guidelines: Consideration should be given to the following points around the issue: There are so many different agencies pursuing the contributory dollar that it is virtually impossible to accommodate them all physically inside the hospital building for their individual annual public campaigns. [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 5 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 91

92 WDHB Management Executive Fundraising and Sponsorship It is not appropriate to have hospital consumers constantly approached for money by fundraisers in the defined hospital area. 5.3 The DHB has set up the foundation as its own official fundraising body, which focuses specifically on the North Shore, West Auckland & Rodney regions. The foundation is also engaged in a partnership with The HECTOR Hospital Trust which presents weekly markets at both the North Shore and Waitakere campuses and provides the foundation with an annual Margaret Gadsdon Memorial Endowment to be used for the DHB s Health Excellence Awards. Revenue from the HECTOR stalls are channelled into DHB priority projects via the Well Foundation. Charitable agencies that will be allowed into the interior of the hospital will be those who have a direct clinical impact on, and connection to, Waitemata DHB s strategic objectives. This will be decided by the foundation, in consultation with senior DHB management. Priority will be given to fundraising groups that contribute funds/ services directly to the foundation and/or DHB services e.g. HECTOR Trust, Hospital Auxiliary and the Red Cross. 7. Well Foundation Donation Reimbursement Process Well Foundation Donation Reimbursement Process: 1. WDHB and the foundation agree on priority items for fundraising/external support (via ELT endorsement/approval and compliance with WF funding criteria) for each financial year. 2. Appropriate DHB Mgr/Asset Mgr informs DHB service of foundation fundraising for agreed item/project. 3. The foundation ensures it has relevant information from the DHB (layman s description of need to help with fundraising/communicating with potential donors) and supplier quote; the foundation s fundraising target becomes the GST exclusive amount from the quote. 4. The foundation begins fundraising for item/project. 5. The foundation informs the DHB Asset Mgr once the fundraising target has been reached, who then contacts the service. The service raises a CAPEX request with the unique code allocated to the item by the Asset Mgr. 6. DHB service procures the item and pays supplier (incl GST). 7. The foundation reimburses DHB via a grant (ex GST) on proof of DHB purchase provided by the Asset Manager. If the quoted amount from supplier has increased during fundraising period, the DHB must fund the additional cost. On a case by case basis, the foundations may look to cover the increase if they have sufficient untagged donation revenue. Currently, general WDHB staff can visit the foundation website or get specific info from StaffNet to see WF criteria, the agreed selection processes and to access the foundation proposal form: [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 6 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 92

93 WDHB Management Executive Fundraising and Sponsorship 8. Sponsorship Management The Benefits of Corporate Partnerships Corporate partnerships are highly-valued by charities as the business sector often has financial resources that can support a charity with money as well as brand promotion. Corporate partnerships which are well structured and planned can result in charities benefiting from: Annual sponsorship income, agreed up front Multi-year agreements, which gives the charity financial security and an ability to plan best use of the funds Brand awareness and promotion through any marketing the corporate organisation invests in to promote their association with the cause Cause-related marketing campaigns which engage consumers and the wider public to support the cause Additional donations/payroll giving from corporate employees; this is very common offshore and has been adopted by many NZ companies Additional skills/resources from the corporate eg volunteer days, mentoring, pro bono professional services Cost savings where the corporate provides goods or services instead of the charity paying for them The personal engagement of highly skilled and/or networked individuals from the private sector eg as board trustees or other key advocates In return, corporate partners receive: Positive brand association with a cause that they expect will increase their profitability through greater consumer warmth to their brand and products/services Differentiation from their competitors Improved staff morale/company culture through the feel-good factor employees feel they are doing more than just making money for a corporate entity 8.2 The Management of Corporate Partnerships Before partnerships are formalised, it s important to ensure both the charity and the corporate organisation have: Shared values, the same broad objectives Insight into the value of their respective brands A shared commitment to the relationship not just resting on a single individual from each organisation, but involving multiple staff and levels Some overlap of target audience An understanding of each other s objectives and what they want/need out of the partnership A realistic view that corporate sponsorships are based on commercial terms, where the corporate desires a commercial return on their investment, while with philanthropic partnerships this may not be the case, An agreement on the projects which will benefit from the partnership before any promotion or public marketing is started [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 7 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 93

94 WDHB Management Executive Fundraising and Sponsorship Agreement on what each party will bring to the table eg exposure to charity s database, access to charity board trustees, personal involvement of senior management etc An agreement on how the partnership will be measured for success eg % growth in sales, % growth in brand awareness/consumer warmth, % reduction in staff turnover, % increase in consumer retention, % increase in consumer and donor acquisition, new networking opportunities, increased brand awareness Starting Framework for Sponsorship Evaluation Each potential partnership needs to be evaluated on its own merits around values, motivations, business plan, objectives and the return expected. However, there are sectors which we would not advise partnerships with: Tobacco/legal high organisations as there is no positive brand fit between an organisation promoting health and wellness and the tobacco/legal high industry which causes or is perceived to cause much harm. The DHB must also bear in mind potential public disquiet or brand damage which may result from engaging with a controversial partner. Adult industry/pornography promoters; again there is no brand fit with the foundation or WDHB which have family values. Organisations involved in illegal activity. Case by case evaluations of potential partnerships could include: Liquor again the cause of much health and social harm, but can be well managed depending on the liquor brand s image and reputation. Gambling or Gaming Trusts which have to by law contribute a percentage of revenue back into the community. If the Well Foundation/Waitemata DHB doesn t apply for these grants, there are many other charities that will. Fast food/sugar-heavy product manufacturers with the increase in obesity-related health issues, we need to tread carefully in this area. There has been a lot of criticism around the brand infiltration of fast food brands marketing heavily in low-socio economic communities. The acid test is whether the Well Foundation or Waitemata DHB would feel proud to have their logos next to a potential sponsor? What is the proposed sponsor s brand fit with the foundation s objective to drive innovation and advancement within WDHB? 8.4 Summary Matrix The foundation and the DHB senior management will use the matrix below to score potential sponsorships, utilising the thinking above: Key Questions around potential Sponsor: Shares DHB s values Has a brand with positive public perception Low (0 3 pts) ie possibly not good for the DHB Med (4 7pts) High (8 10 pts) ie very good for the DHB [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 8 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. Total 94

95 WDHB Management Executive Fundraising and Sponsorship Wants to support DHB long-term (multi-year agreement/support) Has identified a project which is a DHB priority The beneficiary project meets the Well Foundation s criteria Is a partner the DHB is proud to associate with Is a partnership likely to generate positive media attention/public sentiment Total: 5.3 The Waitemata DHB Board Chair and Chief Executive Officer acting together have the final right of decision as to whether a potential sponsorship partner should be approached or sponsorship accepted from a potential sponsorship partner. 9. Questions If after reading the Fundraising and Sponsorship Policy document you have any questions, please first discuss with your Head of Department/Manager to check their understanding. If there is still uncertainty please contact the Well Foundation on [Type text] Issued by Issued by Issued Date Month YYYY Classification Class # Authorised by Authorised by Review Period ## mths Page Page 9 of 9 This information is correct at date of issue. Always check on Waitemata DHB Controlled Documents site that this is the most recent version. 95

96 6.1 Financial Performance June 2018 Recommendation: That the Board note the content of this report Prepared by: Simon Watts (Deputy Chief Financial Officer) and Cliff La Grange (Funder Finance) Endorsed by: Robert Paine (Chief Financial Officer and Head of Corporate Services) 6.1 Glossary IDF - Inter District Flow NGO - Non Government Organisation YTD - Year To Date 1. Executive Summary The operating result for the DHB for the year ended 30 June 2018 is a surplus of $19k against a breakeven budget. The DHB has, therefore, on a business as usual basis, lived within its means during the last financial year. Since this result was achieved, there have been two extraordinary issues that have arisen that have meant that the Annual Report of the DHB that will be issued in September will have a reported loss of approximately $14.8m. These two issues, that have been the subject of a separate Board report circulated recently to members, concern: (1) accounting for an estimated liability regarding holiday pay underpayment over the last seven years, and (2) the effects of the recently settled nursing pay dispute on annual leave revaluations. Both the operating result reported above, and the planned Annual Report result, include a provision for back pay for pay negotiations that have not yet been settled. Audit New Zealand has advised that liability for potential back pay should not be recognised at 30 June 2018 until awards are settled. Audit New Zealand have yet to finalise their audit of these matters. The DHB disagrees with this treatment, and believes that such an adjustment would distort the results in both the 2017/18 and 2018/19 financial years. The following comments relate solely to the business as usual operating result. The operating result for the year ended 30 June 2018 was a surplus of $19k, against a zero budgeted surplus, and therefore is $19k favourable to budget. The June 2018 month result was a deficit of $180k which was $80k unfavourable to budget. The Provider made a deficit of $3.705m, against a budgeted deficit of $683k, and therefore was unfavourable to budget by $3.022m. The Governance and Funding Administration Arm made a surplus of $887k and the Funder made a surplus of $2.637m, both against a breakeven budget. The Provider Arm YTD result primarily reflects unbudgeted expenditure in non-personnel costs, unrealised expenditure reduction initiatives, and an increase over budgeted growth in acute demand. Non-personnel expenditure consisted of outsourced services and labour (to cover budgeted 96

97 vacancies), increased clinical supplies (volume demand and pricing) and utility costs. Within the Provider Arm, an actively managed Financial Sustainability Portfolio is being executed. Capital expenditure for the year ended June 2018 was $19.835m against a previously planned $21m, and a $30m approved budget. The cash position at year end is a balance of $29.1m. 6.1 The financial cash position of $29.1m is an improvement from the balance a year ago by $11.6m. The cash position has improved through daily monitoring of expenditure and greater scrutiny of capital expenditure. The year end balance is a very significant improvement as forecast earlier in the year of small if not negative cash at year end. Safety however, has not been compromised by the attention to capital expenditure. The financial position as at 30 June 2018 indicates a net worth of $ m including $29.078m in cash. 2. Financial Performance - June 2018 The operating result for the DHB for the month ended June 2018 compared to the budget is summarised in the following table: Waitemata DHB Consolidated Statement of Financial Performance June 2018 ($000's) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE Crown 145, ,219 5,002 1,693,083 1,683,292 9,790 1,683,292 Other 2,083 3,870 (1,788) 31,667 32,579 (912) 32,579 Total Revenue 147, ,089 3,214 1,724,750 1,715,872 8,878 1,715,872 EXPENDITURE Personnel - Medical 12,583 15,676 3, , ,419 5, ,419 - Nursing 21,508 20,199 (1,309) 241, ,775 (1,265) 239,775 - Allied Health 9,915 9, , ,043 3, ,043 - Support 1,504 1, ,964 19, ,785 - Management / Administration 5,658 6, ,455 77,360 1,905 77,360 51,169 54,211 3, , ,382 10, ,382 Other expenditure Outsourced Services 6,024 5,661 (363) 74,167 68,253 (5,914) 68,253 Clinical Supplies 11,284 9,732 (1,553) 123, ,849 (8,093) 115,849 Infrastructure & Non-Clinical Supplies 13,094 8,770 (4,324) 120, ,608 (16,120) 104,608 Funder Provider Payments 65,912 65,815 (97) 778, ,782 10, ,782 96,315 89,978 (6,336) 1,097,751 1,078,491 (19,260) 1,078,491 Total Expenditure 147, ,189 (3,295) 1,724,732 1,715,872 (8,859) 1,715,872 NET RESULT (180) (100) (80) 19 (0) 19 (0) 97

98 Financial result to be reported in annual report:

99 3. Financial Performance - DHB Arms (YTD) The financial performance for each of the DHB Arms for the month and the year is summarised in the following table. A detailed Statement of Financial Performance by DHB Arm is provided as Attachment 1. Waitemata DHB Statement of Financial Performance By DHB Arm June 2018 ($000's) MONTH YEAR TO DATE FULL YEAR Actual Budget Variance Actual Budget Variance Budget REVENUE Provider Arm - Clinical Services 2,650 2,823 (173) 33,075 32, ,988 Provider Arm - Corporate & Support Services 74,808 73,683 1, , ,261 5, ,892 Governance & Funding Admin Arm 1,296 1, ,040 14,209 (169) 14,209 Funder 142, ,097 5,151 1,653,963 1,645,170 8, ,782 Elimination (73,698) (70,699) (2,999) (854,538) (848,389) (6,149) 0 Consolidated 147, ,089 3,215 1,724,750 1,715,872 8,878 1,715, EXPENDITURE Provider Arm - Clinical Services 61,887 58,657 (3,230) 655, ,520 (18,729) 647,008 Provider Arm - Corporate & Support Services 19,276 18,533 (743) 278, ,362 (3,306) 264,872 Governance & Funding Administration 409 1, ,899 14,209 2,310 14,209 Funder 139, ,514 (3,096) 1,633,453 1,638,170 4, ,782 Elimination (73,698) (70,699) 2,999 (854,538) (848,389) 6,149 0 Consolidated 147, ,189 (3,295) 1,724,731 1,715,872 (8,859) 1,715,872 NET RESULT Provider Arm - Clinical Services (59,237) (55,833) (3,404) (622,175) (603,900) (18,274) (613,020) Provider Arm - Corporate & Support Services 55,532 55, , ,899 2, ,020 Governance & Funding Admin Arm 887 (0) 887 2, ,141 0 Funder 2, ,054 20,510 7,000 13,510 7,000 Elimination (0) 0 (0) (0) 0 (0) 0 Consolidated (180) (100) (80) 19 (0) 19 0 Comment on Major Variances for the year Net Result - Consolidated The overall DHB result for the year ended June 2018 was a surplus of $19k which is $19k favourable to budget. Provider Arm - Clinical Services The Provider Clinical Services was $18.274m unfavourable YTD. The key drivers of the variance are summarised below: Acute and Emergency Medicine ($3.591m unfavourable YTD) The variance was driven by unbudgeted increased RMO costs due to over allocations, pricing variations and increased allowance costs. The strategies for reducing costs have focused on optimising the operational efficiency gains have been achieved from the TransforMED Home Warding initiative through maximising leave consumption and opportunistic bed closures. Specialty Medicine and HOPS ($5.394m unfavourable YTD) The variance was driven by outsourced gastroscopy and colonoscopy procedures, and increased demand for high level respite care for complex needs patients and a change to the model of care in the Kingsley Mortimer Unit. Surgical and Ambulatory Services ($11.040m unfavourable YTD) The variance was driven by increased unbudgeted outsourcing expenditure associated with Radiology. Radiology procedures were outsourced to meet MoH targets and population demand. 99

100 Increasing implant and consumable costs, unbudgeted repairs and maintenance and minor purchases, other one-off costs such as Otorhinolaryngology outsourcing and unrealised saving initiatives have also had an unfavourable impact. Elective Surgical Centre ($79k favourable YTD) The variance was driven by lower than budgeted Orthopaedic and Gynaecology procedure volumes and case mix variances which is resulting in favourable package of care and clinical supplies costs. 6.1 Child, Women and Family Services ($526k favourable YTD) The variance was driven by higher than anticipated Allied Health and Management/Administration vacancies across the division. Partially offsetting this are unrealised cost reduction initiatives, cost pressures associated with midwife staff retention and recruitment linked to national workforce shortages and a provision for an Obstetrics and Gynaecology run category change for Registrars. Other cost pressures are evident in ARDS repairs and maintenance of clinical equipment, treatment disposables and patient meals driven by service demand as well as laundry and cleaning supplies. Specialist Mental Health and Addiction Services ($1.147m favourable YTD) The variance was driven by vacancies in nursing, partially offset by casual staff and overtime cover. There were also vacancies in medical which was partly offset by locum cover. To minimise vacancies, a retention and recruitment committee explore ways of attracting and retaining staff. We have had a trend of declining vacancies over the last year, and mental health has been successful in bringing down vacancy numbers, particularly in nursing in recent months. Provider Arm - Corporate and Support Services Corporate and Support Services were $2.962m favourable YTD. The variance was due to the wash-up of accruals and revaluation of year end provisions, partially off-set by unrealised budgeted financial sustainability initiatives across Corporate and Provider Support and unbudgeted inpatient pharmaceuticals and patient meal contract price increases in Hospital Operations. The overall result for Hospital Operations was $338k favourable for June and $2.809m unfavourable for the YTD. The favourable result for the month was due to a larger than expected Pharmac rebate for Hospital Medicines $656k favourable. The unfavourable result for YTD was due to activity related pharmaceutical and patient meal costs. Governance and Funding Administration Arm The Governance and Funding Administration represents the Waitemata DHB share of the Joint Planning Funding and Outcomes Arm and includes the Waitemata DHB share of the Northern Regional Alliance expenditure. The Governance and Funding Administration Core net variance against budget for the month is $887k favourable against budget for the month and $2.141m favourable against budget for the year. The main factors contributing to the favourable result relate to staffing and include lower than budgeted expenditure across both payroll and outsourced contractors. Funder The Funder net result for June is $2.054m favourable against budget for the month and $13.510m favourable against budget for the year. This is derived from a favourable Funder annual revenue position of $8.793m against budget and a favourable Funder annual expenditure position of $4.717m against budget. This Funder result is for the totality of the Funder Services across all its divisions and is inclusive of Funder Provider Arm, Funder NGO and Funder IDF. Also of note is that a substantive component of the Funder net result is interrelated and compensatory in nature The Funder favourable revenue variance mainly results from various prior year adjustments, current year IDF wash-up expectations, the unbudgeted Hospital Medicines Initiative contribution received 100

101 from Pharmac (paid against Community Drug Rebates), the unbudgeted Mental Health Pay Equity Initiative revenue received from the Ministry and various other Funded Initiatives with equivalent expenditure. The Funder favourable expenditure variance mainly results from adjustments relating to prior years, the current year IDF wash-up as advised by the Ministry, normal expenditure variations across Funder demand services, lower Pharmac rebates than budgeted (both budget and actuals are as advised by Pharmac), Pharmac Hospitals Medicines Initiative funding paid out of Community Rebates, unbudgeted Mental Health Pay Equity expenditure, additional revenue allocations to Provider Arm Services (Funder expenditure) and changes relating to Funded Initiatives subsequent to budgets having been set Capital Expenditure Capital expenditure for the year ended June 2018 was $19.835m against a revised stretch target of $21m and $30.901m approved budget. Management has improved the scrutiny over capital expenditure with all strategic investment decisions now being made by the Portfolio Investment Committee, comprising of the Executive Leadership Team supported by the Portfolio Support Office. Waitemata DHB Capital Expenditure Budget June 2018 FULL YEAR FULL YEAR ($000's) Actual Original Budget Variance Actual Stretch Budget Variance Land Buildings & Plant 615 1, ,644 14,864 4,220 Clinical Equipment (28) 6,400 3,869 (2,531) Other Equipment ,832 1,541 Information Technology ,276 6,408 4,132 Motor Vehicles (64) Purchase of Software ,768 3,768 Total Capital Expenditure 1,512 2,649 1,137 19,835 21,000 11,

102 5. Financial Position/Cash Flow Position The financial position as at June 2018 is given below. This indicates a net worth of $ m including $29.078m in cash. The detailed Statement of Financial Position for the DHB is provided as Attachment 2. Waitemata DHB Statement of Financial Position OPENING June 2018 MONTH FULL YEAR ($000's) 30-Jun-18 Actual Budget Variance Budget Crown Equity 614, , ,588 (1,353) 615, Represented by : Current Assets 85,857 95,191 90,853 4,338 90,853 Current Liabilities 218, , ,674 (9,595) 221,674 Net Working Capital (132,496) (136,077) (130,821) (5,256) (130,821) Fixed Assets 784, , ,912 (18,189) 796,912 Term Liabilities 37,678 28,411 50,503 22,092 50,503 Total Employment of Capital 614, , ,588 (1,353) 615,588 Summary of the cash flow statement as at June 2018 is given below. The detailed Cash flow statement is provided as Attachment 3. Waitemata DHB Statement of Cash Flows MONTH June 2018 YEAR TO DATE ($000's) Actual Budget Variance Actual Budget Variance Opening cash 41,447 16,882 24,565 17,812 17,812 0 Operating (9,802) 2,348 (12,150) 40,252 29,670 10,582 Investing (2,567) (2,649) 82 (28,987) (30,901) 1,914 Financing Closing cash 29,078 16,581 12,497 29,078 16,581 12,496 The Cash operating outflow in June reflects the payment of $18.3m Capital charge (half yearly payment) on 21 June to the MoH. 102

103 Attachment 1 Waitemata DHB Statement of Financial Performance By DHB Service Group Month - June 2018 Direct Revenue Direct Expenditure Net Result ($000's) Actual Budget Variance Actual Budget Variance Actual Budget Variance PROVIDER Acute & Emerg Medicine ,026 12,599 (427) (12,694) (12,297) (398) Sub Specialty Med HOPS ,604 8,271 (332) (7,724) (7,524) (200) Medical Services 1,211 1, ,630 20,870 (759) (20,418) (19,820) (598) Surgical Services (349) 16,164 14,290 (1,875) (15,665) (13,441) (2,224) ESC (0) 0 (0) 2,803 2,504 (299) (2,803) (2,504) (299) Child, Women & Family Services ,429 8, (7,941) (8,004) 63 Mental Health (20) 12,861 12,535 (325) (12,409) (12,064) (345) Sub Total - Clinical Services 2,650 2,823 (173) 61,887 58,657 (3,230) (59,237) (55,833) (3,403) Director of Hospital Services 1,341 1, ,463 1,985 (478) (1,123) (934) (189) Elective & Outpatient S (73) (500) (429) (72) Sub Total-Hospital Services 1,356 1, ,979 2,428 (551) (1,623) (1,363) (260) Hospital Operations 1, ,278 6,831 (447) (6,104) (6,442) 338 Facilities ,125 2,812 (313) (3,085) (2,807) (278) Provider Management 70,756 70, (2,908) (3,396) (488) 73,664 73, Corporate 1,483 2,040 (557) 8,803 9,858 1,056 (7,320) (7,818) 498 Sub Total - Corporate & Support Services 74,808 73,683 1,125 19,276 18,533 (743) 55,532 55, Total Provider 77,458 76, ,162 77,190 (3,973) (3,705) (683) (3,022) 6.1 Governance & Funding Administration 1,296 1, , (0) 887 FUNDER ARM Funder NGOs 43,675 41,406 2,269 43,569 40,822 (2,747) (478) Funder Inter District Flows 25,284 24, ,343 24,993 2,650 2, ,941 Funder Governance 1,274 1, ,274 1,166 (109) (0) 0 (0) Funder Own Provider 72,015 69,533 2,482 72,424 69,534 (2,891) (409) 0 (409) Elimination (73,698) (70,699) (2,999) (73,698) (70,699) 2,999 (0) 0 (0) Total Funder Arm 68,550 66,399 2,151 65,912 65,815 (97) 2, ,053 Consolidated 147, ,090 3, , ,189 (3,295) (180) (100) (80) Waitemata DHB Statement of Financial Performance By DHB Service Group Full Year - June 2018 Direct Revenue Direct Expenditure Net Result ($000's) Actual Budget Variance Actual Budget Variance Actual Budget Variance PROVIDER Acute & Emerg Medicine 3,702 3, , ,880 (3,650) (133,829) (130,237) (3,591) Sub Specialty Med HOPS 8,629 8,916 (287) 94,089 88,982 (5,107) (85,460) (80,066) (5,394) Medical Services 12,330 12,559 (229) 231, ,863 (8,757) (219,289) (210,304) (8,985) Surgical Services 9,047 8, , ,276 (11,101) (164,329) (153,289) (11,040) ESC (0) (0) (0) 28,153 28, (28,153) (28,232) 79 Child, Women & Family Services 5,476 5, ,283 90, (84,807) (85,334) 526 Mental Health 6,221 5, , , (125,596) (126,742) 1,147 Sub Total - Clinical Services 33,075 32, , ,520 (18,729) (622,175) (603,900) (18,274) Director of Hospital Services 13,718 12, ,642 20,220 (4,422) (10,924) (7,361) (3,562) Elective & Outpatient S ,833 4,490 (343) (4,643) (4,322) (321) Sub Total-Hospital Services 13,908 13, ,475 24,710 (4,765) (15,567) (11,683) (3,884) Hospital Operations 5,517 4, ,537 81,882 (3,655) (80,020) (77,211) (2,809) Facilities ,202 33,921 (3,281) (36,755) (33,636) (3,118) Provider Management 839, ,087 3,408 9,972 15,993 6, , ,094 9,429 Corporate 18,842 18, , ,855 2,373 (97,640) (100,664) 3,024 Sub Total - Corporate & Support Services 878, ,261 5, , ,362 (3,306) 599, ,899 2,642 Total Provider 911, ,881 6, , ,882 (22,035) (22,633) (7,001) (15,632) Governance & Funding Administration 14,040 14,209 (169) 11,899 14,209 2,310 2, ,141 FUNDER ARM Funder NGOs 500, ,866 3, , ,866 10,449 21,349 7,000 14,349 Funder Inter District Flows 300, , , , , ,050 Funder Governance 13,922 13,987 (65) 13,922 13, (0) 0 (0) Funder Own Provider 838, ,402 4, , ,402 (6,215) (1,889) 0 (1,889) Elimination (854,538) (848,389) (6,149) (854,538) (848,389) 6,149 (0) 0 (0) Total Funder Arm 799, ,782 2, , ,782 10,867 20,510 7,000 13,510 Consolidated 1,724,750 1,715,872 8,878 1,724,732 1,715,873 (8,859) 19 (0)

104 Attachment 2 Waitemata DHB Statement of Financial Position 30 June 2018 ($000's) 30/06/ /06/ /06/2018 Actual Actual Budget Crown Equity Crown Equity 379, , ,721 Revaluation Reserve 273, , ,512 Retained Earnings - Prior Years (40,935) (39,019) (37,645) Retained Earnings /18 1, , , , Represented by : Current Assets Bank and Short Term Deposits 17,812 29,077 19,599 Debtors 55,291 57,422 58,000 Prepayments 5, ,201 Inventory 7,553 7,933 8,053 Assets Held for Resale ,857 95,191 90,853 Current Liabilities Bank Overdraft Creditors 108, , ,874 Provisions and Accruals 1,051 2,363 1,051 Staff Related Liabilities - Current 108,175 97, ,721 Term Debt - Current Portion , , ,674 Net Working Capital (132,496) (136,077) (130,821) Fixed Assets Land, Buildings and Plant (net) 641, , ,890 Leasehold Building Works (net) 3,328 3,038 3,329 Equipment (net) 37,963 37,709 39,127 Information Technology (net) ,382 Intangible Software (net) ,846 Vehicles (net) 3,474 2,433 2,522 Work in Progress 55,991 35,952 54, , , ,338 LT & Investments in Associates 41,649 43,278 49,574 41,649 43,278 49,574 Term Liabilities Staff Related Liabilities- Term 36,988 28,064 37,334 Trust and Special Funds ,827 Term Debt - External ,678 28,411 50, , , ,

