hospital advisory committee (hac) meeting 5 june 2019 · 6/5/2019 · • director, sport new...

Counties Manukau District Health Board – Hospital Advisory Committee 5 June 2019

HOSPITAL ADVISORY COMMITTEE (HAC) MEETING 5 June 2019

Venue: Boardroom, Otara Spinal Unit, 30 Bairds Road, Papatoetoe, Auckland

Time: 1.30pm

Committee Members Dr Lyn Murphy – Committee Chair Catherine Abel-Pattinson – Deputy Chair (via conference call) Dr Ashraf Choudhary – CMDHB Board Member Colleen Brown – CMDHB Board Member Dianne Glenn – CMDHB Board Member George Ngatai – CMDHB Board Member Kylie Clegg – CMDHB Board Member

CMDHB Management Margie Apa – Chief Executive Dr Gloria Johnson – Chief Medical Officer Dr Jenny Parr – Chief Nurse and Director of Patient and Whaanau Experience Sanjoy Nand – Chief of Allied Health, Scientific & Technical Professions (Apologies) Avinesh Anand – Deputy CFO Provider (Apologies) Dr Kate Yang – Executive Advisor, CEO’s Office

Teresa Opai – Secretariat APOLOGIES 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 I – Items to be Considered in Public Meeting

1.30pm TOUR OF OTARA SPINAL UNIT – Dana Ralph-Smith, General Manager ARHOP

2.30pm 1. AGENDA ORDER AND TIMING Page

1.1 Attendance Schedule 1.2 Disclosure of Interests 1.3 Specific Interests

03 04 07

2.35pm 2. CONFIRMATION OF MINUTES

2.1 Minutes of the Hospital Advisory Committee Meeting – 2 May 2019 2.2 Action Items Register 2.3 Hospital Advisory Committee Work Plan

08 17 20

3. PROVIDER ARM PERFORMANCE REPORT

2.45pm 2.55pm 3.05pm 3.15pm

3.1 Executive Summary (Margie Apa) 3.2 Balanced Scorecard (Margie Apa) 3.3 Hospital Services Project Portfolio Overview (Margie Apa) 3.4 Financial Results – CMDHB Provider Arm (Avinesh Anand)

21 39 42 46

3.20pm Afternoon Tea


4. CORPORATE REPORTS Page

3.30pm 3.35pm 3.40pm 3.40pm 3.50pm 4.00pm

4.1 Patient Experience & Safety Report (Dr David Hughes via conference call) 4.1.1 Safety, Experience, Compliance and Measurement Dashboard 4.1.2 Safety, Experience, Compliance and Measurement Dashboard Variance Report 4.1.3 Inpatient Experience Snapshot Report

4.2 Patient Flow – Every Hour Counts Update (Mary Seddon via conference call) 4.3 CM Health Child Healthy Weight Evaluation Update (Alanna Soupen, info only) 4.4 Hospital in the Home (Penny Magud) 4.5 Corrective Action Update (Jenny Parr) 4.6 ARHOP Deep Dive - Presentation (Dana Ralph-Smith)

51 52 57 58 65 72 79 81 90

4.30pm 5. INFORMATION PAPERS (FOR NOTING ONLY)

5.1 Facilities, Engineering and Asset Management (Anton Venter) 5.2 Emergency Department, Medicine and Integrated Care (Brad Healey) 5.3 Surgery, Anaesthesia and Perioperative Services (Mary Burr) 5.4 Central Clinical Services (Ian Dodson) 5.5 Women’s Health and Kidz First (Nettie Knetsch) 5.6 Adult Rehabilitation and Health of Older People (Dana Ralph-Smith) 5.7 Integrated Mental Health and Addictions (Tess Ahern) 5.8 Middlemore Central (Ian Dodson, Dr David Hughes)

98 103 112 118 126 137 141 146

4.35pm 6. RESOLUTION TO EXCLUDE THE PUBLIC 150

Counties Manukau District Health Board - Hospital Advisory Committee 5 June 2019

BOARD MEMBER ATTENDANCE SCHEDULE – HAC 2019

Name 29 Jan (Tues)

13 March

2 May (Thurs)

5 June 17 July 28 Aug 9 Oct 20 Nov

Dr Lyn Murphy (Chair)

No

Mee

ting

No

Mee

ting

No

Mee

ting

Catherine Abel-Pattinson (Deputy Chair)

Dr Ashraf Choudhary -

Dianne Glenn

George Ngatai

Kylie Clegg

Colleen Brown


HOSPITAL ADVISORY COMMITTEE DISCLOSURE OF INTERESTS

5 June 2019

Member Disclosure of Interest

Dr Ashraf Choudhary

• Board Member, Otara-Papatoetoe Local Board • Member, NZ Labour Party • Chairperson, Advisory Board Pearl of Island Foundation • Co-Patron, Bharatiya Samaj Charitable Trust

Catherine Abel-Pattinson • Board Member, Health Promotion Agency • Board Member, healthAlliance. • National Party Policy Committee Northern Region • Member, NZNO • Member, Directors Institute • Husband (John Abel-Pattinson), Director, Blackstone Group Ltd • Husband, Director, Blackstone Partners Ltd • Husband, Director, Bspoke Ltd • Husband, Director, 540 Great South Ltd • Husband, Director, Barclay Suites • Husband, Director, various single purpose property owning

companies • Co-Chair, National Party Health Policy Committee

Colleen Brown • Chair, Disability Connect (Auckland Metropolitan Area) • Member, Advisory Committee for Disability Programme

Manukau Institute of Technology • Member, NZ Down Syndrome Association • Husband, Determination Referee for Department of Building

and Housing • Director, Charlie Starling Production Ltd • District Representative, Neighbourhood Support NZ Board • Chair, Rawiri Residents Association • Director and Shareholder, Travers Brown Trustee Limited


Member Disclosure of Interest

Dianne Glenn • Member, NZ Institute of Directors • Life Member, Business and Professional Women Franklin • Member, UN Women Aotearoa/NZ • President, Friends of Auckland Botanic Gardens and Chair of

the Friends Trust • Life Member, Ambury Park Centre for Riding Therapy Inc. • Member, National Council of Women of New Zealand • Justice of the Peace • Member, Pacific Women’s Watch (NZ) • Member, Auckland Disabled Women’s Group • Life Member of Business and Professional Women NZ • Interviewer, The Donald Beasley Research Institute for the

monitoring of the United Nations Convention on the Rights of Persons with Disabilities.

George Ngatai • Director, Transitioning Out Aotearoa • Director, The Whanau Ora Community Clinic • Chair, Safer Aotearoa Family Violence Prevention Network • Huakina Development Trust (Partnership Clinic) • Lotteries Community (Auckland) • Board Member, Counties Manukau Rugby League Zone • Member, NZ Maori Council • Director & Shareholder, BDO Marketing & Business Solutions

Limited (TBC) • Director & Shareholder, Ngatai Bhana Limited • Director & Shareholder, Family Care Limited • Member, Restorative Justice Aotearoa

Kylie Clegg • Deputy Chair, Waitemata District Health Board • Trustee (ex officio) - Well Foundation (charity supporting

Waitemata District Health Board) • Director, Auckland Transport • Director, Sport New Zealand • Director, High Performance Sport New Zealand Limited • Trustee & Beneficiary, Mickyla Trust • Trustee & Beneficiary, M&K Investments Limited (includes a

share of less than 1% in Orion Health Group). Orion Health Group has commercial contracts with Counties Manukau District Health Board and healthAlliance.


Dr Lyn Murphy • Director and Shareholder, Bizness Synergy Training Ltd

• Director and Shareholder, Synergex Holdings Ltd • Trustee, Synergex Trust • Member, International Society of Pharmacoeconomics and

Outcome Research (ISPOR NZ) • Member, New Zealand Association of Clinical Research

(NZACRes) • Senior Lecturer, AUT University School of Inter professional

Health Studies • Member, Public Health Association of New Zealand


HOSPITAL ADVISORY COMMITTEE MEMBERS’ REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS

Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 5 June 2019 Director having interest Interest in Particulars of interest Disclosure date Board Action Dr Lyn Murphy

Allied Health Initiative for Education & Development (AHIED)

Senior Lecturer, AUT School of Inter-Professional Health Studies

30 November 2016

8 March 2017

That Dr Murphy’s specific interest be noted. The Committee agreed that she may remain in the room and participate in any discussion but be excluded from any voting, if applicable.

Catherine Abel-Pattinson Whaanau Accommodation Options at MMH

Catherine’s husband owns a business that has hotel/motels in the Counties Manukau catchment area that are from time to time used for CM Health or WINZ clients.

4 April 2018 That Catherine Abel-Pattinson’s specific interest be noted and that the Board agree that she may remain in the room and participate in any deliberations, but be excluded from any voting.

Counties Manukau District Health Board – Hospital Advisory Committee - Public

Minutes of Counties Manukau District Health Board Hospital Advisory Committee

Held on Thursday, 2 May 2019 at 1.00pm Kidz First Seminar Room 2, Middlemore Hospital, Hospital Road, Otahuhu, Auckland

PART I – Items Considered in Public Meeting BOARD MEMBERS PRESENT

Dr Lyn Murphy (Chair) Catherine Abel-Pattinson (Deputy Chair) Dr Ashraf Choudhary Colleen Brown Dianne Glenn George Ngatai Kylie Clegg

ALSO PRESENT

Margie Apa (Chief Executive) Dr Gloria Johnson (Chief Medical Officer) Dr Jenny Parr (Chief Nurse and Director of Patient and Whaanau Experience) Sanjoy Nand (Chief of Allied Health, Scientific & Technical Professions) Avinesh Anand (Deputy CFO, Provider) Dr Kate Yang (Executive Advisor, CEO’s Office Teresa Opai (Secretariat) (Staff members who attended for a particular item are named at the start of their item)

WELCOME The tour of Kidz First commenced at 1.25pm. The meeting commenced at 2.15pm. Dr Murphy opened the meeting by expressing her thanks to Nettie Knetsch for the tour of Kidz First. APOLOGIES There were no apologies for this meeting. DISCLOSURE OF INTEREST/SPECIFIC INTERESTS The following Disclosures of Interest were noted for update: • Ms Clegg – amend reference to Orion per updated advised to Board. • Ms Brown – remove reference to Auckland Council Disability Advisory Panel and NZ Strategy and

Reference Group. • Ms Abel-Pattinson – add membership of Health Alliance Board. There were no Specific Interests to note regarding the agenda for this meeting.


1. AGENDA ORDER AND TIMING Agenda items were taken in the same order as listed on the agenda.

2. BOARD COMMITTEE MINUTES 2.1 Minutes of the Hospital Advisory Committee 13 March 2019

Resolution (Moved: Dianne Glenn/Seconded: Colleen Brown) That the Minutes of the Hospital Advisory Committee meeting held on 13 March 2019 be approved.

Carried

2.2 Action Items Register – Public

Noted. 2.3 Hospital Advisory Committee Work Plan

The report was taken as read.

The Chair requested that ‘draft’ be removed from the work plan.

Action: Secretariat to update Work Plan, removing the reference to ‘draft’. 3. PROVIDER ARM PERFORMANCE REPORT 3.1 Executive Summary (Margie Apa)

The report was noted and taken as read. 3.2 Balanced Scorecard (Margie Apa)

The report was noted and taken as read. 3.3 Hospital Services Project Portfolio Overview (Margie Apa)

The report was noted and taken as read. 3.4 Finance Report (Avinesh Anand)

The report was noted and taken as read. 3.4.1 Non Resident Bad Debt Summary (Avinesh Anand)

The report was noted and taken as read.

Resolution (Moved: Lyn Murphy/Seconded: Catherine Abel-Pattinson) That the Hospital Advisory Committee: Note and receive the reports.

Carried


4. CORPORATE REPORTS 4.1 Patient Experience and Safety Report (Dr David Hughes)

The report was taken as read. 4.1.1 Safety, Experience, Compliance and Measurement Dashboard

The report was taken as read. 4.1.2 National Patient Experience Survey Results


Dr Hughes provided key points: • Internal inpatient experience survey received 346 responses, mostly from maternity. • Overall care rating of 86%. • Still looking at a target for complaint resolution – in discussion with other DHB’s about how

they set their targets. Australian standard is 35 working days. • Patient Experience report released today. CM Health is tracking about the same as the NZ

average with no red zones this quarter. 4.1.3 QSM Local Report


Dr Hughes noted that the only red spot is around the timing of antibiotics but there has been a lot of work with the anaesthetists, particularly around hip replacements and the new electronic record used through the operation to more consistently note down the time the operation commenced compared with the time the antibiotics were given.

Dr Parr advised that CM Health has been accepted by the Health Quality and Safety Commission as a pilot site for a new QSM for Consumer Council.

Resolution (Moved: Lyn Murphy/Seconded: Colleen Brown) That the Hospital Advisory Committee: Note and receive the reports.

Carried

4.2 Patient Flow – Every Hour Counts Portfolio Report (Dr Mary Seddon)


Dr Seddon provided key points: • Patient flow pressure continues across the five acute flow working groups - ED, bed utilisation,

discharge planning, community services and MRI. MRI has reduced the waiting list during April by around 500.

• Proactive discharge planning needs home-base wards in medicine and a system that can capture bed vacancies. Medical representation at the huddles is important. Workaround in place for bed numbering for TrendCare but this will not work for patient flows. Need IPM upgrade scheduled for end of year.

• Since introducing the requirement to list the name of the multi-drug resistant organism when requesting an Isolation Room Clean (previously called Terminally Clean), usage has reduced.


• Staff have been coping with the demand pressures for 12-18 months. • Early work with click process shows people are engaged. Dr Parr advised that recent feedback from nurses indicates they are keen to get flow working but waiting on consultation around medical rostering so it can happen. Nurses expressed that they have a connection with the people at CM Health and feel they are providing value but want more time to do a good job and feel constrained with what they can deliver.

Resolution (Moved: Lyn Murphy/Seconded: Dr Choudhary) That the Hospital Advisory Committee: Note and receive the report. Carried

4.3 Response to Action Item 3.2 January 2019 HAC - Balanced Scorecard (Brad Healey)


Mr Healey provided key points: • Rate of presentations to ED from persons aged 75 years or older has increased slightly, and in

line with population growth. • DNA rate overall is higher than ideal, but more concerning in Maaori (double) and Pacific

(triple) than the other groups. • Experiments and trials indicate single biggest influencer to patients attending appointments is

having an EN or RN make contact with the patient in advance of the appointment. However, this is labour intensive and creates a resourcing issue.

• Survey being collated on Maaori and Pacific patients. Early themes suggest appointments are not suitable, have multiple appointments and need to link appointments so patient can come once rather than multiple times, affordability (time off work). Transport is not as big an issue as previously thought.

Mr Ngatai noted having people that look and sound like our patients will get a response from our patients, and talking about the relationship rather than the appointment.

Resolution (Moved: Lyn Murphy/Seconded: Ms Brown)

That the Hospital Advisory Committee:

Note and receive the report.

Carried

4.4 Women’s Health – Presentation (Nettie Knetsch, Thelma Thompson, Dr Sarah Tout)

Ms Knetsch provided a presentation to the meeting. Key points: • 3% increase in births in hospital with 5% decrease at Primary Birthing Unit. • Total number of births YTD down 1% from FY17/18. • Increase in complexity of births reflected in increased Caesarean section, induction of labour,

epidurals used, diabetes in pregnancy and transfers to Neonatal Unit.


• Primary Birthing unit is used extensively for post natal stay. • Phased 3-stage implementation plan to address capacity and workforce shortages are in place.

4.5 Smokefree Policy Update (Basil Fernandes, Dr Sarah Sharpe, Dr Gary Jackson)


Dr Sharpe, Public Health Physician, advised the Ministry of Health and CM Health’s Smokefree Team were proposing a risk proportionate approach. She acknowledged that there is not enough known about the harms of vaping at this point, but there is clear evidence that for those that smoke, it is far better for them to vape. Eleven percent are much more likely to quit successfully with vaping than with a nicotine patch. The DHB is well off target for reaching their Smokefree goals for Maaori and Pacific, and vaping could be used to change the trajectory. The Smoke Environment Act does not cover vaping so it is currently legal to supply to under 18’s. This is expected to be revised later in the year.

Mr Fernandes advised that the Ministry has strongly recommended the DHB come up with a policy to include vaping as soon as possible.

An extended discussion took place with many of the Committee strongly opposed to the proposed changes to the existing policy.

Views of Committee members included: • Ms Clegg noted the current policy states ‘DHBs could allow vaping in outdoor spaces if they so

choose’. The biggest issue is of younger people getting into vaping, so why would the DHB look to change the policy?

• Ms Able-Pattinson advised she was strongly against introducing vaping for a range of clinical reasons. The DHB runs the risk of the public asking why they have allowed vaping and assuming it is endorsing it as being safe. She had read the World Health Organisation does not support vaping.

• Dr Choudhary advised he was totally opposed to vaping. • Mr Ngatai noted that people are vaping in public spaces and the proposed change to the policy

is to create an environment to support patients in their journey. He acknowledged that the Board would need to work with Facilities to create an area that is not visible.

• Ms Glenn did not like vaping but acknowledged it was a tool to get people off cigarettes. • Ms Brown asked what response we as a Board should give to people vaping on site. Ms Brown

asked what are other DHBs were doing. Dr Sharpe responded that all DHB’s were working to address this. Vaping was raised at a recent WDHB Board meeting with the Board asking for more information to understand the nuances.

• Dr Murphy asked if vaping was covered under the current Smokefree policy. CM Health policy does prohibit e-cigarettes but does not mention the word vaping. She suggested that any change in the policy is deferred until the DHB receives a clear signal from the Government. Dr Sharpe responded that the view of the Ministry of Health was that vaping was an effective tool for current smokers who wish to switch over, in order to quit smoking.

Ms Apa advised that the context of the policy is to develop two sites in which people can vape, which can be controlled. The DHB is actively engaging with schools as health promoters, and view vaping as a tool to stop smoking. From an inpatient perspective, tools are limited and vaping would be an additional tool. The DHB is not proposing to promote vaping, but to use it as an additional support for smokers trying to quit. Ms Apa suggested to the meeting that the DHB approach this on a trial basis, collect data, and review after a year.


The Committee agreed that this matter be referred to the Board with HAC’s advice minuted, requesting background information about vaping, access to the evidence that informs the decision, and some options.

Resolution: Moved: Colleen Brown/Seconded: Catherine Abel-Pattinson That the Hospital Advisory Committee:

Refer the proposed changes to the Smokefree policy, including vaping on the hospital grounds, to the full Board for further discussion.

Carried

4.6 Fast Cancer Treatment (Anne-Marie Wilkins, Dr Jon Mathy, Dr Gary Jackson) Dr Mathy, Ms Wilkins and Dr Jackson provided a presentation to the meeting. Key points:

• CM Health population growing and aging, with 3.6% growth per annum in cancer by 2023. • Chemotherapy and radiotherapy volumes rising by 7% per annum. • Diagnostics and surgery is undertaken at Middlemore, with most patients going to Auckland for

chemotherapy and all for radiotherapy as per regional agreement. • CM Health has consistent not met the Faster Cancer Treatment target since June 2018 due to

enormous increase in volume, with capacity to meet demand unable to be realised. • There are several initiatives in place to try to achieve this target again. Goal is to report and

guide regional and local strategy to optimise cancer services. • Future focus is the optimisation of the patient journey, a regionally coordinated model of care

and resource requirements. • Cancer is the biggest killer of the NZ population. Survival is improving overall but not as fast as

in Australia. • Differences between NZ and Australia:

• Overall survival across every stream where NZ lags behind. • NZ behind in screening approach to catch patients at an earlier stage and access to

capacity overall. Auckland already at 100% capacity so unable to treat patients in a timely fashion.

• Access to drugs – too expensive for NZ to fund. • Public/Private split where 40-50% have private sector access but in CM Health it is 5-

10%. 4.7 Human Resources Report

The report was noted taken as read.

Resolution (Moved: Lynn Murphy/Kylie Clegg) That the Hospital Advisory Committee: Note and receive the report.

Carried

4.8 Auckland Regional Public Health Service – Nitrate Levels in Drinking Water



5. INFORMATION PAPERS 5.1 Facilities Service Report (Anton Venter)

The report was noted and taken as read. 5.2 Emergency Department Medicine Integrated Care (Brad Healey)

The report was noted and taken as read. 5.3 Surgery, Anaesthesia and Perioperative Services (Mary Burr)

The report was noted and taken as read. 5.4 Central Clinic Services (Ian Dodson)

The report was noted and taken as read. 5.5 Women’s Health and Kidz First (Nettie Knetsch)

The report was noted and taken as read. 5.6 Adult Rehabilitation and Health of Older People (Dana Ralph-Smith)

The report was noted and taken as read. 5.7 Integrated Mental Health and Addictions (Tess Ahern)

The report was noted and taken as read. 5.8 Middlemore Central (Ian Dodson, Dr David Hughes)


Resolution (Moved: Lynn Murphy/Seconded: George Ngatai) That the Hospital Advisory Committee: Note and receive the reports.

Carried

6. GENERAL BUSINESS 6.1 Update on Strike Management (Dr Gloria Johnson)

Overall, pleased with how things have gone to date, helped by a significant proportion of RMO’s (Registrars and House Officers) working through (67% of RMO’s: 80% of Registrars and 44% of House Officers). Unaware of any complaints to date and the general public have been incredibly understanding. The situation has been complicated by the stolen mail, with a very small number of patients turning up for appointments that had been cancelled. The long term impact will be the need to rebook clinics, with some services running Saturday and/or extended clinics. There will be a potential effect on revenue in relation to the elective surgeries, due to the necessity to delay more complex cases. Main concern is for those patients who have relatively infrequent appointments, ie: yearly appointments, as clinics are already full. Morale is good as coverage was well managed. Facilitation is scheduled to start next week and two facilitators have been appointed. The key issue seems to be that DHB would like changes to the process around introducing new rostering and how it runs, but the RDA has the right of veto which is seen as a fundamental problem. The Minister is fully informed and is supportive of the DHB’s position.


6.2 Certification Update (Jenny Parr) Comprehensive 4 days of auditing commencing 7 May. One set of evidence for continuous improvement around Fundamentals of Care has been submitted. Controlled documents down from 28% to 16%. Anticipate corrective actions reducing from 13 to 8. For the first time will be including an action around the safe staffing CCDM programme. Because we don’t have TrendCare implemented and don’t have data, we are expecting a corrective action. HAC members have been invited to the welcome session. The recent success of new Nurse Practitioners - Julena Ardern (Neonatal) and Bobbie Milne (Community Diabetes) were noted. Recently agreed that CNS’s in the Neonatal unit are to become Nurse Practitioners over time, which will grow our NP’s to about 10. Senior medical staff becoming getting interested in the opportunities this presents.

7. RESOLUTION TO EXCLUDE THE PUBLIC

Resolution (Moved: Dianne Glenn/Seconded: Catherine Abel-Pattinson)

That the Hospital Advisory Committee in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 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

Reason for passing this resolution

in relation to each item

Ground(s) under Clause 32 for passing this resolution

Public Excluded Minutes of 13 March 2019 and Actions

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(3)(g)(i))of the Official Information Act 1982. [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes As per the resolution from the public section of the minutes, as per the NZPH&D Act.

Strategy and Infrastructure Update


Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Committee to carry out, without prejudice or disadvantage, commercial activities.


General subject of items

to be considered Reason for passing this

resolution in relation to each item


Service Coverage for FY19/20 (Price Volume Schedule)


Commercial Activities The disclosure of information would not be in the public interest because of the greater need to enable the Committee to carry out, without prejudice or disadvantage, commercial activities.

Carried The Public Meeting closed at 4.34pm.

The next meeting of the Hospital Advisory Committee will be held on Wednesday 5 June 2019.

Signed as a true and correct record of Counties Manukau District Health Board’s Hospital Advisory Committee meeting held on 2 May 2019.

Dr Lyn Murphy Chair

Date

Note: Items ticked (other than Standing Action Items) and completed are included on the Register for the next meetings review and can then be removed the following month.


Hospital Advisory Committee Meeting – Public Action Items Register – 5 June 2019

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

2 May 2019 2.3 Hospital Advisory Committee Work Plan The word ‘draft’ to be removed from the Work Plan.

5 June 2019

Secretariat

13 March 2019 3.7 Q2 2018-19 Non Financial Summary Report The Child Health Team are to provide the Committee with the outcomes of the evaluation of the Child Healthy Weight Programme when complete and publicly available.

5 June 2019

Alanna Soupen

29 January 2019 3.1 Executive Summary A review of the Tamaki Oranga facility is to be circulated to the Committee once completed.

17 July 2019

Tess Ahern




Standing Action Items

9 April 2019 CM Health Board Meeting

Fast Cancer Treatment Regularly monitor and provide a quarterly report for these actions: • Service-led action plans for each of the 4 tumour

streams. • Gynaecology, Head & Neck, Lower GI (Bowel) and Lung

Cancer team to take a more detailed look at hot spots and stream-specific issues.

• Cancer Nurse Coordinators and Cancer Trackers meetings to be held to review and discuss hotspots.

28 August 2019

Brad Healey

18 August 2018 3 Chronic Conditions Provide a regular update at each meeting as part of the Executive Summary.

5 June 2019

Penny Magud to

provide update to Mary Burr

Include in Executive Summary

14 March 2018 3 Finance – Bad Debt Summary Provide a quarterly report to HAC.

28 August 2019

Avinesh Anand

19 February 2019 via Email from Margie Apa

Patient Flow – Every Hour Counts Provide a regular update at each meeting.

5 June 2019

Mary Seddon

31 January 2018 6.11 Medicine Provide a regular update at each meeting on the Bowel Screening Programme.

5 June 2019

Brad Healey

31 January 2018 2 Patient Survey Provide a regular update at each meeting on response rates to the patient survey and the complaints review process

5 June 2019

David Hughes




31 January 2018 6.1 Hospital Services 2018/19 Project Initiatives Provide a regular update at each meeting on current projects.

5 June 2019

Mary Burr

Include in Executive Summary

4 October 2017 2.4 Human Resources Report Provide a quarterly report for those staff that have had annual leave paid out, their current leave balance, leave accrual and leave taken. This report will not specifically identify particular individuals due to privacy issues.

28 August 2019

Elizabeth Jeffs

15 November 2011 5.1 Certification Provide a quarterly report showing progress being made against each corrective action.

5 June 2019

Jenny Parr


HAC Committee Work Plan 2019

Meeting Date Finance Corporate Reports Site visit Risk Service Update Deep Dives

29 January Consolidated Finance Report - - - -

13 March Consolidated Finance Report Q4 Performance Report

Q4 Quality and Safety Reports Manukau SuperClinic Risk Register Surgery, Anaesthesia

and Perioperative Services (Mary Burr)

2 May Consolidated Finance Report

Service Coverage for FY19/20 (PVS)

- KidzFirst Risk Register KidzFirst

(Nettie Knetsch)

5 June Consolidated Finance Report Hospital in the Home

(Penny Magud, Brad Healey) Spinal Rehabilitation Unit Risk Register Adult Rehabilitation and Health of Older People

(Dana Ralph-Smith)

17 July Consolidated Finance Report Q3 Performance Report

Q3 Quality and Safety Reports Tiaho Mai Risk Register Mental Health & Addiction

(Tess Ahern)

28 August Consolidated Finance Report

- Medical Wards Risk Register Medicine

(Brad Healey)

9 October Consolidated Finance Report Equity – How To Discussion (Aroha Haggie) Laboratories Risk Register

Central Clinical Services (Ian Dodson)

20 November Consolidated Finance Report

Q3 Performance Report Q3 Quality and Safety Reports

Equity Report (Aroha Haggie)

Age Residential Care Facility Risk Register -


Counties Manukau District Health Board Hospital Advisory Committee

Hospital Services Report – June 2019

Recommendation It is recommended that the Hospital Advisory Committee: Receive the Hospital Services Report covering activity in April 2019. Prepared and submitted by Mary Burr, General Manager, Surgery, Anaesthesia and Perioperative Services on behalf the Hospital Services Directorate. Executive Summary Glossary ERCP Endoscopic Retrograde Cholangiopancreatography EUS Endoscopic Ultrasound EWS Early Warning Score ESPI Elective Service Productivity Indicator FCT Faster Cancer Treatment FSA First Specialist Appointment MECA Multi-Employer Collective Agreement MERAS Midwifery Employment Relations Advisory Service (union) NHI National Health Index NZNO New Zealand Nurse Organisation (union) PSA Public Service Association (union) SMO Senior Medical Officer Overview The hospital-wide balanced scorecard, finance, and divisional reports included in this report provide a consolidated view of organisational performance. We have also provided a high level overview of our 2018/19 project initiatives programme. Key Highlights for April 2019 • Our Respiratory Function Laboratory Service has been accredited by the Thoracic Society of Australia

and New Zealand (TSANZ) for the next for five years. CM Health has never achieved accreditation before.

• Two 20,000 bed day projects – “Increasing Diabetes Care for Inpatients” (Diabetes Service) and “Feet for Life” (Renal Service) have resulted in a significant drop in the rate of amputations for our patients and considerably improved their quality of life.

• The Integrated Stroke Project began back in 2016 as a result of having no such unit at Counties Manukau Health. Since then, a lot of work has gone into implementing a new model of care, standardising service delivery and workforce, and improved patient outcomes across the whole of system pathway. The project is now complete as of April 2019.

• CM Health has managed to keep theatres running during the numerous periods of strike in 2019 which has allowed us to reduce the impact on elective throughput (although it has still had a dramatic effect).

• Theatre utilisation for March and April has increased with Middlemore Theatres reaching 99% utilisation and MSC at 81.7%.


• The MRI waitlist reduced by over 500 patients from 1 March to end April due to additional staff doing alternate weekend sessions and improved workflow and staffing productivity.

• Community central is progressing well. It is now managing all respite bookings, short term services as well as undertaking clinical triage and allocations for over 2,000 requests for community services per month.

Finance Overview- April 2019 The Provider Arm produced a $385k favourable result against budget for April 2019 and a $10.2M favourable YTD. The YTD favourable result is driven mainly by unbudgeted MECA settlement revenue from MoH, continuing vacancies across the system and one-off releases. RDA strikes have led to SMO claim costs over budget and have had a negative YTD impact on the delivery of the elective programme reflecting a lower level of revenue expectation against this programme. Unrealised Turn Around Plan (TAP) savings, and additional approved but unbudgeted clinical outsourcing in Surgical Services have also had an adverse impact on the bottom line. Volumes Activity for the month of April is lower than contract by 471 WIES (6.7%) due to decreased volumes in Plastic & Burns, Respiratory and Orthopaedic procedures driven by a level of annual leave taken over the Easter-Anzac period, reducing the number of surgical lists during this time. Year to date ED discharges are 60 cases less than last year and Acute WIES have under delivered to contract by 3.1% YTD reflecting a milder winter, a focus on front door admissions, continued enhanced capacity in the community as well as the impact of the RDA Strikes. Note that the above volumes reflect CM Health core activity delivered for all DHBs. The Elective Programme volumes below, reflect MoH contracted activity delivered from all DHB’s for the CM Health population. Key Drivers of the April Result Revenue Revenue: Apr $791k unfavourable, YTD $2.9M favourable • ACC revenue behind budget -$522k (Apr YTD $532k) • Interest received higher than budget $103k (Apr YTD $880k) • Revenue from Tahitian Burns $62k above budget (Apr YTD $1.2M) • Pacific Regional revenue offset by costs $2k over budget (Apr YTD $1.6M) • Retail pharmacy decreased sales volumes -$36k (Apr YTD $699k) • Provider unrealised TAP Savings -$159k (Apr YTD -$938k) • Bowel screening volumes behind contract -$31k (Apr YTD -$593k) • CTA training revenue ahead of budget $106k (Apr YTD $621k) • Funded research revenue received higher than budget $57k (Apr YTD $544k) • Bad debts recovered higher than budget $128k (Apr YTD $402k) • MoH supplementary revenue for MECA settlement in PSA Nursing (Apr YTD $776k) and PSA Allied

Health (Apr YTD) Elective Programme Revenue: Apr $1.7M, Apr YTD -$5.3M • The elective programme is tracking 4.8% (1,041.09 WIES) behind contract (see table below),

reflecting an adverse position of -$1.7M for the month, -$5.3M unfavourable YTD. • The variance is driven by YTD volumes lower than contract in general surgery, ENT services,

Gynaecology and Ophthalmology.


• The CM Health elective programme volume unfavourable variance is driven by Anaesthetic Consultant shortfalls, Day of Surgery cancellations and the impact of the RDA strikes, highlighting a risk of not achieving our elective programme volumes balance of year.

• A level of additional outsourcing has been approved to meet the MoH elective discharge target to mitigate the introduction of capped volumes for skin lesion activity for the year.