105 Attachment 3 Waitemata DHB Statement of Cash Flows 30 June 2018 MONTH FULL YEAR Actual Budget Variance Actual Budget Variance Cash flows from operating activities: Inflows Crown 147, ,127 8,030 1,675,846 1,670,120 5,726 Interest Received ,076 2,810 (734) Other Revenue (525) 4,722 (5,247) 37,850 42,941 (5,091) Outflows Staff 53,982 54, , ,270 12,885 Suppliers 20,228 17,872 (2,356) 237, ,213 (23,851) Other Providers 65,912 66, , ,794 19,879 Capital Charge 18,321 3,077 (15,244) 36,679 36, GST (net) (1,673) 0 1,673 (1,523) 0 1,523 Net cash from Operations (9,802) 2,348 (12,150) 40,252 29,670 10,582 Cash flows from investing activities: Inflows Sale of Fixed Assets Associates Outflows Capital Expenditure 2,567 2, ,035 30,901 4,866 Investments ,952 0 (2,952) Net cash from Investing (2,567) (2,649) 82 (28,987) (30,901) 1,914 Cash flows from financing activities: Inflows Equity Injections New Debt Deposits Recovered Outflows 0 Interest Paid Funds to Deposit Net cash from Financing Net increase / (decrease) (12,369) (301) (12,068) 11,265 (1,231) 12,496 Opening cash 41,447 16,882 24,565 17,812 17,812 0 Closing cash 29,078 16,581 12,497 29,078 16,581 12,497 Closing Cash Balance in HBL Sweep account 29,078 29,

106 Attachment 4 Waitemata DHB Statement of Accounts Receivable June 2018 ($) As % Total Outstanding Current 1-30 D D D 91 Days + Prior Month ACC 3.2% 744, ,336 2,830 1, , ,290 Accredited Employers 0.1% 10, ,304 8,795 12,727 Commercial 2.1% 346, , ,852 16,520 2,015-26, ,988 Crown (excluding MoH) 10.1% 2,258,434 1,977, , ,877 2,843 29,472 1,466,103 DHBS' 21.6% 2,786,737 1,713,655 32, ,161 88, ,932 3,148,111 MOH 39.7% 8,326,737 3,872,624 4,319, , ,781 5,790,877 Non Residents 23.2% 3,511, , , ,225 2,160,372 3,380,900 Overseas Govt 0.0% Patient 0.1% 16, , ,059 17,806 Staff 0.0% WDHB Total 100% 18,000,819 8,497,453 5,300, , ,282 2,850,146 14,585,802 58% 36% 6% 3% 20% 6.1 Total Less Non- residents 11,204,902 8,497,453 4,638, ,311 95, ,774 76% 41% 5% 1% 6% Total 30+ 1,354,142 12% 106

107 7.1 Minutes of the Hospital Advisory Committee Meeting held on 01 August 2018 Recommendation: That the draft minutes of the Hospital Advisory Committee meeting held on 01 August 2018 be received

108 Minutes of the meeting of the Waitemata District Health Board Hospital Advisory Committee Wednesday 01 August 2018 held at Waitemata District Health Board Boardroom, Level 1, 15 Shea Terrace, Takapuna, commencing at 1.30 pm PART I Items considered in public meeting 7.1 COMMITTEE MEMBERS PRESENT Sandra Coney (Acting Committee Chair) Max Abbott (present from 1.35 p.m., Item 3.1) Kylie Clegg (Deputy Board Chair) Judy McGregor (Board Chair) Brian Neeson Morris Pita (present from 3.10p.m public excluded session only) ALSO PRESENT Warren Flaunty (Board member) Dale Bramley (Chief Executive Officer) (present from 2.20p.m, during Item 3.1.) Andrew Brant (Deputy Chief Executive Officer and Chief Medical Officer) Robert Paine (Chief Financial Officer and Head of Corporate Services) Cath Cronin (Director of Hospital Services) Fiona McCarthy (Director of Human Resources) Jocelyn Peach (Director of Nursing and Midwifery) Tamzin Brott (Director of Allied Health) Jacky Bush (Quality and Risk Manager) Joanne Brown (Funding and Development Manager, Hospitals) Paul Garbett (Board Secretary - Temporary) (Staff members who attended for a particular item are named at the start of the minute for that item.) PUBLIC AND MEDIA REPRESENTATIVES PRESENT WELCOME APOLOGIES Sue Claridge, Auckland Women s Health Council There were no media representatives present. The Acting Committee Chair welcomed those present. Apologies were received and accepted from James Le Fevre and Allison Roe, together with apologies for late arrival from Morris Pita and Dale Bramley. DISCLOSURE OF INTERESTS There were no additions or amendments to the declarations of interest. 108

109 There were no declarations of interest relating to the open section of the agenda. 1. AGENDA ORDER AND TIMING Items were taken in the same order as listed in the agenda. 2. COMMITTEE MINUTES 2.1 Confirmation of the Minutes of the Hospital Advisory Committee Meeting held on 20 June 2018 (agenda pages 5 to 14) 7.1 Resolution (Moved Sandra Coney/Seconded Judy McGregor) That the Minutes of the Hospital Advisory Committee meeting held on 20 June 2018 be approved. Carried Actions Arising (agenda page 15 ) These were noted. In addition a request arising from the 20 June 2018 meeting was added a request for a more detailed report on Waitakere Hospital utilisation. 3. PROVIDER ARM PERFORMANCE REPORT 3.1 Provider Arm Performance Report May 2018 (agenda pages 16 to 81) Cath Cronin summarised the overview section of this report. Matters that she highlighted included the establishment of the coffee with Cath sessions with teams; responding to the challenges with radiology volumes and the emphasis on addressing pressure injuries. Matters covered in discussion and response to questions included: With the health target for shorter waits in ED, at North Shore Hospital patients were triaged and for cases that were not serious, patients were offered coupons to get treatment at White Cross. The Funder provided the coupons. The Deputy Board Chair commented on the Coffee with Cath sessions and said that she would be keen to see trends and ideas like this brought back to the Committee. Cath Cronin noted the value of these sessions in getting immediate feedback from staff members. The increase in Radiology was not seen primarily as being about population growth. Anecdotally the advice being received is that it is more about changes in cancer treatment which require more frequent radiology checks. There are a number of different theories but nothing substantive yet. The Committee was advised to refer to the Audit and Finance agenda for 1 August where there was more detailed information on the growth in demand for radiology and the measures proposed to address it. The question was asked as to how much of the increase in presentations at EDs was population growth related. Dr Gerard de Jong (Division Head, Acute 109

110 and Emergency Medicine) and Alex Boersma (General Manager, Acute and Emergency Medicine) advised that this is an unrelenting trend and they will come back to the Committee with more information on it. Financial Performance (agenda pages 29-32) Robert Paine s response to questions relating to this section of the report included: He believed that Ministry of Health funding had tracked population growth about right, but the 2% allowance for inflation was problematic for next year. The Board Chair advised that she had real concerns about the way population is calculated. There is a fundamental question about how population is calculated in relation to the census and an issue with under-reporting and concealment of the total number of people actually in New Zealand. 7.1 Human Resources (agenda page 33 to 36) Fiona McCarthy (Director, Human Resources) summarised this section of the report. She noted that sick leave levels were currently normal and that there had been a slight reduction in staff turnover. With annual leave approximately 400 staff members had balances of over two years leave not taken. This has been communicated to services and the achievement of leave plans will be actively monitored. Acute and Emergency Medicine Division (agenda page 37 to 47) Dr Gerard de Jong (Division Head Acute and Emergency Medicine) and Alex Boersma, (General Manager, Acute and Emergency Medicine) summarised this section of the report. Matters that they highlighted included: Phase 4 of the Acute and Specialist Medicine Patient Flow Project (TransforMED) focused on implementing an improved model of care in the ADU for General Medicine. What they want is to not have patients staying overnight unnecessarily. The aim is to have no patients waiting for a bed in the morning and more going home during the day. Members of the leadership team are looking at other places where this type of progress has been achieved. The key issue of the Medical Nursing Workforce Model (detailed on page 39 of the agenda). The question of why four patients were mistakenly included in the data as STEMI patients (page 41 of the agenda) will be looked into. Ongoing work to reduce the incidence of pressure injuries. Continuing work to try and reduce staff turnover. Specialty Medicine and Health of Older Persons (agenda page 48 to 54) Dr John Scott (Head of Division, Specialty Medicine and Health of Older People), and Alex Boersma presented this section of the report. Matters that they highlighted included: Insulin self-management (detailed on pages of the agenda). Initiatives to reduce the number of pressure injuries occurring (pages of the agenda). The slight increase in the staff turnover rate (page 51 of the agenda). 110

111 Matters covered in discussion and response to questions included: With insulin management, when patients are assessed for competence in selfmanagement, they do identify that some are doing this wrongly. Part of the benefit of the self-management programme is that it provides an opportunity to review skills and the ability to self-manage. John Scott advised that anecdotally a reason for losing staff is that some are shifting to locations where the cost of living is lower. Alex Boersma confirmed that in the analysis done on staff leaving acute areas, there were a number of factors, but this was one of them. Fiona McCarthy confirmed that exit interviews are analysed and thought is being given to how to improve retention. 7.1 Child Women and Family (agenda page 55 to 64) Dr Meia Schmidt-Uili (Head of Division Medical Child Women and Family), Stephanie Doe (General Manager Child Women and Family Services) and Emma Farmer (Head of Division Midwifery) were present for this item. Matters that they highlighted included: The report highlights ARDS Improvement Activities, including work on reducing inequalities through the outreach fluoride programme; improving access through Saturday clinics; standardising recall times to increase frequency of appointments for high needs children; and the work done on systems and processes that support services. The key issue of recruitment and retention of dental therapists (pages of the agenda). This is an issue across the region and across New Zealand and they are looking at how better to recruit and retain. Another issue that is being worked on is to how communicate better with the 82 clinics across the Auckland metropolitan region. Matters covered in discussion and response to questions included: Max Abbott advised that AUT has substantially increased its first year intake of dental therapists, almost doubling that. Training takes three years, but hopefully the increase will have an impact in the future. Stephanie Doe advised that dual scope (working also with a private provider) was supported and seen as a way of maintaining a range of competencies for dental therapists. The particular difficulty in recruiting dental therapists in South Auckland and the high vacancy rate there was discussed. In response to a question on whether the significant number of people dependant on roof water (for example in some Rodney rural areas) posed an issue in terms of fluoride, Stephanie Doe advised that this would be checked. Specialist Mental Health and Addiction (agenda page 65 to 71) Dr Jeremy Skipworth (Clinical Director, Mason Clinic), Alex Craig (Head of Division Nursing) and Dr Jessica Henry (registrar) were present for this section of the report. Matters highlighted included: The graph on page 66 of the agenda illustrating the significant increase in face to face client contacts for Te Atea Marino. The service was also showing 111

112 increased satisfaction levels and increased retention (clients averaging 7-8 sessions compared to 2-3 a decade ago). Surgical and Ambulatory Services/Elective Surgical Centre (agenda page 72 to 81) Debbie Eastwood (General Manager) presented this section of the report. She conveyed an apology from Michael Rodgers (Chief of Surgery). Matters that she highlighted included: The challenges with the major increase in demand for radiology (page 75 of the agenda). The work being done to improve theatre utilisation at Waitakere Hospital (page 75 of the agenda). The three month pilot approved for Dedicated Abscess Theatres, as part of the General Surgical Clinical Pathways Initiatives (page 80 of the agenda). 7.1 Matters covered in discussion and response to questions included: The question was raised as to whether knee surgery using the robot (pages of the agenda) had higher or lower infection rates and complications than non-robotic surgery. Also information was requested on ethnicity of patients receiving the robotic surgery. Information on these two matters will be obtained and reported back to the Committee. With regard to the length of stay figures in the table on page 74 of the agenda, work is underway with the wards to reduce time to theatre and review the criteria for discharge. The target will take time to achieve. Dale Bramley advised that there was no age at which operations were no longer done; it was all about the ability of the individual to have the surgery. Resolution (Moved Kylie Clegg/Seconded Max Abbott) That the report be received. Carried 4. CORPORATE REPORTS 4.1 Clinical Leaders Report (agenda pages 82 to 87) Dr Andrew Brant (Deputy Chief Executive Officer and Chief Medical Officer), Dr Jocelyn Peach (Director of Nursing and Midwifery; Emergency Systems Planner) and Tamzin Brott (Director of Allied Health, Scientific and Technical Professions) presented this item. Medical Staff The point that accreditation standards are defined by organisations outside of New Zealand was noted. Nursing and Midwifery Jocelyn Peach highlighted the ten nurses achieving Registered Nurse Level 4. It was very important to have a pool of experts. More detail on this would be provided in future. 112

113 The Board Chair said that she would love to see at a regional level something done to acknowledge the value of nurses; it is vital to retain nurses, to secure the best graduates etc. Jocelyn Peach advised that they were doing some work to understand what nurses and candidates for nursing see as problematic. In the recovery period after a strike it is important to think about what might help strengthen relationships. The conclusions reached will be brought to the Board. Jocelyn Peach was thanked for the hard work she had done related to the nurses strike. In further discussion on recruitment and retention, Max Abbott advised that he thought the number of candidates applying for nursing programmes had fallen off. Once everything had settled down there would be a need for some positive stories about the profession. Jocelyn Peach commented that after so much bad publicity, there is a need to remind people why they enjoy their job. They need to feel that they matter. How that is articulated and worked through with them is very important. The values are very important, including compassion. The Acting Committee Chair asked if the Board could be given advice on how it could contribute more to this process. It was also noted that there were potential flow on effects from the nurses settlement for the wider health sector; wider workforce issues. 7.1 Allied Health, Scientific and Technical Professions Tamzin Brott highlighted that the Waitemata DHB Matariki Award for Everyone Matters had been awarded to Te Hine-ngaro Tuterangiwhiu, a new graduate physiotherapist at Waitakere Hospital. Resolution (Moved Kylie Clegg/Seconded Max Abbott) That the report be received. Carried 4.2 Human Resources (agenda pages 88 to 98) Fiona McCarthy (Director of Human Resources) highlighted the improvement in average time to recruit for May (page 88 of the agenda); the values related work (pages of the agenda) and the section of the report on the Maori and Pacific workforces (pages of the agenda). Matters covered in discussion and response to questions included: The entire recruitment process is automated. With regard to identifying where delays occur in the recruitment process, Human Resources does have visibility of how long each step takes and is getting data that they will be reporting on to the Committee. With regard to ethnicity of new employees (page 91 of the agenda) the chart seemed to indicate that Maori recruitment had gone down. Fiona McCarthy advised that she would obtain information for the last 12 months and advise the Committee. 113

114 Sandra Coney advised that Auckland Council is allocating money for youth employment in West Auckland. This might be something that the DHB could tap into. Fiona McCarthy said that she would talk to the Council about that. Resolution (Moved Kylie Clegg/Max Abbott) That the report be received. Carried Quality Report (agenda pages 99 to 201) Jacky Bush (Quality and Risk Manager), (Penny Andrew (Clinical Lead Quality) and David Price (Director of Patient Experience) were present for this item. Matters highlighted included: The hello my name is campaign (page 162 of the agenda). This is a global phenomenon. An Auckland regional event took place on 23 July to highlight the importance of introducing yourself to patients, whanau, visitors and colleagues. They had found photos of over 350 staff posing with their names in support of the campaign. They had been able to create resources for each ward. This had been very much a staff initiative. Work is being considered to look at improving communication about medical side effects and improving communication with family and friends of patients. The number of volunteers continually grows and is now close to 200. There is continual expansion of the roles that volunteers are involved in. With regard to key quality indicators, Jacky Bush highlighted: The increase in vascular device HABSIs (page 107 of the agenda) is being worked on to address. The latest hand hygiene results are excellent. In the latest national report Waitemata DHB is ranked first for hand hygiene. Patient Safety week this year also focuses on hand hygiene. More work still needs to be done on falls (page 115 of the agenda) and pressure injuries (page 117). A number of initiatives in place are not achieving the results needed. Overall response to complaints times have greatly improved over the last four years to sit below the target of 15 days (page 120 of the agenda). This reflects the effort made in all services and divisions. So far this year the influenza rate is significantly lower than last year (page 151 of the agenda). Matters covered in discussion and response to questions included: With regard to falls, Jocelyn Peach advised that they found some patients deconditioned very quickly when confined to bed. Also there was a high incidence of falls from those cognitively impaired. With the problem mentioned in the report of IPads freezing, the question requiring answer is whether the problem is with the IPads or the environment. 114

115 The Committee will be kept updated. Penny Andrew advised that the IPads can still be used but cause delays that are very frustrating for frontline staff. The Committee asked that the Board s congratulations be passed on to the DHB s volunteers following acknowledgement at the Minister of Health s Volunteer Awards (page 160 of the agenda). Penny Andrew advised that the Survive Sepsis project which is closing (page 121 of the agenda) is being absorbed into the Patient Deterioration Programme. There had been some decreases in sepsis mortality and this will be reported on to the next meeting. 7.1 Jacky Bush, Penny Andrew and David Price were thanked for the report. Resolution (Moved Kylie Clegg/Max Abbott) That the report be received. Carried 5. RESOLUTION TO EXCLUDE THE PUBLIC (agenda page 202) Resolution (Moved Sandra Coney/Seconded Kylie Clegg) That, in accordance with the provisions of Schedule 3, Sections 32 and 33, of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below: General subject of items to be considered 1. Confirmation of Public Excluded Minutes Hospital Advisory Committee Meeting of 20/06/18 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 Confirmation of Minutes As per resolution(s) to exclude the public from the open section of the minutes of the above meeting, in terms of the NZPH&D Act. 2. Quality Report That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act [NZPH&D Act 2000 Schedule 3, S.32 Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] 115

116 General subject of items to be considered Reason for passing this resolution in relation to each item (a)] Ground(s) under Clause 32 for passing this resolution 3. Legal Proceedings Report That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act [NZPH&D Act 2000 Schedule 3, S.32 (a)] Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] Human Resources Report That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act [NZPH&D Act 2000 Schedule 3, S.32 (a)] Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] Negotiations The disclosure of information would not be in the public interest because of the greater need to enable the board to carry on, without prejudice or disadvantage, negotiations. [Official Information Act 1982 S.9 (2) (j)] Carried The open session of the meeting concluded at 3.02 p.m. SIGNED AS A CORRECT RECORD OF THE WAITEMATA DISTRICT HEALTH BOARD HOSPITAL ADVISORY COMMITTEE MEETING OF 01 AUGUST 2018 ACTING COMMITTEE CHAIR 116

117 7.2 Minutes of the Hospital Advisory Committee Meeting held on 20 June 2018 Recommendation: That the minutes of the Hospital Advisory Committee meeting held on 20 June 2018 be received

118 Minutes of the meeting of the Waitemata District Health Board Hospital Advisory Committee Wednesday 20 June 2018 held at Waitemata District Health Board Boardroom, Level 1, 15 Shea Terrace, Takapuna, commencing at 2.03pm PART I Items considered in public meeting 7.2 COMMITTEE MEMBERS PRESENT James Le Fevre (Committee Chair) Judy McGregor Max Abbott Kylie Clegg Sandra Coney Brian Neeson Allison Roe ALSO PRESENT Warren Flaunty (Board member) Dale Bramley (Chief Executive Officer) Andrew Brant (Deputy Chief Executive Officer and Chief Medical Officer) Cath Cronin (Director of Hospital Services) Fiona McCarthy (Director of Human Resources) Jocelyn Peach (Director of Nursing and Midwifery) Tamzin Brott (Director of Allied Health) Penny Andrew (Clinical Leader Quality) 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 PRESENT WELCOME APOLOGIES Sue Claridge, Auckland Women s Health Council There were no media representatives present. The Committee Chair welcomed those present and warmly welcomed the new Board Chair Judy McGregor. An apology was received and accepted from Morris Pita. DISCLOSURE OF INTERESTS There were no additions or amendments to the declarations of interest. 118

119 There were no declarations of interest relating to the open section of the agenda. 1. AGENDA ORDER AND TIMING Items were taken in the same order as listed in the agenda. 2. COMMITTEE MINUTES 2.1 Confirmation of the Minutes of the Hospital Advisory Committee Meeting held on 09 May 2018 (agenda pages 5 to 14) 7.2 Resolution (Moved Kylie Clegg/Seconded Max Abbott) That the Minutes of the Hospital Advisory Committee meeting held on 09 May 2018 be approved. Carried Actions Arising (agenda page 15 ) Noted. 3. PROVIDER ARM PERFORMANCE REPORT 3.1 Provider Arm Performance Report March 2018 (agenda pages 16 to 79) Cath introduced this item. She summarised the reported updates on winter capacity, Herceptin Pink Ribbon Celebration Day (24 May) and the improving communication with our teams initiative. The improving communication/coffee sessions are being attended by approximately ten people per session and positive feedback has been received. Cath also noted the DNA rates as reported in the scorecard, improvements are being seen in small specialities. To investigate this matter further a discussion paper was prepared (available to Committee members in the Diligent Boardbooks resource centre). Karen Bartholomew summarised the discussion paper. Matters covered in discussion and response to questions on this paper included: That Maori and Pacific data was presented as data for refugee and migrant patients was much smaller and there was no specific analysis to be reported. That more granular data on age, gender and ethnicity is available, but there are no signals in that data to suggest any problems. This can be provided to the Committee. That ways in providing timely care are being looked at and can be provided to the Committee in the resource centre. In response to a query about whether information can be provided on appointments that had no value, Cath Cronin said that this data is starting to be collected, with a lot of work being undertaken in Cardiology. 119

120 Max Abbott acknowledged the predicted vs actual bed days graph reported (page 20 of the agenda) and the achievement in do this. It was noted that this is due to a vast array of activities and interlinking of services, a credit to the team and hospital. Waitemata DHB has the fastest reducing length of stay in Australasia. Jocelyn Peach provided an update on pressure injuries and noted work underway with the Head of Division for Surgical Nursing. The work is to refocus on the strategy and have target actions in place for different parts of the patient journey. Issues with pressure injures are recognised and it is important to get patients up, dressed and moving. In response to a question, it was noted the strategy work is not just a refresh, it will be more than that, going back to root cause and rebuilding. 7.2 The Committee viewed a short video filmed as part of the Herceptin Pink Ribbon Celebration Day. Allison Roe queried the outsourced services reported (page 31 of the agenda) and what they were. Cath Cronin advised that the main areas are endoscopy and radiology; more information on this can be provided to the Committee via , and include a data comparison over the past five years. Human Resources (agenda page 34 to 37) Fiona McCarthy (Director, Human Resources) summarised this section of the report. Acute and Emergency Medicine Division (agenda page 38 to 46) Gerard de Jong (Division head Acute and Emergency Medicine), Alex Boersma, (General Manager, Acute and Emergency Medicine) and Lucy Adams (Associate Director of Nursing) summarised this section of the report. Alex Boersma summarised the reported highlight of the month implementation of SWIFT CARE in both EDs. The Committee Chair acknowledged the steady progress on outpatient transthoracic ECHO wait times. In response to a question from the Committee Chair about the turnover rates and whether there were any underlying issues, it was noted the reason for leaving is not always available as it is voluntary to have an exit interview. It has been noted that there is a lot of staff going to Australia or overseas. There are also a number of staff who come via the medical wards into the emergency department (ED), once they are in ED there is attraction to move overseas or to another DHB who receive trauma patients. A correction was made to graph 2 on page 39 An increase in the number of WTH patients issued with vouchers for a primary health care facility noting the dates should be 2017/18 (not 2018/19). Specialty Medicine and Health of Older Persons (agenda page 47 to 54) Dr John Scott (Head of Division, Specialty Medicine and Health of Older People), Brian Millen (General Manager, Specialty Medicine and Health of Older People Services), and Lucy Adams (Associate Director of Nursing) were present for this section of the report. 120

121 John Scott introduced the report and summarised the reported highlight of the month a multi initiative approach to improving outcomes for frail older people. The Committee Chair thanked the team for the update and presentation of the information. In response to a query from the Board Chair it was noted that the length of stay does not reflect the quality of care. In response to a further question from the Board Chair, it was noted that with regard to pressure injuries, that potentially any patient can develop a pressure injury although it is generally older patients. In addition, comment was provided on the loss of muscle bulk for patients that remain in bed, after a week muscle loss is substantial. 7.2 Brian Millen summarised the update provided on the vulnerability of small and isolate services (page 49 of the agenda). Child Women and Family (agenda page 55 to 62) Dr Meia Schmidt-Uili (Head of Division Medical Child Women and Family), Stephanie Doe (General Manager Child Women and Family Services) and Emma Farmer (Head of Division Midwifery) were present for this item. Stephanie Doe introduced the report, summarising the update provided on the introduction of patient focussed booking in gynaecology. Cath Cronin noted the benefit of the work being undertaken in this area and that the toolkit developed can be utilised by other specialities. Meia Schmidt summarised the key issue reported neonatal capacity. The level classification of babies was explained with level 1 babies being feeders and growers, level 2 may require some respiratory support and pre-term, down to 32 weeks, with level 3 babies requiring more support than respiratory. Waitemata DHB provides support for babies up to level 2. Counties Manukau and Auckland DHBs provide support for babies from levels 1 to 3. If Waitemata DHB requires tertiary input for care then the baby is transferred to Auckland DHB. It was noted that the metro Auckland DHBs work closely together with regard to transferring babies who require care; it was clarified that the transfer of babies is uncommon, with one baby transferred from Waitemata DHB during The Committee Chair acknowledged the leadership and management of the neonatal services. The Chief Executive noted that he and the Board Chair had recently visited SCBU at Waitakere Hospital. In response to a question from the Board Chair about the unprecedented growth in the area of neonates and whether there was a reason for that, Stephanie advised that data had been reviewed over the past few years and the need is episodic. Kylie Clegg referred to the scorecard presented and the percentage of infants enrolled for oral health by 1 year and queried what Counties Manukau Health are doing to help improve this. Stephanie Doe advised that it is anticipated that both Waitemata and Auckland DHBs enrolment rates will be high. A meeting was held and a process and 121