Hospital Services Project Portfolio Overview Across Hospital Services Divisions and related programmes, there are currently 74 total projects being monitored, which range from localised service improvements through to major transformational activities. There are eight currently in initiation, largely relating to new projects which are commencing as part of the developing Choosing Wisely programme, as well as initiatives in Healthy Together Technology. In total 45 projects are now in Execution compared with 48 in November, demonstrating the bulk of the work plan has now completed initiation and planning, and progressing with delivery. An additional five projects moved into Close Out during the current reporting period, with benefits realisation incorporated into the Turnaround Plan reporting. Portfolio Benefits Realisation – FY18/19 Turnaround Plan The full FY18/19 financial benefit target for the Turnaround Plan for CM Health is $19.418 across all areas of the organisation, inclusive of In total, $11.72M of this target is attributable to Hospital Services initiatives (excluding cross-directorate & whole of system benefits) Monthly tracking and reporting is in place across all of these initiatives, with regular reporting to the Every Dollar Counts Steering Group in place identifying any issues around benefit realisation, and how risks and issues are being mitigated.


Figure 1: Benefits Delivery at end of March ’19 reporting Period (Full FY18/19) – All Figures in $K

YEAR TO DATE FULL FY18/19

Total YTD

Actual

Total YTD

Target

Total YTD Variance

Current Forecast

Benefit High- $K

Baseline Forecast Benefit

High - $K

Forecast Full Year

Variance - $K

Every Hour Counts 913 3,344 -2,430 968 4,458 -3,490

1.0 Acute Patient Flow - Based on bed plan for Medicine, Surgical & ARHOP 748 2,451 -1,703 748 3,268 -2,520

2.0 Ambulatory Flow 165 540 -375 220 720 -500

3.0 Choosing Wisely 0 353 -353 0 470 -470

Every $ Counts 5,677 11,220 -5,543 9,112 14,960 -5,848

4.1 Procurement 3,164 3,900 -736 5,200 5,200 0

4.2 Workforce 0 750 -750 1,000 1,000 0

4.3 Improving Match between Cost and Revenue 822 4,910 -4,088 1,099 6,547 -5,448

4.4 Corporate 496 593 -96 514 790 -276

4.5 Environmental Sustainability 562 284 279 474 378 96

4.6 Individual Service Specific Initiatives 464 495 -31 575 660 -85

4.7 Aligning Services to Need 169 289 -120 250 385 -135

GRAND TOTAL vs. Baseline TAP Target 6,590 14,564 -7,973 10,081 19,418 -9,337 Strike Preparation Industrial Action Strike notices were received and later withdrawn for a 4 day withdrawal of labour in the week preceding Easter. This would have caused significant issues for the DHB coming in a week prior to public holidays. A subsequent notice for a 5 day strike was received for the week commencing the 29th of April. This caused significant disruption in particular for elective services, both outpatient clinics and surgery. The following were deferred due to the strike: • 69 Elective Surgical Procedures • 38 Gastro procedures • 994 outpatient clinics • 16 cardiac tests • 37 ESPI 5 treatment breaches Divisional Highlights for February 2019 Women’s Health and Kidz First Kidz First ED attendances and Paediatric Medicine discharges are higher than April last year with attendances up significantly by 325 and discharges by 52. Discharges YTD are at the same level as last year with ED attendance now almost the same as last year. The lower WIES YTD 2019 is due to lower number of long stay children in July and August compared to previous year where we saw a high WIES attributed to a small number of children with very high acuity and long stay for those 2 months.


Kidz First Outpatient FSAs are 9% lower YTD than last year but follow-ups have increased by 7% YTD as we continue to focus on reducing the Expired Planned Appointments. For April 2019 YTD, total Neonatal volumes are 121 WIES ahead of contract (4%), and compared to prior year, are greater by 266 WIES (9%). Discharges from the Neonatal Unit are up YTD; however discharge volumes for Neonates from the postnatal area are lower than the prior year, reflecting greater levels of acuity and more babies needing to stay in the Neonatal Unit. Occupancy and acuity in April in the Neonatal Unit was high with a high average of resourced occupancy of 100% against the 32 resourced cots for the month for the Neonatal Unit. After the region experiencing a ‘quieter’ 4 months period with babies being able to be transferred back to their domicile DHB as soon as appropriate, towards the end of February and throughout March and April the region has seen an increase in demand again. There has been daily liaison between all 4 Units to ensure that all mothers and babies could remain in the northern region. Despite this work, CM Health had to transfer in-utero twins to Tauranga on Saturday 20 April (Saturday before the Easter weekend). We were however able to repatriate the mother and babies the following week. There were 592 births at MMH and 70 at the community units, a total of 662 births for April 2019, which is up by 9 compared to the prior year. Births for April YTD are down by 39 (1%) compared to the prior year (0% variance at MMH but down 6% at the 3 primary birthing units). Planning for Maternity Day Assessment Clinic at MSC is progressing well with a planned start of clinics in the week of 13 May 2019. The Project Manager for the Ward 21 combined with the Service Manager and Charge Midwife Managers have made incredible progress in preparation for phase 1 of the transition (moving antenatal women and postnatal women whose babies are in the Neonatal Unit) to Ward 21 as well as commissioning 4 Gynaecology beds. Ward clerk and HCA positions have been recruited to and the ATR for 15 RNs has now been approved with 8 RNs already been recruited. An overall Steering Group and 2 Project Groups are in place and working towards phase 1 transition on Monday 13 May 2019. Gynaecology Acute YTD Gynaecology discharges are virtually at the same level as last year; WIES is down by 4%. YTD the elective (combination of elective and arranged admissions) discharges are down 1% compared to prior year but the WIES is down by 4%. We continue to work closely with Surgical and Anaesthetic Services on the production plan for electives as well as maximising the opportunities for Arranged Admissions volumes on the MMH site. In addition, we continue to work with the Elective Services Manager on the ESPI 5 mitigation plan. For April 2019 the MOH reported ESPI 2 had no breaches but ESPI 5 breached by 7. This is directly related to the number of theatre list lost due to the 2 days RMO strike in April as elective operating lists needed to be cancelled. Central Clinical Services Pharmacy • The Pharmacy and Medication Safety teams were successful at the Allied Health Awards winning

Team of the Year. • Rajeshni Naidu was successful in winning the Patient Experience and Innovation Award. • MedChart successfully rolled out in ED supported by the Emergency Department clinical pharmacy

team and the ePA team. The roll out will continue to Medical Assessment and the medical wards over May.

Radiology • The MRI waitlist reduced by over 500 patients from 1 March to end April whilst running business as

usual. This is due to additional staff doing alternate weekend sessions and improved workflow and staffing productivity.


• There has been much interest in permanent work from our registrars completing their training. There have been three applications from current registrars and two from previous registrars. Over the next 9 months this will bring the Radiologist workforce back to full staffing for the first time in nearly 4 years.

Laboratory Services • IANZ completed their annual audit on the laboratory in April. There were no major issues identified

and the feedback was very positive overall. Some useful suggestions were identified that are in the process of being implemented.

Mental Health CM Health Response to the Muslim Community following Christchurch Massacre Following the tragic events in Christchurch in March it was recognised that the Muslim community in Christchurch and Counties Manukau needed additional support to ensure their well-being needs were met - in particular the immediate social, emotional and spiritual needs of the Muslim community (both adult and youth) through culturally appropriate non-clinical community roles. In addition support was needed to raise mental health awareness amongst the Muslim community and ensure people and their families know how and when to seek support to meet their wellbeing needs. Further the service needed to provide Muslim cultural awareness training and support to clinicians working within the CM Health district. Kahui Tu Kaha provided an immediate response to the Christchurch Muslim community by sending 7 Muslim Social Workers/Support Workers and the Operations Manager for a week post the tragic events. They also responded to a request from the CEO of MIT for assistance for Muslim students over the first weekend. Requests were also received from the National phone Helpline 1737 for psychology and counselling staff across the Auckland region to provide extra staffing to help man the increased response required. Staff from Mental Health and Psychological Medicine responded and covered a number of shifts. Participation in the Government Inquiry into MH&A There has been a further delay to the response to the inquiry from the MoH due to staff being deployed to support the response to Christchurch and it is expected the response will be released at the end of May alongside the Budget announcements which will provide direction on what considerations need to be given to the on-going programme of work. New Acute MH Unit Progress Update Hawkins Construction has been awarded the contract for completing stage 2 of the rebuild. The old Tiaho Mai has been demolished and CM Health portable buildings have been moved off site. The site has been cleared and ground preparation is well underway. Emergency Department, Medicine & Integrated Care National Bowel Screening Programme (NBSP) At the end of April over 31,000 test kits have been sent to CM Health residents. Participation by ethnicity for the cohort of participants invited each month shows the lower uptake in Maaori and Pacific populations. Further to this only 36% of our Maaori and Pacific populations who have not returned a kit have been able to be contacted and of those 31% return a kit. We have embarked on strategies to improve response rates which include sending text reminders to everyone who has not returned a kit after the National Co-ordination Centre active follow up process and then our DHB community coordinators contact by phone all Maaori, Pacific and participants living in NZ deprivation areas 9-10 to encourage participation. We have been encouraging primary care to discuss the programme with eligible Maaori and Pacific and then order a kit through their datamart systems. We hope to evaluate this strategy further.


To the end of March, in CM Health there have been 540 positive screening results, 372 colonoscopy procedures have been carried out and 37 participants have been diagnosed with bowel cancer. Acute Demand and Impact on Medicine During April presentations totalled 9,498 which is a 1.5% increase over last year’s volumes for the same month. Emergency Department presentations remain at 316 average presentations per day in April. Respiratory Our Respiratory Function Laboratory Service has been accredited by the Thoracic Society of Australia and New Zealand (TSANZ) for the next five years. CM Health has never achieved accreditation before. We join a limited number of services which have achieved this standard in Australia and NZ. This is a major achievement and puts our service on a footing with centres of excellence in Australasia. It helps the wider Respiratory service to meet credentialing and training accreditation requirements. Renal CM Health Renal and Diabetes Services introduced foot assessments and podiatry care to patients in wards and the dialysis units through two 20,000 bed day projects – “Increasing Diabetes Care for Inpatients” (Diabetes Service) and “Feet for Life” (Renal Service). These two projects have resulted in a significant drop in the rate of amputations for our patients and considerably improved their quality of life. Surgery, Anaesthesia and Perioperative Services • A new ‘walk-in’ screening clinic alongside High Risk Diabetes in Pregnancy clinic has been established.

This clinic has captured several women who have significant retinal disease, some requiring urgent laser treatment to save their sight.

• Ophthalmology Digital Surveillance Clinic has been established with the aim to reduce demand of referrals to FSA (SMO) from Retinal Screening (DRS) merely because of failed screening (often due to cataract eye disease). The new clinic is technology enabled to take a more sophisticated image than the DRS camera. This image is reviewed by an SMO virtually rather than a face to face FSA.

• Successful outpatient pilot and expansion to more volume of linked ORL/audiology appointments is addressing a historically and persistent mismatch of these two queues.

Table 1: CM Health Theatre Outputs (Minutes) for YTD April 2019

• March elective production YTD has moved to a negative variance position with a shortfall of 289

discharges being 98.1% of planned. Awaiting provisional internal April data to get some indication of indicative results for this month however this puts the Elective Funding contract in jeopardy.

Facilities, Engineering and Asset Management Scott Building Recladding The critical building permit required to proceed with Scott Building Recladding has been approved by Auckland Council. The contractor is currently preparing to commence establishment works and updating the programme. The Communication plan has been activated.


Manukau Super Clinic A meeting was held with the surveyors and valuers with regard to the planned sale of Parcel B. Discussions included zoning solutions that would provide the greatest benefit for CM Health. The University of Otago Dental School has finished the initial car park works and have handed over to CM Health. Work on the main facility is moving along at a good speed. Final stages of the required easement agreements with Vector for HV cable and transformers are being finalised. Other Works Capital Investment Committee approval has been reported for the Renal Day Dialysis and 2nd Cath Lab. Ministerial signoff is awaited. A building contract has been awarded for Histopathology and the building contractor is well underway onsite. The tender recommendation for the separate mechanical works contract is expected to be agreed imminently. The mechanical works are being undertaken by an incumbent mechanical contractor, providing least risk to CM Health. The replacement of CM Health owned cars is well underway and in line with the Fleet Replacement Plan. To date, 177 vehicles have been put up for sale, of which 158 have been sold, generating revenue of $414k. The contract to proceed with fleet management and electronic bookings has been signed by healthAlliance. National Health Targets Elective Surgery Note: Performance against the Elective Target is reported one month in arrears. Table 2: Elective Access Result

March (actual) Result

April (indicative)

PP45: Number of publicly funded, case mix included, elective and arranged discharges for people living within the DHB region

Not Achieved × 98.1% Variance from Plan 289

Not Achieved × 98.1%

Elective Waiting times ESPI 2 (FSA) and ESPI 5 (Treatment) wait

time targets

FSA: 907 breaches Treatment: 160 breaches


Commentary Elective Funding is at risk. March elective production YTD has been confirmed as a negative variance position with a shortfall of 289 discharges being 98.1% of planned. With WIES outputs sitting at 96.4% our aim is to maintain this and not dip below 95%. Our focus is to increase discharges to 100% to enable an offset of over production in Ambulatory areas. The position in April has deteriorated due to public holidays and strikes impacting on elective throughput.


Cancer Treatment Table 3: FCT Performance

Commentary Performance has again improved this month and is hitting the target for the first time in seven months. April FCT performance overall 87% (incl. all breach reasons 27/31 patients) Reported FCT performance 96% (excl. patient choice & clinical consideration 27/28 patients) Colonoscopy

Colonoscopy Targets

Description • 90% urgent (P1) colonoscopies done within 14 days • 70% non-urgent (P2) colonoscopies done within 42 days • 70% of Surveillance colonoscopies done with 84 day

April 100% ↑ 75% ↑ 99% ↑

Gastroscopy

Colonoscopy 2018 2019Period End Mar April May June July Aug Sep Oct Nov Dec Jan Feb Mar AprP1 – % within 14 days (target 90%) 100% 98% 95% 92% 98% 96% 94% 97% 96% 99% 100% 99% 100% 100%P1 – % within 30 days (target 100%) 100% 100% 100% 100% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100%

P2 – % within 42 days (target 70%) 68% 65% 65% 69% 84% 91% 92% 87% 82% 93% 75% 82% 84% 75%P2 – % within 120 days (target 100%) 100% 100% 100% 99% 100% 100% 99% 100% 100% 100% 100% 100% 100% 100%

Surveillance – % within 84 days (target 70%) 78% 77% 74% 65% 77% 92% 99% 99% 99% 100% 94% 98% 94% 99%Surveillance - % within 120 days (target 100%) 100% 100% 97% 91% 94% 96% 99% 100% 100% 100% 97% 100% 100% 100%

CT Colonography - % within 42 days (targt 65%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Gastroscopy Targets (CM Health Targets)

Description • 85% urgent (P1) gastroscopies done within 14 days • 70% non-urgent (P2) gastroscopies done within 42 days • 70% of Surveillance gastroscopies done with 84 days

April 94% ↑ 53% 100% ↑


Commentary All MoH targets for colonoscopy were achieved again in April. It should be noted however that the reporting to the NRA and MoH for the secondary 100% targets differs from CM Health’s because deferred patients are included in the NRA and MoH data. The CM Health target for P2 gastroscopy has not been met yet, with this in part being due to the numerous public holidays, school holidays and the RMO strike, which also led to a decrease in the colonoscopy targets too. However, there will be an increased focus on gastroscopies in May and June. Mitigation strategies continue and include recruiting to cover positions for nursing, technicians, clerical staff and we continue to outsource procedures to private providers, as well as outsourcing the BSP equivalent volumes. Plans for a new endoscopy room are now underway, which will increase some capacity for endoscopy.

Cardiology Angiography

Description Cardiology - 95% elective angiograms within 90 days

April Not Achieved 93%

Commentary Target not achieved. A further improvement over previous months. However, acute cases continue to displace elective referrals. Cath Lab nursing staffing is improving with MRT staffing worsening. This is impacting our ability to work extended days and the waiting list is growing. Alternative capacity is required and this may require outsourcing. Ophthalmology

Table 4: Ophthalmology Overdue Follow ups

Commentary Good will and great effort continues with staff running mega clinics at the weekends to reduce overall follow up volumes. Volume reduction in April has been impacted by the number of public holidays. Regional governance is progressing and concentrating on aligning data and processes. FSAs are also becoming a problem as demand continues to exceed resource to treat. A recovery plan has been put in place.

Gastroscopy 2018 2019Period End Mar April May June July Aug Sep Oct Nov Dec Jan Feb Mar AprP1 – % within 14 days (target 85%) 97% 92% 95% 88% 94% 98% 96% 93% 95% 95% 89% 98% 100% 94%P1 – % within 30 days (target 100%) 98% 100% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100%




The MOH has been advised that we will not meet the 5% threshold by 30 June 2019. We continue to focus on reducing overdue follow up volumes with a new goal to achieve 5% only waiting for over 50% of time by the end of December 2019. We have seen the average waiting time per patient in this cohort reduce from 100 days to 58 days. Diagnostic Access The Radiology Service is responsible for one of the six National Health Targets; Diagnostic Access Targets.

April 19 March 19 February 19

MRI – 90% scans completed within 6 weeks 32.5% 29% 38.2%

CT – 95% scans completed within 6 weeks 93.7% 91% 84.2% CT

Commentary • We are still unable to run the 12-8 shift three days per week. • Improved achievement towards target despite some staffing shortages. • CT cardiac – some booking issues/delays related to shortage of Cardiac RN’s and Cardiologists.

Waiting < 6 weeks 21

Waiting < 21 weeks 7

Waiting > 21 weeks 1

MRI

Commentary • New contracted casual MRTs x 2 (weekends) underway – working alternate weekends. • MRI Improvement Project run by Ko Awatea is in progress. • Waiting list reduced by >500 (from 1900 to 1400) since beginning of March whilst running business

as usual. The waitlist is continuing to rapidly decrease and it is anticipated that as the waitlist is cleared there will start to become a steady improvement in the 6 week target.

Emergency Department

Table 5: Shorter Stays in ED

Description 95% of patients will be admitted, discharged, or transferred from an emergency department within six hours


Month April 19 March 19 February

Target achieved 93.7% 91% 84.2%

Acute demand- average weekly 449 448 436

OP/GP demand 241 311 279

Month April 19 March 19 February 19





Commentary: Patient volume and bed demand has resulted in the hospital not reaching the six hour target achieving 84% for April against the target of 95%. This is due to a variety of factors including high consistent surge presentation rates and consistent high hospital occupancy. Steps we are taking to improve our performance include participation in the “Every Hour Counts” programme. The graph below shows daily performance against this target.


Hospital Services Directorate – Challenges reported to HAC in June 2019 (March/April 2019 Activity) This table provides a snapshot of current challenges - For more detail, see individual services reports attached to this report.

Division Challenges Reported Update April 2019 Mitigation Strategies Hospital Directorate

Acute Demand –Beds and TBS

Jan 16 Acute bed availability is inadequate in times of peak demand. Patient volumes, surges and times taken to be seen mean we have been unable to meet the ED Waiting Time target.

In the Acute Flow portfolio continues with several work streams progressing steadily. ED has just rolled out Medchart and will be busy with this fundamental change to processes for a while. The ‘proactive planned discharge project’ in Medicine has floundered due to a lack of capacity within general medicine to support this and needs to be rebooted. Likewise, the ‘optimising access to community services project”, is suffering from a nursing and allied health workforce shortage.

Outpatient Demand

Jan 18 Increased referral inflow for outpatient care is challenging many services. Patient Flow- Every Hour Counts Project is addressing this beginning with the establishment of a Manukau site planning group.

The Ambulatory flow work is also progressing. Grading wait times to be published and sent to HODs for action.

Theatre Access

Dec 2017 Shortage of Anaesthetists has impacted upon our ability to increase theatre access to run all theatres.

Recruitment of anaesthetists is ongoing and theatre cancellations related to the shortage is reducing.

Strike Dec 2018 Strike notices were received and later withdrawn for a 4 day withdrawal of labour in the week preceding Easter. This would have caused significant issues for the DHB coming in a week prior to public holidays. A subsequent notice for a 5 day strike was received for the week commencing the 29th of April. This caused significant disruption in particular for elective services, both outpatient clinics and surgery.

The following was deferred due to the strike: 69 Elective Surgical Procedures, 38 Gastro procedures, 994 outpatient clinics, 16 cardiac tests and 37 ESPI 5 treatment breaches We await further progress nationally in relation to negotiation with the NZRDA.

Women’s Health and Kidz First

Neonatal Unit capacity

Apl 16 Occupancy for April 2019 was 100% (we were able to keep to our resourced cots of 32/33 for the month but with a very high occupancy). After the region experiencing a ‘quieter’ 4 months period with babies being able to be transferred back to their domicile DHB as soon as appropriate, towards the end of February and throughout March and April the region has seen an increase in demand again. There has been daily liaison between all 4 Units to ensure that all mothers and babies could remain in the northern region. Despite this work, CM Health had to transfer in-utero twins to Tauranga on Saturday 20 April (Saturday before the Easter weekend). We were however able to repatriate the mother and babies the following week.

Regional Neonatal Working Group meetings (including Neonatologist, and Planning and Funding) continue bimonthly and report progress on escalation and regional neonatal cot planning through the Child Health Network meeting to the regional SRG group. A regional escalation plan has now been signed off in addition to our own escalation plan.


Division Challenges Reported Update April 2019 Mitigation Strategies Women’s Health and Kidz First

A CM Health Public Health Registrar continues her project investigating local increase in neonatal demand. Catch-ups occurring with the 3 GMs/Neonatal Clinical Leads to assess the regions capacity to an almost daily liaison as all units have seen high occupancy over in March and April.

Caesarean Rate

Jan 17 CS rate for April 2019 was 27% and YTD is 29% (up 1.0% on same period last year) The Induction of Labour rate is 28% YTD April 2019 up 1% compared to last year.

Continue to monitor.

Midwifery workforce

Jan 17 Midwifery vacancies for April 2019 contracted versus budget decreased to 9 FTE shortfalls plus an additional 7 FTE being on parental leave. This reduction in vacancies is due to 14 graduate midwives starting at the end of April 2019. Vacancies also continue to be offset by a high use of bureau midwives – 18.87 FTE for April 2019.

We are now seeing increasing self-employed shortages in both the Manurewa and Mangere areas. Recruitment is underway for all approved new positions.

MCIS Apl 17 Update April 2019- Clevermed visited in early March with much more clarity on the process based view/system used in the UK and Scotland as well as willingness to immediately progress the one way Portal 8/MCIS interface. From this meeting we have agreed that a CM Health medical, midwifery and anaesthesia representative should visit the UK in June for the Clevermed conference as well as visiting a large similar cohort secondary/tertiary hospital using the process based MCIS system and we have informed MoH that we will not make a final recommendation till that visit has taken place and a report received to assist with our final decision on the continuation of MCIS..

Local MCIS Steering Group monthly meetings continue with project management support internally. Anaesthetic paper notes project has been completed. We have now implemented the one-way Portal 8/MCIS interface and other incremental improvements on the current system. Visits to the UK have been confirmed for the Clinical Director Women’s Health (part of CME), Clinical Midwife Specialist, Anaesthetist (as part of CME) and a WDHB Clinical IT specialist/Anaesthetist (WDHB is following CM Health progress closely). Since then MoH has confirmed that their MCIS project manager will travel to UK with the CM Health team

Gynaecology Apl 17 The on-going complexity of women presenting in outpatients has resulted in Follow-Up clinic time for both Gynaecology and Colposcopy to be increased to 20 minutes per patient. This is reflected in the decrease in outpatient volumes. In addition, due to the on-going reduced theatre capacity issues we have needed to decrease FSA volumes with more women now being placed on the GP residual list. Further outsourcing of 200 Hysteroscopies (highest priority clinical work) to be completed by June 2019 was approved and procurement for this was finalised in February.

It is very pleasing that since the outsourcing started we have seen a significant improvement in the number of hysteroscopies provide. YTD we are now at a combined internal and outsourced volume of 370 which is 28% up on last year.


Division Challenges Reported Update April 2019 Mitigation Strategies ED, Medicine and Integrated Care

Bowel Screening Programme

Jul 17 At the end of April over 31,000 test kits have been sent to CM Health residents. Coverage each month slowly increases as priority participants are followed up either by the National Co-ordination Centre (NCC) or the CM Health bowel screen programme team and they return the test kits. We are concerned regarding the lower uptake in Maaori and Pacific populations. The national target is 60%. We have received performance data for active follow up which shows that only 36% of our Maaori and Pacific populations who have not returned a kit have been able to be contacted and of those 31% return a kit. 16% did not have valid contact details. Overall 10% of Maaori and Pacific who have not returned a kit do so after active follow up processes are carried out.

Strategies are in place to improve this including text reminder, the NCC active follow up process and DHB community coordinators contact by phone all Maaori, Pacific and participants living in NZ depn areas 9-10 to encourage participation. We are working with primary care to encourage remaining non respondents to participate; facilitating letters from practices with high numbers of priority participants. To the end of March, in CM Health there have been 540 positive screening results, 372 colonoscopy procedures have been carried out and 37 participants have been diagnosed with bowel cancer.

Bronchoscopy Oct 18 The requirement for a 3rd permanent list has been under discussion since 2015 and has been included in Gastro business cases during this time. The bronchoscopy waitlist has been added to the risk register, given the clinical risk involved.

Has been added as part of the Gastro Business case.

Increased numbers patients requiring In-Centre Dialysis

Recent growth in the volume of patients requiring in-centre dialysis is now a significant concern. Expansion of the Scott Dialysis unit is not scheduled to come on stream for a couple of years (the business case is awaiting approval from Minister).

The interim plan is to increase space at the Satellite Unit at MSC by moving some patients across to RITO 2 (Western Campus) using this capacity for patients who currently dialyse at the Scott Unit. Whilst we can manage the financial implications of these changes within the 2018/19 budget there will be a need for additional investment in staffing and consumables to manage this growth in 2019/20 and beyond – this additional investment is in the order of $2 million per annum.

Central Clinical Supplies

Radiologist FTE

Sep 16 Currently we have 2.6FTE of staff off on parental leave – this impacts the department greatly.

We have worked hard on recruiting to fill vacancies, the CD and staff have interviewed four senior RMOs who will complete their training at the end of the year, two of them have expressed an interest in working at CM Health plus expressions of interest from RMOs who worked here previously who wish to return from overseas to CM Health.


Division Challenges Reported Update April 2019 Mitigation Strategies Central Clinical Supplies

General X-ray/MRT FTE

Sep16 The general x-ray service waiting list is increasing once again due to MRT vacancies and additional seasonal volumes. We are facing similar levels of shortages as last year.

Workforce planning and reviewing of advertising has taken place, investigations into employing non-qualified staff into assistant type roles for a fixed term over the winter is being investigated as well as a review of plans to increase our student numbers. The waiting list dropped from 3425 (January 2019) to 592 (April 2019) by running additional evening sessions.

Histopath Lab Mar 17 The Histopathology work programme remains on track. The design phase is complete and the Registration of Interest has been held for the main construction contractor.

Contract has been let and we are well into the construction. While there have been some delays, it is now on track to be finished in early July.

Transcription Aug18 The backlog of dictation and turn-around times for transcription continued to be maintained over April with all targets being met. On 30/04/2019 the backlog was 168 hours and the turn-around time of maximum of five working days was being met for all services.

This risk is now largely reduced with a number of mitigation plans in place to manage this risk in the future.

Mental Health

CAMHS Growth in Service Demand - Actively monitored growth in demand. On-going refinement of a centralized intake and triage process to ensure standard assessment of acuity, minimization of wait times and align available resources with prioritized need.

Continuing process of monitoring and planning.

Workforce Recruitment

Across the CM Health MH&A division there continues to be areas with significant workforce recruitment and retention issues. Since the last vacancy report, the MH Division has had a net gain of 1FTE to a total of 609 employees. The overall vacancy in the Division remains at 17.5% with the highest vacancy rates across medical, nursing and psychology disciplines (21-25%) and in the CAMHS, MHSOP and Acute MH services. Service delivery is maintained through staff undertaking overtime and additional duties and the use of contractors.

Mitigation includes enhancing our local recruitment and exploring international recruitment opportunities and focussing on supporting staff and teams through values based wellbeing approaches.

Tamaki Oranga Review

Three reviewers from outside this organisation have agreed to undertake a service review of Tamaki Oranga. The review will consider the environment, clinical governance and clinical leadership of TORC and identify recommendations for service improvements. The review team met with staff, service users and family/whaanau and NGO staff to get their perspectives.

A report was expected in early 2019 however the reviewer has informed us this is delayed further due to him being on leave in April. The report is expected imminently and the findings will be shared with staff working in TORC and a summary of the recommendations and our response will be reported to HAC.


Division Challenges Reported Update April 2019 Mitigation Strategies Surgery, Anaesthesia Perioperative Services

Demand for Ophthaly Services

Jul16 High volumes of overdue follow ups continue. Good will and great effort continues with staff running mega clinics at the weekends to reduce overall follow up volumes. Volume reduction in April has been impacted by the number of public holidays. Regional governance is progressing and concentrating on aligning data and processes. FSAs are also becoming a problem as demand continues to exceed resource to treat. A recovery plan has been put in place.

The MOH has been advised that we will not meet the 5% threshold by 30 June 2019. We continue to focus on reducing overdue follow up volumes with a new goal to achieve 5% only waiting for over 50% of time by the end of December 2019. We have seen the average waiting time per patient in this cohort reduce from 100 days to 58 days.

Anaesthetists’ shortage

Oct 17 Recruitment continues with regular interview panels being held. There are currently eight new SMOs contracted to start over the next two to three years. Current service size costs remain within the agreed 18/19 budget because the Service has been unable to recruit to the 18/19 service size.

Recruitment continues. Theatre cancellations due to the shortage have reduced.

Cx Bladder Project

Jul 18 Cx Bladder testing in full swing and progressing well.

Despite deferring the start of the initiative by 1 month the actual numbers exceed the planned production levels. Due to Annual leave of the coordinating CNS for 3 weeks the April volumes are lower than planned but YTD we are still ahead of planned contacts.

CSSD Staffing Nov 18 We have signaled a number of new staff in CSSD who require orientation and educational input. Recruitment continues and we are continuing to provide education support for new employees. FTE papers for more staffing in CSSD and for extra staffing resources to complete the full implementation of T-Doc are to be considered.

Three staff members are due to start in April 2019. Vacancy of 0.7 FTE left to employ to with interviews set for May 2019.


Division Challenges Reported Update April 2019 Mitigation Strategies Surgery, Anaesthesia Perioperative Services

Elective performance is under threat

Oct 17 From an ESPI point of view we continue in Red status (ESPI = FSA and Treatment). We have a recovery plan in place and are reporting to the MoH each month. A number of services are under pressure including Ophthalmology, ORL and Hands/Plastics. The Elective Funding target for 18-19 is at serious risk based on our inability to pick up extra work over and above 17-18 volumes. We were required to complete 800 substituted cases over and above 17-18 volumes and we have been unable to secure outsourced capacity to ensure this will happen.

Current Elective Funding is at risk. With WIES outputs sitting at 96.4% our aim is to maintain this and not dip below 95%. Our focus is to increase discharges to 100% to enable an offset of over production in Ambulatory Areas. The position in April has deteriorated due to public holidays and strikes impacting on elective throughput.