122 pathway agreed to improve enrolment at Counties Manukau Health, however, progress has not been seen to date; the matter will be escalated to improve this. Specialist Mental Health and Addiction (agenda page 63 to 68) Dr Jeremy Skipworth (Clinical Director, Mason Clinic), Pam Lightbown (General Manager) and Alex Craig (Head of Division Nursing) presented this section of the report. Pam Lightbown introduced the report. Matters covered in discussion and response to questions included: Pam Lightbown noted the issue reported on the Substance Addiction Compulsory Assessment and Treatment (SACAT) implementation and that there is a higher demand than originally anticipated; the annual project was estimated at 100, which has now almost doubled. In response to a question from the Committee Chair on the 30 hour assessment timeframe, Alex Craig said that the assessments for new referrals are mostly undertaken by nurses. Assessments will then go forward to a Specialist. There may be a reduction in assessment timeframe as staff become more familiar with the process. It was noted that other regions are experiencing the same length of time for assessments. The Chief Executive noted the Prime Minister s recent announcement for a $16.5million grant to Auckland City Mission. This grant will allow two extra floors to be added; one level will be allocated to medical beds (with a requirement to negotiate the use of five beds), the other level will be social detoxification beds. The building timeline is 2.5 years. It was noted that SACAT data is being gathered on the number of clients being seen and referred as well as the unmet need. It was noted that the panel for the Government Inquiry into Mental Health and Addiction would be visiting the DHB s forensic services as well as Community Drug and Alcohol Services in July. Warren Flaunty congratulated Susanna Galea for the work undertaken in the area of codeine being reclassified as a prescription only medicine. Reclassification of codeine will be in place from 30 January The Committee Chair noted the favourable variance reported for nursing and requested more information on the proportion of FTE time staffed by casual employees as well as in comparison to casual, FTE and part-time employees of other DHBs. He also requested an update on steps being taken (short, long and medium term) on the recruitment and retention of staff, particularly nursing in the area of mental health. 7.2 Surgical and Ambulatory Services/Elective Surgical Centre (agenda page 69 to 79) Debbie Eastwood (General Manager) and Charles McFarlan (Clinical Director of Anaesthesia) presented this section of the report. Apologies were received from Michael Rodgers and Kate Gilmour. Debbie Eastwood introduced the report. Matters covered in discussion and response to questions included: The Chief Executive noted that a meeting had been held with various clinical leads to discuss ICU bed capacity and whether there were sufficient beds on an ongoing 122

123 basis; this was precipitated by a decrease in the total number of beds available. It was noted that the number of beds open was six, but that this needed to move to seven permanent beds open, allowing flex of up to eight beds if needed. A business case will be presented to the Board to address growth and need. It was noted that clinical representation from the Emergency Department was involved in the meeting. That with regard to theatre utilisation at Waitakere, Cath advised that a definitive plan is being worked on and will be reported to the Committee. Debbie Eastwood and her team are liaising with Auckland DHB, paediatrics and dental and sessions have been scheduled in the Waitakere theatres. The update reported on waiting times of ultrasound scans done within six weeks (page 73 of the agenda) was noted and the Committee Chair queried whether there was a long term strategy in place to improve the wait times. Cath Cronin said that there is a transformational programme for Radiology and that there is some very good work being done; the impact the private sector has on recruitment was noted. A further update will be provided to the Committee on this matter. 7.2 Resolution (Moved Sandra Coney/Seconded Kylie Clegg) That the report be received. Carried 3.45pm - Warren Flaunty retired from the meeting. 3.2 Provider Arm Performance Report April 2018 (agenda pages 80 to 90) The Committee Chair noted the need to refresh the strategic initiative updates for all areas; Cath Cronin noted that this will occur when the new plan comes out. Resolution (Moved Sandra Coney/Seconded Kylie Clegg) That the report be received. Carried 4. CORPORATE REPORTS 4.1 Clinical Leaders Report (agenda pages 91 to 98) Dr Andrew Brant (Deputy Chief Executive Officer and Chief Medical Officer), and Dr Jocelyn Peach (Director of Nursing and Midwifery; Emergency Systems Planner) presented this item. Medical Staff Andrew Brant summarised this section of the report. Max Abbott noted the Wellness programme, including Mindfulness and queried how this was received by senior doctors; Andrew advised that the sessions were well received. In addition Fiona McCarthy said that the DHB has a Strategy Health workforce, including wellbeing which is being refreshed. Sessions for nurses will also 123

124 be discussed with the Director of Nursing. Nursing and Midwifery Jocelyn Peach summarised this section of the report. In response to a question from Allison Roe, it was noted that nurse administrators are 2.1 per cent of the team. Fiona McCarthy advised that the percentage of doctors in the hospital is approximately 26 per cent. Jocelyn Peach noted both the recent internal midwives day and international nurses day. 7.2 Allied Health, Scientific and Technical Professions Tamzin Brott summarised this section of the report. Resolution (Moved Kylie Clegg/Max Abbott) That the report be received. Carried 4.2 Human Resources (agenda pages 99 to 107) Fiona McCarthy (Director of Human Resources) summarised the report. She provided an update to the attendance at JOBFest and that 61 expressions of interest were received. Resolution (Moved Kylie Clegg/Max Abbott) That the report be received. Carried 4.3 Quality Report (agenda pages 108 to 224) Jacky Bush (Quality and Risk Manager), (Penny Andrew (Clinical Lead Quality) and David Price (Director of Patient Experience) were present for this item. Jacky Bush summarised the health quality and safety commission QSM dashboard (page 111), acknowledging the hand hygiene results in particular. She congratulated all those involved in achieving them. It was noted that hand hygiene day was held on 8 th May, part of that was highlighting that hand hygiene was part of ensuring patient safety. Matters covered in discussion and response to questions included: Max Abbott noted the steady increase reported in pressure injuries, he queried the feasibility of the plan in place to improve this. In response Jocelyn Peach said that reducing the number of pressure injuries is achievable; one example provided was that new mattresses were being hired which provided heel offload. Further updates will be provided to the Committee on this matter. 124

125 The Committee Chair noted the ongoing issue of ipads freezing on the wards and queried whether this was impacting confidence in moving to a digital environment. In response Penny Andrew noted that the issue needs to be resolved to scale up the use of ipads on the wards, the issue is complex and external advice has been sought to resolve it. It is hoped that preliminary tests being trialled with the Cloud will address a significant part of the problem. The Committee Chair noted the update on reducing inpatient sepsis; Penny Andrew advised that a dashboard is being developed which will provide data to report. David Price noted that the Waitemata DHB received an award during National Volunteer Week. The Committee congratulated the team on this result. David Price advised that the number of volunteers is increasing by word-of-mouth (with approximately five to ten queries each week). He also noted that a Westlake Boys College Prefect had undertaken a project to encourage more students to volunteer in the Hospitals during the weekends; his project included interviewing 45 applicants of which 24 were selected to become volunteers as well as building in a sustainability component to ensure continuation of student volunteers. 7.2 The report was noted. 5. RESOLUTION TO EXCLUDE THE PUBLIC (agenda page 225) Resolution (Moved Brian Neeson/Seconded Allison Roe) That, in accordance with the provisions of Schedule 3, Sections 32 and 33, of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below: General subject of items to be considered 1. Confirmation of Public Excluded Minutes Hospital Advisory Committee Meeting of 09/05/18 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 Confirmation of Minutes As per resolution(s) to exclude the public from the open section of the minutes of the above meeting, in terms of the NZPH&D Act. 2. Quality Report That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9 (2) (g) (i)) of the Official Information Act [NZPH&D Act 2000 Schedule 3, S.32 (a)] Privacy The disclosure of information would not be in the public interest because of the greater need to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] 4. Human Resources Report That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the Privacy The disclosure of information would not be in the public interest because of the greater need 125

126 General subject of items to be considered Reason for passing this resolution in relation to each item 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 to protect the privacy of natural persons, including that of deceased natural persons. [Official Information Act 1982 S.9 (2) (a)] Negotiations The disclosure of information would not be in the public interest because of the greater need to enable the board to carry on, without prejudice or disadvantage, negotiations. [Official Information Act 1982 S.9 (2) (j)] 7.2 Carried The open session of the meeting concluded at 4.16pm. SIGNED AS A CORRECT RECORD OF THE WAITEMATA DISTRICT HEALTH BOARD HOSPITAL ADVISORY COMMITTEE MEETING OF 20 JUNE 2018 COMMITTEE CHAIR 126

127 8.1 Health and Safety Marker Report Recommendation: That the report be received. Prepared by: Fiona McCarthy (Director, Human Resources) 1. Purpose of report The purpose of this report is to provide an update on progress towards meeting the expectations of the Health and Safety at Work Act 2015, which came into effect on 4 April Executive Summary The new Health and Safety at Work Act 2015 came into force on 4 April The new legislation and updated regulations are the result of work from the health and safety taskforce established in 2012 to evaluate whether the workplace and safety system in New Zealand was fit for purpose, and to recommend practical strategies for reducing the high rate of workplace fatalities and serious injuries by From taskforce recommendations made in 2013, WorkSafe NZ was established with one goal to reduce workplace deaths and injuries by 25% by The Waitemata DHB has been working on key aspects of the legislation specifically those related to: Contract and reactive maintenance triage and works management. Incident management. PCBUs, where we share accountability and procurement processes. To monitor our compliance, nine dive audits have been completed in and four are set for 2018/19. Audit actions are noted in the Appendix as applicable. A summary of our compliance with the Health and Safety at Work Act is outlined below and details are outlined in Appendix 1. Key High Medium Low Complies substantially or fully with legislation Some actions to be completed Significant or some key actions to be completed Risk Topic Performance Outstanding actions 1. Policy Nil 2. Worker engagement, participation and representation A proposed national worker participation agreement template is due to be circulated to DHBs. 127

128 Risk Topic Performance Outstanding actions 3. Notifiable events Nil 4. Health, Safety and Wellbeing Committee Nil 5. Orientation Nil Staff and Volunteers Local orientation for staff and students Contractor New systems for recording local orientation are in development. Online induction for non-clinical contractors is now live. Mandatory pre-employment Health and Safety online orientation was rolled out in December Risk Management Funding for dedicated health and safety software will be raised during the year; planned implementation mid 2018/ Contractors (Facilities, healthalliance and IT) Underway (see section 7 and 10 of the appendix). 8. Hazardous substances High use areas accounting for 80% of chemicals currently under audit - over 300 sites still to be completed. This is a three year piece of work. 9. Health of workers Comprehensive health monitoring plan in development Equipment and Maintenance Processes for reactive maintenance triage and works planning and completion is under review. Interim processes for health and safety works assessment are in place. Phase 1 resources now approved for recruitment. 11. Training Health and safety training in place, key components are being reviewed. 12. Audits Audit programme for 2017/18 underway (see section 12). Audits for hazardous substances underway (43% complete). Annual organisational wide Safe Way of Working audits scheduled for April Reporting A health and safety scorecard allowing access to regular divisional level reporting can be delivered following the implementation of dedicated Health and Safety software. 14. Resources Discussion underway to convert existing contract resource to Full Time Equivalent (FTE) for additional Occupational Health Physician and work injury administration support. Discussion underway on possible resourcing for recent updates to the new Health and Safety at Work (Hazardous Substances) Regulations

129 3. Glossary HSNO - Hazardous Substances and New Organisms Act PCBU - person conducting a building or undertaking, and has a primary duty of care to ensure the health and safety of workers. The Waitemata DHB is the PCBU. Officers - Includes Board Directors and the Senior Management team who make governance decisions that significantly affect the business. Officers have a duty of due diligence to ensure their business complies with its health and safety obligations. Officers may be found guilty of an offence under the Act, in addition to the PCBU. 8.1 Due Diligence - taking steps to acquire and keep up to date knowledge of health and safety matters. Gain an understanding of the business and hazards and risk associated with that business. Ensure PCBU has available and use appropriate resources and processes to manage risk. Ensure PCBU has appropriate processes for considering incidents, hazard and risks in a timely way. Ensure PCBU implements processes for complying with obligations under the Act, validates the provision and use of resources and processes to comply with obligations under the Act. Workers - Workers have a duty to take reasonable care for their own safety and that their own actions do not adversely affect the safety of others. They need to comply with reasonable health and safety instructions from the PCBU and co-operate with health and safety policies and procedure. Workers are people who work at the Waitemata DHB and include employees, contractors, subcontractors or their employees, apprentices, trainees, persons gaining work experience, employees of a labour hire company and volunteers. Other people - People who come to the workplace such as visitors or customers also have duties to comply with health and safety processes. Our patients and visitors are in this group. Notifiable injury or illness - an injury or illness that requires immediate treatment (i.e. amputation, serious burn, serious head injury or burn), admission to hospital, serious infection and medical treatment within 48 hours of exposure. All notifiable injuries or illnesses are to be reported to WorkSafe NZ. Notifiable incident - an incident that is an unplanned or uncontrolled incident in a workplace and that exposes a worker or other person to a serious risk to health and safety. Notifiable incidents include events such as: a spillage or leak of a substance, explosion or fire, escape of gas or steam, falls, electric shocks, structural collapses, in rush of water, gas or mud, interruption of underground ventilation. All notifiable instances are to be reported to WorkSafe NZ. Health and Safety Representative - a person elected to represent the workers in relation to health and safety matters. The representative has specific functions and roles under Schedule 2 of the Act. 129

130 Appendix 1 Progress implementing the Health and Safety at Work Act Policy The Waitemata DHB policies have been reviewed and are aligned to the new legislation. Changes and updates to policy will occur over the next few years as new regulations, audits and experiential learnings lead to new processes. Significant policy changes will be endorsed by the Board. 2. Worker engagement, participation, and representation 8.1 What the Act says How do we comply? A PCBU must: Initiate election of health and safety representatives on request of workers. Agree the work groups that are represented by a health and safety representative. Consult about matters related to health and safety. Provide information as requested with due consideration to the Privacy Act. Allow a health and safety representative time to discharge their powers under the act. New regulations on worker engagement, participation and representation were introduced in February 2016 and outline the functions, number, training, powers and participation expectations of health and safety representatives. We have 307 health and safety representatives throughout the business, most of whom have baseline health and safety representative training, as endorsed by WorkSafe NZ, as well as divisional health and safety committees in place to provide ways to participate in local issues. In addition, the annual update of hazards is reviewed by representatives, and representatives participate in the self-assessed departmental health and safety audit. Representatives also undertake Waitemata DHB wide health and safety activity such as flushing low use water outlets. Seven health and safety representatives sit on our health, safety and wellbeing committee. Transition training for representatives has been provided and foundation health and safety training is available online. Meeting with on-site contractors to establish health and safety representatives and discuss health and safety matters have commenced. New For August An election process for representation of the Staff Health, Safety and Wellbeing Committee is underway. 130

131 What is outstanding? The regional employee participation agreement between the Northern Region DHBs and unions has not yet been signed by the Unions. Discussions are progressing nationally with union parties. On-going training needs (as part of the new Worker Engagement, Participation and Representation Regulations) have been assessed following the completion of a special project led by Margaret Kamphuis (Specialist Health and Safety Advisor). We are currently reviewing our training providers to meet these needs. Consequences There are fines for not having appropriate employee participation processes in place Notifiable events What the Act says How do we comply? What is outstanding? Consequences A PCBU must: Report on notifiable injury, illness and incidents as soon as possible after being made aware of them. Secure a site if a notifiable event has occurred. Keep a record of notifiable events. We have robust notifiable event reporting and recording processes in place. There are no outstanding actions. There are fines for not notifying workplace injury or illness as soon as possible after being made aware of them. 4. Health, Safety and Wellbeing Committee What the Act says A PCBU must: Put in place a health and safety committee if requested by a worker. Establish a health and safety committee within two months of this request. Consult about health and safety matters with the committee. Allow time for members to attend and carry out functions as a member of the committee. Provide information to the committee. Within a reasonable time, adopt recommendations made by the committee. A PCBU can also establish a health and safety committee on its own initiative. How do we comply? What is outstanding? The Waitemata DHB has two organisation-wide Health, Safety and Wellbeing Committees focussing on: 1. Executive governance and risk. 2. Operational and policy matters. There are no outstanding actions. 131

132 Consequences There are fines for not setting up a Health and Safety Committee if requested, and if a PCBU does not: Allow time for members to attend committee meetings/consider matters raised at the committee. If a PCBU does not implement recommendations from the committee. 5. Orientation What the Act says How do we comply? What is outstanding? Consequences Orientation to a workplace is an important part of complying with the duty of care to ensure the provision and maintenance of a workplace that does not give rise to health and safety risks. A mandatory pre commencement orientation and safety first video was made available to new staff from the end of December. Reporting on completion rates are included in the Scorecard in the Health and Safety Performance report from April. This online Health and Safety module is also utilised for all new Doctors and volunteers. A departmental health and safety induction checklist (form) is sent to recruiting managers. The current manual departmental health and safety induction form will be moved onto an electronic platform so we can start to record completed departmental inductions. Due date December To put an Officer orientation programme in place, however in the meantime we have run Officer training for both the Senior Management Team and the Waitemata DHB Board. To check orientation processes for students. New for August Volunteer on-boarding processes, including pre-employment health checks, are now in place. There are fines and criminal punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness Risk Management What the Act says PCBUs have a duty of care to ensure the health and safety of another person is not put at risk from work carried out as part of the conduct of the business or undertaking. Risks must be eliminated or minimised so that a PCBU can, in so far is reasonably practicable: Provide a workplace without risk. Provide and maintain safe systems, plant and structures. Ensure the safe handling, storage and use of plants, substances and structures. Provide training or supervise to protect persons from risk. Maintain accommodation so a worker is not exposed to risk. 132

133 How do we comply? There is an online hazard management system where hazards are identified and controls recorded. This is complemented by a corporate risk register where service, division and organisation wide health and safety risks are also recorded, controlled and regularly reviewed. Hazards are reviewed between monthly and annually as well as after any related incidents, depending on the level of risk and risks are reviewed every 12 months by the divisional lead manager and Health and Safety Representatives. Waitemata 2025 design and work impact meetings are occurring. Processes to monitor and maintain operational compliance are in place i.e. fire management plan, training, exercises, maintaining clear egress, etc. 8.1 Entrance ways have non slip flooring and signage to indicate they may be slippery when wet. On wet days, additional signage is displayed to alert patients, staff, visitors, contractors to potential slip, trip and fall hazards. This expectation is spot audited. CCTVs are active in appropriate places in and around our sites. A reception and aggression hazard and security risk assessment tool has been developed for use in Community and inpatient settings. Asbestos surveys are ongoing for buildings constructed before An online Asbestos Register is ready to be populated and a volunteer resource will commence this month to load the information. A fixed term resource has been approved to oversee reactive maintenance triage and works management. Facilities staff have had existing Site Safe training which includes hazard identification. Refresher training has been completed for Trade staff. Remaining Facilities and Development staff booked to complete Hazard and Risk Management training beginning of November. The Safe Way of Working (SWoW) annual audit tool has been rolled out across the Waitemata DHB and completed by all areas, with validation audits now also completed annually. Final 2017 results have been compiled and were presented to the Executive Health, Safety and Wellbeing meeting on 30 October The 2018 Safe Way of Working annual audit goes live on 6 April 2018, for completion by all Waitemata DHB people managers. An additional eight risks have been added to the organisational wide health, safety and wellbeing risk register since December A total of 13 risks are now on the register (legislation, wellbeing, hazardous substances, use of sharps, aggression, community workers, working with machinery, electrical equipment, moving and handling, exposure to blood and body fluids, asbestos, psychosocial stressors, slips/trips and falls, fire safety). Evidence of audit, checks and compliance will be noted where controls prescribe this. Reporting on the register will be via the Executive Health, 133

134 Safety and Wellbeing Committee, and where risks are elevated to the Corporate Risk Register - to the Risk and Compliance Committee, and the Audit and Finance Committee. 21 Draft Safety Maintenance Procedures (SMP) have been created and reviewed to manage Facilities hazards and risks. Electrical Safety tagging and testing has commenced and we are initiating an engagement of a resource to undertake this work going forward. Draft Policy for Tagging and Testing is to be approved at the August 2018 Executive Health and Safety and Well Being committee. New for August Formal training on the Facilities and Development Health and Safety Management System (HSMS) for facilities staff is scheduled to begin 28 August. All Facilities and Development staff will undertake training on the nine modules that make up the HSMS. Training is tailored to provide training appropriate to the roles with in-depth training to match individual requirements. 8.1 What is outstanding? Recent audits have identified a number of Health and Safety Information Technology (IT) systems that are not providing the ability for robust, integrated and systematic analysis across the organisation. A Request for Information has been evaluated in February with a view to go to Request for Proposal in April/May In the interim: A combination of the hazard register and the risk register is being used to store and make visible organisational, divisional and unit hazards (A new organisational risk register has been established as noted above). A Microsoft Access database has been created to provide a greater ability to automate basic reporting of statistics and carry out limited data mining. The new instance of the BEIMS system based on Auckland DHB implantation is being implemented to replace the current system version. Procurement confirmed and implementation by July A recent deep dive audit has identified a number of Facilities technology, systems and processes where improvements of current processes to better implement good practise is warranted. Actions have been identified and will be commented on in this report. Work to review and mitigate high residual risks is underway and due to be completed in Tranche 1 of critical resources for Facilities management works have been approved and recruitment is underway. Working in Confined Spaces: Potential confined spaces have been identified and management protocols developed. We are now accessing each confined space and putting in access protocols by December Consequences There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. 134

135 7. Contractors (Facilities, Health Alliance and Information Technology) What the Act says How do we comply? The PCBU, as well as ensuring the health and safety of its employees (workers), is also required to ensure the health and safety of other workers, as well as ensuring that plant and fixtures and fittings are fit for purpose and without risks to health and safety of any person. There are new asbestos regulations that require a change in how PCBU s currently manage and remove asbestos. Selection of Construction Contractors: The Waitemata DHB has moved to a process of selecting a panel of preferred contractors who can tender for Waitemata DHB construction and refurbishment work as it arises. Each main contractor has to first qualify to be a part of the panel by satisfactorily completing a contractor health and safety questionnaire which allows the organisation to demonstrate their performance against 12 health and safety criteria. Complete for incumbent contractors. Any new contractor must complete a requalification questionnaire. Maintenance contractors do not have a supplier panel arrangement in place as yet but contracts are in place and current for main contractors. All regular contractors have been required to submit prequalification documentation in response to an HS200 questionnaire. Only those that satisfy the prequalification requirements which are safety compliant focused can continue to work for the Waitemata DHB. 1. Supplier Contracts and RFP processes Waitemata DHB contracts provide a standardised health and safety statement for minor or individual contracts. This clause is confirmed as satisfying the Act. The standard terms and conditions applicable to any procurement via an Oracle purchase order are being updated to include condition relevant to serviced included requirements to meet HSWA Orientation: The contractor induction documentation and process has been refreshed (a new document, revised presentation and updated requirements for all contractors). Online contractor inductions have been developed and are now operational. The online induction is required for all contractors, with medium to high risk contractors also needing to attend the Facilities and Development Induction. Contractors cannot receive their security pass without either having completed the online induction (for low risk contractors) and/or the Facilities and Development induction (for medium to high risk contractors). Site access: All building contractors must report to Facilities before commencing their work and all healthalliance staff (IT) will report to security. In addition: New projects must be agreed and coordinated with Facilities prior to commencing. A contractor carrying out an agreed task e.g. for call out that does not need to be reported to Facilities prior they do need to report to the

136 area supervisor prior to and post work. All healthalliance staff and contractors are required to have healthalliance issued photo identification on them at all times and for it to be visible. Usually if they are based on a particular site on a regular basis (i.e. not just visiting) then we will request a security access card with photo ID for that staff member from the site. 2. Facilities Once inducted, contractors working for Facilities are issued with a Waitemata DHB ID card with a photo. Proof of identification (passport/ drivers licence) is required to obtain this ID. The duration of the ID card can be set to cover the estimated time of the project. Contractors carrying out very urgent works are exempt from the requirement to complete the formal induction course and photo ID but must be provided with an induction and safety briefing suitable for their task prior to starting work. 8.1 On the job: Construction Toolbox meetings occur on a scheduled basis. There is active management and collaboration with architects and designers to meet design expectations and requirements. Work impact meetings to assess risk occur regularly and ensure contractor health and safety plans are implemented. All Project managers, including the Waitemata 2025 team are Site Safe certified as they join the team. Asbestos: Asbestos management surveys are completed, and a register of these surveys is in place, with a register by building which notes hazard level. The type, location, condition and personal protective equipment expectations are identified in the survey so staff and contractors are alerted. Staff and contractors need to contact Facilities to seek information from the relevant survey. An online system is being implemented to provide easier access to the detailed information and is due to be complete by November. Corrective actions are being implemented to mitigate identified asbestos hazards. Asbestos management plans are being developed and implemented. This work is being led by the Waitemata DHB Asbestos Management Group in consultation with Auckland DHB Asbestos Management Group. Incidents and Accidents: Reporting of incidents and accidents follow the Waitemata DHB process. Contractors experiencing any accident or incident are required to notify the Waitemata DHB, investigate and report back any findings. On site audits: Regular external audits are conducted for construction site work. Project managers also undertake audits of their projects. Orientation: Induction material is in place. On the job: A pre start safety meeting process is in development for all 136

137 build projects, as well as ensuring work impact meetings occur regularly during the project. Safety in design guidance is in development. Quarterly meetings with maintenance contractors are now in place with the first meeting held late last year. Investigations Facilities adopted an ICAM concept of investigation that will identify why things went wrong and what actions are required to ensure compliance and keep workers safe. Records gained through incident reviews, audits and investigations are saved as confirmation of active management by the Waitemata DHB in its role as the PCBU. 8.1 IT work review and sign off For IT project work related to moves and new fit-outs, the desktop team work closely with the Waitemata DHB Project Manager who reviews and signs-off that the work is complete. Building project health and safety management and sign off A performance review is done mid-way through each major building project. Health and Safety design sign off and pre-occupation processes are complete. The building sign off process follows the relevant policy. Post Implementation Reviews (PIRs) PIRs are done for each facility build project and results provided to the contractor selection panel. New for August The recording of Facilities Maintenance contractor site/workplace inspections is a mandatory KPI. Records of completed inspection reports and evidence that any issues/opportunities for improvement have been actioned and closed out are being tracked and recorded with performance monitoring in place. The inspections are reported monthly in the Audit and Finance/Divisional reports. Contractors engaged by Facilities are required to meet with the Project Manager and Facilities and Development Health and Safety Manager in advance of commencing works to ensure all health and safety requirements including reporting requirements are clearly understood. Clarification of these expectations ensures relevant health and safety records are regularly being collected, recorded and reviewed by WDHB Project Manager and Health and Safety Manager. What is outstanding? Selection of contractors: The Waitemata DHB is moving to the same preferred supplier process for maintenance contractors as noted above for large construction contractors. The Waitemata DHB will transition to this process over the next 12 months. The first step of this transition is underway i.e. Waitemata DHB maintenance team requires contractors to provide suitable prequalification material by a certain date. If not met the contractor will be removed from the approved contractor list. 137