ARHOP Safe Handling and Mobilisation

Nov 18 Evaluation framework is in final draft with research & evaluation team for ethics application and sign off

• Upcoming TROPHI tool audit May 27th – 31st. • TROPHI tool training for 4 new assessors with Dr Mike Fray mid-May. •

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W:\Scorecard\2019\Hospital Scorecards FY1819\Fiscal10_Apr2019\HMT scorecard Apr 2019.xlsxApr

HOSPITAL SERVICES BALANCED SCORECARD April 2019*Red variance figures: non-favourable result for the indicator

Trend by monthFY1718-1819 Apr-19 Target Var Actual Target Var

Emergency Department - 6 hour Length of Stay target 84% 95% -11% 85% 95% -10%FCT % of high suspicion first cancer treatment within 62 days (indicative result) 90% -90% 90% -90%Elective Surgical Discharges incl Arranged Admissions 1,617 -100.0% 13,400 -100.0%


Total Caseweight 6,575 7,046 -6.7% 72,489 73,333 -1.2%Acute Caseweight 5,504 5,629 -2.2% 58,829 58,824 0.0%Elective Caseweight 1,071 1,417 -24.4% 13,661 14,510 -5.9%Total Discharges - performance compared to prior year. 8,178 8,445 -3.2% 85,454 87,319 -2.1%Outpatient First Specialist Assessment Volumes 3,639 4,385 -17.0% 39,703 44,518 -10.8%Outpatient Follow Up Volumes 9,077 10,391 -12.6% 99,040 105,916 -6.5%Virtual First Specialist Assessments (GP consult and nonpatient appointments) 514 346 48.6% 5,281 3,570 47.9%Budgeted FTEs 6,689 6,630 -1% 6,576 6,652 1%Operating Costs ($000) $84,328 $85,039 1% $867,794 $849,931 -2%Personnel Costs ($000) $58,150 $58,747 1% $552,232 $568,805 3%Financial Result Total ($000) -$5,526 -$6,278 12% -$35,953 -$43,094 17%Reduce clinical outsourcing ($000) $1,939 $2,088 7% $22,597 $19,020 -19%


Excess Annual Leave dollars ($000) - estimated cost for excess $5,490 $1,539 -$3,950 $4,547 $1,588 -$2,959Adult Rehabilitation and Health of Older People $128 $134 $6 $128 $110 -$18Medicine, Acute Care and Clinical Support $1,091 $428 -$663 $1,091 $476 -$615Surgical and Ambulatory Care $1,955 $548 -$1,407 $1,955 $569 -$1,386Mental Health $472 $224 -$248 $472 $214 -$258Women's Health and Kidz First $902 $205 -$697 $902 $219 -$683

% Staff Annual Leave >2 years 14.5% 5.0% -9.5% 13.8% 5.0% -8.8%Adult Rehabilitation and Health of Older People 4.8% 5.0% 0.2% 5.8% 5.0% -0.8%Medicine, Acute Care and Clinical Support 12.7% 5.0% -7.7% 11.5% 5.0% -6.5%Surgical and Ambulatory Care 17.8% 5.0% -12.8% 17.2% 5.0% -12.2%Mental Health 10.5% 5.0% -5.5% 11.0% 5.0% -6.0%Women's Health and Kidz First 22.0% 5.0% -17.0% 20.6% 5.0% -15.6%


% Staff Turnover (YTD no. voluntary turnovers by average headcount) 6.4% 10.0% 3.6% 9.7% 10.0% 0.3%% Sick Leave 3.0% 2.8% -0.2% 3.1% 2.8% -0.3%Workplace Injury per 1,000,000 hours 1.5 10.5 9.0 11.1 10.5 -0.6

Apr-19 Target Var Apr-18 Target VarWorkforce Population Workforce Population

Maaori 7% 16% -10% 7% 16% -10%Pacific 13% 23% -10% 13% 23% -10%Asian 35% 23% 12% 33% 23% 10%

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NZ European / non-specified/ other 45% 38% 8% 46% 38% 9%Trend by month

FY1718-1819 Apr-19 Target Var Actual Target Var% e-medication reconciliation - high risk patients within 48hrs 80% -80% 80% -80%% Serious Pressure Injuries rate / 100 Patients (Aug-18) 3.5% 3.5% 3.5% 3.5%Falls causing major harm rate / 1,000 bed days 0.00 0.00 0.00 0.00Adverse Events: % of admissions affected by ≥4 triggers (Jul-18) N/A N/A N/A N/ACentral Line Associated Bacteraemia (CLAB) rate / 1,000 bed days in CCC 0.00 0.00 0.00 0.00Rate of S. aureus bacteraemia rate / 1,000 bed days 0.00 0.00 0.00 0.00

Q2 FY1819 Target Var Actual Target Var% 75+ years assessed for the risk of falling # 93% 90% 3% N/A N/A N/A% 75+ years assessed for falls risk with falls intervention plans # 96% N/A N/A N/A N/A N/A


% Magnetic Resonance Image (MRI) scans completed within 6 weeks from referral 85% -85% 85% -85%% Computerised Tomography (CT) scans completed within 6 weeks from referral 95% -95% 95% -95%% urgent diagnostic colonoscopy within 14 days 85% -85% 85% -85%% diagnostic colonoscopy patients within 42 days 70% -70% 70% -70%% surveillance colonoscopy patients within 84 days 70% -70% 70% -70%% cardiac STEMI-PCI (angiography) <120mins - Northern Region 80% -80% 80% -80%% Coronary Angiography within 90days (1mth arrears) 95% -95% 95% -95%ESPI 2: No. patients waiting >120 days for FSA - Elective ∆ 0 0 0 0ESPI 5: No. patients waiting >120 days treatment - Elective ∆ 0 0 0 0Radiology - Inpatient radiology completion times <24hrs 95% -95% 95% -95%Radiology- Emergency Care radiology completion times <2 hrs 95% -95% 95% -95%FCT - % confirmed diagnosis first cancer treatment within 31 days 85% -85% 85% -85%% Radiology results reported within 24 hours 75% -75% 75% -75%


Average Length of Stay - Acute Inpatient 2.8 2.9 0.1 2.8 2.9 0.1Average Length of Stay - Acute Arranged/ Elective 1.8 1.8 0.0 1.7 1.8 0.1Middlemore Hospital % patients to discharge lounge or home by 1100hrs 30% -30% 30% -30%Acute Readmissions within 7 days - Total 2.7% 2.5% -0.2% 2.7% 2.5% -0.2%Acute Readmissions within 28 days - Total (1 month in arrear) 6.5% 5.6% -0.9% 6.9% 6.7% -0.2%Acute Readmissions within 28 days - 75+ years (1 month in arrear) 8.9% 9.9% 1.0% 9.9% 11.1% 1.2%Emergency Department Presentations - 75+ year olds 1,040 807 -233 10,672 8,070 -2602% clinical summaries (meddocs) authorised <7 days of creation 95% -95% 95% -95%% of patient outliers - not on home ward <5% 58.2% 5.0% -53.2% 62.2% 5.0% -57.2%

% DHB Mental Health Services - children/ youth (0-19years) seen by 3 weeks for non-urgent 80% -80.0% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (0-19yrs) 3.2% -3.2% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (20-64yrs) 3.2% -3.2% N/A N/A N/AMental Health access rate - clients seen in last 12 months as % of population (65+yrs) 2.6% -2.6% N/A N/A N/A

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Outpatient - First Specialist : Follow-up Clinic ratio 40% 42% 2% 40% 42% 2%Outpatient - Did Not Attend rates - Maaori 20% 10% -10% 20% 10% -10%Outpatient - Did Not Attend rates - Pacific 17% 10% -7% 18% 10% -8%Theatre list utilisation - % used MMH/MSC 85% -85% 85% -85%Day of Surgery Admissions (DOSA) 90% -90% 90% -90%Day Case Rate (Elective/ Arranged) 65% -65% 65% -65%% Medical Assessment patients with Length of Stay < 28 hours 82% 65% 17% 81% 65% 16%No. Hospital bed days occupied (against forecast open beds) 21,252 #DIV/0! 191,245 #DIV/0!No. Length of Stay outliers (LOS >10 days)* 160 137 -14% 1,503 1,459 -3%


% smokers receive smokefree advice / support -Total 97% 95% 2% 97% 95% 2%% smokers receive smokefree advice / support - Maaori 97% 95% 2% 97% 95% 2%% smokers receive smokefree advice / support - Pacific 97% 95% 2% 97% 95% 2%% smokers receive smokefree advice / support - Asian 98% 95% 3% 97% 95% 2%

% Women (45-60yrs) with Breastscreen in 24months - Total 2400 -2400 70% -70%% Women (45-60yrs) with Breastscreen in 24months - Maaori 289 -289 70% -70%% Women (45-60yrs) with Breastscreen in 24months - Pacific 377 -377 70% -70%

Trend by month FY1718-1819 Apr-19 Target Var Actual Target VarPatient experience Survey data very good/excellent - month (n=460) and YTD (n=3384) 84% 90% -6% 82% 90% -8%P&

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Hospital Services Project Portfolio Monthly Report – May 2019 Hospital Services Project Portfolio Overview As part of our FY18/19 workplan, Hospital Services is undertaking a workplan consisting of a number of service-led transformation and improvement initiatives aligned with our Healthy Together strategy. A number of these are building and continuing with projects already underway from the previous year, while others have been established to drive our strategic goals around improving services for patients, with a particular focus on Improving Acute Flow, Ambulatory Flow, Choosing Wisely (‘Every Hour Counts’) and maintaining financial sustainability (‘Every Dollar Counts’). Each of these initiatives has identified benefits (either financial benefits, non-financial benefits, or both) which are being tracked, and a standardised process whereby all active Hospital Services initiatives are reported on each month by the respective managers is in place. Turnaround Plan As part of ensuring financial sustainability within CM Health, a Turnaround Plan (TAP) had been established across the organisation to ensure that benefits are delivered and maintained across a number of initiatives. This has now transitioned into the strategic portfolio areas as described above. A large component of the Hospital Services project workplan has been focussed on delivering the planned TAP outcomes, particularly within the Acute Patient Flow programme. Delivery Progress Across Hospital Services Divisions and related programmes, there are currently 72 total projects being monitored, which range from localised service improvements through to major transformational activities. There are eight currently in initiation, largely relating to new projects which are commencing as part of the developing Choosing Wisely programme, as well as initiatives in Healthy Together Technology. In total 47 projects are now in Execution compared with 45 in April, demonstrating the bulk of the work plan has now completed initiation and planning, and progressing with delivery. An additional three projects moved into Close Out during the current reporting period, with benefits realisation incorporated into the Every Dollar Counts and Every Hour Counts reporting.


Figure 1: Breakdown of project delivery by Division, May ’19:

Project Divisions: 1. Initiation

2. Planning

3. Execution

4. Close Out

5. Operations & Benefits Realisation

On Hold Grand Total

ARHOP 1 2 1 4

Central Clinical Services 1 5 6

Facilities, Engineering & Asset Management

2 1 2 3 1 9

Healthy Together Technology 3 2 5 10

Kidz First & Women's Health 1 1 2

Medicine and Emergency Care 3 10 1 14

Mental Health 1 13 1 15

Middlemore Central 1 1

Surgical, Anaesthesia, and Perioperative Care

1 9 1 11

Grand Total 6 11 47 3 3 2 72

Figure 2: Project Portfolio Movements – FY18/19 Workplan:

Number of initiatives in phase

Delivery Phase August '18

September '18

November '18

February '19 April '19 May '19 Shift since

last report

1. Initiation 8 5 8 4 8 6 -2

2. Planning 10 22 16 12 8 11 3

3. Execution 36 35 42 48 45 47 2

4. Close Out 2 0 1 6 5 3 -2

5. Operations 2 1 3 1 4 3 -1

On Hold 2 3 1 4 4 2 -2


Figure 3: Overall progress of Hospital Services projects through delivery lifecycle:

Figure 4: Number of initiatives within each division, and the current state of these projects:


Portfolio Benefits Realisation – FY18/19 Turnaround Plan The full FY18/19 financial benefit target for the Turnaround Plan for CMH is $19.418 across all areas of the organisation, inclusive of In total, $11.72M of this target is attributable to Hospital Services initiatives (excluding cross-directorate & whole of system benefits) Monthly tracking and reporting is in place across all of these initiatives, with regular reporting to the Every Dollar Counts Steering Group in place identifying any issues around benefit realisation, and how risks and issues are being mitigated. Figure 5: Benefits Delivery at end of Apr ’19 reporting Period (Full FY18/19) – All Figures in $K

YEAR TO DATE FULL FY18/19

Total YTD Actual

Total YTD Target

Total YTD Variance

Current Forecast Benefit

High- $K

Baseline Forecast

Benefit High - $K

Forecast Full Year

Variance - $K

Every Hour Counts 913 3,344 -2,430 968 4,458 -3,490 1.0 Acute Patient Flow - Based on bed plan for Medicine, Surgical & ARHOP 748 2,451 -1,703 748 3,268 -2,520 2.0 Ambulatory Flow 165 540 -375 220 720 -500 3.0 Choosing Wisely 0 353 -353 0 470 -470 Every $ Counts 5,677 11,220 -5,543 9,112 14,960 -5,848 4.1 Procurement 3,164 3,900 -736 5,200 5,200 0 4.2 Workforce 0 750 -750 1,000 1,000 0 4.3 Improving Match between Cost and Revenue 822 4,910 -4,088 1,099 6,547 -5,448 4.4 Corporate 496 593 -96 514 790 -276 4.5 Environmental Sustainability 562 284 279 474 378 96 4.6 Individual Service Specific Initiatives 464 495 -31 575 660 -85 4.7 Aligning Services to Need 169 289 -120 250 385 -135

GRAND TOTAL vs. Baseline TAP Target 6,590 14,564 -7,973 10,081 19,418 -9,337


Financial Results – CMDHB Provider Arm Monthly Report – April 2019*

*Due to rounding, numbers presented throughout this document may not add up precisely to the totals provided.

Actual Budget Variance Variance Actual Budget Variance Forecast Budget Variance$(000) $(000) $(000) Prior $(000) $(000) $(000) $(000) $(000) $(000)

IncomeGovernment Revenue 77,805 79,206 (1,401) U 789,841 792,479 (2,638) U 949,600 950,928 (1,328) UPatient/Consumer Sourced 1,324 1,017 307 F 12,177 10,722 1,455 F 14,242 12,757 1,485 FOther Income 2,202 1,899 303 F 22,709 18,585 4,125 F 25,988 22,386 3,602 FTotal Income 81,331 82,123 (791) U 824,727 821,786 2,941 F 989,831 986,071 3,760 FExpenditurePersonnel 57,255 57,839 584 F 543,374 559,758 16,384 F 653,331 672,429 19,098 FOutsourced Personnel 1,268 1,091 (177) U 18,298 10,847 (7,451) U 21,936 13,027 (8,910) UOutsourced Clinical 1,940 2,062 123 F 22,584 18,757 (3,828) U 28,007 22,749 (5,258) UOutsourced Other 3,696 3,761 65 F 37,417 37,606 189 F 45,003 45,128 125 FClinical Supplies (excluding Depreciation) 10,297 10,138 (160) U 102,637 102,935 298 F 124,540 124,304 (237) UOther Expenses 5,957 6,459 502 F 64,168 64,376 208 F 76,061 77,235 1,174 FTotal Operating Expenditure 80,412 81,350 938 F 788,478 794,279 5,800 F 948,879 954,871 5,992 F

Total Operating Surplus/(Deficit) 919 773 146 F 36,249 27,507 8,742 F 40,951 31,200 9,752 FDepreciation 2,941 3,163 222 F 30,322 31,629 1,307 F 36,005 37,955 1,950 FInterest - - 0 F - - 0 F - - 0 FCapital Charge 3,091 3,108 17 F 30,908 31,077 169 F 36,824 37,292 468 FTotal Depreciation, Interest and Capital 6,032 6,271 239 F 61,230 62,706 1,476 F 72,829 75,247 2,418 F

Net Surplus/(Deficit) (5,113) (5,498) 385 F (24,982) (35,199) 10,217 F (31,878) (44,047) 12,168 F


Medical Personnel 18,603 18,417 (185) U 172,893 177,497 4,604 F 209,354 214,234 4,881 FNursing Personnel 21,956 22,526 571 F 214,939 216,929 1,990 F 256,359 259,757 3,398 FAllied Health Personnel 7,345 7,778 433 F 71,177 76,746 5,569 F 85,126 92,112 6,986 FSupport Personnel 3,098 2,644 (454) U 25,554 25,498 (55) U 30,740 30,607 (133) UManagement/Administration Personnel 6,253 6,474 221 F 58,812 63,088 4,276 F 71,752 75,718 3,966 FTotal (before Outsourced Personnel) 57,255 57,839 584 F 543,374 559,758 16,384 F 653,331 672,429 19,098 FOutsourced Medical 636 523 (113) U 9,789 5,169 (4,620) U 11,560 6,212 (5,348) UOutsourced Nursing 77 78 1 F 3,010 781 (2,229) U 3,550 937 (2,613) UOutsourced Allied Health 29 27 (2) U 263 267 4 F 340 321 (19) UOutsourced Support 11 - (11) U 100 - (100) U 382 - (382) UOutsourced Management/Admin 514 463 (51) U 5,136 4,630 (506) U 6,104 5,556 (548) UTotal Outsourced Personnel 1,268 1,091 (177) U 18,298 10,847 (7,451) U 21,936 13,027 (8,910) U

Total Personnel 58,522 58,930 408 F 561,672 570,605 8,933 F 675,267 685,456 10,189 F


Central Clinical Services (8,125) (7,870) (255) U (76,706) (77,929) 1,224 F (92,247) (93,453) 1,206 FEmergency Medicine and Integration (15,520) (15,413) (107) U (149,064) (148,884) (180) U (179,155) (178,222) (932) UMiddlemore Central (3,232) (2,779) (452) U (28,070) (26,855) (1,215) U (33,602) (32,198) (1,404) UARHOP (4,032) (4,040) 8 F (39,489) (39,744) 255 F (47,397) (47,707) 310 FMental Health (6,239) (6,641) 402 F (61,965) (63,888) 1,923 F (74,558) (76,842) 2,284 FSurgical & Ambulatory (16,847) (17,110) 264 F (164,632) (164,839) 207 F (201,415) (200,059) (1,356) UWomen & Child Health (7,082) (6,802) (280) U (65,796) (65,353) (443) U (79,507) (78,434) (1,073) UFacilities Services (2,079) (2,160) 81 F (20,721) (21,543) 822 F (24,868) (25,867) 999 FProvider Management 61,329 60,854 475 F 613,064 608,994 4,071 F 739,639 730,926 8,713 FInnovations Hub & Ko Awatea (617) (810) 193 F (4,537) (8,003) 3,467 F (5,965) (9,601) 3,636 FIntegrated Care (2,670) (2,726) 57 F (27,067) (27,154) 87 F (32,802) (32,589) (213) UNet Surplus/(Deficit) (5,113) (5,498) 385 F (24,982) (35,199) 10,217 F (31,878) (44,047) 12,169 F

Full Year

Surplus / (Deficit) by DivisionMonth

Consolidated Statement of Financial Performance

CMDHB Provider

Month Year to Date

Personnel Costs By Professional Group Month Year to Date Full Year

Year to Date Full Year


Glossary ACC Accident Compensation Corporation ED Emergency Department FSA First Specialist Assessment FTE Full Time Equivalent FU Follow Up Appointment HWFNZ Health Workforce New Zealand (previously CTA (Clinical Training Agency)) LTIP Long Term Investment Plan MECA Multi-Employer Collective Agreement MoH Ministry of Health TAP Turn Around Programme (Savings plan) WIES Weighted Inlier Equivalent Separation (activity based measurement) YTD Year to Date

Actual Contract Variance Variance Actual Contract Variance VarianceVolume Volume Volume % Volume Volume Volume %

M00001 - General Medicine Inpatients 1,282 1,258 23 F 1.9% 13,713 14,094 (380) U -2.7%S00001 - General Surgery Inpatients 792 768 24 F 3.2% 8,185 7,850 335 F 4.3%S45001 - Orthopaedic Inpatients 588 546 41 F 7.6% 5,891 5,585 306 F 5.5%M05001 - Emergency Medical Services Inpatients 386 388 (2) U -0.4% 3,798 3,861 (63) U -1.6%M55001 - Paediatric Medicine Inpatients 197 187 10 F 5.2% 2,129 2,445 (316) U -12.9%S60001 - Plastic & Burns - Inpatients 262 316 (54) U -17.2% 2,852 3,230 (378) U -11.7%M10001 - Cardiology - Inpatients 194 261 (67) U -25.7% 2,147 2,613 (466) U -17.8%M65001 - Respiratory - Inpatients 80 186 (106) U -56.8% 1,483 1,712 (229) U -13.4%S30001 - Gynaecology Inpatients 110 140 (30) U -21.2% 1,328 1,415 (87) U -6.2%M25001 - Gastroenterology - Inpatients 58 87 (28) U -32.6% 645 1,039 (393) U -37.9%All Others 1,161 1,215 (54) U -4.4% 12,107 12,155 (49) U -0.4%Total Acute 5,111 5,352 (242) U -4.5% 54,278 55,998 (1,720) U -3.1%S60001 - Plastic & Burns - Inpatients 151 140 11 F 7.9% 1,433 1,433 (1) U -0.0%S45001 - Orthopaedic Inpatients 47 79 (32) U -40.2% 848 809 39 F 4.8%S00001 - General Surgery Inpatients 32 37 (6) U -15.1% 473 380 93 F 24.5%S30001 - Gynaecology Inpatients 10 8 2 F 22.5% 130 82 48 F 58.4%M10001 - Cardiology - Inpatients 43 0 43 F 0.0% 369 0 369 F 0.0%All Others 110 12 98 F 828.6% 1,298 121 1,176 F 968.2%Total Arranged Admissions 393 276 117 F 42.2% 4,550 2,826 1,725 F 61.0%S45001 - Orthopaedic Inpatients 287 385 (98) U -25.5% 3,882 3,932 (50) U -1.3%S00001 - General Surgery Inpatients 273 331 (58) U -17.5% 3,194 3,381 (187) U -5.5%S60001 - Plastic & Burns - Inpatients 166 223 (56) U -25.3% 2,271 2,277 (5) U -0.2%S30001 - Gynaecology Inpatients 79 114 (35) U -30.5% 948 1,164 (216) U -18.5%S25001 - ORL Inpatients 90 116 (26) U -22.5% 1,014 1,185 (172) U -14.5%S40001 - Ophthalmology Inpatients 108 132 (24) U -17.9% 1,082 1,351 (269) U -19.9%MS02016 - Skin lesions 3 24 (21) U -87.3% 291 245 46 F 18.6%M10001 - Cardiology - Inpatients 28 38 (10) U -25.6% 394 404 (10) U -2.5%S70001 - Urology - Inpatients 22 32 (11) U -32.7% 269 329 (59) U -18.0%All Others 15 23 (8) U -33.5% 315 241 74 F 30.5%Total Elective 1,071 1,417 (346) U -24.4% 13,661 14,510 (849) U -5.9%

Total WIES 6,575 7,046 (471) U -6.7% 72,489 73,333 (844) U -1.2%

ED Discharges 9,486 9,529 (43) U -0.5% 98,019 102,564 (4,545) U -4.4%

Prior Period ComparisonsThis Year Last Year Variance Variance This Year Last Year Variance Variance

% %Acute WIES 5,111 5,398 (287) U -5.3% 54,278 55,170 (892) U -1.6%Arranged Admission WIES 393 434 (41) U -9.4% 4,550 4,928 (378) U -7.7%Elective WIES 1,071 1,389 (318) U -22.9% 13,661 13,944 (283) U -2.0%Acute Discharges 6,697 6,709 (12) U -0.2% 67,746 69,160 (1,414) U -2.0%Arrange Admission Discharges 413 403 10 F 2.5% 4,372 4,720 (348) U -7.4%Elective Discharges 1,068 1,333 (265) U -19.9% 13,336 13,439 (103) U -0.8%Births 662 653 9 F 1.4% 6,233 6,272 (39) U -0.6%ED Discharges 9,486 9,340 146 F 1.6% 98,019 98,079 (60) U -0.1%FSA Volumes 3,740 4,109 (369) U -9.0% 43,561 42,151 1,410 F 3.3%FU Volumes 9,658 10,145 (487) U -4.8% 103,111 104,174 (1,063) U -1.0%

Year to DateMonth

Contract Performance WIESYear to DateMonth


Finance Overview The Provider Arm produced a $385k favourable result against budget for April 2019 and a $10.2M favourable YTD. The YTD favourable result is driven mainly by unbudgeted MECA settlement revenue from MoH, continuing vacancies across the system and one-off releases. RDA strikes have led to SMO claim costs over budget and have had a negative YTD impact on the delivery of the elective programme reflecting a lower level of revenue expectation against this programme. Unrealised Turn Around Plan (TAP) savings, and additional approved but unbudgeted clinical outsourcing in Surgical Services have also had an adverse impact on the bottom line. Volumes Activity for the month of April is lower than contract by 471 WIES (6.7%) due to decreased volumes in Plastic & Burns, Respiratory and Orthopaedic procedures driven by a level of annual leave taken over the Easter-Anzac period, reducing the number of surgical lists during this time. Year to date ED discharges are 60 cases less than last year and Acute WIES have under delivered to contract by 3.1% YTD reflecting a milder winter, a focus on front door admissions, continued enhanced capacity in the community as well as the impact of the RDA Strikes. Note that the above volumes reflect CMH core activity delivered for all DHB’s. The Elective Programme volumes below, reflect MoH contracted activity delivered from all DHB’s for the CMH population. Key Drivers of the April Result Revenue Revenue: Apr $791k unfavourable, YTD $2.9M favourable • ACC revenue behind budget -$522k (Apr YTD $532k) • Interest received higher than budget $103k (Apr YTD $880k) • Revenue from Tahitian Burns $62k above budget (Apr YTD $1.2M) • Pacific Regional revenue offset by costs $2k over budget (Apr YTD $1.6M) • Retail pharmacy decreased sales volumes -$36k (Apr YTD $699k) • Provider unrealised TAP Savings -$159k (Apr YTD -$938k) • Bowel screening volumes behind contract -$31k (Apr YTD -$593k) • CTA training revenue ahead of budget $106k (Apr YTD $621k) • Funded research revenue received higher than budget $57k (Apr YTD $544k) • Bad debts recovered higher than budget $128k (Apr YTD $402k) • MoH supplementary revenue for MECA settlement in PSA Nursing (Apr YTD $776k) and PSA Allied Health

(Apr YTD). Elective Programme Revenue: Apr $1.7M, Apr YTD -$5.3M • The elective programme is tracking 4.8% (1,041.09 WIES) behind contract (see table below), reflecting an

adverse position of -$1.7M for the month, -$5.3M unfavourable YTD. • The variance is driven by YTD volumes lower than contract in general surgery, ENT services, Gynaecology and

Ophthalmology. • The CMH elective programme volume unfavourable variance is driven by Anaesthetic Consultant shortfalls,

Day of Surgery cancellations and the impact of the RDA strikes, highlighting a risk of not achieving our elective programme volumes balance of year.

• A level of additional outsourcing has been approved to meet the MoH elective discharge target to mitigate the introduction of capped volumes for skin lesion activity for the year.


Expenditure Overall operational expenditure is $938k favourable for the month and $5.8M favourable YTD. Net Personnel Costs: Apr $408k favourable; YTD $8.9M favourable The overall personnel cost variance reflects a level of existing vacancies across the system that are currently being recruited to. A comparatively high level of annual leave was taken in April during Easter and School Holidays, which was partly offset by stat day credits for Easter and ANZAC day and the SMO claims expenses to cover the NZRDA strike in April. A number of MECA were settled over the period from December to April with backpay and lump sum payments were made against high level provisions during that time (ETU, PSA AH, PSA Nursing, SToNZ). The MECA over provisions are released progressively till the year end. SMO claims for the four RDA strikes to March have been partly offset by salaries not paid to staff on strike, net cost $1.3M. A total of 4,410 hours have been claimed by SMO’s with unpaid hours to RDA members being 8,712 hours. Further industrial action was planned for 29th April to 4th May 2019, the data was not available at the time of writing this report. High utilisation of bureau, both internal and external have been used to cover existing vacancies and annual leave taken over the month of April. Clinical bureau engagement is driven mainly by high incidences of watches in General Medicine to respond to acute demand as well as specials and watches required in the Burns Unit. A Bureau Efficiency Project is underway led by Jenny Parr, Chief Nurse and Director of Patient and Whaanau Experience, with a view to actively monitor and report both internal and external bureau, working towards providing more permanent and sustainable staffing for CMH. • Net Medical costs are $299k unfavourable for the month and $16k unfavourable YTD, reflecting net cost of RDA

strikes $1.3M offset by the continuing vacancies across the services in difficult to recruit to positions, mainly in Anaesthesiology, Radiology and Mental Health. The cost savings associated with the delayed opening of Tiaho Mai AMHU have also contributed to the variance.


• Net Nursing costs are $572k favourable for the month which is driven by the release of NZNO MECA provision of $667k. The unfavourable YTD $239k reflects an increase in clinical demand and use of internal bureau nurses to cover leave, unmet TAP savings, and the final settlement cost for the PSA MH Nursing MECA, offset by vacancies and MECA/Skill mix variation.

• Net Allied Health costs are $430k favourable for the month which is partly driven by the release of PSA Allied Health MECA provision of $198k. The YTD favourable $5.6M represents vacancies across the services that are being actively recruited to mainly for Psychologists, Anasesthetic Technicians, Social Workers and Occupational Therapists, partly offset by the final settlement cost for the PSA Allied Health MECA settlement.

• Net Support Personnel costs are$465k unfavourable for the month and $155k unfavourable YTD. The unfavourable results reflect the final settlement cost of the ETU MECA which is higher than budget (actual 10% vs budget 2%), this is partly offset by vacancies in Engineering, Facilities Management and Sterile Supplies.

• Net Management and Administration Personnel costs are $169k favourable for the month and $3.6M favourable YTD, reflecting vacancies across all non-clinical services.

Non-Staff Costs • Outsourced Clinical: Apr $123k favourable, YTD -$3.8M unfavourable

Driven by Pacific Health contract expenses (offset by revenue), additional approved surgical outsourcing to meet the MoH elective discharge target as well as increased YTD MRI outsourcing due to staff shortages and delayed implementation of the new MRI machines.

• Outsourced Other: Apr $65k favourable, YTD $189k favourable Unbudgeted charges from hA FPSC and NZHPL mainly in relation to realisation of capital procurement savings.

• Clinical Supplies: Apr -$160k unfavourable, YTD $298k favourable Unrealised TAP savings in the Provider Arm $295k (Apr YTD $2.8M) is offset by volume related reduction largely in renal fluids, bloods, testing kids and shunts and stents. The favourable costs in operating leases of the clinical equipment is also offset by unrelated additional repairs & maintenance costs, mainly in the sterile supply unit.

• Other Expenses: Apr $502k favourable, YTD $208k favourable Favourable variance in the month is driven by a one-off release of bad debt provision $500k and the lower than budgeted maintenance outsourced services in the asbestos programme $167k. These savings are offset by the unrealised TAP savings in the Provider Arm $184k (Apr YTD $1.4M), increased linen expenses and unbudgeted legal and consultant costs (inc EBERT).

• Interest, Depreciation and Capital Charge: Apr $239k favourable, YTD $1.5M favourable Favourable depreciation and capital charge due to timing of capital expenditure and equity injections.

Forecast to Year End The year-end position is a forecast deficit of $31.9M which is a $12.2M favourable variance against budget, reflecting mainly vacancies and one off adjustments that have contributed to the bottom line. A level of vacancies, in difficult to recruit to positions are expected to continue to the year end, but will be offset by overtime and outsourcing. Looking Ahead Planning within the Provider Arm includes: • Facilities Master Planning - Immediate Demand and Facilities Remediation Programmes, to confirm capacity

requirements over the next 3-5 years and align facility investments. • Turn-around-Programme – Implementation of the 2018/19 Savings Programme to deliver budget targets and

benefits realisation. • The first draft of 2019/20 budget submission to MoH.



Patient Experience and Safety Report

Recommendations It is recommended that the Hospital Advisory Committee: Note that this report was submitted to the Executive Leadership Team meeting on 14 May 2019. Receive the Patient Experience and Safety Report June 2019.

Prepared by: Dr David Hughes, Clinical Director Patient Safety & Quality Assurance. Submitted by Dr Gloria Johnson, Chief Medical Officer (Hospital Services) and Jenny Parr, Chief Nurse and Director of Patient and Whaanau Experience. Purpose

To provide a regular update to Counties Manukau Health (CM Health) on the progress of the planned actions as linked to the Annual Plan Improving Quality section work plan. Report content 1. Monthly Safety, experience, compliance and measurement dashboard

2. Monthly Safety, experience, compliance and measurement variance report Appendices 1. Coordination – report from our inpatient experience survey

Safety, experience, compliance and measurement dashboard 1. Monthly divisional summary of serious incidents – AEB As sent during April 2019

2. Health Roundtable - Insights

Target Latest month

0 non-falls serious adverse events

6

This table shows the incidents by Division reviewed by the Adverse Events Operational Group and reported to the Health Quality & Safety Commission as potentially meeting Severity Assessment Code (SAC) 1 or 2 criteria. The target excludes falls as these cannot be completely prevented.

Target Latest month

< 2.2% (baseline) 2.0%

Health Roundtable (Insights) provides data based on coded discharge data. This shows percentage of admissions affected by any Classification of Hospital Acquired Diagnoses (CHADx) codes.

Data provided is three months in arrears due to clinical coding requirements after discharge.

1

Division Description

Medicine 1) Progression of pressure injury from Stage 2 to 3

2) Progression of pressure injury from Stage 2 to 3

3) Unexpected death following chest drain insertion

ARHOP 1) Fall resulting in hip fracture

Mental Health

1) Suspected suicide of community mental health patient

Critical Care 1) Stage 3 pressure injury

Women’s Health

1) Intrauterine death

3. National Quality and Safety Markers (QSM)

3.1 Falls

3.3 Medication Safety

Target Latest month

< 0.09 falls with major harm per month per 1000 bed days

0

This chart shows the rate of Staphylococcus aureus bacteraemia (SAB) per 1000 bed days. This is an outcome measure of Hand hygiene QSM.

Since July 2017 the hand hygiene gold audit programme expanded to 29 clinical areas.

Target Latest month

<0.06 SAB per 1000 bed days 0.14

3.2 Hand Hygiene – outcome measure

This chart shows the number of falls with major harm per 1000 bed days. Since January 2015, on average, there has been a 36 per cent reduction in falls with major harm.

2

Target Latest month

80% 73%

This chart shows the high risk patients with electronic medication reconciliation (eMR) completed within 48 hours of admission. There has been a consistent step up in performance since January 2018. This target is yet to be reported nationally as CM Health is only one of five DHBs where eMR has been implemented.

4.1 Pressure injuries

Target Latest month

0 Stage 3, 4 or unstageable pressure injuries

0

4. Excellent, kind, high quality experience for everyone

This chart shows the severe pressure injuries (Stage 3, 4 or unstageable) per 100 patients on monthly audit. There has been a sustained reduction in the overall number of pressure injuries since June 2012 but common cause variation in Stage 3, 4 and unstageable pressure injuries since that time. This data is from ward based audits .

This chart shows the Intensive Care Unit (ICU) central line associated bacteraemia (CLAB) rate per 1000 line days. The actual line days in ICU average 100 per month.

Target Latest month

<1 CLAB per 1000 line days 0

4.2 Central line associated bacteraemia (CLAB)

3

Target Latest month

0 Stage 2 pressure injuries 14

This chart shows stage 2 pressure injuries per 100 patient admissions. This data is from Incident Reporting System. This relies on self report of stage 2 pressure injuries.

4.3 Venous thromboembolism (VTE)

This chart shows the number of elective orthopaedic provoked venous thromboembolism (VTE) cases per 1000 bed days. This month’s result is common cause variation. The target of <1.7 per 1000 bed days was set when this was the average rate during the period July 2015 to January 2017.

Target Latest month

<1.7 per 1000 bed days 2.1

4

5. Improve consumer engagement

5.1 Internal inpatient experience survey

Target Latest month

> 200 completed surveys per month

653

Since December 2017 there are now three ways for patients to complete the CM Health internal inpatient experience survey: email, text or tablet (Women’s Health). This chart shows the number of patients who completed the survey.

This chart shows the percentage of patients in our internal inpatient experience survey who rated their care as very good or excellent. The average is 80%. The target of 80% was established by ELT in April 2017.

Target Latest month

80% 85%

6. Feedback central

5

Target Latest month

100% 99%

Target Latest month

80% 51%

This chart shows case resolution within target. It is the ratio of cases resolved within 20 days of submission among all cases resolved within the reporting month. In consultation with other DHBs, it was identified that the average performance nationally is approximately 50%. 80% (aspirational) target has been set based on the feedback for CM Health case resolution within 20 working days.

This chart shows case acknowledgement within target. It is the ratio of cases acknowledged within 5 days of submission among all complaints received in the reporting month.

Safety, experience, compliance, measurement dashboard variance report – April 2019

Measure Variance Issue description Action By whom By when

Serious incidents: 0 non-falls serious adverse events

+6 Six non-fall incidents reported in the last month as detailed on the dashboard.

Investigations are underway and they will be reported through the draft Counties Manukau Health Serious Adverse Event Report 2018-2019.

Quality & Risk Managers

November 2019

Hand hygiene outcome measure: <0.06 Staph. Aureus bacteraemia per 1000 bed days

+0.08 Common cause variation in SAB rates despite increased engagement in hand hygiene programme

Increased focus on other causes of SAB including work stream to reduce peripheral IV line associated bacteraemia.

Infection services

ongoing

Medication Safety QSM: 80% of high risk patients with electronic medication reconciliation (eMR) completed within 48 hours of admission

-7% Other than ARHOP, the rate of eMR completion within 48 hours is not achieved mostly due to weekend admissions and availability of pharmacists.

Despite the target not being met, there has been consistent improvement in performance since January 2018. This target is yet to be reported nationally as CM Health is only one of six DHBs where eMR has been implemented. Consider weekend work capacity for clinical pharmacists.

Rebecca Lawn / Chip Gresham

To be determined

Stage 2 pressure injuries: 0 hospital acquired stage 2 pressure injuries

+14 Although we have made significant gains in the prevention of severe pressure injuries our focus has moved to prevention of mild and moderate injuries

Pressure injury prevention group to review risk assessment and prevention plans to consider improvements focussed on mild to moderate pressure injury.

Pressure injury prevention group

August 2019

Venous thromboembolism: <1.7 provoked VTE cases per 1000 elective orthopaedic bed days

+0.4 The target was set to reflect the average rate of VTE during the period July 20165 to January 2017. In the twelve months after this period there was an elevated rate of VTE.

VTE prevention group continues to consider required improvements in risk assessment and prophylaxis. This group will present to CGG / ELT in July 2019.

VTE prevention group

July 2019

Complaints: 80% of cases resolved within 20 working days

-29% This aspirational target has been set following consultation with other DHBs whose performance is similar to our own.

Feedback Central will continue to work with services to ensure that those straightforward complaints are managed efficiently as close to the consumer as possible so that the great majority of complaints are resolved within 20 days

Feedback Central

November 2019

Counties Manukau Health Inpatient Experience Report no.1 April 2019:1

Snapshot report - April 2019

Inpatient Experience

There are a number of clinical guidelines, protocols and pathways at Counties Manukau Health that detail the processes and procedures needed to ensure that our patients experience seamless, coordinated care right from prior to admission through until after discharge.

Most of our patients tell us that these guidelines, protocols and pathways are working well and there are a number of patient stories in our survey data that detail what it feels like for patients when the system works the way it was designed to. There are, however, also stories from frustrated patients who tell us what it is like when these systems don’t work properly. Some are left unsure about what is happening, others tell us they don’t know who to listen to and many of these are left confused as to what is going on. Coordination once a patient leaves hospital is an area where many patients feel let down; one-fifth of all respondents who commented on our coordination said that follow up after discharge was poor.

Overall, we have seen a statistically significant and sustained increase in patient experience ratings over the past 24 months. Excellent and very good ratings have increased by two percentage points to 81%, whilst poor and fair ratings have decreased by the same margin, down two percentage points

from 8% to 6%.

Jenny ParrChief Nurse and Director of Patient

and Whaanau Experience

Consistent and Coordinated CareCM Health patients tell us that they have a good experience of consistent and coordinated care when these things happen...

Clinical records are kept up to date, any instructions are recorded and these are passed on during a thorough handover process. Patients particularly appreciate it when they don’t need to repeat themselves.

Discharge is coordinated and efficient and care is taken to ensure every patient leaves with information on what they should or should not do, who to contact if they are worried and any danger signals to watch out for.

My midwife kept me in the loop, made sure I understood

how to care for myself and baby while at home and reassured me that

if anything was wrong to contact them.

The various tests needed for my several

conditions were coordinated between the different disciplines extremely well with good results

and very clear explanation of my condition.

There were 3 different points

of view when my leg plaster was

coming off.

All staff were well informed and familiar with why I was in hospital

and the care I required. Despite having multiple doctors and midwives I felt they worked well as a team so that all hand

overs were seamless.

All data in this report are from the 6 month period 01.09.18 - 28.02.19. Comparison data are from 01.03.18-31.8.18. Any differences noted are statistically significant (<p.05).

They are informed promptly of any changes or delays in treatment, and given approximate time frames to indicate when things might happen.

Advice, information and treatment processes are consistent between staff and teams.


COORDINATION INSIDE HOSPITAL

CONFLICTING INFORMATIONWe asked our inpatients if they ever received conflicting information from staff, where one person would say something and other would tell them something completely different.

There has been no change on this measure when compared with the six months prior (01 March 2018 - 31 August 2018).

n=1,035

Nearly two-thirds of respondents (64%) said that they were never given conflicting

information by different staff members

11% said this

happened often.

1 in 4 (25%) said this happened

sometimes

Three-quarters of respondents who say that consistent care is important rate us eight or higher out of 10.

HOW DO WE RATE?

n=1600

LowModerateHigh

When consistent and coordinated care matters

of respondents say that getting consistent and coordinated care whilst in hospital is one of the three things that matters most.

33%

AVERAGE RATING OVER 12 MONTHS

TEAMWORK

Just over three-quarters of respondents (77%) rated the way that doctors, nurses and midwives worked together as excellent or very good.

We asked our inpatients how well staff worked together.

Doctors and nurses or midwives

43% 38% 13%

Other staff and healthcare team

43% 37% 15%

Similarly, 78% of respondents rated the way that other staff such as physiotherapists, radiographers, occupational therapists or dietitians worked with other members of the healthcare team as excellent or very good.

41 36 15 5 3

Excellent Very good Good Fair Poor

41 36 15 5 3


41 37 15 5 2


41 36 15 5 3


There has been no change on either of these measures when compared with the six months prior (01 March 2018 - 31 August 2018).

Inpatients who commented positively on our consistent and coordinated care said they:• Received quality care from

compassionate, caring and respectful staff (29% of all comments).

• Witnessed good communication between staff and teams (14%).

• Were given consistent advice and information, and were kept informed as to what was happening (10%).

• Did not experience any delays in care or treatment and were attended to promptly when they needed help (8%).

When CARE IS CONSISTENT

PATIENT FEEDBACK

SUGGESTED IMPROVEMENTSInpatients suggested that their experience of consistent and coordinated care could be improved by: • Better communication with the patient,

particularly around any delays in care or treatment or when decisions or plans are changed (18% of all comments).

• Better communication between staff and teams, taking particular care to apply consistent treatment protocols and provide consistent information and advice (13%).

• Offering consistent patient care which is grounded in compassion, caring and empathy and uses active listening and open communication (11%).

75%

75

19

6

Apr - Jun2018

Jul - Sep2018

Jan - March2018

Oct - Dec 2018

7.7

8.2 8.2 8.3


IN DEPTH: COORDINATION INSIDE HOSPITAL

CONFLICTING INFORMATION

TEAMWORK

BY DIRECTORATE BY ETHNICITY

58

68

68

26

24

24

16

8

8

Women's Health

Surgical & Ambulatory Services

Medical Services

No Sometimes Yes

Women’s Health respondents were significantly more likely to say they were given conflicting information than respondents from Medical or Surgical and Ambulatory services (16% compared with 8%).

Conflicting information by directorate (%)

“Over one day I was given conflicting advice from the 3 different midwives on shift. This was very confusing.”

(Women’s Health)

“Every time nurses handed over to the next shift they told the next nurse exactly what had been happening and also what was to be done.”

(Surgical & Ambulatory)

58

68

68

26

24

24

16

8

8

Women's Health


Medical Services

No Sometimes Yes

Respondents who identify as Pacific or Asian are significantly more likely to say they were given conflicting information than patients of NZ European ethnicity.

66

58

62

64

25

25

22

24

9

17

16

12

NZ European

Asian

Pacific

Maaori

No Sometimes Yes

Conflicting information by ethnicity (%)

66

58

62

64

25

25

22

24

9

17

16

12

NZ European

Asian

Pacific

Maaori

No Sometimes Yes

(Medical Services n=199; Surgical & Ambulatory n=436; Women’s Health n=312) (Maaori n=110; Pacific n=163; Asian n=171; NZ European n=522)

“Was told conflicting information by each person I saw. Each shift change the plan changed. Very confusing.”

(Pacific)

“Communication was consistent and strong so that everyone had the same understanding of the approach and what we were aiming to achieve.”

(NZ European)

Respondents who were cared for in Women’s Health were significantly more likely to rate the teamwork of doctors with nurses and midwives as excellent.



There are no significant differences in the way respondents rate the teamwork of other staff with other members of the healthcare team.

41 36 15 5 3



41 36 15 5 3


46

38

39

29

40

36

17

14

18

5

6

2

3

2

5

Women's Health


Medical Services


(Medical Services n=202; Surgical & Ambulatory n=435; Women’s Health n=317)

46

40

37

32

36

41

12

18

15

6

5

5

3

2

1

Women's Health


Medical Services



4042

5045

403826

31

1414

1216

44

75

32

54

NZ EuropeanAsian

PacificMaaori



41 36 15 5 3


Whilst Pacific respondents were significantly more likely to rate the teamwork of doctors with nurses and midwives as excellent, their overall very good and excellent ratings were comparable with other ethnicities.

(Maaori n=110; Pacific n=163; Asian n=176; NZ European n=520)

37

38

47

31

43

35

28

13

9

3

6

8

1

1

2

NZ European

Asian

Pacific



41 36 15 5 3


Pacific respondents were significantly more likely to rate the teamwork other staff with the rest of the healthcare team as excellent or very good. (Maaori (suppressed as <50 responses); Pacific n=116; Asian n=136; NZ European n=386)

Medicine & Acute Care

Surgery, Anaesthesia and Perioperative Care

Women’s Health



Women’s Health



Women’s Health


COORDINATION OUTSIDE HOSPITAL

Seven out of 10 respondents who say that consistent care is important rate us eight or higher out of 10.

HOW DO WE RATE?

n=515

LowModerateHigh

When coordination between hospital, home and other services matters

of respondents say that coordination between hospital, home and other services is one of the three things that matters most.

12%

AVERAGE RATING OVER 12 MONTHS

DISCHARGE PREPARATION

There has been no change on this measure when compared with the six months prior (01 March 2018 - 31 August 2018).

n=545

Half of inpatient respondents (50%) said that they were very

well prepared for discharge

14% said they

were not prepared.

Almost one in four, or 36% said they were prepared

quite well.

SERVICE COORDINATION

Two-thirds of respondents (68%) rated the coordination of their care prior to hospital as excellent or very good.

We asked our inpatients to rate the coordination of care between the hospital, home and other health services prior to admission and after discharge.

Admission to hospital

43% 38% 13%

After discharge37% 15%

Almost one-quarter of respondents (23%) rated the coordination of their care after leaving hospital as fair or poor.

41 36 15 5 3


41 36 15 5 3


There has been no change on either of these measures when compared with the six months prior (01 March 2018 - 31 August 2018).

Inpatients who commented positively on the coordination between hospital home and other services said:• Follow-up after discharge, from either

the hospital or community-based services was prompt and well planned (23% of all comments).

• They had a good discharge experience, where they were able to discuss the ongoing management of their health and were given information about medications, what to do and who to contact (12%)

When coordination works well

PATIENT FEEDBACK

SUGGESTED IMPROVEMENTSInpatients suggested that their experience of service coordination could be improved by: • A discharge process that is reassuring,

patient-centred, well organised and well coordinated. This includes checking that patients have all the information they need to manage their health and care at home, that they are clear about their medication, and they know what to expect and who to contact if they have any questions or issues (32% of all comments)

• Better follow up after discharge, including checking (where applicable) that equipment has arrived and community-based services have been in contact (and details of who to contact to follow these up) (20%).

We asked our inpatients how well we prepared them for leaving hospital.

37 32 16 8 8


30 32 15 13 10


61%61

23

16

Apr - Jun2018

Jul - Sep2018

Jan - March2018

Oct - Dec 2018

7.17.4 7.5

7.1



Medical services respondents were significantly less likely to say they were not very well prepared for discharge (5%) than respondents from Women’s Health (15%) or Surgical and Ambulatory services (17%).

Conflicting information by directorate (%)

“The discharge information was not complete and confusing around medication and relevant support information ... which then meant I ended up back in hospital.” (Surgical & Ambulatory)

“All resources for aftercare were delivered prior to me being discharged.”

(Women’s Health)

NZ European respondents are significantly more likely to say they were very well prepared for discharge than patients of other ethnicities.

Conflicting information by ethnicity (%)

(Medical Services n=105; Surgical & Ambulatory n=290; Women’s Health n=114) (Maaori (suppressed); Pacific n=81; Asian n=91; NZ European n=295)

“ I was discharged but [didn’t get] my antibiotic tablets until almost 48hrs later as the prescription was not sent to the pharmacy”

(Pacific)

“I was going [overseas]. My Doctor arranged to have an early clinic in Auckland and provided a contact [overseas] for me to make an appointment when I arrived.” (NZ European)


After discharge

41 36 15 5 3



41 36 15 5 3



(Medical Services n=77 Surgical & Ambulatory n=239; Women’s Health n=109)

41 36 15 5 3


Pacific respondents were significantly more likely to rate the coordination of their care after discharge from hospital as fair or poor.

41 36 15 5 3


(Maaori (suppressed); Pacific n=82; Asian n=92; NZ European n=222)

IN DEPTH: COORDINATION OUTSIDE HOSPITAL

SERVICE COORDINATION

DISCHARGE PREPARATION


After discharge

35

36

45

31

33

27

16

15

18

13

6

6

6

10

4

Women's Health


Medical Services

Excellent Very good Good Fair PoorWhilst there is some variation in coordination ratings (prior to admission) between directorates, none of these are statistically significant.

Three out of 10 Women’s Health respondents rate the coordination of their care after discharge as fair or poor.

33

28

30

26

33

38

12

15

18

17

12

10

13

10

4

Women's Health


Medical Services


30

30

34

33

39

25

15

16

13

14

11

13

9

4

14

NZ European

Asian

Pacific


(Maaori (suppressed); Pacific n=76; Asian n=82; NZ European n=235)

41

33

37

29

43

34

17

13

15

7

5

10

6

5

5

NZ European

Asian

Pacific

Excellent Very good Good Fair PoorThere are no significant difference between ethnic groups on ratings of coordination prior to discharge.

55

40

45

31

50

38

14

10

17

NZ European

Asian

Pacific

Very well Quite well Not very well

55

40

45

31

50

38

14

10

17

NZ European

Asian

Pacific

Very well Quite well Not very well44

50

56

41

33

39

15

17

5

Women's Health


Medical Services

No Sometimes Yes

55

40

45

31

50

38

14

10

17

NZ European

Asian

Pacific

Very well Quite well Not very well



Women’s Health



Women’s Health



Women’s Health


Our very good and excellent ratings have averaged 81 percent over the past twelve months, whilst our poor and fair ratings have averaged six percent.

Combined very good/excellent and poor/fair ratings September 2018 to February 2019 (all respondents, %)

WHAT MATTERS TO PATIENTS?Our patients are asked to nominate the three dimensions of care that are important to them, and then to rate us on these (out of 10). The dimensions below are presented in order of what matters most to patients.

Communication n=1,284; Dignity and respect n=1,097; Consistent care n=1,600; Confidence n=729; Information n=709; Pain and nausea n=438; Cleanliness n=472; Decisions n=403; Coordination n=258; Food n=276; Whānau support n=230; Cultural needs n=326.

n=2218

OVERALL CARE AND TREATMENT

80 81 81 8377

86

6 9 6 7 6 60

102030405060708090

100

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

OVERALL EXPERIENCE RATINGS

Combined fair and poorCombined very good and excellent

8.1

8.8

8.3

8.7

8.2

8.0

8.2

8.4

6.3

7.2

8.1

8.4

Communication (discuss care and treatment)

Treated with compassion, dignity and respect

Consistent and coordinated care in hospital

Confidence in care

Getting good information

Cleanliness and hygiene

Involvement in decisions

Managing pain and nausea

Food and dietary needs

Co-ordination between hospital, home etc

Enabling whaanau, family & friends support

Values, beliefs and cultural needs met

Respondents who rated their care as EXCELLENT told us...

“The doctors explained my situation perfectly and what tests and or x-rays would have to take place before a plan for my treatment could be actioned... shout-out to the nursing and cleaning staff, thanks to all of you who make a difference every day in the lives of perfect strangers that come through your doors.”

“All the staff members in my ward were polite, efficient and kind. Always felt acknowledged and updated about everything. Everyone had smiling faces and a offered a helping hand when needed. The rooms were also very hygienic and clean which was really nice.”

“The amount of care and respect I got from medical staff was excellent especially since we had several concerns and were anxious. Staff were empathetic and positive easing our fears and worries with their pleasant manner and attentive care.”

VERY GOOD

“The nurses in [my] ward were excellent. I also thought that the lady who came to clean the rooms and refresh the hand towels etc in the morning was a real breath of fresh air, each morning she would appear with a great big smile on her face and a cheery good morning. People like her are probably not recognised enough but make a real difference to someone stuck in hospital.”

“I was admitted with several problems and I found the coordination of the various disciplines was excellent and the administration and explanation of procedures and results by [the doctor] were both caring and compassionate, especially during the family meeting.”

GOOD

“Staff wanted to help but were frequently overworked, stretched and so didn’t follow up on tasks.”

FAIR

“Some of the doctors was great while others just made me feel they had 2 seconds to spare and rushed through everything and sent me home so I could come back in four days time.”

Overall care and treatment ratings by division September 2018 to February 2019 (all respondents, %)

Overall n= 2218; Medicine & Acute Care n=355; Surgery, Anaesthesia and Perioperative Care n=767; Women’s Health n=850; ARHOP (Rehabilitation) n=187. Note that the data from some divisions are too small to be included here (<100).

The differences between divisions are statistically significant (p<.05)

494952

4546

3231

3139

32

12141112

12

5443

7

22213

OverallWomen's Health

Surgery, Anaesthesia and Perioperative CareARHOP (Rehabilitation)Medicine & Acute Care


494952

4546

3231

3139

32

12141112

12

5443

7

22213

OverallWomen's Health

Surgery, Anaesthesia and Perioperative CareARHOP (Rehabilitation)Medicine & Acute Care




Patient Flow - Every Hour Counts Portfolio Report Recommendation It is recommended that the Hospital Advisory Committee: Receive the Every Hour Counts Portfolio Progress Report for April 2019. Note the issues and risks outlined in the paper.

Prepared and submitted by: Kim Wiseman, General Manager Ko Awatea on behalf of Mary Seddon, Director Ko Awatea and Senior Responsible Officer for Every Hour Counts portfolio.

Purpose The purpose of this paper is to provide the Hospital Advisory Committee with an update of progress, issues and risks associated with the Acute Flow and Ambulatory Flow programmes of work.

Executive Summary There has been an acceptance by the Executive Leadership Team that transformational change is required to truly optimise patient flow in CM Health, and unless these risks are mitigated, the anticipated benefits of the patient flow programme (including support for the winter plan) will not be realised. This paper outlines current risks and highlights from key programmes of work across the Patient Flow portfolio: • Emergency Department – The increased acuity and complexity of presentations continues to

overwhelm the Emergency Department, which is already at tipping point due to a lack of providers. With the imminent onset of the winter peak, it is vital that this is addressed as a priority.

• Home wards – The Home Ward model of care has now been expanded to four medical wards, where the SAFER patient flow bundle is being implemented.

• Bed utilisation – The push back of bed numbering to 2020 is hampering progress of this project. However, a manual patient ‘check-out’ process tested on Ward 8 has decreased the average time from the departure of a patient to cleaning being requested by 19 minutes. This process is now being tested on four other wards.

• Community Services and MRI – Waiting lists for both Community Services and MRIs have been significantly reduced and work continues across these areas to bring waiting times to acceptable levels.

• Outpatient redesign – A major review of the outpatient booking and scheduling system will be presented to stakeholders at the end of May. Key themes from staff and patients have been identified and will form an integral part of the recommendations for redesign.

• Technology infrastructure – There continues to be significant challenges with a lack of technology and analytics to support real-time visibility of patient flow.

Acute Flow Programme 1. Emergency Department (ED) flow project

Acuity, volume and complexity The increased acuity in presentations can be seen in Table 1 below, which compares the 2019 Easter period with Easter 2018. This data shows a doubling in the most acute categories, Triage Categories 1 and 2, and an increase in Ambulance presentations.


The most complex patients, those with multiple comorbidities, generally appear in Triage Category 3, which has also increased.

Table 1: Presentations to ED by Triage Category – Easter 2018 vs 2019 Category 30/03/18 – 02/04/2018 19/04/19 – 22/04/2019

Triage Category 1 14 28




Self-discharge 72 104

Ambulance 270 317 Capacity issues The number of providers in the ED has not increased over the last three years, despite increasing demand. A benchmarking study, outlined in Chart 1 has demonstrated a deficit of 28 decision-makers (SMOs, RMOs, Clinical Nurse Specialists and Nurse Practitioners) in the ED compared to regional organisations that experience lower demand.

Chart 1: Presentations per decision-maker across metro Auckland

Specialty patients housed in the ED Housing specialty patients, eg. those with hand injuries to be reviewed by Plastics, in the ED causes significant delays for those patients. In addition, whilst these patients are not seen by an ED provider, statistically it increases six hour waiting time breach within the department. Risks • The request for additional providers to the ED is not approved in totality. • Staff feel overwhelmed and there is a risk that getting more providers may be viewed as the entire

mitigation, therefore opportunities to improve other flow inefficiencies will not be conducted. • Siloed approach – it is imperative that the rest of hospital understands the pressures of flow

blockages for ED patients. If this is not accepted system-wide, there is a risk that wards will not ‘pull’ patients from the ED.

Mitigation • Three additional ED providers have been requested as part of the winter plan. • A working group has been established to consider options for the relocation of hand patients

currently housed in the ED. Chaired by the Chief Medical Officer, the first meeting of this group was held week commencing 6 May and a follow-up meeting is scheduled for end May.

• Multidisciplinary/divisional huddles are being conducted at change of shift to anticipate flow risks and improve team dynamics.

1506 1197 1097 1071 1024 983 945

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MMH ADHB Waikato SSH NSH WDHB Waitakere

Presentations per provider


• Emergency Q is well established and has diverted over 1,000 patients to date, decreasing Triage Categories 4 and 5 patients.

• All six care bundle pathways (asthma, cellulitis, lower back pain, dental pain, traumatic hip pain, and nausea and vomiting in pregnancy) are complete and have been implemented.

2. High bed occupancy and lack of implementation of Home Wards in Medicine

General Medicine has now expanded the Home Ward model to four wards and is implementing the SAFER patient flow bundle as part of the proactive discharge project.

Senior review - All patients have a senior review before midday by a clinician able to make management and discharge decisions.

All patients will have an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set by assuming ideal recovery and assuming no unnecessary waiting.

Flow of patients to commence at the earliest opportunity from assessment units to inpatient wards. Wards routinely receiving patients from assessment units will ensure the first patient arrives on the ward by 10am.

Early discharge - 33% of patients will be discharged from base inpatient wards before midday.

Review – A systematic multi-disciplinary team (MDT) review of patients with extended lengths of stay (>7 days – also known as ‘stranded patients’) with a clear ‘home first’ mind set.

Bed utilisation There is no way to adequately track where beds are in the turnaround process, eg. cleaning, due to the lack of bed numbering and IT systems. It was hoped that IPM bed numbering would be available in July, however this has been delayed until 2020. A manual patient ‘check-out’ process was tested on Ward 8 during March in order to record accurate discharge times. The departure times of 127 patients were recorded. This intervention saw the average time from departure to cleaning being requested drop to 36 minutes, compared to the baseline sample of 55 minutes.

Risks • Complete implementation of the SAFER patient flow bundle does not eventuate. • Further delay in the implementation of IPM bed numbering.

Mitigations • Work with the Clinical Director and Clinical Nurse Director for Medicine to implement Home Ward’s

and the SAFER patient flow bundle. • Decrease patient bed movements by not returning outliers on other medical wards to a Home

Ward. This will require a change in policy so that patients on a Home Ward are the patients of those SMOs.

• Support winter plan with increased bed capacity and winter medical resourcing. • The patient ‘check-out’ process tested on Ward 8 is now being tested on Wards 1, 5, 6 and 9. • Guidelines for utilising the Discharge Lounge for orthopaedic patients waiting for regional

anaesthetic blocks to wear off are currently out for consultation. • Work is ongoing regarding estimated date of discharge guidelines for common surgeries and

procedures.


3. Optimising access to community services project In April 2019, a manual review of waiting lists identified that the number of patients waiting for community services had increased across all localities. A number of mitigations have been put in place and the culmination of this work is a decrease in the number of patients on the Occupational Therapy (OT) waiting list in the Mangere/Otara locality; reducing from its peak of 161 patients in March 2019 to 107 in April 2019 (see Chart 2 below).

Chart 2: Waiting list for OT in Mangere/Otara January 2018 – April 2018

Hospital in The Home (HiTH) The lack of a lead SMO, capacity of District Nurses, and the absence of a model of care means few patients are referred to HiTH.

Risks • The lack of capacity within community teams reduces the ability to ease the demand pressures in

secondary care. • No IT system in place to monitor progress and support most effective deployment of resource.

Mitigations • Recent work has focused on decreasing the waiting list with increased support from Community

Health Assistants (CHA), redirecting the workforce to areas most in need, and increasing staff capacity and ability.

• All patients on the current OT and Physiotherapy waiting lists have being contacted and reviewed; staff across the wider service have been mobilised to assist with this work.

• An experienced OT has been mobilised to work in Mangere/Otara with the aim of clearing the list of patients waiting for Band 1 equipment assessments. This includes testing geographically clustered allocations and upskilling a CHA to assist with workflow.

• A plan to increase patients referred to HiTH to support the winter plan is being developed by the Clinical Director Medicine. However, due to timescales for recruitment of an SMO, it is unlikely that HiTH will be up and running for winter 2019.

4. Rapid and consistent access to diagnostics project (MRI)

When MRI technician capacity is limited, the scanners in Building 58 – the offsite MRI unit – have historically been the first to cancel appointments. PDSAs have been undertaken with the aim of deploying workforce resources more effectively in MRI to reduce resultant waiting lists. This test of change has increased the utilisation of scanners in this unit, with the time Building 58 was open increasing from 71% in March to 95% in April – see Chart 3 below.

020406080

100120140160180

January February March April

Num

ber o

f Pat

ient

s

Number of Patients on Occupational Therapy Waiting List at Mangere/Otara

Total waitlistnumber

Urgent/Crisis (2-48hours)

Routine Medium(2-5days)

Routine Low risk(6-15 days)


Chart 3: MRI Scanner utilisation – Building 58

Data from 1 February to 1 May 2019 (see Table 2 below) is showing a significant reduction in the MRI waiting list: from 2,129 patients to 1,303 patients. This is due to increased utilisation of scanners and additional weekend lists.

Table 2: MRI Waiting List February-May 2019

Date Waiting List Sum of Hours 01/02/2019 2,129 1,162 01/05/2019 1,303 720 % Reduction 39% 38% # Reduction 826 442

Ambulatory Flow Programme 1. Outpatient Redesign Project

Cardiac Investigation Unit (CIU) Significant duplication and variation in the administrative processes for grading have been identified. The service is currently reviewing ways to improve this. Patient focused booking is being tested for the Pacing Clinic. The current process for ordering inpatient ECGs is extremely inefficient; paper recording of requests requires technicians to visit wards each day. The intention is to move ECG requests to Task Manager in order to have greater visibility of requirements and reduce unnecessary ward visits. The HTT team and healthAlliance are supporting the required IT changes for this, however this is taking longer than expected. A meeting is scheduled for 21 May to ascertain change required and expected date of implementation.

2. Booking & Scheduling Services Review

Data collection for this review has now been completed and the team is analysing the results. The data set consists of multiple data sources including: • 83 staff and patient and whaanau interviews:

• 53 staff interviews across 46 semi-structured individual or group interviews, comprising staff across four module groups (3, 4, 7 & 7a, and 8 & 9), Cardiac Investigation Unit (CIU), Referral and Appointment Centre (RAC).


• 30 patient and whaanau interviews: • 15 Maaori, 15 Pasifika. • In each group of 15: five attending clinics regularly, five attending sometimes, five non

attendants. The non-Maaori/non-Pacific patient experience has been drawn from previous surveys and other feedback.

There are a number of early themes:

Staff Patient

Staff have patients and their experiences at heart

Manaakitanga and competence matter the most to patients

Staff feel stretched beyond their limits Patient centred care is needed, but system centric care is delivered

The system issues often inhibit staff Attending appointments is a complex juggling act

Effort and dedication but not always in the right place

Staff need to communicate in a language that patients understand

Respecting tinana (physical health)

Inappropriate/poor quality referrals A number of challenges between primary and secondary care have been identified including the quality and appropriateness of GP referrals, the ability to request advice rather than refer, and communication to GPs once in the referral pathway. The Ko Awatea team is currently gathering baseline data on the number and reason for declining referrals as well as identifying those referrals that are for advice only. Mitigation A working group meeting has been arranged with the GP Liaison Officers to understand the challenges and opportunities for improvement.

3. Internal e-referral project

There is no reliable data on the number of paper referrals to RACs, so a manual process undertaken across eight days shows that an average of 18 internal paper referrals are still being received each day. This equates to 20% of referrals received by RACs.

The project lead for DEeR continues to promote its use and is working with services to make changes where required. The trend in usage continues to rise, as outlined in Chart 4 below, noting the impact of the public holidays for Easter and ANZAC and school holidays in April:

Chart 4: Monthly electronic referrals received

148 396

741 995

1221 1228 1496 1479

1845 1628

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f DEe

R re

ferr

als

Monthly DEeR numbers


Overarching Issues Technology infrastructure There are significant challenges with a lack of technology and analytics to support real-time visibility of patient flow. This affects both clinical patient flow and the measurement of outcomes, with the following areas being particularly affected: • Bed numbering and tracking – lack of visibility of available beds. • Bottlenecks across the system – no visibility of real-time bottlenecks in flow. • Community teams unable to see inpatient records, progress post referral etc. • Acute teams unable to access community forms online to understand pre-existing community support. • Increasing issues making changes to Task Manager. • Referrals process – still using paper/faxes for internal referrals; DEeR referrals not linked to referral

criteria. Mitigation A review of analytics requirements is commencing as part of the overall strategy to implement a control centre using real time data across patient journey and predictive analytics to inform action.



CM Health Child Healthy Weight Evaluation Update

Recommendation It is recommended that the Hospital Advisory Committee: Receive this update on the findings of CM Health’s Child Healthy Weight Evaluation. Note the focus of this update on the Before School Check referral pathway and Active Futures. Note that the evaluation report containing all of the evaluation findings will be finalised and made available to the organisation by the end of June 2019 (end of Q4). Prepared and submitted by: Alanna Soupen on behalf of Margie Apa, Chief Executive (Note: the child healthy weight work is primarily managed by Amy Carter, Child Health Service Development Manager)

Purpose To provide an update to the Hospital Advisory Committee on the progress and key findings to date of CM Health’s Child Healthy Weight evaluation, with a specific focus on the Before School Check (B4SC) referral pathway and Active Futures programme. Background In 2015 the Ministry of Health (MoH) developed a national Childhood Obesity Plan for New Zealand. Included in this plan was the ‘Raising Healthy Kids’ (RHK) health target, introduced in 2016: By December 2017, 95% of obese children identified in the B4 School Check (B4SC) programme will be offered a referral to a health professional for clinical assessment and family-based nutrition, activity and lifestyle interventions.