138 All regular and new contractors employed by Facilities and Maintenance are required to undertake pre-qualification. Any emergency contractors must provide relevant works planning details and meet work safe requirements. healthalliance processes: The Waitemata DHB is working with healthalliance on site orientation, works planning and safety and procurement processes. These processes will be agreed across the region. healthalliance works affecting a facility will be approved by Facilities management before commencing. Where induction or works are not adequately planned or completed, they will be deferred until signoff/approval has been achieved. 8.1 Building project health and safety management and sign off: Waitemata DHB needs to put in place a complete implementation of project sign off documentation. Project sign off documentation for building commissioning is structured and comprehensive. PCBU meetings Facilities management are implementing a schedule for contractor engagement meetings expected to be initially held quarterly through the year. Consequences There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. 8. Hazardous substances What the Act says A PCBU has a primary duty of care to provide for staff use, handling and storage of substances. The Waitemata DHB is also required to comply with the Hazardous Substances and New Organisms Act 1996 (HSNO) and related regulations which requires the Waitemata DHB to prevent and manage adverse effects of hazardous substances and new organisms. How do we comply? The Waitemata DHB has focused on the 33 areas with high volume and/or exposure risk for the use of hazardous substances, constituting the highest risk areas, with 420 substances identified and added to the online register of substances available on StaffNet. A new and comprehensive HSNO policy has also been developed and published on the intranet, including new legislative updates relating to hazard classifications and tracked substances, with a strong focus on roles and responsibilities. The Intranet HSNO site now contains hot links to information covering: Policy document. Full HSNO database of all hazardous substances identified, including 138

139 constituents, product state, United Nations number, Chemical Abstracts Service number, identified hazards, exposure limits, HSNO class and Personal Protective Equipment specific to each substance. This database has recently been fully upgraded and allows each area to automatically create their own HSNO registers. Master Material Safety Data Sheets repository. Wastewater Disposal Guidelines. Training resources, including introductory PowerPoint. List of all Approved Handlers and their locations. Emergency response requirements. Specific spill kit contents list. Managers responsibilities. Key contacts for staff. Approved handler training has been delivered for high risk areas. Work has also concluded with healthalliance, to ensure that Material Safety Data Sheets are supplied for all new chemicals being procured. 8.1 The North Shore Hospital has a dangerous goods store for holding hazardous substances to be used in the hospital and for storing waste prior to collection. The latest HSNO Legislation was released in November 2017 and we are currently reviewing it to understand all material changes required of us. Our existing HSNO Policy has been updated and republished. Of note, HSNO training will now be required under the new legislation, for all workers who use or handle hazardous substances. We are currently developing mandatory online training modules for these staff, with more specialised training for those staff that have a higher level of oversight and responsibility (competent persons). A new trial process where Orderlies collect HSNO from hospital areas and delivery of these substances to the Hazardous Goods Cabinets/Hazardous Goods Store has been approved and is currently in development. At present the waste removal work is being done via our Hazardous Substances and District Compliance Co-ordinators. New for August The HSNO database has been redeveloped within the Hazard Register, allowing all areas to develop their own local HSNO databases automatically, as well as linking any HSNO to their individual Hazard Registers. Safety Data Cards have also been developed for each individual chemical within our register (over 450). These cards provide quick and easy access to the relevant information for each chemical, without staff needing to read through the entire Safety Data Sheet, which can be very confusing and often isn t complete. What is outstanding? We have another estimated 420 areas to review but a comprehensive audit of the 33 high risk areas, representing 64 physical locations, is underway. The tender for construction of the Dangerous Goods Store will form part of the Waitakere Hospital Development Program. Interim measures are noted below. 139

140 Consequences In the interim a 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, so we are 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. At present materials are delivered via Waitakere to the North Shore Dangerous Goods Store, until we can activate an internal hazardous waste process utilising the dangerous goods cabinets at Waitakere Hospital. There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. It is worth noting that hazardous substances are covered under three sets of national legislation, as well as local bylaws (Health and Safety at Work Act 2015, Hazardous Substances and New Organisms (HSNO) Act 1996, Resource Management Act 1991 and Auckland Council s Water Supply and Wastewater Bylaw ), under all of which fines can be payable Health of workers What the Act says How do we comply? A PCBU must ensure that the health of workers and conditions of the workplace are monitored for the purpose of preventing injury or illness. The PCBU must, as far as reasonably practicable, maintain accommodation so that the worker is not exposed to risks to health and safety. Pre-employment screening in place, however a number of staff still commence work pending their results. A pilot has been completed with the Specialist Mental Health and Addictions Services, and pending discussions on future options to implement across the Waitemata DHB, the pilot will continue and staff and managers asked to complete health screening prior to employment. We undertake occupational health monitoring via our Occupational Physician health clinics and have now extended this to monitoring exposure to noisy areas (facilities), hazardous substances, laser care, and other risk areas. Monitoring for exposure for radiation (Radiology, Cardiac Catheter Lab) occurs externally. We provide free influenza and other vaccinations for staff. We provide and maintain workplace heating, ventilation and cooling. Areas with friable asbestos are sealed and require additional security clearance to gain access. Containers for sharps, hazardous materials and substances are provided on each site. Staff are provided with Personal Protective Equipment (PPE) to wear. PPE requirements are outlined in various policies as well as the hazardous substances register, Infection prevention and control, use of lasers, etc. Infection prevention and control processes are in place to manage any 140

141 disease exposure and outbreaks. Slips, trips and falls posters have also been developed and distributed to the Health and Safety representatives for display within their areas. OH&SS are also displaying these posters in common areas, where Health and Safety Representatives are generally not allocated. Regular communication on hazards is issued. Staff have access to EAP works, the Employee Assistance Programme for up to three free sessions on work or personal matters. Wellbeing, resilience and mindfulness training is available as part of the organisation development team offerings as well as on request. 8.1 The staff influenza campaign is underway, with static clinics having been completed and the in-team vaccinators, over 140 nurses, continuing to vaccinate until the end of August Planning for patient responses, e.g. isolation of suspected flu cases, proactive vaccination of vulnerable cohorts is also underway. The latest HSNO Legislation was released in November 2017 and we are currently reviewing it to understand all material changes required of us. Of note is the expectation that we undertake specific area and hazardous substances task analysis and put in place appropriate processes to manage any possible exposure that may impact staff health. We are also developing mandatory online training modules for these staff, with more specialised training for those staff that have a higher level of oversight and responsibility (also called competent persons (was approved handler)). New for August Planning for staff and patient flu management in 2019 is now underway. What is outstanding? Consequences Health monitoring programmes should be in place across all relevant risk areas. An audit on use of personal protective equipment will be planned as part of the health monitoring programme to validate the application of various policies and risk controls due June There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. 10. Equipment and Maintenance What the Act says How do we comply? A PCBU must provide and maintain a work environment that is without risk to health and safety. Equipment that is broken is escalated for capital replacement as relevant. A register of capital assets is in place and being added to, to ensure that equipment is budgeted for replacement according to the life span of that equipment. All hospital bio-medical equipment is maintained by the Bio-Engineering 141

142 team. An escalation process for urgent health and safety works has been agreed by the Chief Financial Officer, Chief Medical Officer and Director Human Resources. Work on updating the helipad, loading dock and five key pedestrian crossings is progressing, with final costings being sourced. The Waitemata DHB is currently collaborating with regular meetings between Waitemata DHB, Counties Manukau Health, Northland DHB and Auckland DHB on contractor management, asbestos management, aggression risk management and other legislative compliance work. Task planning and sign off process for maintenance work, ensuring competent review and management oversight will be shared. 8.1 Support for Job Safety Analysis and safety planning is underway with training, monitoring and guidance for staff. Management of Job Safety Analysis is being provided by contracted resource prior to recruitment of permanent staff focused on health and safety and work management. What is outstanding? Maintenance work review and sign off: The Waitemata DHB needs to resource reactive maintenance triage and works planning and a fixed term resource has been engaged while a permanent resource is in recruitment. Trades staff have completed training in risk identification prior to undertaking maintenance works. An interim fast track process to approve maintenance triggered for health and safety reasons is in place but this needs to systematise. The BEIMS system is due for update in July The security alert systems for community workers working group have completed their Request for Proposal and a pilot has been completed. An pilot evaluation paper is due to ELT in September. Consequences There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. 11. Training What the Act says A PCBU must provide any information, training, instruction and supervision necessary to protect all persons from risks to health and safety arising from work carried out by the Waitemata DHB. How do we comply? A compulsory online Health and Safety Orientation is provided to staff precommencement. Health and Safety representatives are provided with two days of training (Four half day modules) by the Occupational Health and Safety Service covering an introduction to health and safety management, hazard and 142

143 emergency management, accidents and occupational rehabilitation, safe working procedure, health and wellbeing and the new legislation. All staff are required to complete the mandatory annual health and safety update online. Training is provided on departmental specific instances such as moving and handling in patient areas, crisis intervention in areas where aggressive clients may be experienced, calming and restraint in mental health services, laser care in theatre, handling sharps by infection prevention and control. As already noted, approved handler training is in place for hazardous substances. 8.1 Training is provided on how to access our incident management, risk register and hazard register systems. Training for notifiable events is complete. Emergency Response Training occurs regularly. Fire Response and Evacuation Training occurs for all new staff and annually online and face to face in key areas. Fire Evacuation drills occur across all Waitemata DHB areas six monthly which means each week there are activities in order to cover all areas. Warden Training occurs on all sites annually for all wardens and deputy wardens. This is for all areas so requires multiple sessions annually. Duty Nurse Manager training occurs for all new duty nurse staff three times a year. Incident Management Team training occurs quarterly. Key staff are required to attend Health CIMS2 training which is available monthly and is done as a regional programme with the other DHBs. This is open to all health settings including PHO s Accident and Medical centres and Residential Aged Care key staff. The Waitemata DHB runs particular Health CIMS4 training with a provider twice a year for key areas that have identified a need. Training in the due diligence responsibilities as Officers for the Senior Management team was completed on 7 July 2017 and for Board members on 27 September Training for risk assessment complete for Facilities and Development staff. Safety and Security An introduction course on Managing Aggressive and Potentially Aggressive Situations (MAPA) is available for staff. An advanced training course is being evaluated. New online training to manage difficult communications was launched in mid-february and is now available for all staff. The CALM communication the module teaches good communication and de-escalation skills. 143

144 An online module called Introduction to Staff Safety and Security at WDHB for all staff to complete as part of Orientation is complete and in initial trial stages. The module delivers the foundational requirements to the Staff Safety policy training in the following areas: S.T.E.P. Matrix for risk assessment Know-how to call for assistance and respond to calls for help Security alerts and incident reports Security and safety tools Additional modules for community workers include Risk management, preparedness and safety planning. 8.1 The DHB has also piloted a newly developed programme which will support staff to cope emotionally with challenging work related situations. New For August Board Governance responsibility education will be arranged for September Facilities team training program is commencing in August (See item 7). What is outstanding? Consequences Development of e-learning for hazardous substances and noxious organisms is in development. There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. 12. Audits What the Act says How do we comply? An Officer of a PCBU must verify the provision and use of resources and processes put in place by the Waitemata DHB. Since early 2015 we have completed a number of readiness audits to assess compliance with the new health and safety legislation and to assess new or different resources needed. Regular external audits of contractor sites are in place. A governance audit on the Board charter is completed biannually. An audit programme for 2016/17 has been completed with Internal audit and includes deep dive audits on essential service maintenance, investigation processes and feedback loops, contractor management, community safety, governance assurance, efficacy of works to improve our three top accident types, and environmental controls. The 2017 Safe Way of Working audit has been completed; divisional results have been validated and distributed. 144

145 A review of external third party maintenance and electrical safety contracts is underway to ensure all preventative checks comply with regulations. Due to complete in December The ACC accredited employers partnership programme audit is due in early September. The Audit assesses compliance with the Health, Safety and Wellbeing expectations outlined in the programme. For more information please click here Audits complete for 2017/18 include: 1. Health and safety governance. 2. Companion audits for the 2016/17 deep dive audits for community workers and construction/contractors. These audits are planned to look at contemporary Waitemata DHB practice against industry expectations, as well as understanding what is working well, what we still need to develop and any work we should do regionally in these areas. 3. A follow up audit on the essential services maintenance deep dive audit to check that all critical or immediate steps have reduced overall residual risk. 8.1 For 2018/19 audit topics are as follows: 1. Safety culture 2. Emergency response 3. Control measures for high accident types 4. Safety and security Update for August The organisational wide Safe Way of Working (SWoW) self-assessment audit was undertaken by all areas in June and July Validation audits are currently underway to confirm final compliance levels. What is outstanding? Consequences There are no outstanding actions. Audit findings and actions are reflected in other sections of the report. There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness. 13. Reporting What the Act says How do we comply? An Officer of a PCBU must ensure they acquire and keep up to date on health and safety matters. Monthly reports on health and safety matters are provided to the Board meeting, Audit and Finance Committee meeting and the organisational Health, Safety and Wellbeing committee. A new Board Health and Safety Reporting format has been developed and in place since November 2017 and additional information continues to be identified for inclusion, e.g. the recently added work-related injury claims 145

146 What is outstanding? Consequences cost data. The Waitemata DHB has commenced commentary on trend drivers in Board reporting to give Board members a view on what impacts our health, safety and wellbeing performance. Board reports now also comment on health and safety impacts on stakeholders including contractors, patients and visitors. A health and safety annual report is on the agenda for the first H&S Board workshop, currently being scheduled. Comprehensive health, safety and performance statistics will be attached as appendices. A divisional real time reporting scorecard will be developed alongside the new health and safety IT system. As part of the outcome of the governance audit, an annual assessment of the DHBs risk profile has been suggested. The first annual review will occur in August/September 2018 and measure status as at 30 June There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness Resources What the Act says How do we comply? An Officer of a PCBU must verify the provision and use of resources and processes put in place by the Waitemata DHB. A resource review was completed in Recommended actions were tabled to the Board in August On review of the report we have implemented the following new resource: 0.4 training FTE to an existing Health and Safety adviser role. Hazardous substances co-coordinator (1 FTE). Health monitoring nurse specialist (1FTE fixed term for two years). Health and Safety advisor (1FTE) so we can spread training across the advisory team and allow advisors to have service portfolios for in service outreach, advice, training and assistance. Health and Safety Manager has been employed by Facilities and Development (1FTE). Investigator/auditor (1FTE). An additional Duty Nurse resource has been in place for four months and extended for up to an additional 12 months to June Facilities and Development roles are either currently being approved or in progress. The list of the roles are as follows: Works Manager x1 Works Planner x1 Project Manager for Facilities and Maintenance small projects 0.8FTE x1 BEIMS Administrator Position 0.25FTE x1 146

147 Carpenters x2 Fitters x2 Plumber x1 Engineers x2 Painter x1 What is outstanding? Consequences New for August: An administration resource has been approved for six months to assist with incident follow up and to help cover two vacancies. Discussion underway to convert existing contract resource to FTE for additional Occupational Health Physician and work injury administration support and Duty Nurse role. Discussion underway on possible resourcing for recent updates to the new Health and Safety at Work (Hazardous Substances) Regulations There are fines and punishments of imprisonment for reckless conduct in respect to duty of care, and fines for failing to comply with risks that expose individuals to death or serious injury/illness

148 8.2 Legislative Compliance 2017/18 Recommendation: That the Board notes the results of the legislative compliance survey for 2017/18 Prepared by: Amanda Mark (General Counsel) Endorsed by: Robert Paine (Chief Financial Officer and Head of Corporate Services) 1. Purpose 8.2 The attached paper provides an evaluation of the key legislation Waitemata DHB must comply with and a rating of the risk of non-compliance. 2. Areas assessed as high and medium risk Areas where the risk of non-compliance has been assessed as high or medium are: Statute Building Act and Regulations Crown Entities Act 2004 Fire safety and evacuation of buildings Health and Disability Services (Safety) Act Official Information Act 1982 Health and Disability Commissioner Act and Code of Health and Disability Services Consumers Rights Privacy Act and Health Information Privacy Code Substance Addiction Care and Treatment Act Risk Medium Medium Medium Medium Medium High High High Discussion of the risks and measures in place to address compliance in these areas is set out in Table 3 of the paper. 148

149 8.2 LEGISLATIVE COMPLIANCE CHECKLIST 2017/18 As at 1 July The key legislation with which Waitemata District Health Board must comply has been identified from the following sources: Legislative risk analyses produced by Chapman Tripp and by Waitemata District Health Board s insurance brokers. Risk Management for Local Government (SNZ HB 4360:2000) published by Standards New Zealand. Guidelines for Managing Risk in the Healthcare Sector: (SAA/SNZ HB 228:2001) Health and Disability Sector Standards Hospital Audit Tool (DZ8140) published by Standards New Zealand. Medical Law in New Zealand, Skegg & Patterson (General Editors). Exposure matrix as at 1 June 2004 prepared jointly by Buddle Findlay and Aon. Updates provided by Waitemata DHB s in-house legal advisors. Consultation with legal advisors at other DHBs. The Capital Letter. New Zealand Law Society and Auckland District Law Society seminars. DHB National Lawyers Conference. 2. Senior staff of Waitemata DHB have reviewed the list of legislation and categorised the items as high, medium and low risk in terms in terms of: A. Compliance difficulty. Difficulty of complying with the legislation, whether because of the complexity of the legislation itself or the complexity of situations the legislation is intended to cover. B. Likelihood of non-compliance. The likelihood that Waitemata DHB will breach the legislation to some extent at some stage. 149

150 C. Severity of consequences. The severity of the penalties and/or the extent and volume of negative media coverage if Waitemata DHB breaches the legislation. See Table 1 for these risk ratings. 3. For each piece of legislation an Overall Risk Rating has been derived, taking into account the likelihood of non-compliance and the severity of the consequences. See Table 2. Although there is a possibility of Waitemata DHB inadvertently breaching even those Acts rated as Low risk, the main risk mitigation efforts must be concentrated on the Medium and High risk areas as breaches of these Acts could result in substantial penalties or very adverse publicity and damage to the reputation of the DHB or its staff or Board Legislation with an Overall Risk Rating of Medium or High is shown on Table 3. Appropriate senior officers of the DHB have commented on the risks to the DHB and the measures taken to reduce those risks and maintain a high level of legal compliance. 150

151 WAITEMATA DISTRICT HEALTH BOARD TABLE 1 LEGISLATIVE COMPLIANCE RISK RATING SECTION TO BE UPDATED IN CONSULTATION WITH RELEVANT SENIOR STAFF Act / Regulation Category 1 A Compliance Difficulty B Likelihood of noncompliance C Severity of consequence of noncompliance D Overall risk rating Accident Compensation Act 2001 Births, Deaths, Marriages and Relationships Registration Act 1995 Building Act 2004 S Low Low Low Low P Medium Low Low Low E High Medium Medium Medium Associated Building Regulations Burial and Cremation Act 1964 P Low Low Low Low Cancer Registry Act 1993 P Low Low Low Low Care of Children Act 2004 P Medium Low Low Low Children, Young Persons, and Their Families Act 1989 Civil Defence Emergency Management Act 2002 P Medium Low Medium Low E Medium Low Low Low Commerce Act 1986 A Low Low Medium Low Consumer Guarantees Act P Medium Low Low Low 1993 Contraception Sterilisation P Low Low Low Low and Abortion Act 1977 Copyright Act 1994 A Low Medium Low Low Coroners Act 2006 P Low Low Low Low 151

152 Act / Regulation Category 1 A Compliance Difficulty B Likelihood of noncompliance C Severity of consequence of noncompliance D Overall risk rating 2 Crimes Act 1961 P,S Low Low Low Low Criminal Investigations (Bodily Samples) Act 1998 Criminal Records (Clean Slate) Act 2004 P Low Low Low Low S Low Low Low Low 8.2 Crown Entities Act 2004 A Medium Medium Low Medium Dangerous Goods Regulations Disabled Persons Community Welfare Act 1975 E Low Low Low Low P Medium Low Low Low Electricity Act 1992 E Low Low Low Low Employment Relations Act 2000 S Medium Low Medium Low Fair Trading Act 1986 A Low Low Medium Low Financial Reporting Act 1993 A Low Low Low Low Fire Safety and Evacuation of Buildings Regulations 2006 and Fire Service Act 1975 E High Medium Medium Medium Food Act 1981 P,S,E Low Low Low Low Food Hygiene Regulations 1974 Food (Safety) Regulations 2002 P,S Low Low Low Low P,S Low Low Low Low Gas Act 1992 E Low Low Low Low Goods and Services Tax Act A Low Low Low Low 152

153 Act / Regulation Category 1 A Compliance Difficulty B Likelihood of noncompliance C Severity of consequence of noncompliance D Overall risk rating Harmful Digital Communications Act 2015 Hazardous Substances and New Organisms Act 1996 Health Act 1956 and Regulations Health (Infectious and Notifiable Diseases Regulations 1966) Health (Needles and Syringes) Regulations 1998 Health (Retention of Health Information) Regulations 1996 Health and Disability Commissioner Act 1994 and Code of Consumers Rights 1994 Health and Disability Services (Safety) Act 2001 Health and Safety at Work Act 2015 and associated regulations Health and Safety at Work (Asbestos) Regulations 2016 Health Practitioners Competence Assurance Act S,P,A Medium Low Medium Low P,S,E Low Low Low Low P Medium Medium Low Low P, S, A Low Low Low Low P, A, E Low Low Low Low P Low Low Low Low P High High Medium High P High Low Medium Medium S,E Medium Medium Medium Medium E, P, S Low Low Medium Low S, A Medium Low Medium Low

154 Act / Regulation Category 1 A Compliance Difficulty B Likelihood of noncompliance C Severity of consequence of noncompliance D Overall risk rating 2 Holidays Act 2003 S, A High Medium Low Low Human Rights Act 1993 S,P Low Low Low Low Human Tissue Act 2008 P Low Low Low Low 8.2 Income Tax Act 2007 A Medium Low Low Low Injury Prevention, Rehabilitation and Compensation Act 2001 Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003 S,P Medium Medium Medium Medium P Low Low Low Low Kiwisaver Act 2006 S Medium Medium Low Low Maternal Mortality Research Act 1968 P Low Low Low Low Land Transport Act 1998 S Low Low Low Low Medicines Act 1981 and Medicines Regulations 1984 Mental Health (Compulsory Assessment and Treatment) Act 1992 Misuse of Drugs Act 1975 and Misuse of Drugs Regulations 1977 P,A Medium Low Medium Low P Medium Medium Low Low P Low Low Low Low NZ Bill of Rights Act 1990 P,S Medium Low Low Low NZ Public Health and Disability Act 2000 A,P Low Low Low Low Obstetric Regulations 1986 P Medium Medium Low Low 154

155 Act / Regulation Category 1 A Compliance Difficulty B Likelihood of noncompliance C Severity of consequence of noncompliance D Overall risk rating 2 Official information Act 1982 A High Medium Medium Medium Parental Leave and Employment Protection Act 1987 Protected Disclosures Act 2000 Privacy Act 1993 and Health Information Privacy Code 1994 Protection of Personal Property Rights Act 1988 S Low Low Low Low S,A Low Low Medium Low P,A High Medium Medium High P,A High Medium Low Low 8.2 Public Finance Act 1989 A Low Low Low Low Public Records Act 2005 A High High Low Low Public Works Act 1981 A Medium Medium Low Low Substance Addiction Compulsory Assessment and Treatment Act 2017 Resource Management Act 1991 Substance Addiction Compulsory Assessment and Treatment Act 2017 S,P High High Medium High A,E Medium Low Medium Low P,A Medium Medium Medium Medium Secret Commissions Act 1910 S Low Low Low Low Social Security Act 1964 P Medium Low Low Low Social Security (Long-term Residential Care) Amendment Act 2004 P Medium Low Low Low 155

156 Act / Regulation Category 1 A Compliance Difficulty B Likelihood of noncompliance C Severity of consequence of noncompliance D Overall risk rating 2 Smoke Free Environments Act 1990 P,S Medium Low Low Low Tax Administration Act 1994 A Low Low Low Low 8.2 Treaty of Waitangi Act 1975 P,S Medium Low Low Low Tuberculosis Act 1948 P Low Low Low Low Volunteers Employment Protection Act 1973 S Low Low Low Low Wages Protection Act 1983 S Low Low Low Low In Table 1 above: 1 Category: Refers to the aspect of Waitemata Health s activities most likely to be affected by the legislation: S = Staff related P = Patient related E = Environmental A = Administrative 2 Overall risk rating (Column D): An indication of the priority to be accorded when establishing systems to improve compliance. Based on columns B and C. See Table 2 below. From Table 1, Column B (Likelihood) and Column C (Severity of consequence) are combined to give an Overall risk rating as shown below. This is shown in Column D of Table

157 TABLE 2: OVERALL RISK RATING Severity of Consequence of non-compliance Low Medium High Likelihood of noncompliance High Medium High High 8.2 Medium Low Medium High Low Low Low Medium 157

158 TABLE 3 LEGISLATION WITH MEDIUM OR HIGH OVERALL RISK RATING: MEASURES TO IMPROVE COMPLIANCE THIS SECTION UPDATED IN CONSULTATION WITH RELEVANT SENIOR STAFF Act / Regulation Overall risk rating Building Act 1991 Building Regulations 1992 Medium Exposure: Waitemata DHB operates large buildings with reasonably complex services (lifts, air conditioning, medical gases etc). All construction and completed buildings must meet requirements of the Act and associated regulations. 8.2 Compliance measures: 1. Professional engineers are employed to design and monitor/approve construction activities. Producer statement sign offs and consultant and council inspections confirm construction compliance. 2. Compliance of operational facilities is externally audited by OPUS to gain annual building warrants of fitness. 3. Compliance certificates for new construction are obtained from the Auckland Council. Crown Entities Act 2004 Medium Exposure: Waitemata DHB was unable to meet the requirement to prepare and publish a statement of performance expectations for the 2018/19 financial year before the financial year began on 1 July 2018 because of delays in receiving the Ministry of Health s comments on the draft statement of performance expectations. Fire Safety and Evacuation of Buildings Regulations 1992 and Fire Service Act 1975 Medium Exposure: Waitemata DHB must ensure buildings meet BWOF requirements. All completed buildings must meet requirements of the Act and associated regulations. This includes obtaining Fire Service approval of fire evacuation schemes and demonstrating evacuation practices. Compliance measures: 1. Professional engineers are employed to design and monitor/approve construction activities. Producer statement sign offs and consultant and council inspections confirm construction compliance. 2. Compliance of operational facilities is externally audited by independent quality persons and audited by OPUS to gain annual building warrants of fitness. 3. Compliance certificates for new construction are obtained from the Auckland Council. Status of Fire Evacuation Schemes as at 1 July 2018: 158