CM Health currently offers a dual referral pathway to whaanau during the B4SC. A child who is identified as obese can be referred to their GP and/or to the Active Futures programme, a comprehensive whaanau-based nutrition, activity, lifestyle and parenting skills programme delivered by Otara Health to pre-school children in the obese range and their families. CM Health has consistently achieved the 95% target for offering whaanau a referral to a GP, however the proportion of whaanau who decline the offer of referral is higher than the national average. CM Health is currently evaluating its child healthy weight initiatives, including the B4SC referral pathway. Understanding why whaanau decline referral and how to address this was one of the original aims of the evaluation.


At the previous Hospital Advisory Committee (HAC) meeting, HAC requested that an update be provided on the evaluation findings on the factors driving our rate of declines for offer of referral, and the impact of Active Futures in helping children have a healthy weight. This paper provides an overview of the evaluation and its findings, with a specific focus on the B4SC, healthy weight conversation and Active Futures programme. Discussion 1. Evaluation aim and scope The aim of CM Health’s Child Healthy Weight evaluation was to understand the implementation and outcomes of CM Health’s child healthy weight initiatives. Insights from the evaluation will be used to support identification of service gaps and opportunities for improvement, and to inform effective and equitable future development of the programme. CM Health funds a range of initiatives targeted at helping our children and communities have a healthy weight. Please refer to Appendix 1 for an overview of CM Health’s child healthy weight initiatives. The evaluation to date has focussed on the following initiatives:

• Workforce development activities - Healthy weight conversation training - Weight management in children Health Pathway

• Whaanau services - B4SC and referral pathway - Active Futures programme

2. Evaluation approach A process and outcome evaluation was conducted, to understand the implementation of the programme and how it links to the targeted outcomes. Please refer to Table 1 for the evaluation criteria for the B4SC and Active Futures (whaanau service). The full list of criteria will be provided in the final evaluation report. Table 1 Evaluation process and outcome criteria: B4SC and Active Futures

Evaluation criteria

Component Process criteria Outcome criteria

The Before School Check

• Children identified as being in the obese range during the B4SC are offered referral to a health professional and whaanau-based services

• The healthy weight conversation is understood by whanau

• The healthy weight conversation is a positive experience for whaanau

• Referral to GP/whaanau based services is acceptable to primary care

• Referral to GP/whaanau based services is acceptable to whaanau

• The healthy weight conversation is of use to whanau


Evaluation criteria

Component Process criteria Outcome criteria

Active Futures whaanau-based

nutrition and activity service

• Services are being attended by the target population

• Content is evidence-based • Attending the service is a positive

experience for whaanau • Whaanau attending the service,

complete the programme

• Services provide whaanau with the knowledge required to make healthy nutrition and activity choices

• Services provide whaanau with the skills required to make healthy nutrition and activity choices

• Children that have completed the programme have a reduction in BMI centile

3. Evaluation methods A mixed-methods evaluation approach was used. Table 2 on the following page summarises the methods used to understand the processes and outcomes of the B4SC and Active Futures, and the sample sizes for each method/data source. The final evaluation report will contain a full list of all the methods used.

Table 2 Evaluation methods/data sources and sample sizes: B4SC and Active Futures

Method/data source Sample size

B4SC whaanau survey 80 whaanau 18 Maaori, 32 Pacific, 20 Asian, 7 NZ European, 3 Other

57 children with BMI centile <91st (healthy weight) 11 BMI centile 91st – 97th (overweight) 11 BMI centile ≥ 98th

(obese) 1 BMI not recorded

Raising Healthy Kids target quarterly reports

Analysed for June 2017 – June 2018

Active Futures programme data 225 whaanau enrolled between February 2017 – December 2018

Active Futures exit survey 20 whaanau

4. Limitations A key limitation of the evaluation was that only a small proportion of whaanau who participated in the B4SC had children in an unhealthy weight range and none of the whaanau declined referral to a GP, Active Futures or a community health worker. The whaanau survey results therefore may not reflect the experiences of whaanau with children in an unhealthy weight range or of those whaanau who decline referral. Only three responses were received to the online Active Futures exit survey. To improve the response rate paper-based surveys were offered to graduates of the programme, which had a higher completion rate. However, as there were only a small number of graduates, the sample size is still relatively small.


• 85% (17 whaanau) agreed or totally agreed that being part of Active Futures felt good for their whaanau. 95% (19 whaanau) agreed or totally agreed that they learned things during Active Futures that would help them make healthy food and activity choices.

• BMI remained stable for the vast majority of participants.

Active Futures a useful and positive experience for

whaanau, but childrens’ BMI is mostly stable:

5. Evaluation findings This section focuses specifically on the evaluation findings in relation to the B4SC referral pathway and Active Futures programme. The full evaluation findings will be provided in the final evaluation report which will be made available in June 2019.

6. Recommendations

Consider opportunities for engaging with whaanau who have declined the offer of referral and understanding the reason for declines for Maaori and Pacific whaanau • Conducting focus groups with whaanau who have declined the offer of referral • Follow up via phone by the practice with families who have declined offer of referral • Asking and recording of reason for decline of the offer of referral by the B4SC nurse during the

B4SC Explore other engagement settings and opportunities for whaanau nutrition and activity support services, e.g. Early Childhood Education Centres. • Given the challenges in maintaining whaanau engagement in specific programmes and

challenges in programme retention, settings-based approaches should be explored as an alternative.

Explore opportunities to promote and support routine monitoring and management of child healthy weight during routine primary care visits • Understanding the level at which practices routinely monitor weight and the expectation set

around this for general practice.

• Over 95% of whaanau totally agreed or agreed that the height and weight information provided was clear to them and was useful to them (n=74).

• 96% of whaanau used only positive words to describe the B4SC and healthy weight conversation.

B4SC and healthy weight conversation a clear, useful & positive experience for whaanau:

• As at Q2 2018/19, the total percentage of whaanau who declined the offer of referral was 29% for CM Health and 23% across all DHBs nationally.

• There are differences in the decline rate between ethnic groups. In Q2 2018/19, the decline rate was 36% for Maaori (national: 25%) and 21% for Pacific (national: 16%).

• It is difficult to establish reasons for declining as none of the whaanau who participated in the whaanau survey declined the offer of referral.

• It is important to remember that the B4SC is only one setting where children’s weight is monitored and managed and where a healthy conversation can be held; primary care also plays a critical role and is the first point of contact with many whaanau.

Rate of decline of offer of referral to a GP for clinical

assessment continues to be higher than the national average and worse for

Maaori whaanau:

• Of those children who accepted the offer of referral to Active Futures, 93% enrolled in the programme, 4% did not have an enrolment date listed and 3% declined enrolment.

• 52% of whaanau exited prior to completing the full 12 months of the programme, with roughly two thirds (68%) exiting within 3 months.

High initial enrolment rate for Active Futures, but many

whaanau exit early:


• Explore opportunities to encourage and promote routine weight monitoring in general practice. • Explore options for addressing some of the practical barriers that primary care faces in routinely

monitoring weight e.g. options for increasing access to stadiometers and appropriate charts. Appendices 1. Appendix 1: CM Health’s healthy weight initiatives


Appendix 1: CM Health’s healthy weight initiatives

Development of processes for referrals from B4SC provider New dual electronic referral pathways for children identified as being overweight or obese have been developed. B4SC providers refer children and their whaanau to their general practitioner for medical review and brief intervention. Children can be referred to whaanau-based physical activity, nutrition, and lifestyle programmes by the B4SC provider or their general practitioner. General practitioners and B4SC referrers receive decline notification or completion of programme letters for children referred to whaanau-based programmes. Development of the Weight Management in Children HealthPathway An electronic pathway for the management of overweight and obese children is available at Auckland Regional HealthPathways . This pathway provides access to MOH agreed WHO paediatric growth charts and provides guidance on determining and interpreting body mass index (BMI) centiles in children. Key history, examination, investigations and management points are outlined. Management includes referral to the whaanau-based nutrition, activity and lifestyle programmes detailed below and to non-acute paediatric outpatients, dietitian, or other support services when indicated. The pathway includes the recommendation to READ code overweight and obesity and to set an active recall for follow up every 3 to 6 months. Systems to monitor growth The introduction of electronic growth charts has provided secondary care services with a standardised system to record child growth. We are currently exploring whether use can be extended to primary care. Workforce development Training and mentoring opportunities have been developed to raise awareness of the weight management in children HealthPathway and RHK target, increase the routine and regular monitoring of children’s growth, and to help Well Child nurses, primary care nurses, general practitioners, and secondary care clinicians to have effective brief healthy weight conversations with whaanau. Healthy weight conversation workshops are delivered by Health Literacy NZ. Other activities include the distribution of healthy weight resources and a CME/CNE video and podcast to support effective brief healthy weight interventions. Delivery of whaanau-based nutrition, activity and lifestyle programmes Counties Manukau Health is funded by the Ministry of Health to contract whaanau-based nutrition, activity and lifestyle programmes to support the achievement of the RHK target. The following services are contracted with this funding:

• Te Rito Ora: This community-based service provides breastfeeding information and support during pregnancy and during the postnatal period. Te Rito Ora offers homes visits, support groups, Lactation Consultant home visits, and first food workshops.

• Mum’s Kitchen Rules (MKR): This programme delivers fun and friendly healthy cooking advice for pregnant women and parents/whaanau of 0-2 year olds.

• Active Futures: Otara Health delivers this comprehensive whaanau-based nutrition, activity, lifestyle and parenting skills programme to pre-school children in the obese range and their families. The programme is tailored to whaanau needs and is delivered through a mix of home based and group sessions across South Auckland. The programme currently has capacity to also enrol children in the overweight range.

• Community Health Worker Home Visit service: Community Health Worker home visits support families and whaanau aged 3-4 years who are in the overweight weight range to make, and sustain, a range of healthy lifestyle choices. While this contract will not be funded beyond the 2017/2018 financial year, there is an expectation that this work will be embedded into business as usual and delivered through additional Well Child visits.


• Green Prescription Active Families” Otara Health delivers this programme to children aged 5-13 years and their whaanau. The programme provides regular group sessions that include sport and exercise, parent workshops and family cooking classes. Children are linked to other activities in the community. This programme is well established and receives open referrals, mostly from general practitioners or self-referral.

• Green Prescription Active Families Youth Activate: Otara Health delivers a less structured programme to meet the needs of young people aged 13-18. The programme provides regular group sessions that include crossfit exercise, sport, and Wise Kai workshops. Young people are linked to other activities in the community.



Hospital in the Home Update

Recommendations It is recommended that the Hospital Advisory Committee: Receive the Hospital in the Home update. Prepared and submitted by: Penelope Magud, GM Locality Services and Brad Healey GM Medicine, ED & Integrated Care

Purpose The purpose of this paper is to provide an update on the implementation and utilisation of the Hospital in the Home (HiTH) pathway.

Executive Summary There have been a total of 86 patients admitted to Hospital in the Home since the pathway commenced in June 2018. The SMO capacity for Hospital in the Home has been reduced over the past 8 weeks due to extended leave of a HITH SMO, however despite this constraint we have still maintain some momentum throughout this period with 11 admissions. From 20th May SMO capacity will be reestablished and thus will enable us to again drive the identification of patients and optimize utilization of the pathway. The Division of Medicine have also recently employed two new SMOs who have Hospital in the Home within their roles. These role will commence over the next few months and will be key enablers for optimizing HiTH utilization. These roles will focus on identifying patients suitable for transition to HiTH as an alternative to hospital admission which we believe is the optimal use of the pathway and is in line with international HiTH models.

Hospital in the Home Data Total HiTH Admissions to Date: 86 patients Average Length of Hospital Admission 6.7 days (Median 5.0 days) Average Length of HiTH Admission 5.5 days (Median 5.0 days)


Other Community Health Service Referrals Referrals to Hospital in the Home are only a small fraction of the acute flow demand to the Community Health Service. The below graph illustrates the increasing demand in acute nursing care in the community which together with Hospital in the Home is supporting acute flow. The difference with the Hospital in the Home approach is that for a distinct cohort of patients the duty of care and treatment plan and clinical escalation appropriately remains with a hospital SMO.



May 2019 Certification Audit Draft Corrective Actions

Recommendation It is recommended that the Hospital Advisory Committee: Receive a summary of the Certification findings and draft corrective action requests following the May 2019 Certification audit. Note that Manukau Health was highly commended on living its values and received 13 draft corrective actions during the May 2019 Certification audit, a decrease of six corrective actions from the previous Certification audit in 2016. Prepared and submitted by: Dr Lesa Freeman, Patient Safety and Quality Assurance Manager on behalf of Dr Jenny Parr Chief Nurse and Director of Patient Whaanau Experience.

Executive Summary All providers of healthcare services in New Zealand are required to be certified by the Ministry of Health under the Health and Disability Services (Safety) Act 2001 to meet the NZS8134:2008 Health and Disability Services Standards. The Ministry of Health normally certify district health boards for a period of three years at which time a designated auditing agency on behalf of the Ministry of Health will undertake a Certification audit followed by a mid-point Surveillance audit. Counties Manukau Health’s last Certification Audit took place in 2016 whereby 19 corrective actions were received. A mid-point Surveillance audit was then conducted by the DAA Group against the core health and disability standards in February 2018 and 13 corrective actions were received. Steady progress has been made to resolve a number of these 13 corrective actions in preparation for the May 2019 Certification Audit. The DAA Group during their feedback sessions and closing meeting commended Counties Manukau Health on living its values. Thirteen corrective actions were received; ten low risk and three moderate risk. Six of these were corrective actions from the previous Surveillance 2018 audit, effectively meaning seven corrective actions were closed. Purpose This paper provides the Hospital Advisory Committee with a summary of the Certification findings and draft corrective actions following the May 2019 Certification audit. Background All providers of healthcare services in New Zealand are required to be certified by the Ministry of Health under the Health and Disability Services (Safety) Act 2001 to meet the NZS8134:2008 Health and Disability Services Standards. Counties Manukau Health engaged the DAA Group as the designated auditing agency as part of the three yearly review, to undertake the Certification audit scheduled for May 2019. The Certification audit is a two stage process. Stage one required the DHB to submit 20 days before the audit self-assessment evidence against the core standards including; consumer rights, organisational management, service delivery, safe and appropriate environment, restraint minimisation and safe practice, and infection prevention and control. Further, the auditors reviewed CM Health’s policies and procedures (covering, for example, management systems and clinical systems).


Stage two comprised an on-site audit undertaken by 16 auditors and technical expert advisors across a four day period (7 to 10 May). This on-site audit included 14 patient tracers in each service stream which concentrated on the journey of the patient through the hospital system and three system tracers (infection prevention and control, medication management, and care capacity demand) plus incidental sampling to augment the tracer samples. Two applications are also being made to the Ministry of Health for continuous improvement ratings; The Whanau Ora Evaluation and Fundamentals of Care. The below table shows CM Health’s corrective actions and continuous improvements since 2012.

Year 2012 2013 2014 2016 2018

2019

Type Surveillance Certification Surveillance Certification Surveillance

Certification

No. of CI* rating

0 CI rating

0 CI rating

0 CI rating

1 CI rating

0 CI rating Not confirmed

No. of corrective actions

31 corrective actions 13 moderate risk






* CI refers to continuous improvement whereby the performance exceeds the set standard

Discussion At each of the daily feedback sessions to management and at the closing meeting the DAA Group auditors were very complimentary on how CM Health’s values were lived, the positivity of staff, the high level of collegial discussion between the multi-disciplinary teams and the outstanding ward culture. Human Resources were commended on how well organised personnel files were maintained and that service credentialing plans and recommendations were well managed. The care capacity demand programme, and Fundamentals of Care, were further highlighted along with complaints management, risk management, engaging consumers and patient experience, document control (14.8% out of date controlled documents), and the use of data and evidence to make decisions, particularly noting Ko Awatea.

Thirteen corrective actions were received; ten low risk and three moderate risk (see Appendix 1). Six of these were corrective actions from the previous Surveillance 2018 audit, effectively meaning seven corrective actions were closed (see below Table).

Corrective Action Detail Rating New Existing 1. Sterile equipment Cannot track from theatre to

processing to the end patient use. Noted the plan in place to resolve this

Moderate Yes

2. Documentation of consent

Under Section 59 of the MH Act Low Yes

3. Integrated medical record

Loose sheets in surgical services (not MSC) and ICU clinical chart

Low Yes

4. Food fridge temperature monitoring

Lack of monitoring and action being taken

Low Yes

5. Facilities Spinal Unit, Dialysis Unit, some equipment testing compliance

Moderate Yes

6. Laundry Contract management annual audits and availability of linen

Low Yes

7. Infection Prevention and Control

Reactive programme of activity and no annual plan

Low Yes


Corrective Action Detail Rating New Existing 8. Peripheral

Intravenous Lines Documentation of management of IV lines in practice

Low Yes

9. Medicines management

Multiple issues with paper medication charting, lack of reason for discontinuation of medicines (MedChart in ARHOP), returning patients own Controlled Drugs in a timely way, Medication room temperature in Pukekohe

Low Some elements

Yes

10. Skill mix Mental Health particularly psychiatrists, psychology, registered and enrolled nurses. Anesthetists, MRTs in Cardiology, CCSD staffing levels, midwives

Moderate Yes

11. Care planning Improvement noted, but not always consistent

Low Yes

12. Discharge documentation

Documentation not consistent in surgical areas

Low Yes

13. Restraint Noted lots of progress, but inconsistencies with understanding and documentation of the use of enablers– new pilot underway

Low Yes

Following the Certification Audit the DAA Group will write up their audit report based on the evidence made available, the conditions observed and information provided by staff during the period of time of the on-site visit. A copy of this report will then be sent to Counties Manukau Health for review and feedback prior to submission to the Ministry of Health. This process provides Counties Manukau Health with the opportunity to ensure accuracy of the report prior to submission to the Ministry of Health. The Ministry of Health will then provide CM Health with a copy of the final audit report, and corrective actions and confirm the period of certification. Progress is continuing to be made on the existing corrective actions. Work plans are currently being developed to address the new corrective actions.

Appendices Appendix 1 - Draft Corrective Action Requests


Counties Manukau District Health Board Draft Corrective Action Requests (CAR)

Type of Audit: Certification audit Date(s) of Audit Report: Start Date: 7 May 2019 End Date: 10 May 2019 DAA: The DAA Group Limited Lead Auditor: Joanna Harper

Std Rating Criteria Evidence Timeframe 1. 1.1.10 PA

Low 1.1.10.4 The standard requires:

The service is able to demonstrate that written consent is obtained where required.

Finding: Section 59 under the MH Act requires that informed consent for treatment is sought from the service user within the first three-month period of compulsory treatment. Of 3 clinical files sighted of long stay clients, two did not have completed consents or record of decline of consent. Staff were unaware of a system in place to alert them that the three-month period was imminent.

180 days

2. 1.2.8 PA Mod

1.2.8.1 The standards requires: There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.

Finding Good progress is being made with the implementation of the programme with the plan to introduce the TrendCare acuity tool well on track. There has been an increase in nursing staffing in several areas over the past six months with further appointments inn progress. Improved efficiencies with the internal bureau (resource team) are having a positive impact on use of external bureau and overtime. Although nursing staff were working to full capacity, most staff spoken with felt that with the use of the resource team and other

90 days


senior support roles, the needs of patients was being safely met.

There were some areas with staffing vacancies where this was impacting on the ability to provide safe and timely care. The mental health services are short of psychiatrists (SMOs) with a 23% vacancy rate, at the time of audit. Gaps are being filled by locums. However, this is a significant shortfall. Ongoing recruitment to nursing roles is reducing vacancies, although there continues to be around a 17% vacancy rate of enrolled and registered nurses. Reports indicate that this has resulted increased overtime and sick lave across the service.

There are continuing anaesthetist vacancies, with locum cover filling current gaps. This is impacting on the ability to respond to increased demand.

A shortage of MRTs within the cardiology service is having a significant impact on the ability to increase capacity to cope with increasing demand. Despite various strategies to address demand the waiting list is increasing.

Within the CSSD service, recruitment is ongoing, however increasing demand is impacting on staffing. A business case is in progress to increase staffing in this area.

Maternity services continue to be challenged by a shortage of midwives nationally and regionally. Registered nurses are being well utilised to support midwives, however this shortage continues.

3. 1.2.9 PA Low

1.2.9.10 The standard requires: All records pertaining to individual consumer service delivery are integrated.

Finding: In the surgical services (except for Manukau Surgical Centre), not all patient information is filled in chronological order with several documents loosely held in a pocket at the back of the file.

In ICU (both general and paediatric), the clinical flow chart documentation is not integrated into the file when the patient leaves the unit or is discharged from the hospital. These documents are held in the area.

180 days

4. 1.3.5 PA Low

1.3.5.2 The standard requires: Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.

180 days


Finding: Care Planning continues to improve; however, the related documentation is not being consistently completed in some areas. Evidence of the assessment process was not consistently sighted as being utilised to inform the care plan. Within the mental health area care plans are not integrated.

5. 1.3.10 PA Low

1.3.10.2 The standard requires: Service providers identify, document and minimise risks associated with each consumer’s transition, exit, discharge or transfer, including expressed concerns of the consumer and, if appropriate, family/whanau or choice or other representatives.

Finding: Discharge planning is occurring; however, the documentation related to this is not consistently included in clinical files sighted in surgical areas. There is a discharge protocol for adults prior to leaving the post anaesthesia care unit (PACU); however, there is not one for paediatrics.

180 days

6. 1.3.12 PA Low

1.3.12.1 The standard requires: A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal and medicine reconciliation in order to comply with legislation, protocols and guidelines.

Finding: There is a planned roll out of Med Chart underway across the hospital. Currently, the clinical areas operate either paper-based systems or the electronic Med Chart system.

Where the paper based NMC is in use, the following issues were noted

1. In Paediatrics – mg/kilogram dosages are missing in surgical paediatric ward/ICU and PACU. 2. PRN medication not all indications and max doses are consistently charted by the prescriber. Usually,

these omissions are picked up by pharmacist. Noted in surgical and paediatric ward areas. 3. Sample signatures are not consistently completed by medical staff and designation of the person

administering the medicine is not always included. 4. Allergies not always noted on the inside of the chart. Non approved abbreviations were seen used by

the prescriber. 5. Discontinued medications are not dated and signed. 6. Medication is not always given as prescribed. E.g. paracetamol QID given daily or BD (surgical).

180 days


Med Chart: 1. In ARHOP areas, (4, 5, 23, 24) there is inconsistent inclusion of the reason for discontinued medicines.

Med Chart comments are not always completed.

Controlled Drugs: 1. The C.D Register 6 monthly checks do not meet the requirements of legislation in all areas – paediatric

ward/ICU/PACU 2. In a sample of wards visited, patients own controlled drugs are not consistently disposed of (either

returned to the patient or returned to the Pharmacy) in a timely manner. Weeks of completed weekly physical stocktakes have not identified that the patient is no longer in the ward.

Medication room environment

1. At Pukekohe, the Medication room temperature is monitored but is noted to frequently be above 25degrees (24.5 with door open). Follow up actions taken to resolve this are unclear.

7. 1.3.13 PA Low

1.3.13.5 The standard requires: All aspects of food procurement, production, preparation, storage, transportation, delivery and disposal comply with current legislation and guidelines.

Finding: In several areas/wards visited (paediatric surgical, 32 North, Ward 7 and ward 9) fridges that store patients’ foods are not being managed safely. In one case where temperatures were above the recommended range for a period of a month, no action had been taken to address. This. In one case the fridge was broken and milk was stored on the bench. In several cases food was not dated or covered.

180 days

8. 1.4.2 PA Mod

1.4.2.4 The standard requires: The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.

Finding:

1. There are well documented examples where facilities have been identified as substandard or not fit for purpose. For example, the spinal unit has problems due to age and inpatient configuration of shared rooms and bathrooms. Storage of equipment in inpatient room is a challenge as only one room has electronic overhead ceiling lifting equipment, therefore all rooms need to accommodate patient equipment.

90 days


2. The dialysis unit is over capacity, has inadequate toilet facilities for patients and staff and lacks storage and is not fit for purpose.

3. There are examples where equipment does not display compliance with current testing requirements. Checks with the database demonstrates that while these have been completed, the tags have not been updated. This includes the body protected labels in ICU and portable electrical items in the spinal unit.

4. Not all portable oxygen cylinders are restrained in ICU and paediatric areas.

9. 1.4.6 PA Low

1.4.6.2 The standard requires: The methods, frequency and materials used for cleaning and laundry processes are monitored for effectiveness.

Finding: Laundry: There has been no audit of the Taylors laundry since December 2016 at which time there were several recommendations, three of which were high risk. It was not able to be established prior to the end of the audit that these areas have been followed up and addressed. It is a requirement of the contract that a yearly audit occurs.

Several areas during the audit reported shortages of linen, to the extent this was impacting on patient comfort and the ability of staff to easily complete their work. This was noted at both the Middlemore and Manukau sites.

180 days

10. 2.1.1 PA Low

2.1.1.4 The standard requires: The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer and with the intention of promoting or maintaining consumer independence and safety.

Finding: Staff are aware of changes to documentation is pending. A review undertaken of bedrail use has been undertaken and a trial of bed rail stickers is underway in Ward 24. Daily care plans include use of enablers. Three files reviewed demonstrated inconsistent implementation, e.g. 2 of 3 patients had the required bedrail stickers, but no further documentation in the nursing notes.

In four other wards visited where the new system is yet to be implemented, there were several examples of poor understanding of the difference between a restraint and enabler. Documentation was not always completed as required and little evidence seen that there were bedrails were in use from the nursing variance

180 days


notes. Seven further notes reviewed across four wards indicates inconsistencies such as - A non-verbal person with an intellectual disability had the use of bedrails documented as an enabler.

Subsequently, a patient watch was instigated, but the bedrails remained in situ. The clinical notes referred to bedrails being in use to prevent the patient falling out of bed.

- Shift notes did not refer to enabler use. - A patient whose condition has improved since admission did not have documentation for restraint

initiated nor that this was now being used as an enabler.

11. 3.1 PA Low

3.1.3 The standard requires: The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.

Finding: There is a model of infection prevention and control based on real time; however, there is not an annual organisation infection control plan.

180 days

12. 3.1 PA Mod

3.1.9 The standard requires: Service providers and/or consumers and visitors suffering from, or exposed to and susceptible to, infectious diseases should be prevented from exposing others while infectious.

Sterile equipment used within the operating theatre suite is not able to be traced from the sterilisation department processing to the end patient use. This is in variance to current national standards (ASNZS 4187:2014). There is a plan in progress to commence sterile equipment tracking.

90 days

13. 3.3 PA Low

3.3.1 The standard requires: There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current good practice.

Finding: Policies, procedures and guidelines related to intravenous access devices are in place and support good practice; however, documentation sighted in clinical files did not consistently comply with these.

180 days

Date:

Adult Rehabilitation and Health of Older People (ARHOP)

Divisional Update to HAC

5 June 2019

Created by: Dana Ralph-Smith May 2019

ARHOP Sevices

• Acute Stroke services • Inpatient Stroke Rehabilitation and Community Stroke Rehabilitation • General Adult Rehabilitation • Acute Geriatric Medicine • Community Geriatric Service • Assessment, Treatment & Rehabilitation for Older Persons • Specialised Spinal Cord Injury Rehabilitation - Supra-regional Catchment • Acute Allied Health (Inpatient and Outpatient) • Health of Older People (HOP) Funder services - Aged-related Residential Care (ARRC) – HOP Funder - Home Based Support Services (HBSS) – HOP Funder

ARHOP Professional Groups

• ARHOP Provider Workforce – 610 Staff

• 94% Clinical Workforce (doctors,

nurses, allied health) – 41 Doctors – 214 Nurses – 316 Allied Health

• 6% non-clinical Workforce (Administration, management)

– 39 staff

• HOP Funder Capacity

• HBSS – 8 contracted providers – 4,011 clients

• ARRC – 44 contracted facilities which provide

four levels of care • 37 provide Rest Home • 29 provide Hospital • 8 provide Secure Dementia • 2 provide Secure Psychogeriatric

– Approx. 2450 beds, 90% Occupancy

ARHOP Locations • Middlemore Hospital- 5 wards

- Ward 4 (Scott building): Ortho-Geriatric Rehabilitation - Ward 5 (Scott building): Acute Care of the Elderly, and AT&R - Ward 23 (Colvin Complex): General Rehabilitation for Adults - Ward 24 (Colvin Complex): Health of Older People AT&R - Ward 31 (Edmund Hillary Building): Acute Stroke Unit - Acute Allied Health throughout the Acute hospital inpatients

• Auckland Spinal Rehabilitation Unit (Bairds Road, Otara)

• Community Services

– Community Stroke Rehab – Community Geriatric Service

• MSC – Acute Allied Health Outpatient Services

What we do well (data based off of 12 month averages to 31/03/2019)

Spinal Rehab: - LOS: remains lowest throughout Aus/NZ facilities - 90% of patients return to the same or better

accommodation post discharge - 97% of patients make a Functional Gain

Acute Stroke: - Thrombolysis rate (by DHB of domicile): 14.9%

(target = >10%) - 81% of Acute Stroke patients admitted to the

Acute Stroke Ward (target = >80%) - Acute LOS = 6.0 days

Adult/General Rehab: - Short term rehab on stroke ward (began in

September 2018) - Acute LOS: 6.3 days - Rehab LOS: 8.0 days

- 94% of patients make a Functional Gain

HOP provider services: - 50% of patients seen by ED Geriatric service avoid

admission to hospital - ACE model – shorter LOS than traditional acute +

AT&R LOS HOP Funder services: - 10 CMDHB ARRC facilities with 4 year Certificates,

with the balance having 3 year Certificates (1 with a 1 year due to change of ownership)

- All ARRC facilities have regular Certification and unannounced Surveillance Audits

- There have been no high or critical risk findings for some years

Overall: - Patient Experience Survey- Overall Care Rating

(Good or above) = 96% - 2017-18 budget, living within our means - A culture of strong Clinical & Managerial

partnerships

Current Challenges

• Patient volumes: – Population Growth – Ageing population (highest growth population) – Increase in Acute demand (particularly Stroke and ACE) – Persistent high ASH rates for Stroke – Outpatient service demand (focus towards community services)

• Patient complexity: – Complex, comorbid patients – longer LOS, complex discharges – Bariatric patients – lack of equipment, inadequate space, not appropriate facilities

• Workforce: – Difficulties in attracting, retaining and recruiting specialised rehab workforce – Across all Allied Health in medical sub-specialties

• Environment/Facilities: – Buildings: no longer fit for purpose – Need to future proof against forecast bed demand

Strategies to overcome challenges

• Short term (next 12 months): • Review current models of care

• Test alternative outpatient service delivery models

• Develop and finalise workforce career frameworks to allow top of scope practise (Nursing, Allied Health)

• Improve primary and secondary prevention of stroke (Primary care, AF, TIA etc.)

• Explore immediate, achievable solutions to improve equity of access and outcomes across services

• Contribute to the frail elderly work across the continuum of care (acute patient flow)

• Longer Term (next 5 years): • Specialised Rehab Centre Investment

• Exploring news models of care

• Service Sizing/recruitment/planning

• Increase capacity to deliver ACE models of care on another ward.

Where to from here?

• Investment at MSC – Specialised Rehabilitation Centre.

• Outpatient improvement work (particularly for Spinal Patients).

• Exploring new models of care across all ARHOP services.

• Working with regional partners.

• Continue to benchmark against & engage in conversation with Australia and New Zealand Rehab providers.

• Working with the different specialties across the hospital, particularly via Allied Health to ensure we can align wherever possible to manage Acute Demand.

• Continue to work with various funded providers in ARRC and HBSS to implement the healthy ageing strategy.


Facilities Engineering and Asset Management Monthly Report – April 2019 Service Overview The Facilities, Engineering and Asset Management division is led by Anton Venter, General Manager under the direction of the Director, Strategy & Infrastructure, Parekawhia McLean. The FEAM division is responsible for Engineering Services, Facilities, Property Management, Capital Planning, Capital Development/Construction/Programmes, Clinical Engineering, Transportation and Fleet Management, Enterprise Asset Management, Procurement and Contract Management, Energy Management, IT Systems, Hazardous Substances, and Facilities Safety Compliance/Management. Purpose The purpose of this paper is to update the Hospital Advisory Committee on the current activity, risks and issues for the Facilities, Engineering and Asset Management service as at April 2019. Highlights • Maintenance Trades Collective agreement has been approved by the Ministry of Health and the offer

was approved by the CM Health CEO on 16 May 2019 to make an offer of settlement. • Following completion of demolition, excavation for Stage 2 of the Acute Mental Health Unit has

commenced. To mitigate potential issues with regard to congestion on the northern link road, an alternative southern link road has been created for emergency vehicles; predominantly the ambulance route from the helipad.

• Scaffolding has been erected and shrink wrapped applied to the Scott Building. Internal screens have been installed without issue. Following a noise complaint from a staff member regarding with the installation of the scaffold ties, the methodology was changed and the work continued without any further hindrance. Planning for Stage 2 is now underway. The Communication Plan has been activated with a light box display at the Scott entrance, website and looped video now in place. Media visits are set for May. A multi-lingual information sheet is currently being developed with translation services.

• A Post Implementation Review of the Harley Gray MRI project is planned for May. As reported last month, final costs for the Harley Gray MRI project came in under the Board approved ‘re-budget’ and as such this risk has now been removed from the Risk Register.

• Recommendations for key consultant appointments regarding architecture and building services for the Edmund Hillary Building Gastro Procedure Rooms have been made and an architect has been appointed. The appointment of a Building Services contractor is still outstanding; pending final compilation of the consultant agreement. The Functional Brief and Schedule of Accommodation has been signed-off by all parties. It should be noted that the number of SMO desk spaces requested exceeds the business case requirements.

• A Contracts Register database for the Facilities and Engineering division is being developed in coordination with the SPMO, utilising the organisation’s Daptiv reporting tool at no additional cost, in order to provide traceability and an audit trail of all the contracts in one location. An initial trial of the database has been completed, and the first revision is expected to be complete w/c 13 May.


Emerging Issues • Removal of the first panel on the Scott Building has exposed significant rot in the building.

Assessment has been conducted by Timber Condition Assessors and a significant number of timbers have been marked for replacement. The risk is in not knowing now how much additional work and material will be involved in replacing the timber as it can only be determined as we progress through the stages. We have financial provision to replace 20% of timber. If more timber needs to be replaced as we progress this may likely have a financial impact.

• A condition of the building permit being approved was that the upper windows be tested for air leakage. Testing conducted during April failed. A report from the manufacturer of the windows has been requested to ascertain if the windows were air tested during building construction. Options to remedy are being investigated to ensure compliance to the condition of the permit is adhered to.

• The Contractor for the Scott Building has informally notified the Engineer to Contract of a financial claim due to the considerable deferment in commencement of works specifically pertinent to the delay and revised design build contract to accommodate the Densglass substitution for Rigid Air Barrier (a new Council requirement as a consequence of the Grenfell Tower fire). The claim, yet to be presented, is likely to be substantial and the Engineer to Contract is seeking legal advice as to its contractual validity. If the claim gets validated through legal proceedings there may be a cost implication to CMDHB.

• During the survey process of MSC Area B, it was identified that residential developers from an adjoining property have installed certain structures and landscaping works too close to, or in some cases over, the Area B boundary. CM Health has notified the developers and Auckland Council of the encroachments and is awaiting a response. Given the permanent nature of some of the encroachments, including kerbing, it is possible that a settlement may need to be reached and readjustment of boundaries required to resolve this matter. Accordingly, Ministry of Health approval may be needed at some point.


Update on Previously Reported Issues

Issues Reported Update

Histopathology project time extension

Updated May 2019

The expectation of costs exceeding budget in the hydraulic trade was largely mitigated by a change of subcontractor, however this has resulted in a delay to the practical completion date; now expected mid-July. The mechanical contractor (a separate contractor under CM Health) is performing well and is expected to complete mid-June. Previous asbestos issues on the ground floor of Galbraith have been resolved and work is progressing unencumbered by this issue. The interim relocation of the Executive Office has been avoided and planning for relocation of Histopathology staff and the Executive team has commenced; the Executive team will move to the Histopathology Lab on the first floor of the Bray Building, whilst Histopathology move to Galbraith. The passive fire protection issues are resolved and a clear specification for this work is now with the Contractor. There remains a constraint on plumbing work in the basement where asbestos contamination is more extensive. The plumbing work was delayed due to price difficulties with the nominated sub-contractor who has now been replaced. This has pushed the date for practical completion out to 30 July 2019.

Renal Day Dialysis and Cath Lab

Updated May 2019

Ministerial signoff is still awaited for the Renal Day Dialysis and 2nd Cath Lab. Registrations of Interest for project management and design services are being prepared in the interim.

Shuttle Service Updated May 2019

Due to very low numbers of the public utilising the shuttle service from Papatoetoe and Manukau, the decision was taken by the ELT to discontinue this service, with effect 31 May 2019. A communication plan has been developed to ensure the end of the trial and return to the previous shuttle service is well communicated. Options for a new contract are being investigated, including the potential for providing taxis with disability access between MSC and MMH for people with disabilities.

Esme Green Asbestos update

Updated May 2019

An asbestos survey and assessment has been performed for all refurbishment work notified and where work by the FEAM team has identified potential for increased risk, including MMH Energy Centre and Esme Green Riser. As a result of additional assessment, particularly risk identified in Esme Green risers, increased controls have been introduced and a management plan developed to remediate and/or make safe. The necessary procurement for required asbestos services to undertake and support this project is being progressed. Projected commencement of this work is estimated for June 2019.



Esme Green Asbestos update

Beca continue with a more in-depth study and investigations of CM Health buildings of highest risk (generally beneath 67% NBS); in particular a Detailed Seismic Assessment (DSA) of Esme Green, the building of highest risk. Indications are that Esme Green will prove better than that indicated in the ISA. Asbestos and related expenditure for this period is circa $320k, including relocation costs for Phlebotomy, healthAlliance services, and primary expenditure for Galbraith riser works. Year to date costs are c.$500k. Expenditure currently estimated for the remaining financial year is indicative of c.$300k and includes replacement of lagging in Galbraith risers, unplanned Esme Green Riser work recently prioritised, and minor removal and remediation Galbraith. Bray basement asbestos requirements are noted in this update and currently under review. To make safe the Bray basement area, an estimation of expenditure appears likely to exceed $100k, with a timeframe to procure and complete necessary work predicted by end of Q1 2019/20 financial year.

Community Mental Health Service Facilities Refit Reconfiguration

Updated May 2019

Developed design work is, in the main, complete for the Community Mental Health Service Facilities Refit Reconfigure, including for the additional scope as recently approved. This project is however currently over budget and requires further value management. The Registration of Interest for contractors has been completed and a shortlist agreed.

Specialist Rehabilitation Centre (SRC)

Updated May 2019

The current Manukau Masterplan indicates the preferred site for the SRC will need to move northwards in order to accommodate the proposed Radiology building, and a change of development North South from the previous East West Masterplan. This will involve more of the SRC development being pushed into the flood zone, which will limit future development and advice from the cost consultant indicates a potential substantial increase in SRC site development costs of up to $2.5m. The site will need to be fixed by the end of April to enable concept design to proceed. A scope and request for proposal have gone to market to seek a review of the concept and the MSC Masterplan. Stakeholders will be interviewed as part of the review process. Tender recommendations for the main consultant for the SRC are imminent and a consultant will be appointed thereafter. Land survey and geotechnical advice has been received and have enabled design to commence.

Energy Centre asbestos on roof

Updated May 2019

The cause of a roof fire in the Energy Centre is being investigated. However this has been delayed due to a positive asbestos swab found on the roof. A replacement flue stack is required to get the boiler back up and will enable determining the cause of fire. This work will be completed once the remediation work to the asbestos has been completed – this is scheduled to commence in May.



Infrastructure Asset Risk Profiling Assessment

Updated May 2019

Work on the CM Health Infrastructure Asset Risk Profiling Assessment set for completion in April 2019 has been delayed. The Report is being held up due to resourcing issues in Engineering. The Report could be issued without the review, however this is not recommended. With the establishment of Asset Management within Facilities, this piece of work will now be progressed.

University of Otago (UoO) Dental School

Updated May 2019

The University of Otago Dental School contractors are moving at pace with the first floor and the roof/façade. It is expected that service trades will commence mid-end June. Bridge/Ramp entry has begun and is expected to coincide with the first floor pour. Completion date is under review, however indications are that the building will be complete by Feb 2020.

Scott Building sanitary drainage

Updated January 2019 January 2018

Stage 1 of the Scott Recladding project will involve the replacement of a sewer stack to establish methodology, cost and the actual condition of stack to inform the need for other stack replacements. A provisional sum of $2.5 million has been approved as contingency funding to remove and replace faulty sewer stacks should the need arise.


Emergency Department, Medicine & Integrated Care Monthly Report – April 2019 Glossary BSP Bowel Screening Programme FTE Full-time Equivalent MRT Medical Radiology Technologist RMO Resident Medical Officer SMO Senior Medical Officer Service Overview The Emergency Department, Medicine and Integrated Care service is managed by Brad Healey, General Manager, with Clinical Directors/Heads Dr Carl Eagleton (Medicine), Dr Vanessa Thornton (Emergency Department), Dr Sally Urry (Breastscreen), and Clinical Nurse Directors To’a Fereti (Medicine) and Annie Fogarty (Emergency Department). Report Back on Actions Assigned During Previous Hospital Advisory Committee Meetings The Committee asked for a “Bowel Screening Programme regular update via the Medicine report each meeting” to be provided. National Bowel Screening Programme (NBSP) – Regular Update for the Hospital Advisory Committee At the end of April over 31,000 test kits have been sent to CM Health residents. Participation by ethnicity for the cohort of participants invited each month is shown in the graph below. Coverage each month slowly increases as priority participants are followed up either by the National Co-ordination Centre or the CM Health bowel screen programme team and they return the test kits. We are concerned regarding the lower uptake in Maaori and Pacific populations. The national target is 60%.


We have received performance data for active follow up by the National Co-ordination Centre (NCC) which is contracted by the MoH to provide active follow up for priority populations in our DHB. It is disappointing to note that only 36% of our Maaori and Pacific populations who have not returned a kit have been able to be contacted and of those 31% return a kit. 16% did not have valid contact details. Overall 10% of Maaori and Pacific who have not returned a kit do so after active follow up processes are carried out. We have been sending a text reminder to everyone who has not returned a kit after the NCC active follow up process and then our DHB community coordinators are trying to contact by phone all Maaori, Pacific and participants living in NZ depn areas 9-10 to encourage participation. However as the number of non-responders is high after active follow-up, we are unsure if we can sustain this. We then work with primary care to encourage remaining non respondents to participate; facilitating letters from practices with high numbers of priority participants. We have been encouraging primary care to discuss the programme with eligible Maaori and Pacific and then order a kit through their datamart systems. We are finding a 10% higher participation rate in participants who receive a kit following a discussion with their GP compared to those who just receive it through the mail from the National Co-ordination Centre. We hope to evaluate this strategy further. We continue to advocate to the Ministry of Health for clearer instructions in the test kits, better programme collateral including translated resources and the ability to drop off samples at community laboratories. We believe that drop off to community laboratories will be an option for our population from September this year, but had not received any further detail around this. We also continue to promote the programme in the community. To the end of March, in CM Health there have been 540 positive screening results, 372 colonoscopy procedures have been carried out and 37 participants have been diagnosed with bowel cancer. Highlights Respiratory The Respiratory Function Service is staffed by Clinical Physiologists working in the Respiratory Medicine Team. They perform a range of complex lung function and cardiopulmonary exercise tests. They also analyse and create reports for overnight sleep tests and are based at Manukau SuperClinic in Module 7. We have been informed that our Respiratory Function Laboratory Service has been accredited by the Thoracic Society of Australia and New Zealand (TSANZ). Accreditation is for five years. CM Health has never achieved accreditation before. We join a limited number of services which have achieved this standard in Australia and NZ. This is a major achievement and puts our service on a footing with centres of excellence in Australasia. It helps the wider Respiratory service to meet credentialing and training accreditation requirements. Screening Support Services Contract – Breast and Cervical Screening Members of the team took part in successful North Island Cervical Screening Hui which had 85 attendees from across the country. It hi-lighted that the work we are doing is to the fore. There was a lot of interest from other attendees, around our Mana Wahine days, community clinics and advertising. The work we are doing is achieving very positive results and feedback form other providers. Renal CM Health Renal and Diabetes services were part of a series of articles in the New Zealand Herald on diabetes and related care, including foot assessment and care.


CM Health Renal and Diabetes Services introduced foot assessments and podiatry care to patients in wards and the dialysis units through two 20,000 bed day projects – “Increasing Diabetes Care for Inpatients” (Diabetes Service) and “Feet for Life” (Renal Service). These two projects have resulted in a significant drop in the rate of amputations for our patients and considerably improved their quality of life. Acute Demand Update During April presentations totaled 9,498 which is a 1.5% increase over last year’s volumes for the same month. Emergency Department presentations remain at 316 average presentations per day in April.

Emerging Issues Coronary Angiography Waiting List A senior clinician has reviewed the long outpatient coronary angiography waiting list. There is a real clinical risk of deaths on the waiting list. We have prepared an urgent short-term plan which will involve outsourcing approximately 20 urgent cases to the private sector. The estimated cost of the 20 cases in the order of $120k - $400k. Echo Waitlist We have cleared 500 off the waitlist which totalled over 2,000 in February 2019. This has been achieved through bringing in agency staff at weekends. Funding for this runs out in June 2019 and further consideration will need to be given to funding this initiative 19/20. ED Provider Staffing Notwithstanding the approval of additional resources of 1 NP and 2 CNS, the Clinical Head of ED remains concerned that ED is seriously understaffed with Providers as compared to similar sized DHBs and that this is having a negative impact on workflow and staff morale.


General Medicine Medical Staffing There remains concern that staffing levels are insufficient to ensure adequate patient flow and quality care is delivered to all patients. General Medicine has moved to 4 HBW effective 14 May 2019 and the SMOs are working on a further roster change as signalled to the Board to address some of the Registrars concerns. General Medicine would like confirmation of their requests to the Board in the physicians letter. Renal The Renal Service has completed the change of self-care Satellite (MSC) patients with Rito 2 (MMH) dependent patients and associated staff. This was done primarily to create more in-centre capacity at the Satellite unit, but it also enables the lower dependency/self-care patients to co-locate with the home therapies area on the Western Campus by being dialysed in Rito 2. The additional capacity at the MSC Satellite Unit will be exhausted, potentially, within the next 6 months and so a paper outlining the need for more staff for evening shifts, along with the costs for increasing volumes, has been submitted to SLT and is waiting to be submitted to ELT. The paper outlines a phased approach to employing more staff to manage the increasing volumes for budgeting purposes. It should be noted that evening shifts are sub-optimal in terms of patient outcomes and so further planning for additional in-centre dialysis facilities needs to begin as soon as possible. Currently plans for a Home Therapies Hub at MSC are underway, as part of the 5-10 year plan. Local Delivery Medical Oncology An evaluation paper for LDO has been developed for presentation to regional Oncology Operations Group (ROOG and Northern Region Integrated Cancer Service Group (NRICS), signalling options for the next stage in local delivery. This may include administration of adjuvant chemotherapy in a bid to address the current unmet need as patient’s choice not to have treatment due to having to travel. At CM Health this work may be impacted by a short term need to collocate with the winter ward, but facility planning is being considered alongside the regional work. The regional intent is to fully consider a range of four options: 1. Expanding the breast cohort to include adjuvant, metastatic and oral 2. Commence lower GI adjuvant, metastatic and oral 3. Commence lung – exclude combined treatment 4. Commence wider infusion therapy (melanoma, keytruda etc) Decision criteria could also include: • End-to-end cohorting – providing care locally from suspicion of cancer to the end of treatment • Maori health gain • Patient-centric location ie moving more patient volumes



Issue Date reported Update

Bowel Screening Programme Funding

Oct 2017 The Service delivery contract to June 2020 has been signed and returned to the Ministry of Health. Due to revised (increased) funding received from the MoH in February and a later start of the programme than originally budgeted, there is sufficient funding available for the bowel screening programme for the period of the current contract. However, financial modelling for 20/21 and 21/22 indicates that the funding levels currently being suggested by the MoH will put the programme in a deficit, further discussions with the Ministry will be required around funding prior to the renewal of the contract for this period.

National Health Targets Cancer Treatment

Description 90% of patients receive their first cancer treatment (or other management) within 62 days of being referred with a high suspicion of cancer and a need to be seen within two weeks.

April Achieved 96%

Commentary Performance has again improved this month and is hitting the target for the first time in seven months. April FCT performance overall 87% (incl. all breach reasons 27/31 patients) Reported FCT performance 96% (excl. patient choice & clinical consideration 27/28 patients)


Action Taken Over the Past 4 Weeks • Service-led action plans have been developed for the 4 tumour streams Gynae, Lung, Lower GI and

ORL. Actions include those that can be implemented with little or no cost and those that will only be achievable with further resourcing and may take a longer time to achieve.

• Cancer Nurse coordinators and Cancer pathway tracking team working closely to micromanage patient and pathway timeframes

• ELT paper and HAC presentation for CEO & Executive Leadership Team outlining key hotspots and resources required to sustainably achieve the target. The recommendations made to ELT are: o The resourcing of 2 FTE Cancer Nurse Coordinators across 4 tumour streams at a cost of

$220,560, which is currently unbudgeted and 0.5 additional FTE for Maori Cancer Nurse Coordinator at a cost of $55,139, which Maori Health are looking to fund

o Further review and cost analysis of additional resourcing requirements in radiology and procedural space.

o Further analysis of the other actions identified in the Emerging Issues table, see below o Refresh weekly FCT operations group to improve engagement and accountability of Service

Managers, provision of updates from services on issues and risks and activity towards meeting actions identified on the service action plans

o Development of the Cantrack system to improve ability to navigate and micromanage patients through pathways

Emergency Department

Description 95% of patients will be admitted, discharged, or transferred from an emergency department within six hours


Commentary Patent volume and bed demand mean the hospital is unable to reach the six hour target achieving 84% for April against the target of 95%. This is due to a variety of factors including high consistent surge presentation rates and consistent high hospital occupancy. Steps we are taking to improve our performance include participation in the “Every Hour Counts” programme. The graph below shows daily performance against this target.


Cardiology Angiography

Description Cardiology - 95% elective angiograms within 90 days


Commentary: Target not achieved. A further improvement over previous months. However, acute cases continue to displace elective referrals. Cath Lab nursing staffing is improving with MRT staffing worsening. This is impacting our ability to work extended days and the waiting list is growing. Alternative capacity is required and this may require outsourcing.

Colonoscopy

Colonoscopy Targets

Description • 90% urgent (P1) colonoscopies done within 14 days • 70% non-urgent (P2) colonoscopies done within 42 days • 70% of Surveillance colonoscopies done with 84 day

April 100% ↑ 75% ↑ 99% ↑

Gastroscopy

Gastroscopy Targets (CM Health Targets)

Description • 85% urgent (P1) gastroscopies done within 14 days • 70% non-urgent (P2) gastroscopies done within 42 days • 70% of Surveillance gastroscopies done with 84 days

April 94% ↑ 53% 100% ↑

Commentary All MoH targets for colonoscopy were achieved again in April. It should be noted however that the reporting to the NRA and MoH for the secondary 100% targets differs from CM Health’s because deferred patients are included in the NRA and MoH data, whereas this has been removed from CM Health data. The CM Health target for P2 gastroscopy has not been met yet, with this in part being due to the numerous public holidays, school holidays and the RMO strike, which also led to a decrease in the colonoscopy targets too. However, there will be an increased focus on gastroscopies in May and June. Mitigation strategies continue and include recruiting to cover positions for nursing, technicians, clerical staff and we continue to outsource procedures to private providers, as well as outsourcing the BSP equivalent volumes. Plans for a new endoscopy room are now underway, which will increase some capacity for endoscopy.

Colonoscopy 2018 2019Period End Mar April May June July Aug Sep Oct Nov Dec Jan Feb Mar AprP1 – % within 14 days (target 90%) 100% 98% 95% 92% 98% 96% 94% 97% 96% 99% 100% 99% 100% 100%P1 – % within 30 days (target 100%) 100% 100% 100% 100% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100%



CT Colonography - % within 42 days (targt 65%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Gastroscopy 2018 2019Period End Mar April May June July Aug Sep Oct Nov Dec Jan Feb Mar AprP1 – % within 14 days (target 85%) 97% 92% 95% 88% 94% 98% 96% 93% 95% 95% 89% 98% 100% 94%P1 – % within 30 days (target 100%) 98% 100% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100%




Trend Rating Commentary (by exception)FY1718-1819 Apr-19 Target Var Actual Target Var

Total Caseweight 2,301 2,315 -0.6% 24,582 24,513 0.3%Elective Caseweight 33 55 -40.0% 550 579 -5.0%Acute Caseweight (includes Intensive Care Unit) 2,268 2,260 0.4% 24,032 23,934 0.4%Outpatient First Specialist Assessment (FSA) Volumes 1,137 1,190 -4.5% 13,051 12,730 2.5%Outpatient Follow Up Volumes 2,926 3,325 -12.0% 33,080 33,264 -0.6%Virtual First Specialist Assessments (FSAs) 165 159 3.8% 2,266 1,690 34.1%


% Staff with Annual Leave > 2 years 5.0% 5.0% 5.0% 5.0%% Staff Turnover 10.0% 10.0% 10.0% 10.0%% Sick Leave 2.8% 2.8% 2.8% 2.8%Workplace Injury per 1,000,000 hours 10.5 10.5 10.5 10.5


No. Falls causing major harm 0 0 0 0 0 0


% Radiotherapy commences in 4 weeks

73% 100% -27% 77% 100% -23%

Monthly updates reported through Regional Oncology Operations Group and further reporting will be developed to provide detail of capacity and demand. Delays due to capacity at ADHB radiation oncology has been placed onto the origanisation risk register and rasied to HAC and ELT

% Chemotherapy commences in 4 weeks 100% 100% 0% 100% 100% 0%% of patients admitted, discharged, transferred from ED within 6 hrs

83% 95% -12% 85% 95% -10% still stuggle to meet TBS times as resource doent match surges and presentations, capacity and flow are still a challenge

P1 (urgent) % diagnostic colonoscopy patients receive the procedure within 14 days 100% 85% 15% 98% 85% 13%P2 (routine)% diagnostic colonoscopy patients receive the procedure within 42 days 75% 70% 5% 85% 70% 15%% surveillance colonoscopy patients receive their procedure within 84 days of planned date 99% 70% 29% 96% 70% 26%P1 (urgent) % diagnostic gastroscopy patients receive the procedure within 14 days 94% 85% 9% 95% 85% 10%P2 (routine)% diagnostic gastroscopy patients receive the procedure within 42 days

53% 70% -17% 53% 70% -17%

Gastroscopy target not achieved due to a number of things including school and public holidays and the RMO strike. There will be an increased focus on gastroscopies in May towards achieving the target.

% surveillance gastroscopy patients receive their procedure within 84 days of planned date 100% 70% 30% 90% 70% 20%% cardiac STEMI - PCI (angiography) within 120 mins - Northern Region Target 80% 80% 0% 78% 80% -2%% Coronary Angiography within 90days (1 month in arrears)

93% 95% -2% 82% 95% -13%

A further improvement over previous months. However, acute cases continue to displace elective referrals. Cath Lab nursing staffing is improving with MRT staffing worsening. This is impacting our ability to work extended days and the waiting list is growing. Alternative capacity is required and this may require outsourcing.

Medical Assessment – Triage 3-5 patients seen within 60 minutes

106 60 46 104 60 44

Medicine bed occupancy remains high with little change over previous month. Updating of triage status to be reviewed. Over allocation of Registrar and creation of 3rd RMO on evening shift from June will enable review of this performance.

Door to Cathlab suspected Acute Coronary Syndrome < 3 days (median time)

66% 70% -4% 73% 70% 3%

Note that this result is always measured 1 month in arrears.Acute cardiology demand has been high and this is leads to longer waiting times for in-patients.

EMERGENCY DEPARTMENT, MEDICINE AND INTEGRATED CARE SCORECARD April 2019

Ensu

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Fina

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Year to date

Enab

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High

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12 month average

Safe

ty Year to date

Tim

ely

Year to date


General Medicine - Seen By Time (minutes)1st Time to be seen Triage 1 & 2 patients (median time in minutes) 70 30 -40 73 30 -431st Time to be seen Triage 3 - 5 patients (median time in minutes) 91 60 -31 91 60 -312nd Time to be seen Triage 1 & 2 patients (median time in minutes) 53 30 -23 50 30 -202nd Time to be seen Triage 3-5 patients (median time in minutes) 132 60 -72 121 60 -61

FCT - % high suspicion first cancer treatment within 62 days - MOH Health Target91% 90% 1% 82% 90% -8%

Too early to say if improvement is sustainable at this stage. Presentation to HAC and ELT paper provided.

FCT - %confirmed diagnosis first cancer treatment within 31 days 83% 85% -2% 89% n/a


Average Length of Stay - Acute 3.1 3.5 0.4 3.2 3.5 0.3Acute Readmissions within 28 days - Total 11% 10% 1% 14% 10% -4%Acute Readmissions within 28 days - 75+

12% 10% 2% 16% 10% -5%

% of patients on home wards in General Medicine58% 75% -17% 49% 75% -26%

Similar but slight improvement to previous month, overall % HBW remains over 50% despite over-occupancy

% of Outliers on non-medicine wards5.7% 0.0% -5.7% 7.1% 0.0% -7.1%

While a function of high demand/over-occupancy fewer than 10% of Gen Med patients are in outlier wards. Slight improvement over previous month

100 0% 100%Trend Rating Commentary (by exception)

FY1718-1819 Apr-19 Target Var Actual Target Var% Discharges from transit lounge or home by 1100hrs 33% 30% 3% 30% 30% -2%% Discharged from Medical Assessment Unit by 1100hrs

43% 40% 3% 26% 40% -14%Improvement over March noted. In the context of AMRAC clinics this data may represent increased appropriate admissions from MAU.

% of patients < 28 hrs discharged from inpatient wards 9% 10% -1% 9% 10% -1%Implement Home First Renal policy - (increase Continuous Ambulatory Peritoneal & HD rate)

40% 50% -10% 41% 50% -9% There is a growing number of dialysis patients with an increase of 6 overall. This includes 3 more in-centre haemodialysis, and 3 peritoneal dialysis patients, but there was a decrease in home haemodialysis. This has resulted in a 39.7% Home Therapies dialysis patients. There were also no transplants in April, so a poor month.


% Women with Breastscreen in last 24 months - total 2559 2400 159 72% 70% 2%% Women with Breastscreen in last 24 months - Maaori 258 289 -31 67% 70% -3%% Women with Breastscreen in last 24 months - Pacific 382 377 5 84% 70% 14%

Equi

ty

Volumes Screened % Screened in last 24 Months

We are planning more Mana wahine days in 2019, these days have been successful to increase Maaori screening numbers, Data match with DHB IPM also planned.

EC daily throughput volumes exceeded 400 patients at times during April with frequent callouts to the Gen Med SMO on B call. 3rd RMO on evening shift 4-midnight from June will enable review of timeliness data

Syst

em In

tegr

atio

n (E

ffec

tive

)

Year to date

While the 10% target has not yet been met, both these indicators continue to improve over previous months despite over-occupancy pressures together with maintenance of ALOS below target and despite SMO perceptions.

Effi

cien

t

Year

Tim

ely

(con

tinu

ed)


Surgery, Anaesthesia and Perioperative Services Monthly Report –April 2019 Glossary

CSSD Central Sterile Services Department DRS Digital Retinal Imager ELT Executive Leadership Team ESPI Elective Services Patient Flow Indicator FSA First Specialist Assessment FTE Full Time Equivalent MoH Ministry of Health MSC Manukau SuperClinic ORL Otorhinolaryngology SAPS Surgery, Anaesthesia and Perioperative Services SMO Senior Medical Officer WIES Weighted Inlier Equivalent Separations YTD Year to Date

Service Overview

Surgery, Anaesthesia, and Perioperative Services is managed by Mary Burr (General Manager), with Dr Mark Moores (Clinical Director, Surgery, Anaesthesia and Perioperative Care), Dr Tony Williams (Clinical Director, Critical Care Complex), Jacqui Wynne-Jones (Clinical Nurse Director, Surgery, Anaesthesia and Perioperative Services), and Annie Fogarty (Clinical Nurse Director, Acute and Critical Care Complex). Highlights • A new ‘walk-in’ screening clinic alongside High Risk Diabetes in Pregnancy clinic has been established.

This clinic has captured several women who have significant retinal disease, some requiring urgent laser treatment to save their sight.

• Ophthalmology Digital Surveillance Clinic has been established with the aim to reduce demand of referrals to FSA (SMO) from Retinal Screening (DRS) merely because of failed screening (often due to cataract eye disease). The new clinic is technology enabled to take a more sophisticated image than the DRS camera. This image is reviewed by an SMO virtually rather than a face to face FSA.

• Successful outpatient pilot and expansion to more volume of linked ORL/audiology appointments is addressing a historically and persistent mismatch of these two queues.

• SAPS under budget for month and year to date. Theatre Performance - Year to Date 2019


Challenges - Update on Items Previously Reported

Challenges Date Reported

Update

Demand on Ophthalmology Services

July 2016 Good will and great effort continues with staff running mega clinics at the weekends to reduce overall follow up volumes. Volume reduction in April has been impacted by the number of public holidays. Regional governance is progressing and concentrating on aligning data and processes. FSAs are also becoming a problem as demand continues to exceed resource to treat. A recovery plan has been put in place. The MOH has been advised that we will not meet the 5% threshold by 30 June 2019. We continue to focus on reducing overdue follow up volumes with a new goal to achieve 5% only waiting for over 50% of time by the end of December 2019. We have seen the average waiting time per patient in this cohort reduce from 100 days to 58 days.

Anaesthetists’ shortage

Oct 2017 Recruitment Update • Advertisements for permanent /full time positions continue. • A further set of interviews will be held in May. • ATR raised for 7 fellows for 2019 – 2020. • Total FTE at present 59FTE (Service Size FTE 68.80). Service sizing paper has been presented to ELT and received agreement in principle while further regional comparison is being completed. An appendix to the paper also explored the option of a full time allowance to encourage more anaesthetists to become full time. We are working through the costs and benefits of this option. Theatre cancellations due to anaesthetists shortage have dropped significantly for April 2019:

Urology Cx Bladder Project

July 2018 Cx Bladder testing in full swing and progressing well.


Challenges Date Reported

Update

CSSD Staffing Numbers

Three new staff members have started working in CSSD in April. Vacancy of 0.7 FTE to employ to with interviews set for early May 2019. ELT paper for extra staffing resources to complete the full implementation of T-Doc is to be presented based to ELT. The service continues to work with Security and Fortlock identifying how to lock down both units so that items cannot be removed from CSSD without CSSD Staff knowing. Replacement of old steriliser at MSC is underway. Audit of CSSD on both sites was completed early April. Report due early May 2019.

NBC Review Dec 2018 The Interim Burn Governance Group continues to meet fortnightly. The Terms of Reference for the group have been completed. The executive summary of the Review Report and the recommendations have been widely released and a series of meetings commenced to socialize that document. So far meetings have taken place with the theatre and nursing teams, the Plastic Surgery Department and the Anaesthesia Executive. Further meetings are scheduled with Critical Care, Paediatrics and the wider Department of Anaesthesia. This process will culminate in a workshop scheduled for June 10th at which the summary and recommendations will be presented, further feedback provided and the forward path will be discussed. It is proposed that the next areas of work include the establishment of two working groups; one to look into the establishment of a multi-disciplinary clinic for the follow up of all paediatric burns and the second to look at developing pathways for the management of the complex in patient burn.

Elective performance is under threat

Oct 2017 ESPI target - currently non-compliant red for ESPI 2 and ESPI 5 for ophthalmology, ORL and Plastic. These services continue to struggle meeting waiting time targets. We have provided the MOH with a recovery plan.


National Health Targets Elective Access

Result March (actual)

Result April (indicative)

PP45: Number of publicly funded, case mix included, elective and arranged discharges for people living within the DHB region

Not Achieved × 98.1% Variance from Plan 289

Not Achieved × 98.1%

Elective Waiting times ESPI 2 (FSA) and ESPI 5 (Treatment) wait

time targets



Commentary • The ’Health Target’ for Elective Discharges is no longer with us for 18/19, instead it is known as PP45

– Number of publicly funded, casemix included, elective and arranged discharges for people living within the DHB region.

• March elective production YTD has been confirmed as a negative variance position with a shortfall of 289 discharges being 98.1% of planned. Awaiting provisional internal April data to get some indication of indicative results for this month.


April 2019


Total Casew eight (Prov ider v iew ) 3,248 3,218 0.9% 32,441 32,904 -1.4%Electiv e Casew eight incl Arranged Admissions 1,339 1,517 -11.7% 14,999 15,510 -3.3%Acute Casew eight 1,909 1,701 12.2% 17,443 17,394 0.3%Acute discharges 1,477 1,433 3.1% 14,636 14,653 -0.1%Electiv e Surgical Discharges incl Arranged Admissions 1,197 1,446 -17.2% 14,038 14,845 -5.4%Outpatient FSA Volumes 1,973 2,221 -11.2% 22,783 22,713 0.3%Outpatient Follow Up Volumes 4,599 6,283 -26.8% 48,194 64,243 -25.0%Budgeted FTEs 1,433 1,342 -6.9% 1,387 1,372 -1.1%Operating Costs ($000) 19,315 19,535 1.1% 190,525 189,875 -0.3% Slightly ov er for y tdVirtual FSAs/Follow ups -(GP consult and nonpatient appointments) 311 133 133.8% 1,856 1,374 35.1%Personnel Costs ($000) $13,900 $14,186 2.0% $134,845 $137,570 2.0%Financial Result Total ($m) $16,847 $17,110 1.5% $164,632 $164,839 0.1%

Reduce clinical outsourcing ($000) $487 $613 20.6% $5,343 $4,234 -26.2%Outsourcing to accommodate loss of skin lesion accounting.