159 Act / Regulation Overall risk rating Harmful Digital Communications Act 2015 Low North Shore Hospital: Scheme approved. Elective Surgical Centre: Scheme approved. Waitakere Hospital: Scheme approved. Mason Clinic: Scheme approved. Wilson Home: Scheme approved. Leased building. Pitman House: Scheme approved. Leased building. Exposure: Safe harbour provisions require us to remove any offensive content posted on Waitemata DHB social media sites within 24 hours of complaint. 8.2 Compliance measures: Communications monitor DHB social media sites constantly. Comment: Monitoring requires vigilance on the part of the on-call Communications person, particularly during holiday periods. Health and Disability Commissioner Act 1994 and Code of Consumers Rights 1994 High Exposure: Waitemata DHB must provide services in compliance with the Code of Rights issued by the Health and Disability Commissioner. Waitemata DHB has been found in breach on a number of occasions since the introduction of the Code of Rights, usually of a patient s right to receive services of an appropriate standard. Such findings damage Waitemata DHB s reputation and could strengthen the position of patients considering litigation. Compliance measures: Systematic investigation and management of significant adverse events in accordance with Waitemata DHB s Adverse Event Management policy. Clinical Governance Committee. Clinical Directors Forum. Risk management system and processes now well established. Incident reporting and investigation processes. Health and Disability Services (Safety) Act 2001 Medium Exposure: The Act provides for the appointment of independent external auditors to audit health and disability service providers against the NZ Health and Disability Sector Standards. The Standards are comprehensive and demanding. Currently Waitemata has certification for three years end date 31 March

160 Act / Regulation Overall risk rating Compliance measures: Risk management system and processes now well established. Clinical Governance Committee. Compliance and Risk Committee. Quality Executive Committee. Incident reporting and investigation processes. Quality and Risk team focus on external audits. Six monthly internal Care Standards Audits. 8.2 Health and Safety at Work Act 2016 Medium Health and Safety at Work Act 2015 introduced many additional expectations in relation to health and safety and increased liability for Board and management for breaches. Regulation changes continue to be released, alongside codes of practise and best practise guidance from WorkSafe that, while not legislative in nature, impose direct and indirect duties and expectations. Previous expectations focused on physical risks and hazards which now extends to psychosocial risks and hazards including behaviours and culture. Across New Zealand the level, nature and penalties from investigations and prosecutions has increased. Current DHB IT systems provide for manual update, intervention or reporting processes. Resourcing for health and safety is spread across specialist health and safety staff, management and workers at the DHB meaning some high risk processes and issues have centralised oversight and some are devolved. With respect to facilities, Waitemata DHB must ensure a safe environment for all staff, patients and visitors. With a large staff and facilities open to the public, the potential for Waitemata DHB to be found in breach is ever-present. Compliance measures: Risk assessment and hazard management system in place. A new health and safety IT system RFP is underway. Annual self-audit and environmental checklists in place. Regular internal deep dive audits. Robust reporting to the Board and sub committees. Incident review and investigation processes in place. A healthy workplaces strategy is in place. Safe rostering reviews are underway for multiple 160

161 Act / Regulation Overall risk rating services and professions. Employee assistance support is in place. Values, standards and behaviours are in place with values based campaigns rolled out across the DHB and new material due to be released for bullying and harassment complaints. Significant work done in relation to Hazardous Substances in compliance with regulations. A Facilities specific Health and Safety Management System (FD-HSMS) has been implemented to provide clear expectations for management of health and safety during the delivery of facilities maintenance and facilities development processes. The FD-HSMS includes requirements for leadership, planning and review, assessment and management, training and supervision, recording and investigation, worker participation, contractor management, Inspections and audits. Reporting of health and safety performance against KPI s and incidents and near missies forms part of required reporting and visibility to the Board. 8.2 Official Information Act 1982 Medium Exposure: DHB receives a significant number of requests for official information and responses require significant effort. Ombudsman more active in OIA area in last year and number of complaints to Ombudsman has increased. Compliance measures: Official Information Act policy in place and recently updated. Oversight of responses by Communications and Legal. All responses signed off by General Manager or Director of relevant area and reviewed by Chief Executive Officer. Attendance at training opportunities by key staff as these are offered by Ombudsman s Office. 161

162 Act / Regulation Privacy Act 1993 and Health Information Privacy Code Overall risk rating High Exposure: DHB holds significant quantities of highly sensitive health and personal information about patients and staff and an increasing volume of information is held in computer systems. Measures to ensure compliance include: Elearning module on privacy. On request privacy workshops tailored to needs of requesting services. Privacy and Security Governance Group to oversee privacy issues. Annual completion of Privacy Maturity Assessment ensures steady progress towards implementing a mature privacy culture. Joined up risk identification and management with healthalliance. Risk management and incident reporting and investigation processes. 8.2 Substance Addiction Compulsory Assessment and Treatment Act 2017 Health and Safety in Employment Act 1992 and Health and Safety in Employment Regulations 1995 Medium Medium Exposure: DHB is not resourced to provide response to new Act; SACAT clients impact on Medical Detox Service s capacity to provide service; Staff need training for new Act and demand for response has been double what was modelled prior to implementation. Area Director of SACAT (MOH appointed) role has been added to another role with difficulty in getting coverage across the Northern Region. Waitemata DHB is providing local funds to provide extra resourcing. Exposure: Waitemata DHB must ensure a safe environment for all staff, patients and visitors. Breaches of the Act can lead to adverse publicity and significant financial penalties. With a large staff and facilities open to the public, the potential for Waitemata DHB to be found in breach is everpresent. Compliance measures: Hazard identification and management: Ongoing audits in each Responsibility Centre are reported six-monthly to Occupational Health which checks compliance and notifies General Managers of the compliance status of their services. Accident management: Primary responsibility for investigating accidents and initiating preventive action rests with RC managers assisted by their service s 162

163 Act / Regulation Overall risk rating Quality Manager. Copies of accident forms go to Occ Health which provides an advisory service and audits to ensure that an acceptable standard of investigation and hazard management has occurred. Serious harm incident management: Reported to Occupational Safety and Health which conducts its own ad hoc reviews of policies and procedures. Occupational health services: Diagnosis and treatment of work-related disorders is available from Waitemata DHB s Occupational Health Service. There is potential for an increase in claims related to staff stress. Systematic management of significant events in accordance with Waitemata DHB s Significant Event Management policy. 8.2 Accident Compensation Act 2001 Privacy Act 1993 and Health Information Privacy Code 1994 Medium Medium Exposure: 1. ACC s Medical Misadventure Unit decides whether medical misadventures are mishaps or errors. Acceptance of a claim by ACC usually reduces Waitemata DHB s exposure to litigation except for nervous shock claims. Such claims are uncommon but potentially expensive. 2. If Waitemata DHB s internal health and safety processes are inadequate, ACC may downgrade Waitemata DHB s rating resulting in higher ACC levy. Compliance measures: Exposure 1 is being countered by an extensive programme to improve the quality and safety of Waitemata DHB s clinical services and meet Health & Disability Sector Standards. Exposure 2 is countered by the work of Waitemata DHB s Occupational Health unit to ensure that the organisation maintains its high rating from the audits performed for ACC under the ACC Partnership Programme. Exposure: Breaches of the Health Information Privacy Code damage Waitemata DHB s reputation and may lead to proceedings brought by the Privacy Commissioner or by individuals. In addition, proposed amendments to the Privacy Act will provide for mandatory disclosure of serious breaches. Compliance measures: An online elearning training module must be completed by all staff as part as mandatory training. 163

164 Act / Regulation Overall risk rating The module is updated annually. One-off training sessions are conducted by Waitemata DHB s in-house legal team on request. Advice on specific issues is available from the inhouse legal team. All new staff are required to sign a written statement acknowledging their obligations under the Act and the Code. Annual Privacy Week focus on privacy. Phishing Campaign and phishing button in Outlook to make it easy for staff to reporting suspected phishing. Privacy and Security Governance Group oversees privacy and data security. Privacy Impact Assessments are required for all new IT systems and changes in processes to ensure legislative requirements are met. Annual Privacy Maturity Assessment ensures continued progress towards a mature privacy culture. Full suite of health information-privacy policies. Regular auditing of staff accesses to clinical information systems. 8.2 Comment: Privacy issues are complex. Staff are likely to make errors from time to time and a small number of staff may inappropriately access clinical records and Waitemata DHB may be found to be in breach of the Act or Code. 164

165 8.4 CARE Project Progress Report Recommendations: That the information on progress made in the Co-ordinated care, Assessment, Rehabilitation, Education (CARE) Project be received and that that it be noted that a final evaluation report will be received at the December 2018 meeting. Prepared by: Tim Wood (Deputy Director Funding/Funding and Development Manager, Primary Care), Dr Diana North (Clinical Leader, CARE Project), Dr John Scott (Head of Specialty Medicine and Health of Older People), Dr Tom Robinson (Public Health Physician), Dr Michal Boyd (Associate Professor and Nurse Practitioner, School of Nursing), Vicki Scott (Senior Programme Manager, Primary Care), Jean McQueen (Nurse Director, Primary Care), and Martin Dawe (Project Manager, CARE Project) Endorsed by: Dr Debbie Holdsworth (Director Funding) Reviewed by: Executive Leadership Team Glossary CARE Co-ordinated care, Assessment, Rehabilitation, Education Project (until 30 June 2018) EPOA Enduring Power of Attorney GNS Gerontology Nurse Specialist GP General Practitioner KARE Co-ordinated care, Assessment, Rehabilitation, Education Project (from 1 July 2018) NASC Needs Assessment and Service Coordination PMS Practice Management System 1. Executive Summary The purpose of the Co-ordinated care, Assessment, Rehabilitation, Education Project (CARE) is to implement and evaluate a comprehensive package of primary care-based interventions to help keep older adults healthier so they can stay at home longer (i.e. delay placement in Aged Residential Care) and be less likely to need unplanned hospital visits. The evaluation includes qualitative and quantitative outcome measures. The CARE Project proposal was approved by the Waitemata DHB in November Implementation commenced in five general practices in October 2015, and in a further four in October The project is currently nearing the end of the pilot phase, which runs until 31 August In April 2016 the Board approved a 10-year commitment to continue to work with the General Practices involved in the CARE Project to improve the health of older adults through primary care initiatives. The CARE Project is a complex primary care intervention that implements a new model of care for identified high risk older people enrolled in the General Practices involved in the pilot project. The project is showing promising initial results. The CARE Project Progress Evaluation report, as attached, provides a summary of the progress to date pending a full outcome evaluation that will be presented to the Board in December In summary the attached report describes: What has been delivered to date A summary of the cohort A summary of an external evaluation Some initial outcome data Areas for improvement and next steps pending the full outcome evaluation. 165

166 Overall, there are strong initial indicators that the CARE Project is succeeding in delivering an innovative model of care, enhancing the care and outcomes of older people living in their homes. It has demonstrated a high level of general practice team acceptability, high patient, including Māori patient and whānau, acceptability and is achieving positive outcomes for participants. Further evaluation of outcomes is scheduled to be completed by December 2018; this will report on any quantifiable impact on hospitalisations, Aged Residential Care placements, and overall cost benefit across primary and secondary care. The CARE Project has provided significant learning relevant for the planning, engagement and implementation of any project working with General Practice. These learnings will be able to be applied to future primary care based programmes targeting older people or other populations, such as people with long term conditions. 8.3 From 1 July 2018 the project was renamed KARE, although it is referred to as the CARE Project throughout this report, as the report refers to the pilot phase and this is the term that has been used in previous papers to the Board. The name change was instigated by the General Practices as a means to avoid confusion with other care initiatives. 2. Strategic Alignment The CARE Project aims to improve the health of people aged 75 and over, and Māori and Pacific people aged 65 and over, who are at high risk of unplanned hospitalisation or other adverse outcomes, by providing a whole-system approach, integrating primary care and hospital services. Strategic alignment is summarised below. Community, whanau and patient centred model of care Emphasis and investment on both treatment and keeping people healthy Service integration and/or consolidation Intelligence and insight Evidence informed decision making and practice Outward focus and flexible, service orientation Operational and financial sustainability Piloting of a primary care based model of care that is patient centred and aims to improve quality of life and maintain independence of older adults in the community. The model of care aims to ensure timely access to appropriate treatment and promotes self-management. Improved referrals and communication between primary care and secondary care. Innovative model of care with a comprehensive qualitative and quantitative evaluation that both measures the impact of change and provides learnings for the planning, engagement and implementation of any project working with General Practices and their patients, including Māori patients and whānau. Model of care based on best practice, patient and stakeholder input, and extensive literature review, applied to the Waitemata context. Model of care aims to be applicable to all General Practices across the District. Model of care aims to deliver an overall cost benefit and be sustainable for General Practices. 166

167 3. Introduction/Background In October 2015, Waitemata DHB commenced implementation of a pilot programme aimed at coordinating and enhancing the care of older people living in their homes. The goals of the programme are to reduce hospital admissions, delay or prevent entry to residential aged care, and where possible to improve health and independence. This pilot is due to be completed by the end of 2018 and is on track. The project has been primarily funded by the DHB, and in October 2016 the DHB made a 10-year funding commitment to further develop an effective model of care with General Practices involved in the pilot. Barfoot and Thompson has also contributed to the costs of employing a Gerontology Nurse Specialist (GNS) as part of the CARE Project up to June The CARE Project aims to improve the health of people aged 75 and over and Māori and Pacific people aged 65 and over by providing a whole-system approach integrating primary care and hospital services. In summary, General Practices carry out a comprehensive assessment of patients needs and compile a care plan with each patient. This may include the coordination of services and referrals in a more proactive manner than standard primary care, with the promotion of self-management strategies. Another key feature is supporting and upskilling practice nurses and general practitioners (GPs) in the care of older patients at risk of hospitalisation. The GNS plays a key role providing specialist knowledge, particularly in the continued development of the model of care, nursing workforce development, and fostering primary and secondary care integration. 4. Progress/Achievements/Activity The complexity of the programme together with challenges faced by the project have meant that the time frame and milestones have had to be adjusted on several occasions. The project has been adapted in an iterative, responsive, and pragmatic manner, based on quality improvement principles and working with the primary care sector, while retaining core features to enable a robust evaluation. Phased intervention The project was broadly implemented in two phases, with five General Practices commencing in October 2015 and a further four practices starting in October One General Practice has withdrawn from the project as at 30 June Agreements with the remaining eight participating General Practices are in place from 1 July 2018 to September Following the Board s 10-year commitment, this approval is the first step to providing a level of funding to maintain staffing levels, especially any extra nursing staff that have been committed to the project by practices. Information system issues and risk stratification Implementation and evaluation of a new intervention is dependent on information system support, but given the complex and innovative nature of the project no pre-existing information system was available off the shelf, and development of a new system was outside the scope of the project. The project was initially delayed while exploring various options and eventually a compromise was settled upon, which has involved using a range of systems. This compromise has enabled the project to proceed, but issues in this area remain the single biggest concern from practices. Practices will require a more integrated information system to 167

168 enable their continued involvement in the project, and to provide for sustainable monitoring and evaluation. Inadequacies with the information system solution was a key reason one practice has now withdrawn from the CARE Project. Risk stratification: At the start of the project each General Practice was provided with a full list of patients that could potentially be enrolled into the project together with risk stratification information to assist practices in selecting the specific cohort of patients they would enrol in the project. The experience was that risk stratification of patients within the CARE Project was fraught, the relevance of patient lists with risk scores was complex for practices to understand and use, and this aspect will require rethinking for the future continuation or expansion of the project. Patient cohort In total, 1,186 people aged 75 years and over (Māori/Pacific aged 65 years and over) living in the Waitemata area agreed to participate and have a recorded comprehensive assessment completed by 31 August This was 95% of the originally planned target of 1,250. While the full target was not quite met in the planned timeframe, General Practices have continued to enrol patients and the full target of 1,250 has since been met. 8.3 Those patients enrolled after 31 August 2017 cannot be included in the final evaluation as these patients will not have received a full 12 months of intervention by the time the outcome data will be required. However, 1,186 patients are anticipated to be sufficient to provide a robust overall outcome evaluation. The mean age of participants was 82 years at the baseline assessment, which is consistent with the intent to enrol frail patients. Patients in the CARE cohort will on average become frailer over the course of their involvement. Overall, 72% of patients are of European/NZ ethnicity, followed by 21% Other European. There are 45 Māori in the cohort which represents around 4% and is higher than the target expected (3%) based on the demographics of the practices. Supported implementation Implementation has been supported by having a clear and resourced project structure. The model of care has been developed to be pragmatic and responsive to the implementation within each General Practice whilst ensuring data collection and monitoring were carried out. The CARE Project has also successfully delivered a range of workforce development initiatives to support implementation in primary care. External evaluation An external evaluation consisting of semi-structured interviews from patients, families/whānau, Māori patients and whānau, staff across all CARE Project General Practices, and members of the CARE Project team and leaders shows there is strong support for the CARE Project from participating General Practices and patients involved, including Māori patients and whānau. General Practice stakeholders noted that the project had enabled them to: Detect urgent but previously hidden patient needs and respond to them Get an in-depth picture of the health status of participants and plan accordingly Teach participants about their condition and care so the patient could be prepared and equipped to manage changes in their clinical status Provide care in a more holistic way for example by increasing awareness of home issues which directly impact the health of the patient 168

169 Provide social connection, especially for those socially isolated and/or cognitively impaired Be a potential place of connection with extended family/whānau or care-givers of patients and involve them in on-going care and management of the patient See who needs help earlier and take preventative action. The external evaluation noted that CARE patients were almost always positive about the intervention, and that they understood that the CARE Project was about helping them to continue to live in the community. They also reported feeling they had increased understanding of their condition and its management and felt better equipped to manage as well as recognise and respond to changes in health status. Further, patients greatly appreciated being able to ring their GP clinic, getting advice and being known by someone there. 8.3 Findings of the Māori evaluation The external Māori evaluation showed mixed results, but an overall acceptability for the project and approach from a Māori perspective. Most participants could recall the aims of the programme but could not recall being given specific written information nor did they have a clear understanding about the CARE Project s selection criteria or processes. A strength of the project for Māori was the longer length of appointment times and the high level of whanaungatanga (relationships and connections) that resulted between nurses, GPs and kaumātua. This led to a greater sense of care partnership between the health provider and the older person. The extra time provided a greater opportunity for health providers to ask questions and to really listen to the older person. Whānau also felt included in the process. Greater understanding of the elder person s health needs and circumstances resulted. Participants felt heard and were more confident to take responsibility for their own health. Timely, appropriate referrals resulted from longer assessments. However, participants were generally unaware that a care plan was formulated nor did they discuss or view an actual care plan with their health provider. Preliminary health outcomes Initial outcome results of the CARE Project using the Partners In Health 1 scale (a 12 item tool to assess self-management ability, knowledge, and behaviour in people with chronic diseases) and CARE Project Assessment data have been outlined ahead of a full outcome evaluation of the pilot to be completed by December CARE pre/post data from the Partners In Health scale indicates statistically significant improvements in the patients knowledge of their conditions and treatments, ability to cope, management of symptoms and adherence to treatment. Initial results for the pre/post data of the available 618 CARE Project participants (note: the full cohort will be included in the final report as it is not available currently) showed positive impacts, including: A trend to fewer falls Substantially fewer participants reporting concerning pain A highly significant decrease in reported anxiety Significantly decreased rates of depression Significantly fewer participants reported having questions or concerns about medications, and more reported using medication blister packs to help manage their medications 1 Battersby M, Alex A, Reece M, Markwick M, Collins J. (2003) The Partners in Health scale: The development and psychometric properties of a generic assessment scale for chronic condition self-management. Australian Journal of Primary Health 9,

170 Significant increase in CARE participants designating an Enduring Power of Attorney (EPOA) for health and welfare Significant increase in the General Practice obtaining a record of the EPOA. Next steps and key areas for short to medium term improvement Based on work to date, the following key changes are in process: More flexible patient enrolment (and disenrollment) based on frailty and need, which will be built into an updated PMS tool. Revised eligibility/selection criteria will be further investigated and a full proposal will be developed for practice and DHB agreement. More efficient and integrated Assessment/Care Planning is expected later in the year as part of a more fit for purpose PMS tool. Ongoing practice support and workforce development has been factored into new contracts. Further workforce development will involve: (i) preparation of a structured nursing workforce development framework. (ii) development of specific GP training, and these will be presented as a proposal within the final evaluation. GNS role review and integration with practice workflow has been planned and is currently being implemented including utilisation of the specialist advice function within ereferrals and monthly patient review sessions with each practice. Primary and secondary care interface work is ongoing and specific recommendations will be included in the final evaluation report. Funding model and business model options will be developed for General Practice consultation and any new model will be negotiated and recommendations included in the final evaluation report Conclusion The CARE Project is a complex primary care intervention that involves a model of care facilitated by the nine General Practices involved in the pilot project. The attached report provides a summary of the CARE Project pilot implementation to date ahead of a final outcome evaluation report in December Overall, there are strong initial indicators that the CARE Project has delivered an innovative model of care that enhances the care of older people living in their homes. The project has a high level of general practice team acceptability, and high patient, including Māori patient and whānau acceptability, and is achieving positive outcomes for participants. Further evaluation of these outcomes scheduled to be completed by December 2018 will determine the level of success, especially any quantifiable impact on hospitalisations, Aged Residential Care placements, and overall cost benefit across primary and secondary care. The CARE Project has provided significant learning relevant for the planning, engagement and implementation of any project working with General Practice. These learnings will be able to be applied to future primary care based programmes targeting older people or other populations, such as people with long term conditions. 170

171 CARE Project Progress Evaluation Report 8.3 August 2018 FINAL DRAFT Prepared by: CARE Project Team 171

172 CARE Project Progress Evaluation Report August 2018 Contents Acknowledgements:... 4 Glossary Executive Summary What has been delivered to date Patient cohort External evaluation Preliminary health outcomes Areas for improvement and next steps Conclusion Introduction Background CARE Project goal and aims Evaluation approach Report structure CARE Project delivery Overview of progress and milestones Overview of the pilot Care plan analysis Summary of workforce development provided Iterative changes Cohort summary Feasibility and acceptability of the CARE project Qualitative evaluation method summary Overall qualitative evaluation summary Overview of patient experience Provider Experience of CARE Project: suggestions for further implementation Summary of the Māori experience of CARE Preliminary health outcomes Partners in Health self-management assessment tool pre/post results Assessment pre/post data Discussion and conclusions

173 CARE Project Progress Evaluation Report August 2018 List of figures and charts Figure 1: Summary of items addressed on a random sample of care plans Figure 2: Gender distribution of participants with a baseline and follow-up assessment after one year Figure 3: Participant perception of health at baseline and follow-up assessment after one year Figure 4: Reported pain at baseline and follow-up assessment after one year Figure 5: Severity of reported pain at baseline and follow-up assessment after one year List of tables Table 1: Overview of evaluation objectives and data used for this Progress Evaluation Report Table 2: Summary of CARE assessment and care planning by Phase One and Two practices as of 31 August Table 3: Patient gender for enrolled patients by practices commencing 1 October 2015 through to 31 August 2017 (n=1,186) Table 4: Patient ethnicity by practices commencing 1 October 2015 through to 31 August 2017 (n=1,186) Table 5: Summary of patient drop-outs and reason for leaving CARE Project as at 31 August Table 6: Partners In Health results Table 7: Partners In Health sub-scale domain results Table 8: Activities of daily living comparison Table 9: Medication management at baseline and one year post CARE intervention Table 10: Reported driving experience at baseline and one year post CARE intervention Table 11: Social Isolation and abuse at baseline and one year post CARE intervention Table 12: Mood and Sleep at baseline and one year post CARE intervention Table 13: Gastrointestinal and urinary issues at baseline and one year post CARE intervention Table 14: Bowel incontinence at baseline and one year post CARE intervention Table 15: Use of incontinence products at baseline and one year post CARE intervention Table 16: Weight and appetite changes at baseline and one year post CARE intervention Table 17: Comparison of falls and the use of mobility aids at baseline and one year post CARE intervention Table 18: Comparison of gait speed at baseline and one year post CARE intervention Table 19: Designation of Enduring Power of Attorney at baseline and one year post CARE intervention Table 20: Current areas being explored to enhance KARE

174 CARE Project Progress Evaluation Report August 2018 Acknowledgements: We would like to thank all the older adults/patients who have participated in this study. We would also like to thank the participating general practices who have worked hard to implement the CARE Project and have generously shared their experiences and learning and continue to enhance the project and care of older adults. The project is a partnership between these general practices, Comprehensive Care (previously Waitemata PHO), ProCare, and Waitemata DHB. The CARE Project Steering Group has provided overall guidance during the set-up and implementation. Many stakeholders generously provided input to the project development and during the implementation. In particular, Age Concern and Health Links North enabled focus groups with older people that were invaluable to the project design. 8.3 Health Alliance and Whānau Tahi are acknowledged for providing data captured in the comprehensive assessment and Partners in Health survey. Delwyn Armstrong, Waitemata DHB, John Streeter, ProCare, and Aimee Legge, Waitemata PHO are acknowledged for assisting in the compilation of risk scores and patient lists for the project. This report has been a collective effort across the project team and the primary authors have been: Dr Michal Boyd, Waitemata DHB/The University of Auckland Martin Dawe, project manager/contractor on behalf of Waitemata DHB. Dr Diana North, clinical lead/contractor on behalf of Waitemata DHB Dr Tom Robinson, Waitemata DHB. Research assistants involved in compiling and analysing the data have been: Selina Halewood Rosemary Frey Deborah Raphael. Other project team members that have contributed are: Dr John Scott Vicki Scott Jean McQueen Sally Gregory-Hunt Susan Williamson (Practice Nurse, contracted to the project team) Anne James Joy Owen Jennifer Rowlands. Barfoot & Thompson has contributed to the costs of employing a Gerontology Nurse Specialist (GNS) as part of the CARE Project up to June Finally, we would like to thank and acknowledge the Waitemata DHB for funding this project and research. 174