Trend 12 month average Rating Commentary (by exception)FY1718-1819 Apr-19 Target Var Target Var

% Staff w ith Annual Leav e > 2 y ears 17.8% 5.0% -12.8% 17.2% 5.0% -12.2%Discussions in progress w ith affected staff

% Staff Turnov er 5.1% 10.0% 4.9% 7.9% 10.0% 2.1%% Sick Leav e 3.0% 2.8% -0.2% 2.6% 2.8% 0.2%Workplace Injury per 1,000,000 hours 0.0 10.5 10.5 10.89 10.5 -0.4


Hand Hy giene compliance rate (based on Gold Audit) - Ward 11 87% 80% 7.0% 82% 80% 2.0%Good month's result and achiev ing target YTD

Pressure Injuries / 100 patients 0.00 3.50 -3.50 0.00 0.00 0.00Falls causing major harm / 1000 bed day s 0.00 0.00 0.00 0.00 0.00 0.00Sev ere Pressure Injury (ungradeable) per 1000 bed day s 0.00 0.00 0.00 0.00 0.00 0.00Surgical Site Surv eillance for Major joints-

Antibiotics giv en 0-60mins before "knife to skin" 93% 95% -2% 93% 95% -2%Correct antibiotic 99% 100% -2% 97% 100% -3%Appropriate skin preparation 99% 100% -2% 98% 100% -3%

CLAB rate/ 1000 line day s 0.0 0.0 0.0 7.0 0.0 -7.0 Continue to reinforce CLAB protocols Rate of S. aureus bacteraemia per 1000 bed day s 0.2 0.0 -0.2 0.1 0.0 -0.1VTE - Ortho (Acute and Electiv e) 8.0 2.0 -6.0 54.0 0.0 -54.0 All VTE cases discussed at case

Enab

ling

High

Pe

rform

ing

Peop

leFi

rst,

Do N

o Ha

rm (S

afety)

Year to date

Continuing to monitor monthly

Safet

y (co

nt.)

Electiv e performance continues to be under threat as a result of lost operating due to strike action and three public holiday s during the month

SURGERY, ANAESTHESIA & PERIOPERATIVE SERVICES SCORECARD

Ensu

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Pre-operative Length of Stay Days (from admit to surgery) 0.64 1.0 0.36 1.29 1.0 -0.3 Excellent improvement in Pre op LOSESPI 2 No. patients waiting >120 days for FSA - Elective (Surgical Services incl Gynae) 1075 0 -1075.0 1075 0 -1075.0ESPI 5 No. patients waiting >120 days Treatment - Elective (Surgical Services incl Gynae) 133 0 -133.0 133 0 -133.0


Average Length of Stay - Acute Inpatient incl Burns 3.95 3.6 -0.3 3.89 3.6 -0.29Average Length of Stay - Acute Inpatient excl: Burns 3.93 3.6 -0.3 3.58 3.6 0.02Average Length of Stay - Acute Inpatient excl: Burns and Spinal Ortho 3.93 3.6 -0.3 3.85 3.6 -0.25Average Length of Stay - Electives 1.32 1.5 0.2 1.19 1.5 0.3


Theatre list utilisation - % used MMH/MSC 84.2% 85% -1% 82.0% 85% -3%Theatre session utilisation - % used MMH/MSC 87.5% 95% -8% 84.4% 95% -11%Elective Theatre turnaround times- Mins (MSC only) 12.7 15 2 12.1 15 3Elective cancellations - Day of surgery % of all Elective (all reasons)- SAPS only 9.8% 5% -5% 8.6% 5% -4%Day of Surgery Admissions (DOSA) 93% 90% 3% 90% 90% 0%Day Case Rate (Elective/ Arranged) -Subspecialties in SAPS only Adults/kids 64% 65% -1% 66% 65% 1%MMH % patients discharged to discharge lounge or home by 1100hrs 22% 30% -8% 25% 30% -5%MMH % patients discharged to discharge lounge or home by 1100hrs -GEN SURG 23% 22% 1% 27% 30% -3%MMH % patients discharged to discharge lounge or home by 1100hrs- ORTHO 18% 30% -12% 18% 30% -12%MMH % patients discharged to discharge lounge or home by 1100hrs- PLASTICS 24% 30% -6% 25% 30% -5%Ratio FSA/FU clinic ratio 44% 34% 11% 45% 34% 11%Outpatient DNA rates - overall- Surgical Services only 9.0% 10% 1.0% 8.9% 10% 1.1%Outpatient DNA rates - Maori (FSA) - Surgical Services only 20.4% 10% -10.4% 17.2% 10% -7.2%Outpatient DNA rates - Pacific (FSA)- Surgical Services only 16.9% 10% -6.9% 16.4% 10% -6.4%


% of hospitalised smokers receiving smokefree advice & support -Total (Surgical) 97% 95% 2% 97% 95% 2%Trend Rating Commentary (by exception)

FY1718-1819 Apr-19 Target Var Actual Target VarPatient Experience Survey - month (n=91) and YTD (n=91) 93% 90% 3% 94% 90% 4%

Equi

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CC Year to date

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Very good progress on out before 11am marker across services. Ortho are addressing with new acute coordinator role.

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Acute LOS is slightly higher than target

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Recovery Plan in place for failing ESPIs


Central Clinical Services Monthly Report – April 2019 Glossary CAR Corrective Action Recommendation CM Health Counties Manukau Health CT Computed Tomography CD Clinical Director ePA Electronic prescribing and administration FTE Full Time Equivalent MoH Ministry of Health MOW Meals on Wheels MRI Magnetic Resonance Imaging MRT Medical Radiation Technologist RMO Registered Medical Officer SMO Senior Medical Officer TAP Turn Around Plan YTD Year to date Highlights Pharmacy • The Pharmacy and Medication Safety teams were successful at the Allied Health Awards winning

Team of the Year. • Rajeshni Naidu was successful in winning the Patient Experience and Innovation Award. • MedChart successfully rolled out in ED supported by the Emergency Department clinical pharmacy

team and the ePA team. The roll out will continue to Medical Assessment and the medical wards over May.

Radiology • The MRI waitlist reduced by over 500 patients from 1 March to end April. This is whilst running

business as usual. This is due to additional staff doing alternate weekend sessions and improved workflow and staffing productivity.

• Workforce planning was in full swing since last month- new advertising ideas, alternative staffing models mooted. Human Resources and Recruitment involved.

• There has been a lot of interest in permanent work from our Registrar’s completing their training. There have been three applications from current Registrar’s and two from previous Registrar’s. Over the next 9 months this will bring the Radiologist workforce back to full staffing for the first time in nearly 4 years.

Laboratory Services • IANZ completed their annual audit on the laboratory in April. There were no major issues identified

and the feedback was very positive overall. Some useful suggestions were identified that are in the process of being implemented.

Emerging Issues Pharmacy • The roll out of ePA across the medical wards will place additional workload on ward pharmacists to

support prescribers. This may have an impact on other work e.g. Medicines Reconciliation completion rates.


• Certification coming up in May 2019, we have a number of documents due for update. Controlled Drugs management guideline now updated in Documentation Directory. Clinical Eduction held to educate pharmacists on Controlled Drug management and responsibilities as well as Incident Reporting. Next step is for ward pharmacists to conduct hospital-wide education for nurses. We are also currently in the process of updating the eLearn module that is part of nursing Medication Certification.

Laboratory Services • Training in Delphic v 10 starting on April 1. Many problems with connections between devices

(printers, etc) so progress is slow. • The Histology Service has been under significant pressure with a significant increase in samples

received from gastroenterology. This is a large volume service already for the lab with year to date samples having increased 70% over the past 2 years.


Issue Date Reported

Update

Reduced Radiologist FTE

7 Sept 2016 Currently we have 2.6FTE of staff off on parental leave – this impacts the department. We have worked hard on recruiting to fill vacancies, see details at top of this page- item 3. The CD and staff have interviewed four senior RMO’s who will complete their training at the end of the year, two of them have expressed an interest in working here permanently and the others for a limited time prior to going to commence Fellowships. We have also had strong expressions of interest from RMO’s who worked here previously who wish to return from overseas to CM Health.

General x-ray service (update to the above)

7 Sept 2016

The general x-ray service waiting list (see graph above) increases each winter due to MRT vacancies and additional seasonal volumes. We are facing similar levels of shortages this year. Workforce planning and reviewing of advertising has taken place, investigations into employing non-qualified staff into assistant type roles for a fixed term over the winter is being investigated as well as a review of plans to increase our student numbers. The waiting list dropped from 3425 (January 2019) to 592 (April 2019) by running additional evening sessions.


Issue Date Reported

Update

Histopathology Lab 8 March 2017

Contract has been let and Focus Construction are well into the construction. While there have been some delays to the construction program it is now on track to be finished in early July.

MRT FTE Apr 2017 March 2019 vacancy rate at 10.44FTE – see commentary under the general x-ray service above.

Transcription August 2018 The backlog of dictation and turn-around times for transcription continued to be maintained over April with all targets being met. On 30/04/2019 the backlog was 168 hours and the turn-around time of maximum of five working days was being met for all services. At the time of writing this report (08/05/2019) the backlog was 130 hours. The recruitment process for the two vacancies in the service is underway. Another resignation has been received, effective from 24/05/2019. This risk is now largely reduced with a number of mitigation plans in place to manage this risk in the future.

National Health Targets Radiology The Radiology Service is responsible for one of the six National Health Targets; Diagnostic Access Targets.

April 19 March 19 February 19

MRI – 90% scans completed within 6 weeks 32.5% 29% 38.2%

CT – 95% scans completed within 6 weeks 93.7% 91% 84.2% CT

Commentary • We are still unable to run the 12-8 shift three days per week. • Improved achievement towards target despite some staffing shortages. • CT cardiac – some booking issues/delays related to shortage of Cardiac RN’s and Cardiologists. Waiting < 6 weeks 21 Waiting < 21 weeks 7 Waiting > 21 weeks 1

Month April 19 March 19 February





MRI

Commentary • New contracted casual MRTs x 2 (weekends) underway – working alternate weekends. • MRI Improvement Project run by Ko Awatea is in progress. • Waiting list reduced by >500 (from 1900 to 1400) since beginning of March whilst running business

as usual. The waitlist is continuing to rapidly decrease and it is anticipated that as the waitlist is cleared there will start to become a steady improvement in the 6 week target.

Food Service The patient satisfaction survey response is a KPI in the National Food Service Agreement. These have not been reviewed during the life of the contract, an initial attempt to review the KPI and survey between NZHPL, Compass and the six DHBs, has not progressed for some months. The survey is distributed to a small group of wards each month. In April 160 surveys were distributed with 96 returned, a 60% response rate. Compass KPI Reporting and Patient Satisfaction Results

Compass satisfaction score from the Ok, Good and Very Good responses was 95.8%, slightly lower than last month. Cemplicity Survey Response CM Health patient survey responses are from the post discharge Cemplicity survey with a variable monthly response rate. In April there were 65 verbatim comments responses. Almost half of the comments reflected a positive remark re the food service. The Cemplicity patient satisfaction rating this month is 81% compared with 75% in March. The responses in this survey are significantly different to the Compass inpatient surveys, due to a different response scoring structure.

Month April 19 March 19 February 19





The Compass survey asks questions re the different elements of food service, the responses are reported in the chart below.

Middlemore Hospital Patient Feedback Patient feedback from all sources including Risk Monitor, clinical staff, survey comments, issues reported directly to the kitchen. All items are categorised and placed in a feedback database. This is used as a basis for the quality improvement programme for the kitchen to target areas.


The comments have been categorised to develop action plans where possible to address the issues

April feedback was 96% for the overall satisfaction with the quality of food service. Level of complaints from all sources was again mainly about food quality, service delivery and accuracy being the major causes of complaints. They also received the highest level of positive comments. Continuous Improvement Compass Continuous Improvement plan has been developed with the DHB from the feedback received over the last three months.


Current Plan

Continuous Improvement

Description Responsible Complete

Review of staff VCA vetting status Nick Initial review stages

Review of staff vaccination screening status

Nick Initial review stages

New cleaning roster and regime Nick Completed

BPod cleaning schedule Nick Planning stages

Standard menu description and photo booklet

Danielle Completed –review required

Security and mechanical door access to Tiaho Mai

Nick / Stella Ongoing

FSA daily huddles + trainings Nick / Danielle / Ward Supervisors

Ongoing

Review of patient satisfaction survey methodology

Nick / Ward Supervisors Not yet started

Electronic meal summaries Danielle, Nick, Stella, Clinical team

Implementation stage

Releasing Time to Care Nick / Wards Completed



% Staff with Annual Leave > 2 years 5.0% 5.0% 5.0% 5.0%% Staff Turnover 10% 10% 10% 10%


% electronic medication reconciliation completed for high risk patients within 48hrs

67% 80% -13% 80% -80%

This is possibly due to approximately 30% (268/915) of high-risk patients were admitted over the public holiday short-weeks (18th-26th April). Clinical pharmacy services (2x pharmacists x 5 hours) were only provided on Good Friday and Easter Sunday over that period, which would provide explanation for the drop in high-risk eMR within 48 hours rates. Providing more clinical pharmacy services over weekends and public holidays would help to address this.

9.0%


% MRI scans completed within 6 weeks from acceptance of referral32.5% 85% -53% 32% 85% -53%

New MRI tech working salternate weekends. Waiting list reduced by >500 from 1 March toend April. As from mid June, new tech will be doing 2 x 12 hour days Mon/Tues - this willincrease ability to do evening OP scans. KA MRI Improvement Porject in progress.

% CT scans completed within 6 weeks from acceptance of referral94% 95% -1% 92% 95% -3%

Waiting list of cardiac CT's is affecting stats, they are short staffed in cardiac nurses and sessions offered have not been able to be done due to this. We understand that a new person has been recruited and will be trained.

Radiology - Inpatient radiology times < 24hours85% 95% -10% 85% 95% -10%

We have been doing evening sessions and will continue to do so, waiting list reduced. Increasing staffing vacancies in MRT's starting to affect productivity.

Radiology ED radiology times < 2 hours85% 95% -10% 88% 95% -7%

ED Radiology is extremely busy 24/7 and sometimes battles to cope with the demand. Space constraints.

Laboratory -Test turnaround time (TAT) within 60minsPotassium 98% 90% 8% 98% 90% 8%Haemoglobin 99% 98% 1% 98% 98% 0% TAT targets achievedPT/INR 100% 98% 2% 99% 98% 1%Troponin 1 for ED 95% 90% 5% 95% 90% 5%Histology - All - 5 working days

82% 90% -8% 82% 90% -8%High Sick Leave, Annual Leave and increase in GASTRO workload. Still meeting national target of 80%

Breast - 3 working days 100% 80% 20% 97% 80% 17%Non gynae FNAs - 3 working days 93% 90% 3% 92% 90% 2%Blood Bank - antibody screen within 4 hours 97% 90% 7% 95% 90% 5%

MicrobiologyCSF cell count <30mins 94% 90% 4% 94% 90% 4% TAT targets achievedESBL screens <2days 94% 95% -1% 93% 95% -2% Two critically short staffed days CDT (C. diff Toxin) <25hrs 94% 90% 4% 93% 90% 3%UCHM (Urine Chemistry) <60mins 98% 90% 8% 95% 90% 5%

% radiology results reported within 24 hours53% 75% -22% 59% 75% -16%

All SMO's are sent daily reporting volumes and this has helped. Transciption turnaround time can be an issue. Overall Radiologist staffing levels continue to be the main driver of this performance

Trend Rating Commentary (by exception)

FY1718-1819 Apr-19 Target Var Actual Target Var

% transcribed clinical summaries (meddocs) authorised <7 days of creation58% 95% -37% 62% 95% -33%

Monthly reports being sent to services and clinical directors. Transcription turnaround is now on target

CENTRAL CLINICAL SERVICES SCORECARD April 2019

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Women’s Health and Kidz First Monthly Report – February 2019 Glossary ALOS Average Length of Stay CLAB Central Line Associated Bacteraemia CS Caesarean Section DNA Did Not Attend ED Emergency Department ESPI Elective Services Patient Flow Indicators HCA Health Care Assistant KF Kidz First LMC Lead Maternity Carer MECA Multi-Employer Collective Agreement MoH Ministry of Health MQSP Maternity Quality and Safety Programme NHPPD Nursing Hours per Patient Day RDA Resident Doctors Association SUDI Sudden Unexplained Death of Infant VIP Violence Intervention Programme YTD Year to Date WH Women’s Health WIES Weighted Inlier Equivalent Separations (Case weights – a measure of complexity) Highlights Kidz First Paediatric Medicine and ED Both Kidz First ED attendances and Paediatric Medicine discharges are higher than April last year with attendances up significantly by 325 and discharges up by 52. Discharges YTD are at the same level as last year with ED attendance now almost the same as last year as well. The lower WIES YTD 2019 is due to lower number of long stay children in July and August compared to previous year where we saw a high WIES attributed to a small number of children with very high acuity and long stay for those 2 months. Kidz First Paediatric Medicine Outpatients Kidz First Outpatient FSAs are 9% lower YTD than last year but the Follow-Ups have increased by 7% YTD as we continue to focus on reducing the Planned Expired Appointments. The Planned Expired Appointments increased however to 666 in April (March 588) due to combination of Anzac/Easter and RMO strikes on the last 2 days op April. Due to the cumulative effect of the RMO strikes in February and April we had an ESPI2 breach in April of 3. Neonatal Bolumes For April 2019 YTD, total Neonatal volumes are 121 WIES ahead of contract (4%), and compared to prior year, are greater by 266 WIES (9%). Discharges from the Neonatal Unit are up YTD; however discharge volumes for Neonates from the postnatal area are lower than the prior year, reflecting greater levels of acuity and more babies needing to stay in the Neonatal Unit.


Overview of all Neonatal WIES

Occupancy and acuity in April in the Neonatal Unit was high with a high average of resourced occupancy of 100% against the 32 resourced cots for the month for the Neonatal Unit. After the region experiencing a ‘quieter’ 4 months period with babies being able to be transferred back to their domicile DHB as soon as appropriate, towards the end of February and throughout March and April the region has seen an increase in demand again. There has been daily liaison between all 4 Units to ensure that all mothers and babies could remain in the northern region. Despite this work, CM Health had to transfer in-utero twins to Tauranga on Saturday 20 April (Saturday before the Easter weekend). We were however able to repatriate the mother and babies the following week.


Maternity There were 592 births at MMH and 70 at the community units, a total of 662 births for April 2019, which is up by 9 compared to the prior year. Births for April YTD are down by 39 (1%) compared to the prior year (0% variance at MMH but down 6% at the 3 primary birthing units).

Obstetric outpatients are now reflecting the higher complexity as well with overall FSAs for Antenatal Clinics and Specialist Fetal Medicine Clinics up on last year. Planning for Maternity Day Assessment Clinic at MSC is progressing well with a planned start of clinics in the week of 13 May 2019. The Clinical Quality and Risk Manager combined with all service leaders are focussing on the preparation for the Certification Audit in May. The Project Manager for the Ward 21 combined with the Service Manager and Charge Midwife Managers have made incredible progress in preparation for phase 1 of the transition (moving antenatal women and postnatal women whose babies are in the Neonatal Unit) to Ward 21 as well as commissioning 4 Gynaecology beds. Ward clerk and HCA positions have been recruited to and the ATR for 15 RNs has now been approved with 8 RNs already been recruited. An overall Steering Group and 2 Project Groups are in place and working towards phase 1 transition on Monday 13 May 2019. The budget for the September and December approved funding as well as the additional cots required for 2019/2020 has been phased according to the phased commissioning of all initiatives.

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Total Neonates Run Chart showing resourced beds

Total neonates on NNU Total Median Resourced beds

Births2018-19 2017-18 +/- +/- % 2018-19 2017-18 +/- +/- %

MMH 592 582 10 2% 5,597 5,597 0 0%

Botany 24 23 1 4% 220 246 (26) -11%Papakura 18 19 (1) -5% 178 208 (30) -14%Puke 28 29 (1) -3% 238 221 17 8%Total Community Units 70 71 (1) -1% 636 675 (39) -6%

Total # of Births 662 653 9 1% 6,233 6,272 (39) -1%

Apr-19 Year to Date


Gynaecology Acute YTD Gynaecology discharges are virtually at the same level as last year; WIES is down by 4%. YTD the elective (combination of elective and arranged admissions) discharges are down 1% compared to prior year but the WIES is down by 4%. We continue to work closely with Surgical and Anaesthetic Services on the production plan for electives as well as maximising the opportunities for Acute Arranged volumes on the MMH site. In addition, we continue to work with the Elective Services coordinator on the ESPI 5 mitigation plan. For April 2019 the MOH reported ESPI 2 had no breaches but ESPI 5 breached by 7. This is directly related to the number of theatre list lost due to the 2 days RMO strike in April as all elective operating lists needed to be cancelled. The on-going complexity of women presenting in Outpatients has resulted in Follow-Up clinic time for both Gynaecology and Colposcopy to be increased to 20 minutes per patient. This is reflected in the decrease in Outpatient volumes. In addition, due to the ongoing reduced Theatre capacity issues we have needed to decrease FSA volumes with more women now being placed on the GP residual list. Further Outsourcing of 200 Hysteroscopies (highest priority clinical work) to be completed by June 2019 was approved and procurement for this was finalised in February. It is very pleasing that since the outsourcing started we have seen a significant improvement in the number of hysteroscopies provide. YTD we are now at a combined internal and outsourced volume of 370 which is 28% up on last year. Update on Previously Reported Issues

Issue Date First Reported

Update April 2019


April 2016 • Occupancy for April 2019 was 100% (we were able to keep to our resourced cots of 32/33 for the month but with a very high occupancy).

• Regional Neonatal Working Group meetings (including Neonatologist, and Planning and Funding) continue bimonthly and report progress on escalation and regional neonatal cot planning through the Child Health Network meeting to the regional SRG group. A regional escalation plan has now been signed off in addition to our own escalation plan.

• This work is now combined with the national work on definitions of levels of care in neonatal units and the MoH’s new work on national neonatal cot capacity as most of the country’s units are now reporting significant capacity issues. We have received th3e draft report acknowledging the national pressure on neonatal cots. One of the recommendations from the report is to develop more and formal transitional care i.e. graduates from the neonatal unit being cared for on the postnatal floor with their mothers. CM Health already provides this level of care and will be extending the number of cots to 8 as part of the Ward 21 developments. We have indicated to MoH to be part of a pilot.

• In addition, a CM Health Public Health Registrar continues her project investigating local increase in neonatal demand (also linking back to changes in obstetric guideline changes)

• We have increased the catch-up with the 3 GMs/Neonatal Clinical Leads to assess the regions capacity to an almost daily liaison as all Units have seen high occupancy over in March and April. In particular WDHB Units (Waitakere and North Shore have seen high numbers).



Update April 2019


April 2016 • As mentioned earlier in the report, a transfer of a woman with in-utero occurred in April. As per the regional guidelines a review of this is underway.

• Following the external investigation report and subsequent HR process the Nurse Manager of the Neonatal Unit resigned in early March 2019. An Acting Nurse Manager is in place and recruitment for new Nurse Manager position is underway.

• An additional SMO started on 25 March 2019 – this will allow the SMO group to move to a 1: 7 after hours roster as well have additional SMO time during the day to separate level 2 and 3 cover.

• One of the Clinical Nurse Specialists in the Unit has achieved Nurse Practitioner status. We are working with all current Clinical Nurse Specialist on individual transition plans for all of those working towards Nurse Practitioner status. 2 More Nurse Specialists are expected to achieve Nurse Practitioner status in May 2019.

• The Ko Awatea Improvement Advisor Team commenced the work on the Model of Care (in particular the separation of Level 2 and 3 and how we can do the postnatal work differently as well) with a first meeting on 2 August followed by walk around in the Unit on 13 August. We have received their final report indicating that Ko Awatea will support a structured improvement project for the Unit and anticipate commencing this when the new Nurse Manager is in place

• The ongoing neonatal unit demand and capacity was entered on the organisational Risk Register in July with monthly reviews in place.

Caesarean Section (CS)rate

January 2017

• CS rate for April 2019 was 27% and YTD is 29% (up 1.0% on same period last year)

• The Induction of Labour rate is 28% YTD April 2019 up 1% compared to last year’s actual.

Midwifery workforce

January 2017

• Midwifery vacancies for April 2019 contracted versus budget decreased to 9 FTE shortfalls plus an additional 7 FTE being on parental leave. This reduction in vacancies is due to 14 graduate midwives starting at the end of April 2019. Vacancies also continue to be offset by a high use of bureau midwives – 18.87 FTE for April 2019.

• From October, vacancies and in our Community Midwifery services increased sharply and unexpectedly. Combined with the seasonal increase in workload due to self-employed LMCs taking leave over the December/January period and not taking new bookings for women this has resulted in our Community Midwifery Service has now introduced reduced visits to ensure all women have access to the minimum visits required according to their acuity and social requirements (first pregnancy, limited family support, young mothers, etc.). Although the numbers have not decreased as yet after the Xmas/Holiday period, at this stage we do not need to make further changes to the schedule in decreasing care for low risk women.

• We are now also seeing increasing self-employed shortages in both the Manurewa and Mangere areas.

• Recruitment is underway for all new positions approved.



Update April 2019

MCIS April 2017 Update April 2019 Local MCIS Steering Group monthly meetings continue with project management support internally. Anaesthetic paper notes process to be filed in either the woman's generic medical record or a new generic medical record (if previously not known) has been agreed and resource for this has now been recruited to and the backlog of notes needing to be filed has been completed. Clevermed visited in early March with much more clarity on the process based view/system used in the UK and Scotland as well as willingness to immediately progress the one way Portal 8/MCIS interface. From this meeting we have agreed that a CM Health medical, midwifery and anaesthesia representative should visit the UK in June for the Clevermed conference as well as visiting a large similar cohort secondary/tertiary hospital using the process based MCIS system and we have informed MoH that we will not make a final recommendation till that visit has taken place and a report received to assist with our final decision on the continuation of MCIS. In the meantime we have now implemented the one-way Portal 8/MCIS interface and other incremental improvements on the current system. Visits to the UK have been confirmed for the Clinical Director Women’s Health (part of CME), Clinical Midwife Specialist, Anaesthetist (as part of CME) and a WDHB Clinical IT specialist/Anaesthetist (WDHB is following CMH progress closely). Since then MoH has confirmed that their MCIS project manager will travel to UK with the CMH team.



Total Caseweight 461 430 7% 5,281 4,885 8%Acute Caseweight - Paediatric Medicine Inpatients 208 188 11% 2,256 2,449 -8% Lower long stays in Jul/Aug compared to prior year.Acute Caseweight - Emergency Medicine - ED 77 59 31% 699 588 19%Acute Caseweight - Inpatient Paediatric Intensive Care Unit 0 3 -100% 10 23 -57% Very small numbersAcute Caseweight -Secondary Neonatal Unit 176 180 -2% 2,316 1,825 27% Volume and accuityTotal Discharges - Paediatric Medicine Inpatients 408 356 15% 4,320 4,257 1%Total Discharges - Emergency Medicine - ED 286 197 45% 2,523 2,431 4%Total Discharges - Inpatient Paediatric Intensive Care Unit 0 1 -100% 11 17 -35% Very small numbersTotal Discharges - Secondary Neonatal Unit 39 36 8% 394 309 28% Volume and accuityTotal Discharges- Acute Paed Surg - accounted under Adult Surgery 149 130 15% 1,461 1,703 -14% Total Discharges- Elective Paed Surg - accounted under Adult Surgery 104 106 -2% 1,161 1,259 -8% ED attendances 2,116 1,791 18% 20,892 20,947 0%Paed Medicine - 1st Attendance 201 133 51% 1,956 2,003 -2% Impact of RMO StrikesPaed Medicine - Subsequent Attendance 318 289 10% 3,565 3,255 10% Non-Contact FSA - Any Medical specialty -- Paed Medicine 26 47 -45% 317 485 -35% Reduced as GPs learning to follow Health PathwaysNon contact Follow Up - Any health specialty - Medical 7 16 -56% 106 156 -32% Investigating Variation


Budgeted FTEs 323 302 -7% 316 307 -3% Operating Costs ($000) 312 318 2% 2,854 3,230 12%Personnel Costs ($000) 2,999 2,856 -5% 28,237 27,774 -2% Due to RMO strikes and RMO rotationFinancial Result Total ($000) (3,067) (2,995) -2% (28,661) (29,144) 2%Reduce Clinical Outsourcing ($000) 15 5 -200% 87 50 -74%

Trend Rating Commentary (by exception)

FY1718-1819 Apr-19 Target Var Actual Target Var

% Staff with Annual Leave > 2 years 5.0% 5.0% 5.0% 5.0%% Staff Turnover 10.0% 10.0% 10.0% 10.0%% Sick leave 2.8% 2.8% 2.8% 2.8%Workplace injuries recorded per 1,000,000 hours 10.5 10.5 10.5 10.5

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Neonatal Rate of medication errors/1000 bed days per month 0.0% 0% 0% 3.0%Neonatal Care CLAB rate per 1000 l ine days per month 0.00 0.00 0.00 N/ACLAB insertion bundle compliance - NNU 97.0% 100% 3% 100%CLAB prevention maintenance bundle compliance- NNU 90.0% 90% 0% 90%Emergency trolley checks (compliance with checking) NA 100% 0% N/A Carol has requested from Brett Besley Hand hygiene (compliance with checking) 88.0% 80% -8% N/A KFS 68% , KFM 99%, KFNC 96% discuss due to KFS result

Safe sleep - audits compliance 66.0% 100% 34% N/A KFS 0%, KFM 100%, KFNC 100% discuss due to KFS result

Occupational Health and Safety (OHS) Audit (Bi-Monthly) NA 100% 0% N/A not dueHealth and Safety Environmental Audit (Bi-monthly) 100.0% 100% 0% N/AViolence Intervention Programme (VIP) Screening 85% 80% -5% 80% 80% 0%


ED 6 hour target - National Health target (Kidz First ED) - Initial speciality 95% 95% 0% 94% 95% -1%

ESPI 2 - No. waiting >4 months for FSA - Elective 3.0 0.0 3.0 3.0 0.0 3.0 Due to RMO strikes

Trend Rating Commentary (by exception)FY1718-1819 Apr-19 LY Act Var Actual YTD* Var

Admission Rate Babies in the first year of l ife (Total) 22% 19% -3% 21% 21% 0%Admission Rate Babies in the first year of l ife (Maaori) 28% 27% -1% 25% 25% 0%Admission Rate Babies in the first year of l ife (Pacific) 29% 25% -4% 28% 28% 0%ALOS - Kidz First - Surgical - Surgical Floor 2.68 1.79 -0.9 1.96 1.90 -0.1ALOS - Kidz First Medicine - Kidz First Wards 2.59 2.40 -0.2 2.87 2.73 -0.1ALOS - Kidz First Medicine - ED Short Stay (hrs) 4.18 4.80 0.6 3.91 4.63 0.7ALOS - Kidz First - Neonatal 21.6 18.6 -3.0 22.3 22.2 -0.1


Outpatient DNA - FSA 13% 10% -3% 12% 10% -2% Impact of repeated re-scheduling due to strikes.Outpatient DNA - Follow up 11% 10% -1% 11% 12% 1%


Patient experience survey v good/excellent- month (n=11) YTD (n=75) 100% 76% 24% 83% 76% 7%P&

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Acute Caseweight - Gynaecology Inpatients- acute 112 139 -19% 1,338 1,417 -6%Acute Caseweight - Secondary Neonatal Womens health 95 140 -32% 1,044 1,415 -26% Reflecting fewer babies progressing from neonatal unitAcute RVU - Inpatient maternity care primary maternity facility 577 724 -20% 7,016 7,339 -4%Acute Caseweight - Women's Health secondary 679 633 7% 6,511 6,408 2%Elective Caseweight - Gynaecology Inpatients - elective (includes AA) 89 121 -26% 1,086 1,246 -13% Access to Theatre due to theatre Cancellation and RDA strikeHysteroscopy 47 27 74% 370 289 28% Includes outsourced volumesTotal Discharges - Gynaecology Inpatients- acute 199 235 -15% 2,256 2,297 -2%Total Discharges - Secondary Neonatal Womens health 191 175 9% 1,652 1,754 -6% Reflecting fewer babies progressing from neonatal unitTotal Discharges - Inpatient maternity care primary maternity facility (one 688 715 -4% 6,777 7,038 -4% Lower inpatient activity at primary unitsTotal Discharges - Women's Health secondary 1,333 1,290 3% 12,730 12,504 2% Total Discharges - Gynaecology Inpatients - elective 108 134 -19% 1,347 1,403 -4%Gynaecology - 1st Attendance 200 227 -12% 2,075 2,395 -13% Due to RMO Strikes and SMO ShortagesNon-Contact FSA Gynae Virtual 42 59 -29% 571 621 -8%Non-Contact FSA Maternity 185 124 49% 1,746 1,309 33% New from March 2017, reflecting ability to VFSA in MCIS.