175 CARE Project Progress Evaluation Report August 2018 Glossary ADHB Auckland District Health Board ARC Aged Residential Care CARE Co-ordinated care, Assessment, Rehabilitation, Education Project (until 30 June 2018) Care Plus A primary health care funding initiative to support people with high health needs due to chronic conditions, acute medical or mental health needs, or terminal illness. DHB District Health Board GNS Gerontology Nurse Specialist GP General Practitioner GPT general practice team (includes GPs, PNs, Practice Manager, Receptionist, Health Care Assistants, etc) KARE Co-ordinated care, Assessment, Rehabilitation, Education Project (from 1 July 2018) NASC Needs Assessment and Service Coordination PHO Primary Health Organisation PMS - Practice Management System PN Practice Nurse WDHB Waitemata District Health Board

176 CARE Project Progress Evaluation Report August Executive Summary The purpose of the CARE Project is to implement and evaluate a comprehensive package of primary care-based interventions to help keep older adults healthier so they can stay at home longer (i.e. delay placement in Aged Residential Care) and be less likely to need unplanned hospital visits. The evaluation includes qualitative and quantitative outcome measures. The Co-ordinated care, Assessment, Rehabilitation, Education (CARE) Project proposal was approved by the Waitemata District Health Board in November Implementation commenced in five general practices in October 2015, and in a further four general practices in October The project is currently nearing the end of the pilot phase, which runs until 31 August In April 2016 the Board approved a 10-year commitment to continue to work with the General Practices involved in the CARE Project to improve the health of older adults through primary care initiatives. 8.3 The CARE Project is a complex primary care intervention that implements a new model of care for identified high risk older people enrolled in the General Practices involved in the pilot project. The project is showing promising initial results. The CARE Project Progress Evaluation report, as attached, provides a summary of the progress to date pending a full outcome evaluation that will be presented to the Board in December In summary the attached report describes: What has been delivered to date A summary of the cohort A summary of an external evaluation Preliminary health outcomes Areas for improvement and next steps pending the full outcome evaluation. Overall, there are strong initial indicators that the CARE Project is succeeding in delivering an innovative model of care that enhances the care and outcomes of older people living in their homes. It has demonstrated a high level of general practice team acceptability, high patient, including Māori patient and whānau, acceptability, and is achieving positive outcomes for participants. Further evaluation of outcomes is scheduled to be completed by December 2018 that will report on any quantifiable impact on hospitalisations, Aged Residential Care placements, and overall cost benefit across primary and secondary care. The CARE Project has provided significant learning relevant for the planning, engagement and implementation of any project working with General Practice. These learnings will be able to be applied to future primary care based programmes targeting older people or other populations, such as people with long term conditions. From 1 July 2018 the project was renamed KARE, although it is referred to as the CARE Project throughout this report as the report refers to the pilot phase and this is the term that has been used in previous papers to the Board. The name change was instigated by the General Practices as a means to avoid confusion with other care initiatives. 176

177 CARE Project Progress Evaluation Report August What has been delivered to date The project has been primarily funded by the DHB, and in October 2016 the DHB made a 10- year funding commitment to further develop an effective model of care with General Practices involved in the pilot. Barfoot & Thompson has also contributed to the costs of employing a Gerontology Nurse Specialist (GNS) as part of the CARE Project up to June In summary, General Practices carry out a comprehensive assessment of the patients needs and compile a care plan with the patient. This may include the coordination of services and referrals in a more proactive manner than standard primary care, with the promotion of self-management strategies. Another key feature is supporting and upskilling practice nurses and general practitioners (GPs) in the care of older patients at risk of hospitalisation. The GNS plays a key role providing specialist knowledge, particularly in the continued development of the model of care, nursing workforce development, and fostering primary and secondary care integration. 8.3 The complexity of the programme together with challenges faced by the project have meant that the time frame and milestones have had to be adjusted on several occasions. The project has been adapted in an iterative, responsive, and pragmatic manner, based on quality improvement principles and working with the primary care sector, while retaining core features to enable a robust evaluation. Phased intervention The project was broadly implemented in two phases, with five General Practices commencing in October 2015 and a further four practices starting in October One General Practice has withdrawn from the project as at 30 June Agreements with the remaining eight participating General Practices are in place from 1 July 2018 to September Following the Board s 10-year commitment, this approval is the first step to providing a level of funding to maintain staffing levels, especially any extra nursing staff that have been committed to the project by practices. Information system issues and risk stratification Implementation and evaluation of a new intervention is dependent on information system support, but given the complex and innovative nature of the project no pre-existing information system was available off the shelf, and development of a new system was outside the scope of the project. The project was initially delayed while exploring various options and eventually a compromise was settled upon, which has involved using a range of systems. This compromise has enabled the project to proceed, but issues in this area remain the single biggest concern from practices. Practices will require a more integrated information system to enable their continued involvement in the project, and to provide for sustainable monitoring and evaluation. Inadequacies with the information system solution was a key reason one practice has now withdrawn from the CARE Project. Risk stratification: At the start of the project each General Practice was provided with a full list of patients that could potentially be enrolled into the project together with risk stratification information to assist practices in selecting the specific cohort of patients they would enrol in the project. The experience was that risk stratification of patients within the CARE Project was fraught, the relevance of patient lists with risk scores was complex for practices to understand and use, and this aspect will require rethinking for the future continuation or expansion of the project. 177

178 CARE Project Progress Evaluation Report August 2018 Supported implementation Implementation has been supported by having a clear and resourced project structure. The model of care has been developed to be pragmatic and responsive to the implementation within each General Practice whilst ensuring data collection and monitoring were carried out. The CARE Project has also successfully delivered a range of workforce development initiatives to support implementation in primary care. 1.2 Patient cohort In total, 1,186 people aged 75 years and over (Māori/Pacific aged 65 years and over) living in the Waitemata area agreed to participate and have a recorded comprehensive assessment completed by 31 August This was 95% of the originally planned target of 1,250. While the full target was not quite met in the planned timeframe, General Practices have continued to enrol patients and the full target of 1,250 has since been met. 8.3 Those patients enrolled after 31 August 2017 cannot be included in the final evaluation as these patients will not have received a full 12 months of intervention by the time the outcome data will be required. However, 1,186 patients are anticipated to be sufficient to provide a robust overall outcome evaluation. The mean age of participants was 82 years at the baseline assessment, which is consistent with the intent to enrol frail patients. Patients in the CARE cohort will on average become frailer over the course of their involvement. Overall, 72% of patients are of European/NZ ethnicity, followed by 21% Other European. There are 45 Māori in the cohort which represents around 4% and is higher than the target expected (3%) based on the demographics of the practices. 1.3 External evaluation An external evaluation consisting of semi-structured interviews from patients, families/whānau, Māori patients and whānau, staff across all CARE Project General Practices, and members of the CARE Project team and leaders shows there is strong support for the CARE Project from participating General Practices and patients involved, including Māori patients and whānau. General Practice stakeholders noted that the project had enabled them to: Detect urgent but previously hidden patient needs and respond to them Get an in-depth picture of the health status of participants and plan accordingly Teach participants about their condition and care so the patient could be prepared and equipped to manage changes in their clinical status Provide care in a more holistic way for example by increasing awareness of home issues which directly impact the health of the patient Provide social connection, especially for those socially isolated and/or cognitively impaired Be a potential place of connection with extended family/whānau or care-givers of patients and involve them in on-going care and management of the patient See who needs help earlier and take preventative action. 178

179 CARE Project Progress Evaluation Report August 2018 The external evaluation noted that CARE patients were almost always positive about the intervention, and that they understood that the CARE Project was about helping them to continue to live in the community. They also reported feeling they had increased understanding of their condition and its management and felt better equipped to manage as well as recognise and respond to changes in health status. Further, patients greatly appreciated being able to ring their GP clinic, getting advice and being known by someone there. Findings of the Māori evaluation The external Māori evaluation showed mixed results, but an overall acceptability for the project and approach from a Māori perspective. Most participants could recall the aims of the programme but could not recall being given specific written information nor did they have a clear understanding about the CARE Project s selection criteria or processes. A strength of the project for Māori was the longer length of appointment times and the high level of whanaungatanga (relationships and connections) that resulted between nurses, GPs and kaumātua. This led to a greater sense of care partnership between the health provider and the older person. The extra time provided a greater opportunity for health providers to ask questions and to really listen to the older person. Whānau also felt included in the process. Greater understanding of the elder person s health needs and circumstances resulted. Participants felt heard and were more confident to take responsibility for their own health. Timely, appropriate referrals resulted from longer assessments. However, participants were generally unaware that a care plan was formulated nor did they discuss or view an actual care plan with their health provider Preliminary health outcomes Initial outcome results of the CARE Project using the Partners In Health 1 scale (a 12 item tool to assess self-management ability, knowledge, and behaviour in people with chronic diseases) and CARE Project Assessment data have been outlined ahead of a full outcome evaluation of the pilot to be completed by December CARE pre/post data from the Partners In Health scale indicates statistically significant improvements in the patients knowledge of their conditions and treatments, ability to cope, management of symptoms and adherence to treatment. Initial results for the pre/post data of the available 618 CARE Project participants (note: the full cohort will be included in the final report as it is not available currently) showed positive impacts, including: A trend to fewer falls Substantially fewer participants reporting concerning pain A highly significant decrease in reported anxiety Significantly decreased rates of depression Significantly fewer participants reported having questions or concerns about medications, and more reported using medication blister packs to help manage their medications Significant increase in CARE participants designating an Enduring Power of Attorney (EPOA) for health and welfare Significant increase in the General Practice obtaining a record of the EPOA. 1 Battersby M, Alex A, Reece M, Markwick M, Collins J. (2003) The Partners in Health scale: The development and psychometric properties of a generic assessment scale for chronic condition selfmanagement. Australian Journal of Primary Health 9,

180 CARE Project Progress Evaluation Report August Areas for improvement and next steps Based on work to date, the following key changes are in process: More flexible patient enrolment (and disenrollment) based on frailty and need, which will be built into an updated PMS tool. Revised eligibility/selection criteria will be further investigated and a full proposal will be developed for practice and DHB agreement More efficient and integrated Assessment/Care Planning is expected later in the year as part of a more fit for purpose PMS tool Ongoing practice support and workforce development has been factored into new contracts. Further workforce development will involve: i. preparation of a structured nursing workforce development framework; ii. development of specific GP training, and these will be presented as a proposal within the final evaluation GNS role review and integration with practice workflow has been planned and is currently being implemented including utilisation of the specialist advice function within ereferrals and monthly patient review sessions with each practice Primary and secondary care interface work is ongoing and specific recommendations will be included in the final evaluation report Funding model and business model options will be developed for General Practice consultation and any new model will be negotiated and recommendations included in the final evaluation report. 8.3 Summary of learning The CARE Project is a complex primary care intervention and shows promising results in terms of general practice acceptability, patient uptake, and initial patient outcomes. For any primary care based project to succeed, the clinical model of care and business model need to align. Success factors identified through this project include: It has to be a real problem for primary care and involve systems and processes that fit the individual General Practice work flow Taking a long term commitment (i.e. 10 year time frame) to project development enables changes in models of care while minimising the business risks allowing flexibility of timeframes for practice implementation to fit in with pressure of day to day General Practice workload Staging implementation and working with engaged General Practices, facilitating a practice team (doctors, nurses and practice manager/administrators) approach; and sharing learning between practices/facilitating cross fertilisation is important Having a dedicated budget for project implementation/practice time that reflects true costs is an important enabler along with a clear project structure Utilising a model of care focused on holistic/patient centred care is complex and requires greater team work, clear understanding of roles, effective communication, flexibility and individualised practice problem solving, including a commitment to learn from mistakes and being open to change Empowerment of nurses is critical for providing care for highly complex patients in a sustainable manner; this requires time and space within the practice, professional supervision sessions/patient specific review sessions to increase nursing skills and knowledge, and dedicated workforce development opportunities for knowledge sharing, networking, and building greater understanding of community based services. 180

181 CARE Project Progress Evaluation Report August Conclusion This report provides a summary of the CARE Project pilot implementation to date ahead of a final evaluation report due in December The CARE Project is a complex primary care intervention that involves a model of care facilitated by the nine General Practices involved in the pilot project. Overall, there are strong initial indicators that the CARE Project has delivered an innovative model of care that enhances the care of older people living in their homes. The project has a high level of general practice team acceptability, and high patient, including Māori patient and whānau acceptability, and is achieving positive outcomes for participants. Further evaluation of these outcomes scheduled to be completed by December 2018 will determine the level of success, especially any quantifiable impact on hospitalisations, Aged Residential Care placements, and overall cost benefit across primary and secondary care. 8.3 The CARE Project has provided significant learning relevant for the planning, engagement and implementation of any project working with General Practice. These learnings will be able to be applied to future primary care based programmes targeting older people or other populations, such as people with long term conditions. 181

182 CARE Project Progress Evaluation Report August Introduction This report provides a summary of the progress to date pending a full outcome evaluation that will be presented to the Board in December In summary, the report describes: What has been delivered to date A summary of the cohort A summary of an external evaluation Preliminary health outcomes Areas for improvement and next steps pending the full outcome evaluation. 2.1 Background In October 2015, Waitemata DHB commenced implementation of a pilot programme aimed at coordinating and enhancing the care of older people living in their homes. The goals of the programme are to reduce hospital admissions, delay or prevent entry to residential aged care, and where possible to improve health and independence. This pilot is due to be completed by the end of 2018 and is on track. 8.3 The project has been primarily funded by the DHB, and in October 2016 the DHB made a 10- year funding commitment to further develop an effective model of care with General Practices involved in the pilot. Barfoot & Thompson has also contributed to the costs of employing a Gerontology Nurse Specialist (GNS) as part of the CARE Project up to June The CARE (Co-ordinated care, Assessment, Rehabilitation and Education) Project aims to improve the health of people aged 75 and over and Maori and Pacific people aged 65 and over by providing a whole-system approach integrating primary care and hospital services. General practices carry out a comprehensive assessment of the patients needs and compile a care plan with the patient. This may include the coordination of services and referrals in a more proactive manner than standard primary care, with the promotion of selfmanagement strategies. A key feature is supporting and upskilling practice nurses and general practitioners in the care of older patients at risk of hospitalisation. The purpose of the CARE Project is to evaluate a comprehensive package of interventions to help keep older adults healthier so they can stay at home longer (i.e. delay placement in Aged Residential Care) and are less likely to need to go to hospital. 2.2 CARE Project goal and aims The overall goal of the CARE Project is: to reduce hospitalisations and delay aged residential care placements in the intervention cohort (relative to a matched group of control patients) so as to deliver improved health outcomes and reduced costs to the health care system. CARE Project aims are: a) To demonstrate a model of care, that if successful, can be transferred to other areas in WDHB, and provide insights for other population groups. b) To trial a nurse led model of care based on self-management and patient centred care for older adults. c) To trial the use of available IT tools that enable improved primary care based care planning and care coordination. 182

183 CARE Project Progress Evaluation Report August 2018 d) To foster improved integration between primary care and secondary care for older adults. e) To trial an approach that aligns care, funding and business models so that these models are sustainable. f) To enhance workforce development and quality processes within primary care and a shared care approach. Specifically mention nursing led care? 2.3 Evaluation approach The CARE Project is undergoing a comprehensive evaluation which is broadly divided into two components: An outcome evaluation to determine whether CARE is achieving its primary and secondary objectives An implementation (qualitative) evaluation to understand and support the intervention. 8.3 The evaluation objectives from the 2014 Business Case are: i. Monitor programme implementation against KPIs and milestones. Monitoring of progress will occur through project management reports to the steering group. ii. Describe CARE programme iterative changes and rationale during the programme development phase. During the development phase the CARE model will be adjusted through consultation with patients and their carers, general practice team participants, GNS, and DHB geriatrician and community services by the project management team. Iterative changes and rationale will be recorded. iii. Describe the CARE programme enrolled population and interventions. The Project will capture a range of process measures that describe the implementation of CARE. All components of the CARE model will be described including: i) patients identified as high risk, ii) patients entered into the project, iii) information on initial assessments, iv) care provided by the general practice (Project and non-project), v) transition care provided by GP, vi) continuing education, GNS support, and quality process activity. iv. Describe the impact on the patient and carer experience: Survey and qualitative interviews will be used to determine patient experience during their enrolment in the CARE model. This will include Partners in Health survey and a quality of life survey via telephone compared to a non-intervention control group. v. Determine if the intervention is acceptable to general practice teams: CARE model Intervention acceptability and usability will be determined qualitatively through ongoing GP general practice team meetings and focus groups with GPs and PNs. vi. Compare the impact of the CARE model on patient healthcare outcomes: The primary outcomes measured will be unplanned hospitalisation, unplanned readmission, ED attendance, and aged residential care placement. In addition we will measure health related quality of life (from surveys). Other health service utilisation such as DHB community services will also be measured. A non-equivalent control group will be used to compare before and after design to assess impact. The control group will be obtained by matching to other WDHB practices and by matching patients (using the CARE high risk selection process). vii. Complete a financial and economic analysis: An analysis of costs and benefits of CARE from a funder perspective will be included. This will include the long run costs of the 183

184 CARE Project Progress Evaluation Report August 2018 project (development costs will be identified separately), and estimated changes of health service, home-based support, DHB community services and age residential care utilisation. Medication use will not be measured. WDHB average costs of health services will be utilised. viii. In this report the following data in relation to the evaluation objectives above are outlined: Table 1: Overview of evaluation objectives and data used for this Progress Evaluation Report Evaluation objective: Data report in this report: 2.1 Implementation KPIs Description of implementation in relation to milestones and milestones 2.2 Iterative changes and Overview of iterative project changes and rationale rationale 2.3 Impact on the patient and carer experience Partners in Health (self-management assessment) baseline assessment compared to second annual assessment from CARE participants Patient and family/whanāu interviews Focus group and interviews with Māori patients Feedback from practices 2.4 Acceptability to Practice meeting/workshop notes general practice teams Structured practice interviews 2.5 Describe enrolled population and interventions Cohort data as at 31 August 2017 (to enable outcome evaluation of patients as at 31 August 2018, i.e. at least 12 months intervention in the programme) Patient drop-outs as at 31 August 2017 Description of different practices approaches to assessments (e.g. home visits), care planning GNS support Summary of workforce development provided 2.6 Healthcare outcomes Comparison of baseline and one year post CARE intervention comprehensive geriatric assessment data Hospitalisation and age residential care data to be included in outcome evaluation report 2.7 Financial and economic analysis Data to be included in outcome evaluation report Report structure The following report is structured as follows: a) CARE Project delivery summary of what was delivered by the CARE Project b) Feasibility and acceptability of the project summary of the external evaluation (semi-structured interviews from patients, families/whānau, Māori patients and whānau, staff across all CARE Project General Practices, and members of the CARE Project team and leaders) c) Initial outcomes of the project (available pre/post data for Partners In Health and the CARE Project Assessment) d) Discussion and conclusions. 184

185 CARE Project Progress Evaluation Report August CARE Project delivery This section outlines a summary of what has delivered by the CARE Project to date. 3.1 Overview of progress and milestones The complexity of the programme together with challenges faced by the project have meant that the time frame and milestones have had to be adjusted on several occasions. The project has been adapted in an iterative, responsive, and pragmatic manner, based on quality improvement principles and working with the primary care sector, while retaining core features to enable a robust evaluation. A summary of the overall timeframe, milestones, and related changes to the CARE Project are as follows: 8.3 Establishment Original proposal accepted by the Board in November 2013 Core project team formed in March 2014 Project design adapted through stakeholder input during 2014 Business Case approved by the Board on 5 November 2014 General Practice engagement in early to mid-2015 Phase One Initial implementation commenced in October 2015 with five practices Review of the project funding and timeframe due to insufficient practice uptake, and subsequent recommendations to the Board approved in April 2016 Extended time frame to June 2018 to enable a two phased approach to implementation, along with a 10-year commitment to work with participating practices to develop models of care for the health of older adults Phase One practices continue Phase Two Four additional practices agreed to participate in August 2016 Phase Two practices commence implementation in October 2016 Mid 2017, delays in Phase One and Two practices recruiting patients so pilot is extended to 31 August 2018 to enable a large as possible cohort to be included in the outcome evaluation Reporting, funding and next steps Improvements to the project identified and tested with practices and other stakeholders during early to mid-2018 Broad improvements to the project planned and commence implementation from August 2018 A progress evaluation report presented to the Board in August A final outcome evaluation report will be completed by November 2018 and will be reported to the Board in December Funding rollover has been arranged for 3 years and 3 months as of 1 July 2018 via PHOs to enable time within the next financial year to review and agree any changes to the funding or payment model based on the evaluation due by the end of the year. The 3 year and 3 month time frame provides baseline funding security to maintain staffing levels, especially any extra nursing staff that have been committed to the project by practices. 185

186 CARE Project Progress Evaluation Report August 2018 Depending on the outcome evaluation the project will continue with agreed improvements/changes and/or planning will commence for any further roll-out. 3.2 Overview of the pilot This section outlines an overview of the pilot project and commentary on what was delivered General Practice involvement The pilot was to initially run until September 2017 but was extended to August 2018 to enable a phased approach. Five Phase One general practices participated in the CARE Project and commenced enrolling patients from October 2015, and Kaipara commenced in mid-february 2016: Kaipara Medical Centre Orewa Medical Centre Silverdale Medical Centre Family Doctors Whangaparaoa Whangaparaoa Medical Centre 8.3 Four Phase Two general practices participated and commenced set-up in July 2016, and commenced enrolling patients in mid-october 2016: Dodson Medical Centre Manly Medical Centre Hibiscus Coast Medical Centre Apollo Medical Centre Plus extra patients allocated to Family Doctors Whangaparaoa. Dodson Medical Centre withdrew from the pilot as at 30 June 2018, but related data will be included in the final evaluation. The two key reasons for the withdrawal outlined by the practice were: a) Insufficient nurse resource to deliver the project, which is unlikely to be resolved in the short to medium term; and b) Uncertainty about the proposed improved systems and processes (especially an integrated IT tool) to support the practice to efficiently deliver the project. The remaining eight practices continue in the project and have funding in place until September Overview of interventions General Practice interventions under the CARE Project include: A comprehensive assessment undertaken with each patient by a practice nurse at the start of the intervention, identifying major health concerns/issues. A tailored care plan developed for 2-3 major health concerns for each patient. Flexible care coordination established and delivered by the practice nurses. An active patient review at six months to determine any new or on-going needs and management options for each patient. An active review at twelve months to determine whether the patient should remain in the programme or graduate back to standard care (although in the pilot all patients continue). 186

187 CARE Project Progress Evaluation Report August 2018 Transition of care Participating general practices are funded to enable a Practice Nurse phone call, home visit or extended GP consult post hospital discharge for patients to enable a smooth transition back into the community. The GNS plays a key role in all of the above components of the CARE project, providing specialist knowledge, particularly in the continued development of the model of care, nursing workforce development, and fostering primary and secondary care integration Project structure From the outset a clear project structure was in place with a Steering Group Terms of Reference. As the project progressed a clearer distinction between the Steering Group and Project Team was established. The project is also supported by a project team including a GP/clinical lead, project manager, practice nurse support, research assistants, other clinical specialists, and a funding and planning programme manager. 8.3 Key points: An interdisciplinary project team along with positive, transparent and open project discussions within the project team is invaluable in ensuring robust planning and critique of the project and deliverables A later formation of a clinical sub-team to plan/resolve detail/practice by practice issues assisted tailoring practice support A dedicated Project Management resource helps to keep the project on track Data collection/cleaning resource was essential to ensuring data is accurate and upto-date Steering Group providing governance/not day-to-day operational input useful in maintaining overall direction (this group was involved in more decision-making in the early phases of the project and this has moved more to a monitoring role) Tailoring to each General Practice Each general practice required a system tailored to their practice with ongoing support to fit the initiative into the practice s work flow and overall operation. Key components have included: Facilitating implementation with a practice team including doctor, nurse and manager from the outset to ensure efficient division of labour and improved role clarity/overall practice system change and model of care establishment Flexibility of timeframes for practice implementation to fit in with pressure of practice workload. A stop pause reflect process for resolving issues/problem solving enabled a more sustained and sustainable change process to occur Internal practice meetings were needed to enable the practice to develop their own service delivery model and ownership of the project Meeting and process review/problem-solving with the CARE Project clinical sub team (Clinical Lead, GNS, Practice Nurse Support and Project Manager) on a practice by practice basis was useful to embedding processes, systems and project approaches, e.g. Care Planning, and resolving specific issues as they arose from practices The variable knowledge of GPs and nurses working with older people required a highly tailored approach to support workforce development (opportunistic, practice level training, etc.) along with more structured workforce development across practices The process of sharing learning between practices/facilitating cross fertilisation (e.g. through workshops) was invaluable. 187

188 CARE Project Progress Evaluation Report August Models of Care Overall the model of care developed has remained largely intact, although some practice by practice variability/tailoring has occurred during implementation. This adaption by practices was anticipated and encouraged as the intention is to develop a model that has wide applicability across the DHB if it provides effective. The practices have approached the assessments and care planning (refer Section 3.3 below) in a variety of ways to fit the overall general practice approach and work flow. The variations include: Home visits for assessments and shared Nurse/GP care planning with patient Assessments in practice (occasional home visit) and Nurse/GP care planning with patient Assessments in practice with primarily nurse care planning with patient and discussion with doctor to address medical concerns Assessments in practice with primarily doctor led care planning with information from the nurse to address psycho-social concerns. 8.3 Follow-up from hospital discharge Transition of care Participating general practices are funded to enable a Practice Nurse phone call, home visit or extended GP consult post hospital discharge for patients to enable a smooth transition back into the community Practices have outlined some difficulty of knowing who was discharged from hospital. Some practices did a weekly query that worked well, while other nurses did not get alerts and therefore did not know when to follow up. This was further complicated in that sometimes patient discharge summaries were not being sent through to the practice until a few days after discharge making it hard to follow-up with the patients in a timely manner There has been general feedback that it was positive to follow-up after hospital admissions However, there has some confusion about when the patient was eligible for a free visit as part of the CARE Project funding Anecdotal feedback has been that this process helped the patient feel wanted and cared for Data collection and monitoring Implementation and evaluation of a new intervention is dependent on information system support, but given the complex and innovative nature of the project no pre-existing information system was available off the shelf, and development of a new system was outside the scope of the project. The project was initially delayed while exploring various options and eventually a compromise was settled upon, which has involved using a range of systems. This compromise has enabled the project to proceed, but issues in this area remain the single biggest concern from practices. Practices will require a more integrated information system to enable their continued involvement in the project, and to provide for sustainable monitoring and evaluation. Inadequacies with the information system solution was a key reason one practice has now withdrawn from the CARE Project. In summary, data for the project was provided and collected through multiple sources as follows: 188

189 CARE Project Progress Evaluation Report August 2018 a) Patient lists were provided to the practice that included a risk score and if a NASC needs assessment had been done (these data will enable outcome evaluation comparisons with control patients from practices not involved in the pilot) b) Data obtained from practices: Practice tracking spreadsheet provided to the practice, but maintained/updated by the practice to record patients recruited, etc. A query from PMS data on key activity codes pertaining to patients, e.g. assessment completed, care planning session completed, transition care followup, etc.). c) Shared Care data via health Alliance/Whānau Tahi (patients enrolled in the project, Partners In Health data and assessment data). d) Practice record of care planning, usually captured in the PMS daily record. e) ereferrals (practice PMS outbox and DHB clinical records) 8.3 At the start of the project each General Practice was provided with a full list of patients that could potentially be enrolled into the project together with risk stratification information to assist practices in selecting the specific cohort of patients they would enrol in the project. This included all patients enrolled in the practice aged 75 years and older and Maori and Pacific patients aged 65 years and older. These lists were updated and provided to practices several times during the primary enrolment period depending on project Phase. General practices were free to enrol any patient they believed to be a risk into the CARE Project. As noted, the project provided two pieces of information to assist in this decision: a risk score and whether a NASC needs assessment had been done. Each patient was assigned a risk score, between 0 and 1, which is an estimation of the risk of their being acutely admitted to hospital over the next six months. This was calculated using a predictive risk model developed for ProCare. In practice, each General Practice used a variety of methods to select patients. Each practice also had to review and clean the patient lists as it included patients who had subsequently died or moved into Aged Residential Care (i.e. not eligible for the project). The experience was that risk stratification of patients within the CARE Project was fraught, the relevance of patient lists with risk scores was complex for practices to understand and use, and this aspect will require rethinking for the future continuation or expansion of the project. Marrying up the different data sources was resource intensive throughout the pilot and efforts were made to streamline this still resulted in a substantial amount of work to clean and confirm data, resulting in issues monitoring progress and providing an up to date definitive summary of the cohort. For example, variances occurred throughout the project between the Shared Care report (patients enrolled but not assessed, missing patients not having assessment data loaded) and Practice Report (missing patients compared to Shared Care). Due to these issues, work to establish a definitive cohort summary for the pilot has only recently been completed. Feedback from practices throughout the project highlights ongoing concerns with the collection and recording processes. A more integrated system will be required to support practices continued involvement in the project and for more sustainable monitoring and evaluation. 189

190 CARE Project Progress Evaluation Report August 2018 Capture of care plans has been problematic and again a compromise solution was instigated using the daily record within the PMS. Further, the current system does not easily enable providing patients with information on their assessment or care plans. These multiple data sources (e.g. patient list, tracking spreadsheet, PMS, and shared care) create a lot of work compiling and cleaning data, practice follow-up, etc. The project resourced this to minimise extra workload for the practice. A more integrated and user friendly IT model is required for any future rollout, the ongoing sustainability of the project or other similar projects. This is currently being pursued by the project team in consultation with practices. Ideally, the project requires a single system/database to avoid double/triple handling of data, cleaning data and reducing errors inputting/coding. A more standardised approach to care planning and the capture of care plans is also required along with the ability to share this with patients, whānau and others Care plan analysis For each CARE patient, a care plan was developed after the assessment was completed (Refer Section for a breakdown of the number of assessments and care plans completed by practice). The care plan was developed in collaboration with the older person and based on their perceived needs and goals as well as the results of the comprehensive geriatric assessment. Due to individual practice procedures and preferences, each practice recorded care plans in the patient management system slightly differently. For this analysis, a random sample of 111 care plans collected from all nine participating practices were analysed to describe the most common issues addressed in care plans for CARE participants. There was a mean of 3.7 individual issues identified in each care plan. A summary of the proportion of the focus of care planning is presented in Figure 1. The most common issue addressed in care plans was pain, and most commonly this pain was associated with arthritis and gout. Falls were the second most commonly addressed issue. This was followed by skin issues, most often related to skin lesions such as suspected skin cancers. Cardiac and blood pressure issues were included in the top five issues identified and included such issues as dysrhythmias, peripheral oedema and elevated blood pressure. Advanced care planning was frequently included and mainly included discussions about organising an Enduring Power of Attorney. Urinary and gastrointestinal issues were common features of the care plans and mainly addressed constipation and urinary incontinence concerns. Low mood and anxiety and social isolation were regularly addressed in care plans as well. Cognitive impairment was frequently identified as an issue. Figure 1 represents 89% of all the items in the care plans. There were 11% included in a miscellaneous category. 190

191 CARE Project Progress Evaluation Report August 2018 Figure 1: Summary of items addressed on a random sample of care plans Items included in Care Plans Pain Falls Skin issues Cardiac/Blood Pressure Advanced Care Plans Urinary incontinence, UTI GI issues/constipation Low mood/anxiety Cognitive impairment Social isolation Weight loss/gain Respiratory issues, cough Mobility issues Hearing issues Eyes/vision Carer stress Limited ADL Diabetes Sleep issues Specialist referral Nocturia Fatigue 1% 1% 1% 1% 1% 1% 1% 2% 2% 3% 3% 3% 3% 3% 4% 5% 5% 6% 8% 7% 10% 15% 8.3 0% 2% 4% 6% 8% 10% 12% 14% 16% 3.4 Summary of workforce development provided Provision for workforce development for the CARE Project to date is summarised as follows: Development meeting funding ($1, per practice) for meeting time for meetings up to 30 June 2015 and funding was based on an estimate of 6 hours of GP and 4.5 hours PN time per practice: 2 hour evening meeting on 22 April hour evening meeting on 16 June 2015 Incidental other meetings depending on practice. Phase Two (funding of $1, per practice paid in 2016/17) incidental meetings depending on practice between April/May 2016 (supplemented by Phase One and Phase Two practice team workshop held on 29 June 2016 see below). Overview training funding ($3,840 per practice) initially planned to be delivered between July and September 2015 and funding was based on an estimate of 8 hours of GP time, 8 hours of Practice Manager time and 16 hours PN (i.e. 16 hours of funding for 2 PNs per practice) time per practice: 4 hour morning meeting for GPs, Practice Managers and PNs (up to 2 per practice) on 2 July hour workshop for PNs (up to 2 per practice) on 20 August hour morning meeting for GPs, Practice Managers and PNs on 12 November

192 CARE Project Progress Evaluation Report August 2018 Incidental other meetings depending on practices but covered by separate general Set Up Cost funding based on estimated number of patients and 3 months of Proactive Care funding pro rata of $257.5 per patient. Phase Two (funding of $3,840 per practice paid in 2016/17, plus funding/time included in the 3 month Set-up Cost ) incorporated into 26 June 2016 half day workshop and followup practice nurse training 9 November 2016, and practice by practice support during September/October Quality & Evaluation Workshops based on 16 hours for the lead GP, Practice Manager and lead PN each for Year 1 and Year 2 of the programme (i.e. Year 1 = October 2015 to September 2016, and Year 2 = October 2016 to September 2017) ($5, per practice per Year) and extended to June 2018 ($5, pro rata at 9 months): Phase Two pro rata 1 year and 9 months, i.e. total $8,820.00: Half day workshop of PNs held on 17 February 2016 (3 hours) 1 hour practice by practice follow-up meeting in March 2016 (excluding Kaipara) 4 hour morning meeting for GPs, Practice Managers and PNs on 29 June 2016 One day PN workshop (approx. 2 nurses per practice) on 9 November hours GPs, Practice Managers and PNs practice by practice 1 hour meetings April-May 2017 GPs and Practice Managers 2 hour workshop on 16 June 2017 PN one day workshop on 30 August 2017 Half day co-design workshop with GPs, Practice Managers and PNs on 20 April 2018 Regular incidental practice specific coaching and training via GNS and/or Practice Nurse support team from August 2016 and previously from GNS team As required practice specific meetings with the Clinical Lead, Project Manager and/or GNS and Practice Nurse Support to problem solve or address specific issues Iterative changes The following section provides a summary of the iterative changes to the project as outlined in the November 2015 Business Case and related rationale for these changes along with a description of the model of care and funding and related resources. Overall the model of care developed has remained largely intact, although some practice by practice variability/tailoring has occurred during implementation. This adaption by practices was anticipated and encouraged as the intention is to develop a model that has wide applicability across the DHB if it provides effective Establishing a phased and tailored approach to implementation The key project change involved staging the implementation across two phases as a full cohort of 1,250 patients was unable to be obtained due to less than expected initial uptake by general practices by July This resulted in a review of the CARE Project and three key areas of change were recommended and approved by the Board in April 2016: 1. A longer 10 year time frame to work with participating practices to develop models of care for the health of older adults. This longer time frame enabled General Practice teams to recruit new staff and embark on the change management required at a clinical and service delivery level to improve the health of older adults. 2. Change the funding model by removing the PHO Care Plus funding contribution from the project and enabling the charging of co-payments by practices if required. The removal of the Care Plus contribution being used for the CARE Project allowed 192

193 CARE Project Progress Evaluation Report August 2018 General Practice to continue to allocate this funding to previously committed patient programmes/interventions targeted at individuals with long term conditions. 3. Factoring in further practice support to adopt/refine the model of care into practice operations, including a general practice workflow. This ensured that learnings from the project to date were applied, enabling smoother implementation and confidence building in the phase two primary care teams. Work was then undertaken to incorporate the Phase One and Phase Two practices and the four new general practices were able to draw on learnings from the Phase One general practices. A focus for knowledge sharing was a combined workshop of Phase One and Two general practice teams held on 29 June Phase One practices shared their experience to date and were able to make recommendations to the Phase Two practices including: Reinforcing that the CARE project is a nurse led model and patient centred. Highlighting that the GNS can work effectively with practices, to support care planning and facilitate wider access to community resources and secondary care. The aim is to increase gerontology knowledge within both the doctor and nursing teams in primary care. 8.3 At that time, extra practice support was secured to support Phase Two practices in their process and system set-up, and this was provided in a tailored manner practice by practice. It was also followed up by specific gerontology training of Practice Nurses. After a relatively short period support was provided relatively equally across Phase One and Phase Two practices which continues through regular visits by an experienced Practice Nurse (contracted to the project) and the GNS, with occasional meetings with the project clinical lead and project manager Evolving role of GNS support to the project The other key area of change has been the delivery of the GNS component. Initially the GNS role was actively involved in the development of resources and providing training and support for the practice nurses. As the project progressed the need for more tailored support was identified. Various models were tried and eventually a model whereby the GNS was more explicitly integrated into the practice nurse activity was developed. This is currently established across all the practices and operates as follows: Managing ereferrals/guidance/advice via ereferrals Accepting relevant GNS referrals for follow-up (small percentage of CARE Project patients) Establishing a proactive relationship with nominated CARE Project practice/s Meeting practice nurses from nominated practices once per month for 1 hour for case reviews Providing tailored workforce development for practices and/or contribution to occasional CARE Project workshops Project name change to KARE A final key change to the project is the project name. Practices had struggled with the CARE name throughout the pilot as there are numerous care programmes and projects, and it can be very confusing. Throughout the project codes within the practice management system were named KARE1, KARE2, etc. and hence the proposed change. Within the new agreements that commenced on 1 July 2018 with PHOs and practices the name has been changed from CARE to KARE. There has been unanimous practice support for changing the 193

194 CARE Project Progress Evaluation Report August 2018 name to the KARE project. For the purposes of this report we have retained the use of CARE as it pertains to the pilot. 3.6 Cohort summary In total, 1,186 people aged 75 years and over (Māori/Pacific aged 65 years and over) living in the Waitemata area agreed to participate and have a recorded comprehensive assessment completed by 31 August This was 95% of the originally planned target of 1,250. While the full target was not quite met in the planned timeframe, General Practices have continued to enrol patients and the full target of 1,250 has since been met. Regardless of the length of time within the project all assessed patients have been included in the cohort. This is based on the principle of intention to treat. The cohort was achieved in two broad phases commencing in October 2015 for Phase One (5 practices) and October 2016 for Phase Two (a further 4 practices and a small number of extra patients for one of the Phase One practices). 8.3 By the completion of the pilot phase in August 2018, some of the patients will have been on project for two years or more. Those patients enrolled after 31 August 2017 cannot be included in the final evaluation as these patients will not have received a full 12 months of intervention by the time the outcome data will be required. However, 1,186 patients are anticipated to be sufficient to provide a robust overall outcome evaluation Target numbers, assessments and care plans completed Phase One practices all reached or exceeded their target cohort as they were able to continue to recruit and assess patients for a longer period than the Phase Two practices. Further, they were encouraged to recruit new patients if a patient dropped out of the project after being on the project for less than six months. In summary, Phase One practices had an overall target of 710 patients and completed 730 assessments (103% of the target). Phase Two practices generally did not reach their targets as at 31 August 2017 and one practice has had its target reduced. In summary, Phase Two practices had an overall target of 540 and completed 455 assessments (84% of the target). However, these practices have since reached their cohort targets, but these patient data will not be included in the final analysis as the patients will not have received a full 12 months of intervention by the time the outcome data will be available. Therefore, overall the cohort includes 1,186 patients and is 64 less than the original target (1,250). A similar pattern for completion of care plans by 31 August 2017 shows that 691 care plans had been completed by Phase One practices and 430 care plans by Phase Two practices resulting in a total of 1,118 care plans across the cohort (89% of the target). Table 2 over page outlines the practice breakdowns for assessments and care plans completed by 31 August

195 CARE Project Progress Evaluation Report August 2018 Table 2: Summary of CARE assessment and care planning by Phase One and Two practices as of 31 August 2017 Practice Target CARE Assessments % Assessments to target Care Planning % Care Plan to target Kaipara Medical* % 96 92% Family Doctors** % % Orewa Medical % % Silverdale Medical % % Whangaparaoa % % Medical Sub-total Phase One % % Dodson Medical % 87 90% Centre Hibiscus Coast % % Medical Centre*** Apollo Medical % 99 76% Centre Manly Medical % % Centre Sub-total Phase Two % % Total cohort 1,250 1,186 95% 1,118 89% Adjusted 1,217 1,186 95% 1,118 92% *Assessments commenced mid-february One active patient excluded as does not meet age criteria. **Includes 34 extra patients allocated as part of Phase Two. One patient removed (i.e. 171 assessments completed) as transferred early in project to Manly Medical and re-assessed/managed there. ***Target adjusted to 157 in November Cohort gender Table 3 over page shows that, overall there are 700 females (59%) and 486 males (41%) enrolled in the CARE Project cohort. There is some variation between practices, with Orewa Medical having the highest percentage of females (72%) and Apollo (50%), Manly (47%) and Whangaparaoa (56%) having a more even split of females to males. Table 3: Patient gender for enrolled patients by practices commencing 1 October 2015 through to 31 August 2017 (n=1,186) Practice Male Female % Male % Female Kaipara Medical % 55% Family Doctors % 60% Orewa Medical % 72% Silverdale Medical % 55% Whangaparaoa % 56% Medical Sub-total Phase One % 61% Dodson Medical % 57% Centre Hibiscus Coast Medical % 64% Centre Apollo Medical Centre % 50% Manly Medical Centre % 53% Sub-total Phase Two % 56% Total cohort % 59% 195

196 CARE Project Progress Evaluation Report August Cohort ethnicity Table 4 shows that, in terms of ethnicity, overall that 858 (72%) patients were of European/NZ ethnicity, followed by 253 (21%) Other European. There are 45 Māori in the cohort which represents around 4% of the cohort and is slightly highly than the target expected (3%) based on the demographics of the practices. In Auckland region the Māori pop was 143,000 (2013 Census), but only 1.3% of those were over 75 and 4.4% over 65 (compared with overall population where 5.9% were over 75 years and 14% over 65). In Phase One practices there are around 5% Māori as would be expected from the overall patient cohort within these practices, and in Phase Two practices the cohort includes around 2% Māori, again as would be expected. Kaipara Medical Centre had the highest number of Māori with 16 or 16% of their cohort. 8.3 Table 4: Patient ethnicity by practices commencing 1 October 2015 through to 31 August 2017 (n=1,186) Practice European/ NZ Other European Pacific Maori Asian % Maori Expected % Maori Kaipara Medical % 17% Family Doctors % 3% Orewa Medical % 1% Silverdale Medical % 3% Whangaparaoa % 5% Medical Sub-total Phase One % 5% Dodson Medical % 2% Centre Hibiscus Coast Medical % 2% Centre Apollo Medical Centre % 1% Manly Medical Centre % 2% Sub-total Phase Two % 2% *Total cohort % 3% *13 patients had missing ethnicity classification Cohort drop-outs as at 31 August 2017 Table 5 (over page) outlines the breakdown of patients leaving the project and the reason. In total 156 patients of the cohort (13% of the cohort) had left the project as at 31 August 2017, 44 had died (4%), 38 moved into Aged Residential Care (3%), 33 moved out of the area or transferred practices (3%). For 33 the patient/family decided the project was not appropriate (3%), and for 8 the practice decided the programme wasn t appropriate or cited an other reason for the patient leaving the programme (1%). As would be expected Phase One practices overall had a higher percentage of patients leave the project (14% of cohort) as on average patients had been in the project longer compared with Phase Two practices (7% of cohort). Whangaparaoa had the highest percentage of patients leave with 24%. Dodson and Manly had the lowest percentage with 2% and 1% respectively. 196

197 CARE Project Progress Evaluation Report August 2018 Table 5: Summary of patient drop-outs and reason for leaving CARE Project as at 31 August 2017 Practice No. of Reason patients left project Deceased Transferred / moved Moved into ARC Patient / family reason Practice decision/other Kaipara Medical Family Doctors Orewa Medical Silverdale Medical Whangaparaoa Medical Sub-total Phase One Dodson Medical Centre Hibiscus Coast Medical Centre Apollo Medical Centre Manly Medical Centre Sub-total Phase Two Total cohort

198 CARE Project Progress Evaluation Report August Feasibility and acceptability of the CARE project The following section outlines summary results of an external evaluation process. This is a summary of the results of semi-structured interviews from patients, families/whānau and staff across all CARE Project General Practices. Also included were interviews from members of the CARE Project team and leaders. Interviews included provider stakeholders GPs, Practice Nurses, practice managers and/or administrators (n=20), as well as with patient CARE participants (n=14). All non-māori semi-structured interviews (n=34) were conducted by Dr Deborah Balmer, an independent qualitative researcher. Full reports for the external evaluation are available as separate reports Qualitative evaluation method summary The interviews inquired into CARE Project delivery across the nine GP practices. Topics investigated were staff training and programme roll-out, recruitment and selection of CARE patients, on-going conduct/structure of the CARE Project, funding, and successes and challenges. Patients, on the other hand, were asked about their experiences of being involved in the CARE Project, their constructions of what the project had been about and areas for praise and/or improvement. Dr Tess Moeke-Maxwell, an independent Māori researcher interviewed Māori participants and their whānau to explore their experience of the CARE programme from their unique cultural perspectives. This included interviews and focus group with eight Māori Kaumātua and three of their whanau. Patients were largely interviewed in their own homes and often had family/whānau members also present. Interviews were conducted between November 2017 and June All interviews were transcribed and coded according to content using NVivo 11. Coding and analysis was undertaken by Dr Balmer and Dr Moeke-Maxwell. Ethics approval for this study was granted by the University of Auckland Human Participants Ethics Committee (#020001). 4.2 Overall qualitative evaluation summary Overall, the interviewees recounted many instances where the CARE Project has enabled General Practices to: pick up urgent but previously hidden patient needs and respond to them get an in-depth picture of the health status of participants and plan accordingly teach participants about their condition and care so the patient could be prepared and equipped to manage and see changes in status provide care in a more holistic way for example increasing awareness of home issues which directly impacted the health of the patient provide social connection, especially for those socially isolated and/or cognitively impaired be a potential place of connection with extended family/whānau or care-givers of patients and involve them in on-going care and management of the patient. see who needs help earlier and take preventative action. I've been thrilled with the whole project, I've appreciated the funding for some extra time to do a really good comprehensive review of patient s needs. We re constantly 198

199 CARE Project Progress Evaluation Report August 2018 identifying things which we wouldn't have identified before, either because we haven't got the time or the patient s not likely to disclose them (GP) Overall there was strong support for the CARE Project from participating General Practices especially from GPs, even some who had initially been very sceptical or who had had significant challenges with initial implementation. Practice Nurses were supportive of the project but were divided on their experiences of its implementation at the individual GP practice level. Doubts voiced by some interviewees about the benefits of CARE included: patients not seeing any value in the programme and therefore not opting into it difficulty with availability of interventions for identified needs the project being all about evaluation and not about actually delivering the services patients need 8.3 One Practice Nurse expressed her concerns as follows: And we can identify that someone has incontinence, but there s no one more nappy over their allotment of one a day that they get from the DHB and that s it. So, when you come to actually delivering services to try and keep them out of hospital, particularly the NASC assessors are overworked, and unavailable, and it s slow getting them. And from that point of view the project doesn t really help keep people out of hospital in situations where perhaps it could. I mean it s not always appropriate to keep people out of hospital, sometimes they need to go in. That s the other problem with a project like this is 4.3 Overview of patient experience In summary patient views noted were: CARE patients mostly were very positive about the CARE intervention Patients understood CARE was about helping them to continue to live in the community Strongest supporters seemed to be those with higher levels of co-morbidities Patients reported feeling they had increased their understanding of their condition and its care and felt better equipped to manage as well as recognize and respond to changes in health status Patients reported really appreciating being able to ring their GP clinic and get advice and being known by someone there Some patients felt they had benefitted all they could from CARE and that others with more health issues would benefit from their place in the project Patients displayed personal responsibility in responding to their health needs and management. General Practice teams perspectives on CARE outcomes with patients can be summarised as follows: CARE built social capital in the GP practices it has been operating in CARE enabled more timely, preventative action with participant s health CARE revealed patient needs that were not able to be met by existing services either in primary care or by the District Health Board. 199

200 CARE Project Progress Evaluation Report August Provider Experience of CARE Project: suggestions for further implementation In summary: Providers expressed the need to ensure a consistent orientation across key stakeholders of General Practices with key messaging on time allocation required and examples of how different General Practices have situated the project in their clinical operations The initial implementation time needs to avoid peak demand and holiday periods in the yearly calendar cycle On-going training is needed and delivery on-site at General Practices in response to felt need as well as staff turn-over Ensuring the availability of sufficient physical space to deliver the project in the clinic or consider alternate arrangements (e.g. home visits) Devising a mechanism inside the programme to be able to move patients on and off the CARE Project, e.g., where a patient has initially benefitted from in-depth assessment but no longer needs an intensive follow-up every six months and others would benefit more Increased focus on post-hospital admission follow-up to manage on-going health issues Examination of the bulk funding of the programme as this may dissolve the autonomy the project gave to RNs Suggestions for future recruitment of participants Involvement of GPs in recruitment of patients into CARE has been key in some practices to getting potential patients on-board Consistent messaging about the mix of patients to be recruited, and if there are certain requirements. This process needs to include scope for GP practices to selfselect participants to be part of the CARE programme. Begin recruitment with lower risk patients and use it to set up and refine systems within the GP practice Clear and easy messaging for patients when being initially recruited re-examine written material used in the project for ease of understanding and messaging Inclusion of administrators in training and in providing support for booking patients/following up as this part of the project is very time consuming, partly because it challenges patients current understanding and experience of their relationship with their GP and Practice Nurse. Change the name of the project so it is less confusing for patients Up front and initial acknowledgement that CARE is primarily concerned with building closer relationships between the practice nurse, the GP and the CARE patient to reduce risk of health and/or functional issues. The creation of this relationship with patients creates expectations from patients that need to be managed and/or fulfilled. Risk to CARE of staff turnover, especially practice nurses, and this issue requires further strategy for training new staff about CARE processes and procedures. Possibly developing the flexibility in the programme where everybody over 75 years old gets assessed to establish a baseline with the flexibility to move people on and off the project after the care planning session. 200

201 CARE Project Progress Evaluation Report August Structure of delivery across General Practices CARE has been helpful for reinforcing clinic practice team collaboration but that was not consistent across GP practices GP practices varied in their response to whether extra nursing time was introduced alongside the project The CARE programme requires a champion at each GP practice to be a resource and provide continuity Larger GP practices have additional challenges in implementing CARE Home visits found to be an essential and cost-effective tool in delivery of CARE Project assessment for some of the practices. Not all practices did home visits however Assessment, assessment tool and skill The CARE assessment tool needs to propagate more discussion as it was felt discussions reveal health issues that would not normally be picked up through usual appointment visits. The CARE assessment tool helped to pick up more cases of cognitive impairment than would be found normally GP practices need direct access to referring for gerontology services, including social workers as part of assessment & follow-up CARE assessment tool & CARE Project were useful in RN upskilling including assessment skills, care planning, community support although that was a contested notion An updated and managed repository of local support and activities needs to be available to Practice Nurses for informing CARE patients and for care planning IT structure of CARE & Data collection for evaluation IT support system for the CARE Project needs to be more time efficient, easier to use, and not an impediment to assessment. Some IT savvy GP practices developed their own solutions to the unwieldy IT system. Advanced forms are needed for collecting CARE activity at each clinic and monthly reporting Streamlining reporting data requirements and collection tools for the overall project evaluation is needed as the system currently used is unsustainable Nurse-GP Dynamic CARE Project has been a tool for team building in the General Practice teams as well as fostering therapeutic relationships between the patients and the Practice Nurses CARE work has increased mutual understanding of Practice Nurse & GP roles within General Practices and facilitated a focus on how the different roles can be more complementary to benefit patients Practice Nurses felt respected by the GPs for their sphere of knowledge and felt their practice was valued by them Adaptations in clinic operations in response to CARE Project demands are on-going as the CARE Project is rolled out. 201