First Obstetric Consults S/B Doctors 239 260 -8% 2,447 2,746 -11%Reduced as more virtual FSAs, plus separating out Feotal medicine, see below.

Foetal Medicine/Anomalies Clinic - MDC 91 NA NA 738 NA NADHB non-specialist antenatal consults 1,446 1,515 -5% 14,743 15,803 -7% Volumes similar to last year's actual. Gynaecology - Subsequent Attendance 185 255 -27% 2,231 2,695 -17% Incresed appointment time due to complexity.Subsequent Obstetric Consults F/U S/B Doctors 220 233 -6% 1,843 2,457 -25% InvestigatingDHB non-specialist postnatal consults 524 1,221 -57% 7,557 12,899 -41% More women transferred to post-natal follow up


Budgeted FTEs 393 367 -7% 381 367 -4% Maternity Initiatives ImpactOperating Costs ($000) 524 442 -19% 4,505 4,424 -2%Personnel Costs ($000) 3,549 3,436 -3% 33,210 32,494 -2% RMO Strike and Additional DutiesFinancial Result Total ($000) (4,015) (3,493) -15% (37,134) (32,401) -15%Reduce Clinical Outsourcing ($000) 68 5 -1260% 310 54 -474% Locum SMO Cost plus Hysteroscopies


% Staff with Annual Leave > 2 years - (one month in arrear) 5.0% 5.0% 5.0% 5.0%% Staff Turnover - (one month in arrear) 10.0% 10.0% 10.0% 10.0%% Sick leave - (one month in arrears) 2.8% 2.8% 2.8% 2.8%Workplace injuries recorded per 1,000,000 hours - (one months in arrears) 10.5 10.5 10.5 10.5

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Trend Year to date Rating Commentary (by exception)FY1718-1819 Apr-19 Target Var Actual Target Var

Emergency trolley checks (days checked) per month 100% -100% N/A 0%Hand hygiene (compliance with checks) per month 80% -80% N/A 0%Safe Sleep audits compliance 100% -100% N/A 0%Health and Safety Environmental Audit (bi-monthly) 100% -100% N/A 0%Violence Intervention Programme (VIP) Screening 53% 80% -27% 69% 80% -11%


ED 6 hour target - National Health target (Gynae) 83% 95% -13% 75% 95% -20%ESPI 2 - No. waiting >4 months for FSA - Elective 0.0 0.0 0.0 0.0 0.0 0.0 ESPI 5 - No. waiting > 4 months for treatment - Elective 7.0 0.0 -7.0 7.0 0.0 -7.0 impact of accumulated strikes

Trend Year Rating Commentary (by exception)FY1718-1819 Apr-19 Target Var Actual Target Var

% transcribed clinic letters authorised <7 days created 77% 95% -18% 76% 95% -19%ALOS Women's Health - babies (WNB and Neonates) 2.60 2.40 -0.20 2.60 3.10 0.50 reflecting lower accuity on postnatal floorAverage Length of Stay Gynaecology - Middlemore 1.64 1.33 -0.31 1.75 1.72 -0.03Average Length of Stay Gynaecology - MSC Inpatients 0.89 0.64 -0.25 0.67 0.85 0.18Average Length of Stay Obstetric (DHB Mat) (1 month in arrear) 2.31 2.43 -0.12 2.45 2.37 0.08Average Length of Stay Obstetric (Ind. Mat) (1 month in arrear) 2.43 2.40 0.03 2.41 2.24 0.17Average Length of Stay Vaginal Deliveries overall 2.10 2.29 -0.19 2.20 2.16 0.04

Maaori - 1st time mothers 3.20 3.24 -0.04 2.60 2.64 -0.04 Very small numbersPacific - 1st time mothers 2.50 3.17 -0.67 2.90 3.20 -0.30 Very small numbers

Trend Year Rating Commentary (by exception)FY1718-1819 Apr-19 Target Var Actual Target Var

FSA / Follow up ratio - Gynae 1.07:1 1:1 1.24:1 1:1DNA - Midwifery Antenatal clinics - First 12% 10% -2% 13% 15% 2%DNA - Midwifery Antenatal clinic - Follow up 10% 11% 1% 12% 13% 1%DNA - Doctor Antenatal clinics- FSA 10% 7% -3% 13% 12% -1%DNA - Doctor Antenatal clinics - Follow up 11% 13% 2% 10% 12% 2%


Patient experience survey v good/excellent- month (n=154), YTD (n=1249) 76% -76% 76% -76%

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Further performance information Risk Register Items 1. Planned Expired Appointments:

The Planned Expired Appointments increased to 666 in March. Ongoing review in place and increased clinic capacity planned for May/June 2019.

2. MCIS Access to information

• As per Update on Previously reported issues.

3. Neonatal Capacity and Resource • As per Update on Previously reported issues.

4. Maternity Bed Capacity

• ELT has approved the Ward 21 proposal for a phased implementation of utilisation of Ward 21 for maternity and gynaecology. Planning for this commenced in January 2019 with a reconfiguration and relocation of antenatal beds to ward 21 commencing from 13 May 2019 being the first area to focus on. Also see earlier in the report.

5. Midwifery workforce

• Risk cited under Chief Nurse Division and to be completed by DoM. • Also see earlier in the report on Previously Reported Issues update.

6. Medical staffing rostering Women’s Health

• New risk was entered in March 2019 highlighting the ongoing inaccuracies with both the junior and senior medical staff rosters.

• Since then a project resource has been allocated to work with the Service Manager and Clinical Director and the NRA Roster coordination staff to improve the current process as well as look at new roster options (in particualr the way we organise the after-hours work) for the senior medical staff.

• Currently exploring electronic rostering tool to reduce multiple hard copy and various Excel spreadsheets resulting in errors and duplication.


Adult Rehabilitation and Health of Older People Monthly Report – April 2019 Glossary ACC Accident Compensation Corporation ACE Acute Care of the Elderly ARHOP Adult Rehabilitation and Health of Older People ASRU Auckland Spinal Rehabilitation Unit AT&R Assessment, Treatment and Rehabilitation Services CGG Clinical Governance Group FLS Fracture Liaison Service HBSS Home Based Support Services HOP Heath of Older People IBC Indicative Business Case LOS Length of Stay MMH Middlemore Hospital SMO Senior Medical Officer SPHM Safe Patient Handling and Mobility SRC Specialised Rehabilitation Centre YTD Year to Date Service Overview The Adult Rehabilitation and Health of Older People Division is managed by Dana Ralph-Smith (General Manager), with Dr Peter Gow (Clinical Director) and Julie Beck (Clinical Nurse Director). Response to HAC: Deep Dive ARHOP A PowerPoint presentation has been developed to provide a grand overview of the ARHOP division at Counties Manukau Health. This will be presented at the meeting on 5th June, 2019. Highlights Title Notes

Annual Planning 2019/20

ARHOP business planning for 2019/20 is well underway and is now in the final draft stage. These will be in place as of 01/07/2019.

Fundamentals of Care (FOC)

ARHOP wards underwent their FOC audits in April. The results for these will be available at a later date and will be reviewed by the Charge Nurse Managers alongside the Clinical Quality and Risk Manager for ARHOP.

Integrated Stroke Project

This project began back in 2016 as a result of having no integrated acute stroke unit at Counties Manukau Health. Since then, a lot of work has gone into implementing a new model of care, standardising service delivery and workforce, and improved patient outcomes across the whole of system pathway. The project is now complete as of April 2019.


Challenges Title Notes

RMO Strikes The ongoing RMO strikes were difficult to manage alongside continuous high demand across our services, particularly in the outpatient setting.

Activity ARHOP Occupied Bed Days were below budget by 1,261 for YTD. This includes the closure of 281 bed days during the summer holiday period.


Issue Date reported

Update

Safe Patient Handling and Mobility

06/05/2019 General • Upcoming TROPHI tool audit May 27th – 31st. • TROPHI tool training for 4 new assessors with Dr Mike Fray mid-May. • Evaluation framework is in final draft with research & evaluation team for ethics application and sign off

Revenue Revenue is $17k above budget for the month and $228k above budget YTD mainly due to ACC revenue regarding treatment injuries being above budget. Expenditure Overall expenditure is $9k overspent for the month and $27k underspent YTD Key expenditure variances are summarised below: Personnel Costs ($8k unfavourable for the month and $299k favourable YTD partly offset by outsourced personnel overspend of $189k overspend YTD)

Variances in Personnel Cost categories were as follows: • Medical staff costs are $57k over budget for the month mainly due to SMOs filling in for RMOs and HOs during

the strikes and $97k favourable YTD. • Nursing staff costs are under spent by $48k for the month and $129k underspent YTD. The underspend is

offset by the overspend for outsourced nursing of $291k YTD • Allied Health staff costs are $29k overspent for the month due to salary and step increases above budget and

vacancy savings built in budget not realised and $51k overspent YTD • Outsourced Personnel costs are $6k favourable for the month and $189k unfavourable YTD. The adverse

variance is mainly due to the nursing bureau relating to patient watches partly offset by favourable variances of $89k(F) YTD re CSW and $15k(F) YTD re outsourced doctors

Actual Budget Variance Comparative Actual Budget Variance Forecast Budget Variance

Volume Volume VolumeVariance to Prev Mnth Volume Volume Volume Volume Volume Volume

AT & R 1,291 1,509 (218) U 14,002 15,289 (1,287) U 17,070 18,357 (1,287) USpinal 433 478 (45) U 3,979 4,231 (252) U 5,418 5,670 (252) UStroke Rehabilitation_Mainly WD 23 428 574 (146) U 6,304 5,820 484 F 7,472 6,988 484 FIntegrated Stroke Ward 422 513 (91) U 4,250 5,198 (948) U 5,294 6,242 (948) UAcute Care for Elderly_Mainly Ward 5 458 416 42 F 4,610 3,868 742 F 5,806 5,064 742 F

Total 3,032 3,490 (458) 33,145 34,406 (1,261) U 41,060 42,321 (1,261) U

VolumesApril 2019

Month Year to Date Full Year


Non Staff Costs • Outsourced clinical costs are $22k underspent for the month and $120k underspent YTD and mainly relates to

the hire of short term equipment provided to patients • Clinical Supplies are $43k overspent for the month and $342k unfavourable YTD. The variances are mostly due

to community continence supplies (current clients have increased from June ’18 by 181 to 2,648 clients) and burns garments.

• Other Expenses are underspent for the month by $14k and $139k underspent YTD. This is mainly due to favourable variances in Laundry, Bedding & Linen $8k(F) for the month and $74k(F) YTD, Other Equipment minor purchases $10k(F) for the month and $86k(F) YTD and Other Equipment Repairs and Maintenance $2k(F) for the month and $ 30k(F) YTD.


Trend Rating Commentary (by exception)Current month FY1718-1819 Apr-19 Target Var Actual Target VarASRU Bulk fund contract performance - Bulk (Actual) vs previous FFS (target) $663,090 $709,724 -7% $6,505,556 $5,104,454 22% continues to demonstrate an upside YTDBudgeted FTEs 520 515 -1% 532 518 -3%Operating Costs ($000) $4,538 $4,553 0% $44,960 $45,012 0%Personnel Costs ($000) $3,692 $3,709 0% $36,237 $36,560 1%Financial Result Total ($000) $4,008 $4,040 1% $39,465 $39,744 1%Reduce clinical outsourcing ($000) $200 $222 10% $2,097 $2,217 5%

Trend Rating Commentary (by exception)Month in arrears FY1718-1819 Apr-19 Target Var Actual Target Var% Staff with Annual Leave > 2 years (1) 4.8% 5.0% 0.2% 6.8% 5.0% -1.8%% Staff Turnover (2) 9.6% 10.0% 0.4% 9.7% 10.0% 0.3%% Sick Leave (3) 3.1% 2.8% -0.3% 2.7% 2.8% 0.1%Workplace Injury per 1,000,000 hours (4) 0.0 10.5 10.5 3.3 10.5 7.2

Trend Rating Commentary (by exception)Current month FY1718-1819 Apr-19 Target Var Actual Target VarFalls - % of falls assessments done in first 6 hours (5) n/a 100% #VALUE! 81% 100% -19%Falls - % of Interventions completed n/a 100% #VALUE! 96% 100% -4% Care Compass audits not done this month due to new forms being developed.Pressure Injuries - % of assessments done in first 6 hours n/a 100% #VALUE! 82% 100% -18%Pressure Injuries - % of interventions completed n/a 100% #VALUE! 98% 100% -2%% Over ride rate of Pyxis on AT&R wards + ASRU (excludes Ward 31) 13% 15% 2% 12% 15% 3%

Trend Rating Commentary (by exception)Month in arrears FY1718-1819 Mar-19 Target Var Actual Target Var% Acute Stroke Patients Transferred to Inpatient Rehab within 7 days 60% 80% -20% 60% 80% -20% Some delays - audit of those >7days showed increased complexity and facility/infrastructure issues% Patients Referred to Community Stroke Rehab seen within 7 days 63% 60% 3% 46% 60% -14%

Trend Rating Commentary (by exception)Month in arrears FY1718-1819 Mar-19 Target Var Actual Target Var% Acute Stroke Patients Admitted to Organised Stroke Unit 88% 80% 8% 81% 80% 1%% Eligible Patients Thromboylsed by DHB of domicile (includes ACH IVT patients) 18.4% 10% 8% 15.0% 10% 5%Acute 28 Day Readmission Rate - Stroke 9.4% 4% -5% 8.0% 4% -4% secondary stroke issues (TIA, AF)Acute 28 Day Readmission Rate - ACE 6.4% 11% 5% 15.0% 11% -4%Acute 28 Day Readmission Rate (AT&R and Adult Rehab) 8.4% 11% 2.6% 11.4% 11% -0.4%Current month FY1718-1819 Apr-19 Target Var Actual Target VarNumber of Patients Seen by ED Geriatrics Service 41 50 -9 55 50 5 less eligible patients presented to ED during April, YTD tracking well.% Patients Seen by ED Geriatrics discharge to Community (inc Respite and POAC) 44% 50% -6% 50% 50% 0% Suitability of patients not for POAC or discharge homeAcute 7 Day Readmission Rate - Stroke 5.3% 2% -3% 4.0% 2% -2% 2 patients with multiple re-admissions ended up in gen med, 1 died.Acute 7 Day Readmission Rate - ACE 4.2% 4% 0% 4.0% 4% 0%Acute 7 Day Readmission Rate (AT&R and Adult Rehab) 1.5% 3% 2% 3.1% 3% 0%

Trend Rating Commentary (by exception)Current month FY1718-1819 Apr-19 Target Var Actual Target VarMMH % patients discharged to discharge lounge or home by 1100hrs 23% 32% -10% 22% 32% -10% Family training by MDT on ward results in more patients d/c from ward vs d/c lounge

Trend Rating Commentary (by exception)Month in arrears FY1718-1819 Mar-19 Target Var Actual Target Var% Acute Stroke Patients Admitted to Organised Stroke Unit - Maori/Pacific 88% 80% 8% 81% 80% 1%

% Acute Stroke Patients Transferred to IP Rehab within 7 days - Maori/Pacific 0% 80% -80% 66% 80% -14% 1 pacific patient referred for Rehab, severe stroke, didn't make 7 day target.

Trend Rating Commentary (by exception)Current month FY1718-1819 Apr-19 Target Var Actual Target VarPatient experience rated good or above - month (n=27) and YTD (n=291) 100% 90% 10% 96% 90% 6%P&

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Mental Health & Addictions Monthly Report - April 2019 Glossary CAMHS Child Adolescent Mental Health Service CMH Counties Manukau Health MH Mental Health MH&A Mental Health & Addictions ILoC Integrated Locality Care NGO Non-Government Organisation TORC Tamaki Oranga Recovery Centre OT Oranga Tamariki C&P Care and Protection RFF Regional Funding Forum Service Overview The Mental Health and Addictions (MH&A) Division is managed by Tess Ahern (General Manager) with Dr Peter Watson (Clinical Director) and Anne Brebner (Clinical Nurse Director). Highlights CM Health Response to the Muslim Community following Christchurch Massacre Following the tragic events in Christchurch in March it was recognised that the Muslim community in Christchurch and Counties Manukau needed additional support to ensure their well-being needs were met. The objective of providing additional support was to meet the immediate social, emotional and spiritual needs of the Muslim community (both adult and youth) through culturally appropriate non-clinical community roles. In addition support was needed to raise mental health awareness amongst the Muslim community and ensure people and their families know how and when to seek support to meet their wellbeing needs. Further the service needed to provide Muslim cultural awareness training and support to clinicians working within the CM Health district. Kahui Tu Kaha provided an immediate response to the Christchurch Muslim community by sending 7 Muslim Social Workers/Support Workers and the Operations Manager for a week post the tragic events. They also responded to a request from the CEO of MIT for assistance for Muslim students over the first weekend. This support was reduced the week after to 2.6 FTE and then further reduced to 1.6 FTE for a further 4 weeks. During this time support was provided directly to the community and Muslim cultural training was provided to primary and secondary care staff. CM Health Mental Health and Addictions team already contracted Kahui Tu Kaha to provide Asian specific support to the community (1 FTE), but for a period of 6 months (April to September 2019) this has been increased by 2.5 FTE. The increase in FTE includes 1 FTE Muslim liaison & mental health support, 0.5 FTE to run Muslim community groups, 0.5 FTE to support access to Primary Care and 0.5 FTE Muslim youth mental health support. Requests were also received from the National phone Helpline 1737 for psychology and counselling staff across the Auckland region to provide extra staffing to help man the increased response required. Staff from Mental Health and Psychological Medicine responded and covered a number of shifts.


Participation in the Government Inquiry into MH&A There has been a further delay to the response to the inquiry from the MoH due to staff being deployed to support the response to the massacre in Christchurch. It is expected the response will be released at the end of May alongside the Budget announcements which will provide direction on what considerations need to be given to the on-going programme of work. Clinical Director Sabbatical Dr Peter Watson, Clinical Director MH&A has just returned from a 3 month sabbatical at the Mental Health and Addictions Directorate at the Ministry of Health in Wellington. Pete's sabbatical aims were to develop knowledge, skills and relationships of central Government processes and functions including policy development, DHB and Sector funding and performance management, sector relationships, interagency work and Ministerial-Ministry functioning. He spent his time at the Ministry working on a number of key Government priorities including: Child and Youth Wellbeing; the response to He Ara Oranga - the Government's Inquiry into Mental Health and Addictions; MH&A workforce capacity issues; funding bids for Budget19. Pete's reflections included that he gained: • A greatly increased understanding in the theory and practice of the machinery of Government

including the priorities of the Ministry to the Minister and the Government as well as their regulatory and accountability functions.

• An enhanced appreciation of the MoH staff expertise but also concerns about the lack of effective sector engagement by some staff at the Ministry.

Pete says he grew his leadership skills, developed more self-reflective skills and a greater awareness of how to influence and impact in an organisation/sector/situation. Pete has related that his sabbatical experiences have equipped him to more effectively contribute his skills and experience in a senior leadership role here at CMH and to contribute to the work of the Ministry of Health. Pete has presented to his Clinical Director colleagues and strongly encouraged clinical leaders to consider taking up a sabbatical in the Ministry of Health. Official Opening of Ngaa Raukohekohe Community Mental Health Team in Pukekohe The development of an adult community mental health centre in Pukekohe was one of the key actions detailed in the Specialist Mental Health & Addictions community reconfiguration. Ngaa Raukohekohe had its official opening at Pukekohe hospital on 26th March 2019, it was attended by the senior leadership team from Mental Health and Pukekohe Hospital as well as CMH board members, local MP Andrew Bayley, NGO Partners and primary care representatives. The majority of clinicians working on that team live within the Franklin community and were pleased to have the opportunity to deliver mental health services from within that locality, ensuring that services are now ‘closer to home’ and removing the obstacle of clients having to travel up to Papakura (as had been practice for the last 20 years). The team have been resourced to work efficiently in a mobile manner – staff have tablets and smart phones which enables them to work from a variety of locations across the district. It also supports the ability for clinicians, as part of their ILoC work in Franklin (integrated locality care) to effectively liaise and support the primary care providers who they engage with (schools, GP practices, aged care residential and Marae based clinics). Being based in Pukekohe has also provided an opportunity to strengthen the working partnership with the other CMH specialist services (Community Health, Public Health, Allied Health) as well as the Mental Health and Addiction NGO providers. The focus is to develop positive integration with the other providers delivering services within Franklin and to ensure that people are receiving the appropriate care in a timely and holistic manner.


New Acute MH Unit Progress Update Hawkins Construction has been awarded the contract for completing stage 2 of the rebuild. The old Tiaho Mai has been demolished and CMH portable buildings have been moved off site. The site has been cleared and ground preparation is well underway. WOS Integration Progress is being made to prepare for procurement of NGO services. Following the CPHAC workshop in early April, endorsement is being sought from ELT/ARF/Board and from the MoH. Alongside this work, discussions are on-going with existing NGOs about improving the way that specialist community mental health teams and NGO community teams work together in a more joined-up model. Some progress has been made with interest in the roles within the addiction liaison team. It is unlikely that all positions will be recruited to from the outset, with careful consideration to be given to how to effectively support a small number of people in these new roles. Summary of Safeside Suicide Prevention Training April 2019 In April, 29 MH Staff attended the Safeside Suicide Prevention training hosted by GROW. Dr Anthony Pisani (Psychiatrist) and Kristina Mossgraber (Patient Advocate) presented a framework for recovery oriented suicide prevention. For a number of years Mental Health Services have attempted to “predict” risk based on past behaviour and risk factors and the categorisation of “low”, “medium” and “high” risk. Safeside Suicide Prevention has the focus of being strengths based and recovery focussed. It is an understandable model that provides a clear framework for clinicians and their work with our service users. The feedback received from all that attended was that “it makes sense” and “when can we start using it?” The Mental Health Division has already made moves to change the focus of Risk Assessment and training and this framework would sit nicely alongside. The Suicide Prevention Co-ordinator and Clinical Lead alongside the Clinical Director are putting together a proposal of how we can utilise the training received for the benefit of our service users. Safeside Prevention is an American based program that has a number of training packages for implementation within clinical Mental Health settings. Emerging Issues Workforce Recruitment and Retention Since the last vacancy report, the MH Division has had a net gain of 1FTE to a total of 609 employees. The overall vacancy in the Division remains at 17.5% with the highest vacancy rates across medical, nursing and psychology disciplines (21-25%) and in the CAMHS, MHSOP and Acute MH services. Service delivery is maintained through staff undertaking overtime and additional duties and the use of contractors. The workforce issues are common across DHBs and were reflected in He Ara Oranga - the report form the Government's Inquiry into Mental Health and Addictions. Concerns exists about potential impacts on staff wellbeing and service responsiveness. Mitigation includes enhancing our local recruitment and exploring international recruitment opportunities and focussing on supporting staff and teams through values based wellbeing approaches.


Update on Previously Reported Issues Issue Date

reported Update

Three reviewers from outside this organisation undertook a service review of Tamaki Oranga. The review considered the environment, clinical governance and clinical leadership of TORC and will identify recommendations for service improvements.

Oct 18 The review team met with staff, service users and family/whaanau and NGO staff to get their perspectives. A report was expected in early 2019 however the reviewer has informed us this is delayed further due to him being on leave in April. The report is expected imminently and the findings will be shared with staff working in TORC and a summary of the recommendations and our response will be reported to HAC.



Overtime costs ($000) $163 $149 -9.5% $1,727 $1,489 -16.0% High acute demand, off-set by community vacanciesBudgeted FTEs 653 742 12.0% 649 736 11.8%Operating Costs ($000) $6,320 $6,703 5.7% $62,784 $64,508 2.7%Personnel Costs ($000) $5,663 $6,350 10.8% $56,199 $60,976 7.8%Financial Result Total ($000) $6,225 $6,641 6.3% $61,951 $63,888 3.0%


% Staff with Annual Leave > 2 years 5.0% 5.0% 5.0% 5.0%% Staff Turnover 10.0% 10.0% 10.0% 10.0%% Sick Leave 2.8% 2.8% 2.8% 2.8%Workplace Injury Per 1,000,000 hours 10.5 10.5 10.5 10.5


Number of Seclusion events/ 100,000 3.9 5.0 1.1 N/A N/A N/A )

Seclusion hours/ 100,000 88 50 -38 N/A N/A N/A)All seclusion events are reviewed at the weekly risk review meeting

Number of Clients Secluded/ 100,000 2.4 3.0 0.6 N/A N/A N/A )


Shorter wait times for non urgent mental health and addiction Services (%< 3 week wait) - 12 months rolling

0-19 years 71% 80% -9.2% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 114820-64 years 87% 80% 7.2% N/A N/A N/A65+ years 87% 80% 7.0% N/A N/A N/A

Shorter wait times for non urgent mental health and addiction Services (%< 8 week wait)- 12 months rolling

0-19 years 90% 95% -5.4% N/A N/A N/A Unique Clients seen has exceeded MOH Target by 114820-64 years 96% 95% 1.3% N/A N/A N/A65+ years 96% 95% 0.5% N/A N/A N/A


Access rate - Number of CM domiciled unique clients seen by all MH services ((PRIMHD reporting services include AOD and NGO services) 12 months as a % of population) - Total

0-19 years 3.8% 3.2% 0.7% N/A N/A N/A20-64 years 3.8% 3.2% 0.7% N/A N/A N/A65+ years 2.1% 2.6% -0.5% N/A N/A N/A Meeting the wait time targets - no build-up of a waitlist

Readmissions to Tiaho Mai within 28 days - Total (1 month in arrears) 4.7% 12.0% 7.4% 8.5% 12.0% 3.5%


Inpatient Occupancy - Tiaho Mai Acute Mental Health Unit 82% 85% 2.8% 91% 85% -5.5%Number of Tiaho Mai Inpatient LOS >35 days 5 10 5.0 8 10 1.9


Access rate - Number of CM domiciled unique clients seen by MH services (PRIMHD) 12 months as a % of population - Maori

0-19 years 5.8% 4.5% 1.4% N/A N/A N/A20-64 years 9.2% 7.7% 1.5% N/A N/A N/A65+ years 2.7% 2.6% 0.1% N/A N/A N/A

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Middlemore Central Monthly Report – April 2019 Glossary CapPlan Capacity Planning Tool CaaG Capacity at a Glance CCDM Care Capacity Demand Management MAPA Management of Actual or Potential Aggression MMC Middlemore Central SSHW Safe Staffing Healthy Workplace SMO Senior Medical Officer Service Overview Middlemore Central is currently managed by Ian Dodson (General Manager Central Clinical Services) with Dr David Hughes (Clinical Director). The Division is responsible for Daily Operations Unit, Bureau Service, Transit Nurses, Discharge Lounge, Emergency Response and Non-Clinical Support Services (Cleaners, Orderlies, Security, Interpreter & Translation services, and patient transport). Highlights Influenza Planning & Campaign 2019 National Influenza Planning meetings for 2019 are continuing. Middlemore Central are supporting Occupational Health & Safety to increase uptake of flu vaccinations in Non Clinical Support Staff and are offering vaccinations 24/7 at Middlemore Central. Care Capacity Demand Management Two CCDM coordinators have commenced in their role. CCDM Accord Funding – 68% of positions have been appointed to, 53% have commenced. Remaining positions are in progress or have been readvertised. The core data set (CDS) working group has been activated and the stocktake has been initiated. Summary of findings to date indicate that there is no hospital wide consistency with different reporting pathways and data from various systems going to various audiences. CDS specifications require centralisation, visibility and accessibililty of reports. The variance response management (VRM) working group has been activated and stocktake completed. Summary of findings indicate CM Health has a well-established integrated operations centre that has capability to be adapted to CCDM specifications. A proposal has been reaised ot further develop the Capacity at a Glance (CaaG). A business case will be required for CaaG screens in clinical areas. A draft communications plan has been finalised and communications to staff has commenced with Daily Dose updates and a re-vamp of the CCDM intranet site. Wards have been asked to create a CCDM noticeboard and posters have been developed, printed and distributed to all wards in time for certification.


Reporting requirements for April included the bi-monthly report to staff, bi-monthly report to MoH for Accord funding, quarterly report to SSHW Governance Group. A risk register is under development for the programme. Bureau Continued participation in Every Dollar Counts optimising bureau costs. Reviewing all aspects of casual bureau and external bureau use and costs associated – this includes mapping the staffing process from roster creation to requesting bureau staff. Opportunities for improvement have been identified and quick wins are currently being implemented. Currently investigating increasing the Bureau Resource Team by moving casual staff into permanent roles giving the ability to proactively match rostering with demand. A paper has been submitted to Executive Leadership Team. Awaiting implementation of bureau app within the next month – will provide an alternative for requesting staff. One Duty Manager vacancy outstanding is currently funding a trial of the Behaviours of Concern Nurse Specialist role. This role reviews all patients in Medicine and ARHOP to determine their need for a watch as well as educating ward staff on their responsibilies around watches. Feedback to date has been that there is a decrease in the number of watches requested. The trial has been extended for a further three months and on completion a report will be produced. Discharge Lounge & Transit Care The Consultation paper looking at the amalgamation of the Transit Care team with the Discharge Lounge to gain additional efficiencies is currently on hold with Director of Human Resources until clarity is gained around future structures. Charge Nurse Manager has been appointed. Casual Clerical Staff A further recruitment drive is being aligned with Manukau Institute of Technology education calendar to try to match graduates with vacancies. Emergency Response Carbapenemase producing Enterobacteriaceae (CPE) in Middlemore Hospital – the response group is continuing improvement work. Information has been sent to the Ministry of Health regarding our CPE status and they have removed our Transmission Risk Area (TRA) label. NZRDA Industrial Action– we received advice on the 12th April 2019 from the NZRDA that their members will be taking strike action of a complete withdrawal of labour on 0800hours 29th April 2019 to 0800hours 4th May 2019. Contingency planning meetings commenced for services affected. Below shows the numbers of RMOs working during the week long industrial action.

Mon

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4/19

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Total RMOs - Working # of RMOs working during Strike 207 212 215 211 194

Total RMOs – Normally Working # of RMOs rostered to work 309 320 325 320 292

% total % of work force in the hospital 67% 66% 66% 66% 66%


Document Exchange Mail Incident – on the 24th April 2019 we were alerted that the Document Exchange East Tamaki branch was broken into and mail stolen. This included mail sent from CM Health to seven post codes. An immediate incident meeting was set up to respond to this incident. Majority of affected letters were identified and resent. Ongoing work is being completed and a debrief meeting will be held with New Zealand Document Exchange. Emerging Issues Contracts Management Linen – Middlemore Hospital continues to have linen shortages, especially over the weekend. This was due to mechanical issues in the Taylors plant that took a significant time to resolve. Taylors Linen have downgraded the incident alert from a major to a minor incident, daily updates are being provided. There will need to be further long-term engagement with the linen supplier to resolve some of the ongoing service issues. Security Services Middlemore Hospital Carparks – One staff member was assaulted on the railway bridge leaving work on the 7th April 2019. This occurred only two weeks after the assault on two staff members on the 23rd of March in which both staff members were injured. The security presence in the two main hospital car parks, Western Campus and the S-Bend carpark have been increased and extended to cover all days in the weekends and every night from 4.00pm to 7.30am. A number of other security measures are in progress including improving fencing, lighting and surveillance cameras. Improvements are being looked at for a number of other CM Health satellite sites including MSC and the Spinal unit in Baird’s Road. Three cars were broken into over April 2019 - two in visitor car parks and one in the Tiaho Mai car park. With the increase in security staff there have been a significant increase in escorts for staff and visitors back to their vehicles after hours. Over the month of April there were 3710 escorts of staff and visitors exiting the hospital. Update on Previously Reported Issues

Issue Date Reported Update

RDA Industrial Action

February 2019 Strike notices were received and later withdrawn for a 4 day withdrawl of labour in the week preceding Easter. This would have caused significant issues for the DHB coming in a week prior to public holidays. A subsequent notice for a 5 day strike was received for the week commencing the 29th of April. This caused significant disruption in particular for elective services, both outpatient clinics and surgery. The following was deferred due to the strike: 69 Elective Surgical Procedures 38 Gastro procedures 994 outpatient clinics 16 cardiac tests 37 ESPI 5 treatment breaches


Issue Date Reported Update

CPE December 2018

The transmission risk area (TRA) applied by the MoH has been lifted following no further related cross infections occurring. The 2 cases were identified as being linked to an earlier admission to hospital with a similar CPE typing. The method or cause of the cross infection has not been able to be identified. Ongoing work is underway to implement better screening in ED and the wards. Options are also being review to improve cleaning in ED and discharge cleaning on the wards


Hospital Advisory Committee Meeting Resolution to Exclude the Public

Resolution

That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 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

Reason for passing this resolution in relation to each item


Public Excluded Minutes of 2 May 2019 and Actions


Confirmation of Minutes As per the resolution from the public section of the minutes, as per the NZPH&D Act.

hospital advisory committee (hac) meeting 5 june 2019 · 6/5/2019 · • director, sport new...

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