202 CARE Project Progress Evaluation Report August Nurse Training and CARE On-going training for the CARE Project post orientation and implementation has evolved into a clinic led approach with the trainer responding to felt training needs of GP practices and delivering them on-site in convenient times like lunch breaks Additional attention is required on this aspect of on-going support and training moving forward with the CARE. In conclusion, capturing experiences and narratives which provide context to the delivery of the CARE Project across General Practices in WDHB not only provides a rich description for reflection but allows areas which would benefit from further research and/or attention to emerge. There are many areas for improvement moving forward; however, what has been achieved is worth celebrating given that older people have benefitted from increased care and attention from their local GP clinic. 8.3 Capturing the innovation and development of the CARE Project into an implementation manual for orientation and training of new General Practices may be a helpful way forward. Providing examples of practice and administration systems developed by participating General Practices to implement the programme, as well as highlighting potential challenges and ways pilot General Practices have overcome implementation issues may benefit new CARE providers in the iterations to follow. 4.5 Summary of the Māori experience of CARE The following section is a summary of the evaluation findings of the CARE Project, based on the perspectives of Māori Kaumātua (aged 65 years and over living in the Waitemata District Health Board) and whānau members. The evaluation of the CARE Project was conducted in 2018 and included eight kaumātua and three whānau members participating in either a one-off face to face interview or focus group. They were asked open ended questions about their experiences of being involved in the CARE Project, and how they found the assessment process, care planning and overall implementation of the CARE Project. The purpose of this qualitative portion of the evaluation was to determine the positive benefits of the CARE Project specifically from the Māori perspective and any adjustments required to inform future implementation of the programme in other areas Key findings Contextual information: Culture, cultural identity formation and life experiences (coping with life changes, bereavement) influenced ageing, living circumstances and health care needs. Multiple and complex health issues were common and the need for medical and psychosocial support was critical to support ageing and well-being. Invitation to participate in CARE Project: Most kaumātua recalled being invited to participate in the CARE Project by a Practice Nurse or GP at their local clinic. Most could recall the aims (rationale) for the programme but they could not recall being given specific written information nor did they have a clear understanding about the CARE Project s selection criteria or processes. CARE Project s thorough assessment: Participants recalled having a health assessment (thorough exploration of their physical and mental health and wellbeing) by a Practice Nurse or GP. The length of time, assessment content and questions were found to be appropriate. However, participants were generally 202

203 CARE Project Progress Evaluation Report August 2018 unaware that a health care plan was formulated nor did they discuss or view an actual care plan with their health provider. Strengths of the CARE Project: A key strength was the longer length of appointment times and the high level of whanaungatanga (relationships and connections) that resulted between nurses, GPs and kaumātua. This led to a greater sense of care partnership between the health provider and the older person. The extra time provided a greater opportunity for health providers to ask questions and to really listen to the older person. Whānau also felt included in the process. Greater understanding of the elder person s health needs and circumstances resulted. Participants felt heard and were more confident to take responsibility for their own health. Timely, appropriate referrals resulted from longer assessments Recommendations Future adjustments to support Māori through the CARE Project 1. Kaumātua are part of a broader whānau system of care, therefore, consulting whānau about their involvement early in the selection process would help to ensure those who are in most need benefit from the programme. 2. Participants identified a critical need to assist rural whānau to take part in this programme in the future as the high financial costs associated with seeking medical assistance and transport issues prevent rural kaumātua from accessing health care. 3. Written information is needed during the recruitment phase to help kaumātua understand the CARE Project s selection criteria, aims and processes prior to commencing involvement. 4. New assessment content was suggested; this includes guided conversations about coping with change and ageing. 5. Written care plans should be verbally discussed and shared with kaumātua and their whānau to ensure they have a good understanding of their health concerns, changes and ongoing improvements to increase their personal health literacy. See Appendix B for the full Māori participants report. 203

204 CARE Project Progress Evaluation Report August Preliminary health outcomes The following section outlines a summary of initial outcome results of the CARE Project using key uncontrolled before and after Partners In Health scale and CARE Project Assessment data. A fuller outcome evaluation of the pilot will be completed by December Partners in Health self-management assessment tool pre/post results One of the main objectives of the CARE Project is to promote self-management for older adults at risk of health decline. The Partners in Health 1 scale was collected at baseline and at the 12-month intervals for most patients to indicate any improvement in self-management confidence and ability. The Partners in Health 2 (PIH) scale is a 12 item generic tool to assess patients current self-management ability. The patient was asked to indicate for each PIH question their self-management ability on a 0-8 Likert-type scale. Baseline and follow up Partners in Health assessment results were evaluated using repeated measures ANOVA univariate analysis. The individual item scores are outlined in Table 6 and Appendix 1 includes the full the PIH scale. 8.3 Table 6: Partners In Health results Partners in Health Item N 1 st assessment Mean Score 1. Overall, what I know about my health condition/s is: 2. Overall, what I know about my medication/s & treatment/s for my health condition/s is: 3. I take medications or carry out the treatments asked by my healthcare team 4. I share in decisions made about my health condition/s with my healthcare team 5. I am able to deal with health professionals to get the service I need that fit with my culture, values and beliefs 6. I attend appointments as asked by my healthcare team 7. I keep track of my symptoms and early warning signs (e.g. blood sugar levels, peak flow, weight, shortness of breath, swelling, pain, sleep problems, mood) 8. I take action when my early warning signs or symptoms get worse 9. I manage the effect of my health condition/s on my daily physical activities (e.g. walking, hobbies & household tasks) 10. I manage the effect of my health condition/s on how I feel (i.e. my emotions and spiritual wellbeing) 2nd assessment Mean Score (1.63) 6.42(1.47).001* (1.71) 6.49(1.55).000** (1.11) 7.72(.90).008* (1.48) 7.38(1.19).000** (1.39) 7.49(1.09).000** (.82) 7.83(.60) (1.31) 7.01(1.35) (1.29) 7.01(1.34) (1.87) 6.32(1.73).013* (1.64) 6.49(1.56).010* P 2 Battersby M, Alex A, Reece M, Markwick M, Collins J. (2003) The Partners in Health scale: The development and psychometric properties of a generic assessment scale for chronic condition selfmanagement. Australian Journal of Primary Health 9,

205 CARE Project Progress Evaluation Report August a. I manage the effect of my health condition/s on my social life (i.e. how I mix and connect with others and in my personal relationships) (1.77) 6.63(1.62).031* 11b. I have enough support from my family/whānau or carers to manage my health (1.44) 7.22(1.36).000** 12. Overall I manage to live a healthy lifestyle (e.g. I don t smoke and I am not a heavy drinker, I eat healthy food, do regular physical activity, manage my stress and sleep well) (1.53) 6.70(1.55).016* *= p<0.05, **p<0.001 For questions 1 and 2 the scale is: 0 = very little, 4 = something, and 8 = a lot. For questions 3 through 8 and 11b the scale is: 0 = never, 4 = sometimes, and 8 = always. For questions 9,10, 11b and 12 the scale is: 0 = not very well, 4 = fairly well, and 8 = very well. 8.3 The PIH also has subscales to assess separate domains of self-management as follows: The knowledge domain includes items 1,2,4, and 8 (maximum score 32) The coping domain includes 10, 11a, 11b, and 12 (maximum score 32) The health management domain includes questions 6, 7 and 9 (maximum score 24) The adherence domain includes questions 3 and 5 (maximum score of 16). The maximum score for the entire scale is 104. A higher score indicates more patient selfmanagement confidence and ability. Overall, the baseline and one year follow-up assessment of patient perceived self-management skills improved. This included a significant improvement in the total PIH tool score pre and post CARE intervention assessment, as well as for sub-categories of knowledge, coping, management and adherence. (see Table 7 for subscale and total score results). Table 7: Partners In Health sub-scale domain results n 1 st assessment 2 nd assessment P value Eta Knowledge (4.79) 27.35(4.01) Coping (4.73) 27.19(4.64) Management (3.15) 20.95(2.90) Adherence (2.23) 15.21(1.59) *Scale Total (12.27) 90.72(10.79) * scale range In conclusion, CARE pre/post data from the Partners In Health scale indicates statistically significant improvements in the patients knowledge of their conditions and treatments, ability to cope, management of symptoms and adherence to treatment. 205

206 CARE Project Progress Evaluation Report August Assessment pre/post data Included in this summary of the CARE Project Assessment data are participants that completed the baseline assessment and a follow up assessment a year later and for which data was available at the time of extraction from the Shared Care database (May 2018). A fuller summary of the full cohort will be provided in the December 2018 report. Demographics Of the 618 CARE participants that completed baseline and post intervention assessments, the mean age was 82.4 years (range was years). Figure 2 shows the gender distribution of the participants. 47% participants reported living with a partner and 42% lived alone. Participant reported accommodation showed 64% owned their home or apartment, 10% rented their home or apartment. And 21% of participants lived in a retirement village. 8.3 Figure 2: Gender distribution of participants with a baseline and follow-up assessment after one year Female 59% Male 41% Perceptions of health Participants were asked to rate their perception of health. This question has been shown to be highly correlated with healthcare utilization and quality of life. Interestingly, there was no difference in perception of health at baseline and follow-up after one year of the intervention (see Figure 3 below). Figure 3: Participant perception of health at baseline and follow-up assessment after one year Perception*of*Health* 70. 0% 60. 0% 61.3% 61.4% 50. 0% 40. 0% 30. 0% 24.5% 25.3% 20. 0% 10. 0% 9.6% 8.9% 4.6% 4.4% 0. 0% Ex cellent Good Fair Poor Initial assessment Second assessment p"="

207 CARE Project Progress Evaluation Report August 2018 Activities of daily living The participants reported significantly more difficulty with getting groceries, meal preparation, housework, dressing and toileting one year after the CARE intervention. This is not surprising since the mean age of participants was 82 years old at the baseline assessment and signals that the CARE cohort are frail and became frailer over the course of the CARE Project. The purpose of the CARE Project is to identify high needs older people at risk of physical or functional decline. It is interesting that overall the cohort data shows increasing functional impairment after one year. Systematically identifying the needs of the frail is an important focus of the CARE Project (see Table 8 below). Table 8: Activities of daily living comparison Instrumental Activities of Daily Living 1 st assessment 2 nd assessment P value Difficulty getting groceries 21.0% 25.9% p =.000** 8.3 Difficulty with meal preparation 15.2% 18.2% p =.012* Difficulty with ordinary housework 40.4% 45.0% p =.004* Difficulty with showering 9.0% 10.3% p =.163 Difficulty with dressing 4.8% 7.1% p =.017* Difficulty with toileting 1.5% 1.8% p =.754 *p<0.05, **p<0.001 Pain There were significantly fewer CARE participants reporting concerning pain one year post intervention. This is noteworthy since the most commonly addressed issue in care plans was pain (see Figure 4). Figure 4: Reported pain at baseline and follow-up assessment after one year 60% 50% 40% 30% 52% PAIN A CONCERN 47% 20% 10% 0% Baseline Assessment p= year follow up assessment Figure 5 (over page) shows the comparison of the severity of reported pain and follows the same pattern. The severity of all pain reduced, except for the severe category, however this is offset by the decrease in horrible or excruciating pain. The significant differences found in the baseline and annual assessment of pain. 207

208 CARE Project Progress Evaluation Report August 2018 Figure 5: Severity of reported pain at baseline and follow-up assessment after one year 40% 35% 30% 25% 20% 15% 10% 5% 0% 29% 35% 22% 18% Severity of Reported Pain Assessment 1 Assessment 2 28% 25% 16% 14% No Pain Mild Moderate Severe Horrible or excruciating 6% 5% 8.3 Medications Medication issues were assessed at baseline and one year post CARE intervention. There were significantly fewer participants that reported having questions or concerns about medications after one year of CARE intervention, and more were using medication blister packs to help manage their medications. These results align with the results of the Partners in Health medication questions two and three (refer to Section 5.1 above). Participants reported that they were significantly more confident with medications a year after the being part of the CARE intervention. See Table 9 below for the assessment data and Table 2 for Partners in Health results. Table 9: Medication management at baseline and one year post CARE intervention Medications 1 st assessment 2 nd assessment P value Do you have problems taking medications? 10.6% 1 0.4% p = 1.00 Do you have any concerns or questions about medications? 7.9% 5.8% p =.038* Do you use a blister pack? 15.4% 18.3% p =.008* Are you taking over the counter or complementary/alternative medicines? 45.0% 43.6% p =.412 Driving More participants reported continuing drive a vehicle after one year of the CARE intervention than at the baseline assessment. There were also fewer reported family concerns about participants driving and accidents than at baseline although these results did not reach statistical significance (see Table 10 below). Table 10: Reported driving experience at baseline and one year post CARE intervention Driving 1 st assessment 2 nd assessment P value Has not driven in the last three months 71.6% 68.7% p =.017* Reports that family has concerns about driving medications? 10.7% 7.3% p =.003* Reports driving accident in the last three months 5.2% 3.6% p =

209 CARE Project Progress Evaluation Report August 2018 Social isolation Although social isolation is a significant issue for frail older people, there was little change in reported isolation from baseline and the annual assessment. There were fewer reports of physical, emotional or financial abuse, though these were not statistically significant differences (see Table 11 below). Table 11: Social Isolation and abuse at baseline and one year post CARE intervention Social Issues 1 st assessment 2 nd assessment P value Reports feeling lonely or socially isolated 20.8% 20.1% p =.665 Reports being physically threatened or hurt? 0.7% 0.3% p =.250 Reports being emotionally harmed/abused 4.6% 3.6% p =.281 Report being financially abused 2.8% 1.6% p = Mood and sleep One of the most interesting results were changes in reported mood and sleeping issues from baseline to one year after the CARE intervention. A highly significant decrease in anxiety was found, as well as significantly decreased reports of depression. This may be related to the reports of participants feeling more supported by the practices found in the qualitative interviews with CARE participants (see Table 12 below). Table 12: Mood and Sleep at baseline and one year post CARE intervention Mood 1 st assessment 2 nd assessment P value Reports feeling anxious or restless 34.8% 28.8% p =.001* in the last 3 months Reports feeling sad or depressed 49.0% 45.2% p =.048* in the last 3 months Reports sleep problems 44.0% 41.1% p =.093 Gastrointestinal and urinary issues Participants reported a non-significant decrease in abdomen discomfort and urinary burning and/or discomfort after one year. There was also a sizeable decrease in bowel issues of such as constipation and diarrhoea, although this also did not quite reach statistical significance. There was no change in urinary and bowel incontinence (see Table 13 below and Table 14 over page). Table 13: Gastrointestinal and urinary issues at baseline and one year post CARE intervention Gastrointestinal/Urinary Issues 1 st assessment 2 nd assessment P value Lower abdomen pain/discomfort 15.4% 13.2% p =.119 Bowel issues such as constipation or diarrhoea 34.3% 30.9% p =.055 Urinary burning and/or frequency 25.6% 24.0% p =.358 Urinary Incontinence 35.7% 35.3% Frequency of urinary incontinence Never 64.3% 64.7% Occasionally (1 to 2 times per week) 21.3% 20.7% Frequently (> once in the last 3 days) 4.0% 3.5% Daily 10.5% 11.1% p =.842 p =

210 CARE Project Progress Evaluation Report August 2018 Table 14: Bowel incontinence at baseline and one year post CARE intervention Bowel Incontinence 1 st assessment 2 nd assessment P value Never 90.5% 90.7% p =.913 Occasionally (1-2 times per week) 7.8% 7.8% Frequently (> once in the last 3 days) 1.0% 0.7% Daily 0.7% 0.8% Although there was no difference in reported urinary or bowel incontinence at baseline and one year post CARE interventions, there was an increase in the use of the incontinence products. This included a significant increase in the use of pull ups type products (see Table 15). 8.3 Table 15: Use of incontinence products at baseline and one year post CARE intervention Urinary Continence Product Use 1 st assessment 2 nd assessment P value Uses incontinence products 26.6% 28.1% p =.272 Urinary pads (excludes panty liners) 24.7% 26.1% p =.322 Pull ups 4.0% 5.7% p =.022* Weight There were no reported changes in weight gain or loss over the year. However, there were significantly fewer reports of biting and chewing issues. Paradoxically there were significantly more reports of decreased appetite over the year with less participants reporting a very good appetite and more participants reporting a fair appetite (See Table 16). Table 16: Weight and appetite changes at baseline and one year post CARE intervention Nutrition 1 st assessment 2 nd assessment P value Reports gaining or losing weight in the last 3 months 35.8% 34.7% p =.668 Reports difficulty biting or chewing 15.9% 11.9% p =.000* Appetite p =.004* Very Good 21.4% 18.4% Good 61.8% 61.4% Fair 14.3% 17.8% Poor 2.5% 2.4% Falls Participants reported fewer falls after a year of the CARE intervention, although this was not a statistically significant difference. The reported decrease in falls may be related to the significantly higher use of mobility aids reported by participants (see Table 17 over page). 210

211 CARE Project Progress Evaluation Report August 2018 Table 17: Comparison of falls and the use of mobility aids at baseline and one year post CARE intervention Mobility/Falls 1 st assessment 2 nd assessment P value Reports falling in the last three months 20.2% 18.9% p =.521 Reports balance problems 50.4% 50.4% p = 1.00 Uses mobility aids 31.9% 38.2% p =.000** Type of aids (percent of those using mobility aids) Walker 32.6% 31.2% p =.690 Walking stick 65.1% 66.5% p =.690 Wheelchair 2.3% 2.3% p = Timed Up and Go Decreased gait speed after one year of the CARE intervention was rather unexpected since there were fewer reported falls by participants. However, these results were not statistically significant and could be due to the reported increase in the use of mobility aids (see Table 18). Table 18: Comparison of gait speed at baseline and one year post CARE intervention Timed Up and Go 1 st assessment 2 nd assessment P value Under 14 seconds 63.1% 61.1% p = seconds 28.6% 31.6% (14 and above indicates falls risk) seconds 6.4% 5.8% 31 seconds and over 1.9% 1.6%) Enduring Power of Attorney There was a significant increase in CARE participants reportedly designating an Enduring Power of Attorney (EPOA) for health and welfare. There was also a significant increase in the GP practice obtaining a copy of the EPOA (see Table 19 below). Table 19: Designation of Enduring Power of Attorney at baseline and one year post CARE intervention Advanced Care Planning 1 st assessment 2 nd assessment P value Designated Enduring Power of Attorney (EPOA) 63.6% 69.8% p =.000** Health & Welfare EPOA Status p =.105 Not documented 23.7% 21.8% Documented but not activated 60.2% 60.2% Documented and activated 16.1% 18.0% Copy at the practice? 1.8% 3.9% p =.002* Documented advanced care plan 6.3% 5.7% p =

212 CARE Project Progress Evaluation Report August 2018 Discussion and conclusions The CARE Project is a complex primary care intervention that implements a new model of care for identified high risk older people enrolled in the General Practices involved in the pilot project. The project is showing promising initial results. Outlined in this report is a summary of the progress to date pending a full outcome evaluation that will be presented to the Board in December In summary the report describes: What has been delivered to date A summary of the cohort A summary of an external evaluation Some initial outcome data Areas for improvement and next steps pending the full outcome evaluation. 8.3 Overall, there are strong initial indicators that the CARE Project is succeeding in delivering an innovative model of care that enhances the care and outcomes of older people living in their homes. It has demonstrated a high level of general practice team acceptability, high patient, including Māori patient and whānau, acceptability, and is achieving positive outcomes for participants. Further evaluation of outcomes is scheduled to be completed by December 2018 that will report on any quantifiable impact on hospitalisations, Aged Residential Care placements, and overall cost benefit across primary and secondary care. Summary of learning The CARE Project has provided significant learning relevant for the planning, engagement and implementation of any project working with General Practice. These learnings will be able to be applied to future primary care based programmes targeting older people or other populations, such as people with long term conditions. For any primary care based project to succeed, the clinical model of care and business model need to align. Success factors identified through this project include: It has to be a real problem for primary care and involve systems and processes that fit the individual General Practice work flow Taking a long term commitment (i.e. 10 year time frame) to project development enables changes in models of care while minimising the business risks allowing flexibility of timeframes for practice implementation to fit in with pressure of day to day General Practice workload Staging implementation and working with engaged General Practices, facilitating a practice team (doctors, nurses and practice manager/administrators) approach; and sharing learning between practices/facilitating cross fertilisation is important Having a dedicated budget for project implementation/practice time that reflects true costs is an important enabler along with a clear project structure Utilising a model of care focused on holistic/patient centred care is complex and requires greater team work, clear understanding of roles, effective communication, flexibility and individualised practice problem solving, including a commitment to learn from mistakes and being open to change Empowerment of nurses is critical for providing care for highly complex patients in a sustainable manner; this requires time and space within the practice, professional supervision sessions/patient specific review sessions to increase nursing skills and knowledge, and dedicated workforce development opportunities for knowledge sharing, networking, and building greater understanding of community based services. 212

213 CARE Project Progress Evaluation Report August 2018 Key areas for short to medium term improvement Based on work to date the following key changes are in process as outlined in Table 20 below. Table 20: Current areas being explored to enhance KARE Area for Activity to date improvement Flexible patient Flexibility will be built into an updated enrolment and PMS tool in relation to work flow disenrollment Details and a full proposal in process of based on frailty being developed for practice and DHB and need agreement More efficient and integrated Assessment/Care Planning More fit for purpose PMS tool integrated into the PMS Workforce development GNS role and integration with practice workflow Review and revision of the assessment template and how to better integrate into PMS and work flow completed Review of care planning and investigation of more efficient process that streamlines planning, accessing resources, setting tasks and providing summary to patient completed Review and development of components noted above along with overall flow Liaison with PMS vendors to determine approach to development/integration into PMS Proposal in development Draft nursing workforce development framework developed, but requires further work-up Ongoing practice support and workforce development factored into new contracts GP training to be developed GNS role review complete and implementation in process from July 2018 Trial of GNS-Practice use of Specialist Advice Only function in ereferrals in process Timeline Some flexibility to be introduced from July 2018 under new contract Full model to be negotiated and recommendations included in December 2018 Board report Available later in 2018 (dependent on PMS tool development see below) Working to being available by late 2018 Training plan for 2018/19 established by September 2018 Final draft nurse workforce development framework by October/November 2018 Recommendations for nurse workforce development to be included in December 2018 Board report GNS role and monthly meetings with practice nurses to commence from August 2018 Annual (or as required) reviews of the model 8.3 Primary and secondary care interface Stakeholder review of interface completed Ongoing liaison to improve interface Ongoing Include key recommendations in December 2018 Board report 213

214 CARE Project Progress Evaluation Report August 2018 Area for improvement Funding model and business model Activity to date Options explored with practices Initial discussions with PHOs Rollover of funding for 3 years and 3 months agreed and in process Timeline Develop proposal and/or options for feedback by practices by October 2018 New model to be negotiated and recommendations included in December 2018 Board report Conclusion This report provides a summary of the CARE Project pilot implementation to date ahead of a final evaluation report due in December The CARE Project is a complex primary care intervention that involves a model of care facilitated by the nine General Practices involved in the pilot project. 8.3 Overall, there are strong initial indicators that the CARE Project has delivered an innovative model of care that enhances the care of older people living in their homes. The project has a high level of general practice team acceptability, and high patient, including Māori patient and whānau acceptability, and is achieving positive outcomes for participants. Further evaluation of these outcomes scheduled to be completed by December 2018 will determine the level of success, especially any quantifiable impact on hospitalisations, Aged Residential Care placements, and overall cost benefit across primary and secondary care. The CARE Project has provided significant learning relevant for the planning, engagement and implementation of any project working with General Practice. These learnings will be able to be applied to future primary care based programmes targeting older people or other populations, such as people with long term conditions. 214

215 8.4 Values Programme Update Recommendation: That the report be received. Prepared by: Jarrard O Brien (Associate Director, Institute for Innovation and Improvement) Endorsed by: Dr Dale Bramley (Chief Executive) 1. Executive Summary 8.4 The revised Values Programme Charter was approved by the Board in March 2018 with a request that the Board be updated every six months. Since that time an implementation plan has been developed and a summary of activity is provided in this report including: Campaign 1 - Pink Shirt Day Campaign 2 Compassion Campaign Campaign 3 Hello my name is Leadership development session for provider arm senior managers Inaugural Matariki Awards Health Literacy Symposium 2. Strategic Alignment Community, whānau and patient centred model of care Emphasis and investment on both treatment and keeping people healthy Service integration and/or consolidation Intelligence and insight Evidence informed decision making and practice The values programme uses feedback from patients and staff to measure whether we are living up to our promise and values. In this way, patients are central to driving changes in our workplace culture, and through this, models of care. The Values Programme is essentially about behaviour, and a continual drive towards behaviours we love to see. Evidence shows that patients who report a positive experience also have better health outcomes, for example, less anxiety, less pain, and reduced length of stay. Better patient experience is correlated with positive staff experience and engagement. The values programme addresses both of these needs, working to ensure that both our staff, and the community are healthy and happy. Key to the values programme is a focus on healthy teams. This requires looking across traditional or structural boundaries and getting people working better together. The values programme generates insights at multiple levels to inform organisational and cultural change. The values programme is based on latest evidence, and the activities within the programme are defined, and prioritised according to evidence of organisational need, reported through patient and staff feedback. 215

216 Operational and financial sustainability The Values Programme has the potential to contribute towards operational and financial sustainability by ensuring that staff are happy and engaged in their roles, reducing absence and attrition. As above, positive staff engagement is correlated with better patient experience, which in turns relates to improved outcomes, such as less pain, reduced length of stay, increased likelihood to selfmanage; all of which have operational and financial benefits to the organisation. 3. Introduction/Background 8.4 In March 2018 the Board approved the revised Values Programme Charter. This report provides a summary of activity supported by the values programme, including: Pink Shirt Day Organisational campaign around compassion Leadership development session for provider arm senior managers Inaugural Matariki Awards Health Literacy Symposium Hello my name is campaign 4. Progress/Achievements/Activity 4.1. Intranet pages updated The values pages on the intranet have been revised to ensure staff have easy access to up-to-date information about the values programme and are able to follow organisational campaigns. A generic address (livethevalues@waitematadhb.govt.nz) and hashtag (#ivethevalues) were created to foster ongoing engagement using social media. The address is working well with staff sending in requests for posters and values appreciation cards, as well as submitting feedback and suggestions Pink Shirt Day (18 May 2018) Pink Shirt Day was a national campaign to foster positive social relationships, celebrate diversity and to stop bullying. Alongside this the bullying and harassment policy was updated and information to support staff to speak up about bullying behaviours was created from the excellent Speak Up materials at Auckland DHB. These are currently being designed and are due for release this month. 216